State of Privileging in Pharmacy: A Survey of Vizient-Affiliated Institutions

Abstract

Purpose: The process of privileging pharmacists is an important step in developing optimal pharmacy practice models. Currently, little published literature exists detailing the status of pharmacist privileging efforts. The objective of this study is to assess and characterize a snapshot of the current and future state of privileging practices in pharmacy at Vizient academic medical centers (AMCs) and their affiliate institutions. Methods: An electronic survey questionnaire was sent to Vizient pharmacy directors and their affiliates to assess institutional privileging practices and identify perceived or actual barriers. The survey was divided into 2 pathways based on the current status of privileging at the institution. Results: In total, 46 directors of pharmacy completed the survey. Only 33% (15/46) of pharmacy directors indicated they had a current privileging process in place. About 70% (21/30) of institutions without an established privileging process indicated they were considering establishing a process. For institutions without an established privileging process, most pharmacy directors identified a lack of organizational support and resources as barriers to implementation. Conclusion: Although credentialing and privileging is considered a national priority to aid in expanding and enhancing pharmacists’ scope of practice, our survey demonstrated that few respondents currently have a privileging process in place. The results from this study may highlight important barriers and keys to success to be considered when implementing a privileging process.

Introduction

As the pharmacy practice model shifts toward enhanced collaborative practice, institutional credentialing and privileging of pharmacists may become a vital component to reaching this goal. The Council on Credentialing in Pharmacy published a resource paper in November 2014 designed to assist with the development or enhancement of current credentialing and privileging processes within the health care system.¹ Additionally, a recent publication reviewed the impact of pharmacist privileging efforts on elevating the scope of pharmacy practice.² The purpose of a credentialing process is to document and validate that a health care professional has obtained the qualifications to provide care within a designated scope of practice. Examples of pharmacist’s credentials include licensure, residency training, and board certification. Privileging is the permission or authorization granted by a hospital to an individual to render specific diagnostic, procedural, or therapeutic services.¹

Through a privileging process, pharmacists may be granted privileges at an individual institution to conduct specific patient care services. For example, pharmacist X may be privileged at institution Y to prescribe and monitor all anticoagulation medication therapy following approval of application and verification of required credentials. State legislation and institution specific policies dictate the scope of practice granted under the process. The process is comparable to the privileging of physicians and advanced practice providers and is conducted at the level of the medical staff board.^1-3

To date, very little published literature exists detailing the status of pharmacist privileging efforts, in addition to the barriers associated with establishing a privileging process. Therefore, the objective of this study is to assess and characterize a snapshot of the current and future state of privileging practices in pharmacy at Vizient academic medical centers (AMCs) and their affiliate institutions.

Methods

Vizient University Health System Consortium is a collaboration of AMC and affiliate hospitals across the United States. A survey was conducted by the Vizient AMC Pharmacy Network Professional Development and Workforce Committee. The Vizient Professional Development and Workforce Committee serves as a central coordinating body to promote and conduct practice-based outcomes research related to professional development of the pharmacy workforce. Committee members developed, distributed, and analyzed the results of this survey. The primary purpose of this survey was to describe the current and future state of privileging practices in pharmacy on a national level. Secondary outcomes of the survey included identifying perceived or actual barriers to privileging and identifying resources needed to establish a privileging process.

The survey was approved by the institutional review board (IRB) at Nebraska Medicine and was sent to pharmacy directors in February 2016. Pharmacy directors were identified by the Vizient listserv and received an email message containing a link to the electronic survey (SurveyMonkey^®).

Demographic questions were asked to determine the following: type of institution (community hospital, AMC, specialty hospital, or health system), ownership of institution (for profit, nonprofit, governmental entity, or other), geographic region, and the number of licensed beds. Pharmacy directors were also provided with a background paragraph that included a definition and examples of privileging (Appendix). For the purpose of this study, we focused solely on the privileging process as it relates to an individual pharmacist being granted privileges from an institution credentialing committee. A variety of question types were utilized including the following: multiple choice, 5-point Likert scale, discrete (yes/no), check all that apply, and free text. For several Likert scale questions an additional response, “at this time, I do not know” was available for the respondents to select.

