Keys to a Successful Privileging Project

Keys to a Successful Privileging Project

Aug 5, 2022
  • Author:
    Noelle Abarelli

Medical Staff Professionals (MSPs) everywhere agree that privileging projects are tricky, but they also agree they're essential. Standardizing privileges ensures you have consistent criteria for privileges across a health system and equips you to deliver next-level patient care and provider experiences. Standardization also means everybody on the medical staff has access to the same information, eliminating redundancies, inefficiencies, and confusion.

While successfully implementing a privileging project is difficult, it can be done. With the right guidance and planning, you can have a dependable structure for success in place in no time. Read on for our tips on how to best go about it. Remember, the most important thing to do is to ensure every step you take is getting you closer to achieving your end goal: implementing standardized privileges.

Why Launch a Privileging Project?

If you're going to dedicate resources, time, and money to a large undertaking like a privileging project, it's important to confirm that the benefits far outweigh the risks or cost. Fortunately, there are countless benefits associated with a well-implemented privileging project such as:

  • Demonstrates regulatory and accreditation compliance
  • Provides nursing staff with access to privilege and procedure look-up, giving them peace of mind that they have all the information they need to do their jobs
  • Provides a unified and centralized repository for Primary Source Verification
  • Equips staff with adequate processes for FPPE and OPPE
  • Leads to a faster approval process for initial and reappointment applications
  • Grants access to delineated privilege forms that have acceptable qualifications and criteria for procedures
  • Improves user and end-user productivity
  • Helps with data classification

Clearly, the benefits speak for itself. But before you launch a privileging project, it's important to determine your readiness for one.

Indications You Might Need to Start a Privileging Project

"If it ain't broke, don't fix it." We've all heard that before, and when it comes to implementing a privileging project, truer words have never been spoken. The thing is, more often than not, there is something broken that needs attention, we may have just gotten so used to it that we can't even see it. So, what are some red flags that might signal you're in need of a privileging project?

  • Do your nurses call the medical staff office multiple times throughout the day to verify if a provider is privileged to perform a certain procedure?
  • Have you had a provider assist in surgery without the requisite privilege to do so?
  • Do your privilege forms contain procedures that are not even offered at your organization?
  • Do you have FPPE plans for new providers that have never been implemented?
  • Do you have little insight into what clinical activities are being performed at your organization by your providers?

If you've answered "yes" to any of those questions, then it may be time to implement a privileging project. There are also some real-world examples showcasing why a privileging project is a necessary step to take:

Scenario 1 Scenario 2 Scenario 3

You overhear leadership discuss the purchase of a Da Vinci Robot, and how providers are signed up to use it. But this is the first you're hearing of the device, which means none of the providers have the necessary privilege to use it in the first place.

A Credentials Committee may not complete their recommendation during a meeting, which means documentation hasn't been approved to move forward with granting privileges, leading to unnecessary delays.

A provider at your organization performs a newsworthy cutting-edge procedure, it's even in the papers, but the medical staff discovers the procedure wasn't one the provider was privileged for in the first place.

What to Consider Before You Kick Off a Privileging Project

If you determine the need to standardize privileges, it's important to assess your organization's readiness to adapt to change. You'll also want to put a team in place to spearhead the project. Key considerations and actions include:

  • Confirm whether your organization will support a standardized privileging process. This may entail multiple presentations to leadership explaining why the project is a worthwhile endeavor.
  • Review your current privileging/credentialing process. You want to ensure you know exactly what that process entails so improvements can be made holistically.
  • Examine problems or issues that your Medical Staff Department may be experiencing, this is an opportunity to address all problem areas in one fell swoop.
  • Designate a project manager to oversee the project. You want someone who is completely dedicated to ensuring it goes off without a hitch.
  • Create a task force team. Make sure to select appropriate medical staff members who are well-respected and will provide adequate recommendations to ensure the implementation goes well.
  • Assure that there are reliable and available resources to implement the project.
  • Generate a privileging project structure that is realistic, attainable, and reliable.

With these actions tackled, you're ready to start your privileging project. Privileging projects are by nature lengthy and time-consuming. Because of this, it's important to begin with a clearly determined and thought-out end in mind. You want to know from the get-go what method will be used for your privileging project: Will it be a single facility, multi-facility, or enterprise? While circumstances can change throughout a project, advance planning helps assure the transition process has been appropriately designed and resourced.

A great way to navigate the complexities of implementing standardized privileges is to consider the experiences of organizations that have been there and done that. That's the case for The University of North Carolina Health Care System. Here's a quick overview of their successful privileging project.

Privileging Project Spotlight: The University of North Carolina Health Care System

The University of North Carolina (UNC) Health Care System is a large medical system of 19 hospitals, with CVOs that credential over 8,000 providers. Their culture is one that supports forward mobility and growth, with a fully electronic and paperless environment dedicated to maximizing technology. Their journey to automate and standardize privileges started back in 2014, where they established an internal CVO. They spent several years focused on their credentialing and enrollment processes, before turning their full attention on standardizing privileges in 2021. In an effort to achieve the best results, they closely followed the guidelines outlined in this post. Key actions included:

  • Assessed their current privileging process to see where there were variations in privileges and privileging criteria.
  • Medical Staff issues were examined, like frustration with multiple forms and variation in criteria.
  • Designated a strong leader, a dedicated Project Manager to oversee the project who helped the medical staff office expand technology while assisting with process creation.
  • Created a task force team that served as strategic leadership and functioned as an ongoing governance council.
  • Cleaned data before implementation/transition.
  • Followed guidance from CredentialStream to generate a successful project structure.

At this point in time, UNC Health Care System is continuing to complete the preliminary work of drafting forms and cleaning up data, before launching their new standardized privileging process powered by CredentialStream in 2023. You can get all the details on their journey in our webinar: How UNC Health Care System Automated and Accelerated their Privileging and How You Can, Too. Learn from their experience, and if you want to discover how you can implement a privileging project, reach out for a demo! As always, we're here to help, every step of the way.