CCPP Module 7, Section 3: Privileging within Health Systems and Clinics
Module 7: Credentialing, Privileging, and Malpractice Setup

Section 7.3: Privileging within Health Systems and Clinics

An in-depth guide to the process of obtaining clinical privileges, from defining your requested scope of practice in a “delineation of privileges” form to navigating the medical staff credentialing committee.

SECTION 7.3

Privileging within Health Systems and Clinics

From Formulary Approval to Clinical Authority: Earning Your Scope of Practice.

7.3.1 The “Why”: The Crucial Difference Between a Paycheck and Permission

You have successfully navigated the labyrinth of payer credentialing. You are now an “in-network” provider with Medicare, Medicaid, and a host of commercial insurance plans. You have been added to their “formulary of providers,” and the pathway to reimbursement is open. It is a monumental achievement, but it is only half the battle. Payer credentialing gives you the authority to get paid for your services. It does not give you the permission to perform those services within the walls—real or virtual—of a specific health system, hospital, or medical group. That permission is granted through a separate, and arguably more rigorous, process known as privileging.

Privileging is the process by which a healthcare organization authorizes a specific provider to perform a specific scope of patient care services in their facility. While credentialing is focused on financial viability and network adequacy from the payer’s perspective, privileging is fundamentally about patient safety and clinical governance from the health system’s perspective. The organization’s governing body (usually the Board of Directors) is legally and ethically responsible for every single clinical activity that occurs under its roof. They must ensure that every provider, regardless of their profession, is not only licensed and qualified but also competent to perform the specific procedures and make the specific clinical decisions they are requesting to make.

For the collaborative practice pharmacist, this is where your clinical practice is formally defined and authorized. It is the process by which you translate the broad language of your Collaborative Practice Agreement (CPA) into a granular, specific “menu” of approved clinical activities. Do you want to independently order and interpret A1c tests? Do you want to initiate and titrate insulin? Do you want to manage anticoagulation therapy? Each of these activities is a “privilege” that must be formally requested, reviewed, and granted by the organization’s medical staff. Successfully navigating this process is the final administrative step that transforms you from a qualified professional into a fully empowered clinical practitioner within a specific care delivery system. It is the organization’s formal declaration of trust in your competence and judgment.

Pharmacist Analogy: Gaining the Keys to the C-II Safe

As a licensed pharmacist, your credentials have been verified by the state. You have a license number, an NPI, and you are employed by the pharmacy. This is equivalent to being credentialed. The pharmacy’s PBM will pay for the prescriptions you dispense. However, on your first day as a new pharmacist, you cannot simply walk to the double-locked C-II safe, open it, and begin handling fentanyl patches and oxycodone tablets. You have not yet been privileged to do so.

To gain access to that high-risk, highly regulated environment, you must undergo a separate, internal process governed by the Pharmacist-in-Charge (PIC) and company policy. This process includes:

  • A Specific Request: You are requesting the privilege of accessing and handling Schedule II controlled substances.
  • Competency Verification: The PIC observes your workflow, verifies your understanding of perpetual inventory logs, and confirms your knowledge of all state and federal regulations regarding controlled substances.
  • Formal Authorization: You may need to sign specific policy documents acknowledging your responsibilities. Once the PIC is satisfied, they formally grant you the privilege. They might give you the key, the alarm code, or add your fingerprint to a biometric scanner.

Only after you are privileged can you perform those specific, high-risk functions within that pharmacy. The same principle applies to your new role. Your CPA is like the federal law allowing for the handling of controlled substances, and payer credentialing is like the PBM agreeing to pay for them. But clinical privileging is the PIC (the hospital’s Medical Executive Committee) personally handing you the keys to the safe and saying, “I have vetted you, I trust you, and I am now authorizing you to perform these specific, high-risk clinical functions on our patients.”

The “menu” of privileges you request—your Delineation of Privileges (DOP) form—is your specific list of actions. Instead of “accessing the C-II safe,” your list will say “initiate and titrate basal insulin” or “order and interpret INR.” Just as accessing the safe carries immense responsibility, each of these clinical privileges comes with the expectation of expert competence and the highest standard of care. This process is the health system’s way of ensuring you are ready for that responsibility.

7.3.2 The Privileging Framework: The Medical Staff Office and Its Governance

The entire privileging process is managed by a department within the health system known as the Medical Staff Office (MSO), governed by the organized Medical Staff. The MSO is the administrative engine of clinical governance. They are responsible for processing applications, conducting primary source verification (similar to payers, but often more in-depth), and preparing files for review by a series of powerful physician-led committees. Understanding the key players and the flow of information is essential.