The survey was divided into 2 pathways based on the current status of privileging at the institution. The first pathway included those directors who indicated they currently have an established privileging process in place and the second pathway included those directors who indicated they did not have a privileging process in place.

Data were collected and analyzed using descriptive statistics. Questions not answered were removed from the analysis. Like answers and overall themes were categorized for questions with free text answers.

Results

Demographics

The survey was sent to 336 pharmacy directors representing 265 AMCs and their affiliate institutions. Forty-six pharmacy directors responded to the survey, resulting in a response rate of 14%. Not every respondent answered all questions. Of the respondents that answered questions related to demographics, the majority (83%; 35/42) indicated they practice in an AMC. About 90% (38/42) of respondents indicated their institution was larger than 300 beds, and 74% (31/42) of institutions indicated their ownership was not-for-profit. The majority of participating institutions were from the Northeast and Midwest (64%; 27/42). In total, 33% (15/46) of respondents indicated they have an established privileging process in place. Around 56% (26/46) indicated they did not have an established privileging process, and 11% (5/46) indicated they had previously attempted to establish a process but did not have a current process. The pharmacy directors who had previously attempted to establish a privileging process were primarily from large, nonprofit institutions located in the Midwest (Table 1).

Table 1.

Demographics (n = 42).

Question	Answer	n (%)
Type of institution. Check all that apply.a	Academic medical center	35
	Health system	7
	Community hospital	4
	Specialty hospital	3
Ownership of institution.	Nonprofit	31 (73.8)
	Government entity	9 (21.4)
	For profit	1 (2.4)
	Other	1 (2.4)
Location of institution.	Midwest	14 (33.3)
	Northeast	13 (30.1)
	Southeast	8 (19.1)
	West	4 (9.5)
	Southwest	3 (7.1)
Number of beds at institution.	<50	0 (0)
	51-99	0 (0)
	100-199	1 (2.4)
	200-299	3 (7.1)
	300-399	4 (9.5)
	400-499	5 (11.9)
	Over 500	29 (69.1)
Do you have an established privileging process at your institution (n = 46)?	Yes	15 (32.6)
	No	26 (56.5)
	No, but attempted	5 (10.9)

^aRespondents were able to select more than one answer.

Pathway 1

Fifteen pharmacy directors indicated they had a current privileging process in place. Pharmacy directors were asked a series of 12 questions; however, not all respondents answered all questions. When asked what environment their pharmacists were privileged in the responses were as follows: 14% (2/14) inpatient only, 21% (3/14) outpatient only, and 64% (9/14) both inpatient and outpatient. Pharmacy directors were asked how long their privileging process has been in place. The majority of respondents indicated the privileging process at their institution was developed within the last 2 years or within the last 2 to 5 years (50%, 7/14; 36%, 5/14, respectively). Only two directors (14%; 2/14) indicated the privileging process at their institution was established greater than 5 years ago. To further appreciate the magnitude of current privileging processes nationwide, pharmacy directors were asked how many pharmacists are currently privileged at their institution. Six directors (43%; 6/14) indicated that 11 to 20 pharmacists were privileged at their institution; 4 directors (29%; 4/14) indicated 1 to 10 pharmacists were privileged, and the remaining 4 directors indicated that there were greater than 30 pharmacists with privileges at their institution. At institutions with 1 to 10 privileged pharmacists, all directors indicated less than 20% of their pharmacy staff were privileged. For institutions with 11 to 20 privileged pharmacists, the total percentage of pharmacy staff ranged from less than 20% to 59%. For institutions with greater than or equal to 31 privileged pharmacists, 3 of 4 directors indicated 40% to 59% of their pharmacy staff were privileged. The majority of institutions did not privilege residents (79%; 11/14). None of the respondents indicated they did not have a residency program.

