The privilege approval process

Key medical staff members and committees are responsible for reviewing the request for privileges and making recommendations. The process varies depending on the size and structure of the medical staff. A large hospital’s medical staff may have a number of committees performing this function. In hospitals with a small medical staff, the medical staff as a whole may perform the privileging function. Here is an example of how the review and approval process would flow in a medium-to-large hospital:
  1. Department chair: The department chair reviews the applicant’s request for privileges and all supporting information and makes a recommendation to the credentials committee regarding the applicant’s qualifications and competency to perform the privileges requested.
  2. Credentials committee: The credentials committee reviews the request and the department chair’s recommendations and makes recommendations to the medical executive committee (MEC) regarding clinical privileges.
  3. Medical executive committee: The MEC receives the recommendations of the department chair and credentials committee. The MEC is responsible for submitting a recommendation to the hospital’s governing body regarding the clinical privileges. 
  4. Governing board: The governing body makes the final decision (taking into consideration the recommendations of the medical staff) regarding the granting of clinical privileges. The governing body is the final authority in these decisions.
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