Masterclass Table: The Language of Privileging

Term / Player Definition Role in Your Process
Medical Staff Office (MSO) The administrative department responsible for managing all aspects of credentialing and privileging for every provider in the health system. They are the gatekeepers of the process. You will submit your application and all supporting documents to the MSO. A credentialing specialist within the MSO will be your primary point of contact.
Scope of Practice The range of procedures, actions, and processes that a healthcare practitioner is permitted to undertake in keeping with the terms of their professional license. Your state’s Pharmacy Practice Act defines your maximum potential scope of practice. Your privileges can only be a subset of what your state license legally allows.
Delineation of Privileges (DOP) A detailed, granular list of specific clinical activities that a provider is requesting permission to perform. This is the core document of a privileging application. You will complete a DOP form, often specific to clinical pharmacists, where you will check off or list the exact services you intend to provide (e.g., titrate ACE inhibitors, order CBCs).
Department Chair The physician leader of a specific clinical department (e.g., Chair of Medicine, Chair of Family Practice). Pharmacists often fall under the Department of Medicine or Pharmacy. The Department Chair must review and approve your requested privileges before your application can move forward. Their signature is a crucial endorsement.
Credentials Committee A committee of medical staff members (physicians) that performs a detailed peer review of your application, DOP, and all verified credentials. This committee scrutinizes your file for completeness, accuracy, and any red flags. They make a formal recommendation to the Medical Executive Committee.
Medical Executive Committee (MEC) The primary governance committee of the medical staff, composed of senior physician leaders. They have the ultimate authority to approve, deny, or modify privileging requests. The MEC makes the final decision on your application based on the Credentials Committee’s recommendation. Their approval is the most significant step.
Board of Directors The ultimate governing body of the healthcare organization. The Board provides the final, formal ratification of the MEC’s decision. This is typically a procedural step, but it is the source of the MEC’s legal authority.

Visualizing the Health System Privileging Workflow

This process is even more linear and hierarchical than payer credentialing. Each step is a gateway to the next, and approval is required at every stage before proceeding.

Phase 1: Application to Medical Staff Office (MSO)

You submit the comprehensive privileging application, including your CV, licenses, references, and the all-important Delineation of Privileges (DOP) form, to the MSO.

Phase 2: MSO Verification Process

The MSO credentialing specialists conduct a rigorous primary source verification of every item in your file and contact your professional references.

Phase 3: Department Chair Review & Approval

Once your file is complete, it is forwarded to the appropriate Department Chair (e.g., Chair of Medicine). The Chair reviews your qualifications and your requested privileges and must sign off, sponsoring your application.

Phase 4: Credentials Committee Review

The file, now endorsed by the Department Chair, is presented to the Credentials Committee for a formal peer review. They vote and make a recommendation to the MEC.

Phase 5: Medical Executive Committee (MEC) Decision

The MEC reviews the recommendation from the Credentials Committee and makes the final binding decision to approve, modify, or deny your privileges.

Phase 6: Board of Directors Ratification

The MEC’s decision is formally ratified by the organization’s Board of Directors. You are then notified in writing that your privileges have been granted.

7.3.3 Masterclass: The Delineation of Privileges (DOP) Form

The Delineation of Privileges (DOP) form is the single most important document in your application. It is where theory meets practice. This is not a time for vague descriptions; it requires a level of granularity that may feel foreign but is absolutely essential. You must think about every single clinical action you will perform and translate it into a specific, requestable privilege. The medical staff needs to know precisely what you are asking for permission to do. A request for “manage diabetes” is meaningless. A request to “initiate and titrate metformin, SGLT2 inhibitors, and GLP-1 agonists according to the attached, board-approved protocol” is a specific, reviewable privilege.

Most established health systems with clinical pharmacists will have a standardized DOP form for your specialty. If they don’t, you have the opportunity—and the challenge—of helping them create one. Your requests must be evidence-based, consistent with your training and residency experience, and directly supported by your Collaborative Practice Agreement and institutional protocols.

Core Principles of a Strong DOP

  • Be Specific and Granular: Avoid broad categories. Break down large concepts like “anticoagulation management” into specific actions like “Initiate warfarin therapy,” “Order and interpret INRs,” “Adjust warfarin dose per protocol,” and “Provide patient education on warfarin.”
  • Reference Your CPA and Protocols: Every requested privilege should tie back to a foundational document. Your DOP should state, “All privileges will be exercised in accordance with the signed Collaborative Practice Agreement between the pharmacist and the collaborating physician, and in accordance with all relevant institutional policies and protocols.”
  • Distinguish Between Independent and Consultative Actions: Clearly define what you will do independently (per protocol) versus what you will do only after consulting with a physician. This demonstrates a clear understanding of the collaborative nature of your role.
  • Only Request What You Will Actually Do: Do not request privileges for activities you are not trained for or will not be performing. Requesting an exhaustive list of every possible pharmacist activity can raise red flags. Your DOP should be a realistic reflection of your specific job description.