To quantify barriers encountered and support needed to establish a privileging process, pharmacy directors were asked a series of 5-point Likert scale questions (Table 2). The majority of pharmacy directors agreed or strongly agreed the pharmacy staff was supportive in the development of the privileging process (85%; 11/13), the support of the medical staff board was instrumental to the successful development of the privileging process (93%; 13/14), and the state/statute was supportive to the implementation of the privileging process at their institution (64%; 9/14). Conversely, the majority of pharmacy directors disagreed or strongly disagreed that a lack of resources was a barrier to the implementation of the privileging process (71%; 10/14).

Table 2.

Respondents Indicating They Have an Established Privileging Process in Place (n = 14).

Survey questionsa	Median
The support of the medical staff board was instrumental to the successful development of the privileging process at my institution (n = 13).	5
The pharmacy staff was supportive in the development of the privileging process at my institution.	4
The state/statute was supportive to the implementation of the privileging process at my institution.	4
A lack of resources was a barrier to the implementation of the privileging process at my institution.	2

^aRated on a 5-point Likert scale: 1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, 5 = strongly agree.

Pharmacy directors were able to comment on additional barriers to the implementation of the privileging process at their institution. The common themes revolved around people, education, and a lack of time (Table 3).

Table 3.

Barriers to Implementation of Privileging Process for Respondents Indicating They Have an Established Process in Place (n = 8).

People	Education	Time
Nursing pushback	Lack of awareness of pharmacy practice by nonpharmacists. Significant amount of time spent educating leadership to gain their support	Time involved to get process established
Unable to include pharmacy residents	Physician understanding of clinical pharmacist training	Setting privileging criteria and scope
Medical staff office understanding		Extensive commitment of medical staff office to process all pharmacist applications

Directors were also asked to list any vital resources needed to establish a privileging process at their institution. Identified themes included the following: finding a pharmacy leader to manage the process, utilization of the American Society of Health-System Pharmacy (ASHP) credentialing resource center, establishment of a competency process, and ascertainment of medical staff champions. The final question was designed to determine what activities pharmacists are currently privileged to perform. All respondents (100%; 12/12) indicated their pharmacists are privileged to order laboratory tests and adjust medication doses related to the monitoring of medication therapy, adjust administration routes of existing medication orders, transition patients from intravenous to oral therapy, and monitor and adjust medications based on patient specific parameters. About 83% (10/12) also indicated their pharmacists were privileged to delete duplicate medication therapy within the same therapeutic class. Additional activities included the following: managing parenteral nutrition therapy, adjusting anticoagulation doses, ordering preoperative antimicrobials and stress ulcer prophylaxis, ordering ventilator associated pneumonia prophylaxis, and prescribing for targeted diseases states.

Pathway 2

Thirty-one pharmacy directors indicated they did not have a current privileging process in place. They were asked a series of 7 questions, and respondents did not answer all questions. Pharmacy directors were asked if they were considering establishing a process. In total, 70% of respondents answered yes (21/30), 10% answered no (3/30), and 20% indicated they were undecided (6/30). Directors were then asked to indicate when they planned on establishing such a process. The majority of respondents indicated they were considering establishing a process within the next 2 years (59%; 17/29). Of the 5 pharmacy directors who had previously attempted to establish a privileging process, 4 indicated they will consider reattempting in the next 0 to 2 years.

To gain an understanding for the perceived barriers associated with the establishment of a privileging process, pharmacy directors were asked to select barriers from a series of choices. About 48% (14/29) of respondents indicated institutional or organization hurdles and 45% (13/29) identified a lack of appropriate resources to be perceived barriers to the implementation of a privileging process at their institution. Only 17% (5/29) believed the state/statute would be a barrier to establishing a process and 24% (7/29) indicated at this time they were unsure what barriers lie ahead. Additionally, respondents were asked a series of 5-point Likert scale questions (Table 4). Pharmacy directors agreed or strongly agreed their state pharmacy practice would allow for the development of a privileging process (63%; 19/30), and felt their pharmacy staff was supportive of the development of a privileging process (63%; 19/30). Only 37% of respondents agreed or strongly agreed their medical staff board would support the development of a privileging process (11/30). Nine pharmacy directors indicated they did not know whether the medical staff board would support the development of a privileging practice. One-third (10/30) of respondents agreed they had the appropriate resources to implement a privileging process at their institution, 20% disagreed (6/30), and 17% strongly disagreed (5/30) they had appropriate resources.

