Introduction to Privileges: Understanding Privilege Form Components and Best Practices

Introduction to Privileges: Understanding Privilege Form Components and Best Practices

May 12, 2020
  • Author:
    Jackie Jones, CPMSM
    Senior Consultant
    Jackie works with VerityStream clients on development/conversion of facilities' privileges and has over 25 years of experience as a Medical Staff Services Professional. Prior to joining VerityStream in August 2015, Jackie was the Director of Medical Staff Services at Kaiser Foundation Hospital in San Diego for nearly 18 years.

For Medical Services Professionals (MSPs) who are new to the profession, or even seasoned MSPs who are not regularly involved in privileging processes and are interested in a brief refresher, the following are some privilege basics.

"Introduction to Privileges: Part One" of this two-part blog covered Credentialing vs Privileging, the Centers for Medicare and Medicaid Services (CMS) requirements for privileging, and Accrediting bodies and Healthcare Organizations to which privileging is applicable.

Based on the CMS and other Accrediting body requirements (discussed in Part One of this blog), it is best practice to organize privilege forms by specialty, not by medical staff organization departments. If privileges are organized by medical staff organization departments, it may lead to confusion about the criteria/ qualifications required to apply for the privileges. Additionally, organizing privilege forms by medical staff organization departments may lead to very lengthy forms, and also providers who may inadvertently request privileges outside of their specialty or scope of practice. Once privilege forms are organized by specialty, there are certain components that typically should make up each specialty’s privilege form.

Components of a Privilege Form:

Required Qualifications:

At the beginning of a privilege form, before the actual privilege detail, it is best practice to have a section for Required Qualifications.

  • The criteria listed here should address required education/training, continuing education (if applicable), board certification requirements (if applicable) as well as clinical experience (activity and outcomes), for both for Initial Privileging and Re-privileging. This is what helps to determine if the provider is competent to perform the privileges they are requesting. To determine competency, the first question is always: Did the provider perform it?; the second question is: How well did the provider perform it?
  • Also, any additional privilege criteria that is required would be listed in this section as well. For example, manufacturer designated training or supervising/collaborating requirements for Advanced Practice Professionals.
  • Privilege criteria should always be objective so that it can be consistently and uniformly applied across all specialties and providers.

Privilege Detail:

After the Required Qualifications, next is the actual Privilege Detail. Privilege detail should be written so that privileges with similar criteria and transferable skills are grouped together. Under Privilege detail the privileges are typically categorized as follows:

  • Primary/Core Privileges

    Since the CMS requires that Core Privileges must be able to be modified, when formatting Core Privilege detail, it is imperative to ensure that the providers requesting privileges as well as the clinical reviewers making recommendations, are able to modify the Core Privileges. On an electronic privilege form, the privileges within the Core Privilege group would need to be listed out individually, so that each privilege detail can be “checked” or “unchecked” as opposed to on a paper privilege form where Core Privileges within a group/paragraph could be crossed out.

    • Cognitive Privileges
      • This is where the admitting, history and physical exam, and the evaluate, diagnose, manage and treat type privileges would be listed.


    • Procedural Privileges
      • Procedural privileges should be written/defined in such a way, that enables the medical staff organization to easily monitor the performance of the privileges/procedures granted to providers, to ensure providers are not exceeding the scope of the privileges granted to them. This is a CMS requirement, as well as a requirement by other Accreditation Organizations.
  • Advanced Privilege Clusters
    • Advanced Privileges/Procedures that required Additional Training, such as a Fellowship, or maybe training for a specific advanced procedure during their Residency (for example, formal training during a residency is required for advanced laparoscopic procedures); another example might be required manufacturer recommended training (as is the case with Transcatheter Aortic Heart Valve Replacement (TAVR) ).
  • Conditions - Focused Professional Practice Evaluation (FPPE)/Proctoring
    • After Privilege detail, some organization’s privileges forms may have the actual requirements FPPE (Focused Professional Practice Evaluation) or Proctoring (as called by some organizations). FPPE/Proctoring is a requirement by some Accreditation Organizations (like TJC, DNV, and HFAP). This is the process for confirmation of competency of the full scope of privileges granted and should be implemented as soon as new privileges are granted to a provider.
  • Provider Acknowledgement
    • Next, there should be a Provider Acknowledgement section on the privilege delineation. This is the attestation that the provider is only requesting those privileges they are currently competent for based on their education/training and current experience. It should also indicate that any restriction on the clinical privileges granted to the provider are waived in an emergency situation, and in such situation their actions are governed by the applicable section of the health care organizations Medical Staff Bylaws or other related documents.
  • Clinical Reviewer(s) Recommendation
    • The final component of the privilege form for discussion is the section for the Clinical Reviewer (for example, Specialty Chiefs, Dept. Chairs, Chief of Staffs, CMOs) to make their recommendation regarding the privileges requested by the Provider. This would include any Privilege Conditions, Modifications, Deletions or explanations, and it also may include comments related to the FPPE/Proctoring recommendation (if applicable).

Once privilege forms have been developed, medical staff organizations should have a plan for regular review and updating of all privilege forms in order to keep privilege forms relevant and in alignment with current requirements. Some privilege forms will require annual review while others might be reviewed every other year.

Additionally, in between formal review periods, medical staff organizations should have policies and procedures in place for when new procedures/privileges/technology need to be added to their privilege delineations. The medical staff organization must determine that the privilege/procedure in question should be added to the scope of services for the medical staff organization and must develop criteria for what providers will be eligible to apply for the new privilege/procedure.