The Greeley Company
July 29, 2020 3 Min Read

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

Go back to the Greeley Insights Blog >

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. Greeley 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 Greeley to learn how we can help: 888.749.3054 or

Let’s Start the Conversation

Copyright © 2022 The Greeley Company

Log in with your credentials

Forgot your details?