Masterclass Table: Sample Delineation of Privileges for an Ambulatory Care Clinical Pharmacist

Below is a sample structure for a pharmacist’s DOP, illustrating the necessary level of detail. This is a foundational template you can adapt to your specific practice.

Category of Privilege Specific Privileges Requested (Sample Language) Supporting Evidence / Justification
I. Patient Assessment & Monitoring
  • Perform patient interviews and obtain comprehensive medication histories.
  • Perform targeted physical assessments relevant to medication management (e.g., blood pressure, heart rate, lower extremity edema checks for heart failure, monofilament foot exams for diabetes).
  • Order and interpret laboratory tests as defined by specific disease-state protocols (see Category III).
 PGY1/PGY2 residency training in ambulatory care; Board Certification (BCACP); State license authorizing these activities under a CPA.
II. Disease State Management (per approved protocol) A. Diabetes Mellitus:
  • Initiate, adjust, and discontinue oral and injectable non-insulin antihyperglycemic agents.
  • Initiate and titrate basal, prandial, and combination insulin regimens.
  • Provide comprehensive patient education on glucose monitoring, diet, and medication administration.
B. Hypertension:
  • Initiate, adjust, and discontinue antihypertensive agents from first-line classes (ACEi, ARB, Thiazides, CCBs) to achieve guideline-directed goals.
 Evidence-based institutional protocols for Diabetes and Hypertension Management; Signed CPA with collaborating physician; Documented competency through residency and/or board certification.
III. Ordering Authority (per approved protocol)
  • Laboratory Tests: A1c, SCr, eGFR, LFTs, Lipid Panel, TSH, electrolytes, CBC, INR, anti-Xa levels.
  • Medications: Initiate, modify, and discontinue medications as defined in the CPA and disease-state protocols.
  • Vaccinations: Order and administer ACIP-recommended adult immunizations.
 State law and regulations authorizing pharmacist ordering under CPA; Specific list of orderable labs and medications outlined in the signed CPA.
IV. Consultative Services & Documentation
  • Provide formal medication management consults at the request of other providers.
  • Document all patient encounters, assessments, and plans in the official Electronic Health Record (EHR).
 Job description requirement; Included as a core function in the CPA.

7.3.4 The Application Packet: Assembling Your Evidence File

The privileging application packet required by the MSO will be even more comprehensive than what you assembled for CAQH. While there is significant overlap, health systems often require additional items, particularly peer references who can speak directly to your clinical competence.

The Pharmacist’s Privileging Application Checklist

Use this as a guide to assemble your packet. Having everything ready in a digital folder will streamline your submission.

  • Completed Application Form: The MSO’s official, multi-page application. Fill it out digitally if possible to ensure legibility.
  • Detailed, Up-to-Date Curriculum Vitae (CV): Ensure your work history is gapless and all dates are accurate.
  • Copies of All Licenses, Certifications, and Diplomas: High-quality PDF scans of your state license(s), BPS certification, residency certificate(s), and PharmD diploma.
  • Completed Delineation of Privileges (DOP) Form: The meticulously completed “menu” of your requested clinical activities.
  • Signed Collaborative Practice Agreement (CPA): A copy of the fully executed CPA with your collaborating physician(s). This is the legal foundation for your DOP.
  • Professional Peer References: This is a key difference from payer credentialing. You will need to provide contact information for 2-3 clinical peers who can attest to your skills.

    Who to ask: Your residency program director, a senior clinical pharmacist you worked with, or a physician you have a strong collaborative relationship with. Pro Tip: Always contact your references beforehand to ask for their permission and to give them a copy of your CV and DOP so they know what you are applying for. This allows them to provide a specific and supportive reference.

  • National Practitioner Data Bank (NPDB) Self-Query: Many MSOs will require you to perform a self-query of the NPDB and include the report in your application. The NPDB is a confidential database of malpractice payments and adverse actions related to providers. A self-query costs a small fee and can be done on the NPDB website.
  • Proof of Malpractice Insurance: Your policy face sheet.
The Duty of Candor: Disclosure is Non-Negotiable

The privileging application’s disclosure section is the most sensitive part of the process. You will be asked, under penalty of perjury, about any past malpractice claims, license investigations or restrictions, criminal history, or loss of privileges at other institutions. The MSO’s background check is exhaustive. They will find out. An honest disclosure of a past issue, with a well-written explanation of the circumstances and lessons learned, can often be overcome. A dishonest omission that is later discovered is considered a breach of ethics and is almost always grounds for immediate and permanent denial.