10 Essential Steps to Successfully Achieve Criteria-based Privileging Across a System

3 minutes

As healthcare becomes more and more integrated through consolidation, acquisitions, and mergers, one of the most difficult challenges for a system or network to achieve is a highly effective system-wide criteria based privileging methodology. Chartis Clinical Quality Solutions' experts Sally Pelletier, Chief Credentialing Officer and Frances Ponsioen, Advisory Consultant identify strategies for optimizing privileging performance across an integrated delivery system below.

Step 1: Evaluate existing privileges across the system

  • Identify and resolve disparate requirements in MS bylaws
  • Identify tried and true criteria
  • Understand current services/technology -including those under consideration
  • Agree on a format
    • Practitioner friendly / Leading practice
    • Electronic or paper
  • Have an awareness for current forms that may be “untouchable” due to a sense of ownership

Step 2: Secure support throughout the system

  • Utilize social capital
  • Understand MSL strategic goals
  • Cultivate the shared vision of physician success, hospital success, and good patient care
  • Project communique
    • Remember the previous goals and objectives – WIIFM
  • Medical staff leaders
    • Physician champions
    • Task Force – Credentials committee
  • Administration/Hospital personnel
    • Medical services professionals
    • IT
    • OR director / Clinical managers
    • Quality department
  • Governing board

Step 3: Project Planning

  • Determine who will oversee project
    • Project steering committee
    • Multiple directors/Managers MSSD
  • Develop a project plan that includes tasks, accountabilities, and timelines
  • Identify the specialties/subspecialties (physician and advanced practice): Who? What? Where?
  • Research exclusive contracts
  • Begin to identify representatives

Step 4: Provide education to key stakeholders

  • Project steering committee
  • Medical staff and MS leadership
    • Specialty representatives
  • Administration
  • Clinical departments (e.g., operating room)
  • Quality department
  • MSSD/Credentialing
  • Group administrators
  • Time commitment
  • Roles and responsibilities
  • Resources
  • Decision points
    • Volumes
    • Grandfathering
    • Cross-specialty disputes
    • Approval process

Step 5: Develop draft privilege forms

  • Don’t reinvent the wheel unless you need to
    • Determine whether any forms are current and/or adequate
      • Templates/Software content
      • The Internet is a beautiful thing
    • Initial customization
      • Identify common and site-specific privileges or services
      • Eliminate services that are not offered
    • Conduct specialty specific interviews
      • Engage physician leaders
      • Selecting representatives
        • Department chairs / Section chiefs

        • Specialty “experts”

      • Communicate expectations and time frames
      • Be respectful of practitioners’ time
        • Existing DOPs and criteria

        • Governance documents

      • Conduct specialty-specific interviews
        • Interview approach
          • Largest facility first or is that a mistake?
          • Communicate schedule and agenda
          • Consolidate across the system
            • Avoid he said /she said
            • Avoid having too many opinions at the table
            • Manage politics
          • Advanced practice professionals

Step 6: Approve new/revised privileging criteria and forms

  • Establish a strategy for timely review of all forms across all facilities
  • Electronic review and approval


  • Stonewalling
  • 100% department or section approval
  • Loss of momentum
  • Setting unrealistic time frames

Step 7:  Implement new forms

  • Coordinated effort
    • Project steering committee
  • Specialty / Departments
  • Technology
    • Credentialing/Privileging database

Step 8: Communicate current privileges

  • Privileged practitioners
  • Hospital staff
  • Group administrators

Step 9: Evaluate criteria and forms periodically

  • Develop schedule for review
  • Avoid referencing dated or archived criteria
  • Be proactive about new services/new technology

Step 10: Continuously orient new medical staff leaders to the privileging system

Is your organization ready to start implementing these essential steps towards integration? Contact us to learn how we can help: 888.749.3054.

© 2023 Chartis Clinical Quality Solutions. All rights reserved. This content draws on the research and experience of Chartis consultants and other sources. It is for general information purposes only and should not be used as a substitute for consultation with professional advisors. It does not constitute legal advice.

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