Table 4.

Respondents Indicating They Do Not Have a Privileging Process in Place (n = 30).

Survey questionsa	Median	Unknownb
My state pharmacy practice will allow the development of a privileging process at my institution.	4	3
I feel my pharmacy staff will support the development of a privileging process.	4	3
My medical staff board will support the development of a privileging process.	4	9
I have the appropriate resources to implement a privileging process at my hospital/organization.	3	1

^aRated on a 5-point Likert scale: 1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, 5 = strongly agree.

^bRespondents had the ability to answer “at this time, I do not know.”

Discussion

According to the national Practice Advancement Initiative (PAI), formerly referred to as the Pharmacy Practice Model Initiative (PPMI), as the health care landscape continues to evolve, changes related to the practice and advancement of pharmacy will be necessary for continued success of the profession.^4,5 The goal of PAI is “to significantly advance patient health by developing and disseminating futuristic practice recommendations that support pharmacists’ roles as direct patient care providers.” The process of privileging is an important step in achieving this goal and developing optimal pharmacy practice models for hospitals and health systems.⁶ In addition to furthering direct patient care roles, a priority of the American College of Clinical Pharmacy (ACCP) is to ensure pharmacists are competent to engage in clinical practice and perform direct patient care activities.⁷ One way to demonstrate competence is through obtaining board certification and credentialing.⁸ ACCP believes

clinical pharmacists engaged in direct patient care should be board certified and have established a valid collaborative drug therapy management (CDTM) agreement or have been formally granted clinical privileges by the medical staff or credentialing system within the health care environment in which they practice.⁷

The movement toward credentialing and privileging in pharmacy is similar to other nonphysician disciplines such as physician assistants and nurse practitioners. For example, acute care nurse practitioners (ACNPs) pursue specialized training and credentialing to care for complex and critically ill patients.⁹ ACNPs must be credentialed and privileged to perform functions within their institution of employment. A recent survey of institutions in California found while privileges related to conducting invasive procedures varied between institutions, the one commonality was that medical staff offices oversaw the credentialing and privileging process. Not only does privileging allow for nonphysician providers to perform at the top of their license, it improves efficiency by lessening the need for direct physician oversight.⁶ Additionally, nonphysician providers have been shown to reduce health care costs while improving the quality of care which is attractive in today’s costly health care environment.^2,10

While major pharmacy organizations endorse and promote the development of a privileging process, we found only 33% of institutions that responded to our survey have an established privileging process in place with half of these institutions having established a privileging process within the past 2 years. This may be due, in part, to a variety of perceived or actual barriers. Our survey results demonstrated pharmacy directors from institutions without an established privileging process were primarily concerned with having the necessary institutional resources and organizational support and identified a lack of resources as a barrier to implementation. In contrast, the majority of directors from institutions with a current privileging process did not believe a lack of resources alone was a barrier to the development and implementation. Pharmacy directors with established processes cited the support of the medical staff board and physician champions as important resources, while many of the directors without a process believed they would not have the necessary support for development. To gain further support for pharmacists’ privileging efforts, pharmacists must be willing to demonstrate and prove their competence and expertise.¹¹ Board certification and credentialing is a potential way to build consensus and align pharmacists with other direct care providers including physicians, nurse practitioners, and physician assistants.^8,11 While many institutions currently allow pharmacists to conduct activities such as IV to PO conversion and anticoagulation management through institutional protocols and departmental competencies, formalizing a privileging process allows pharmacy to align with other disciplines and be acknowledged at the level of the medical staff board. Additionally, a privileging process provides a system for ongoing evaluation.

There were several limitations to this study, including a low response rate and a homogenous sample population. As this research was conducted during a first year postgraduate pharmacy residency, the duration of the survey period was limited. Additionally, due to the scope of the project, the survey was sent only to Vizient institutions and their affiliates, limiting the sample population to primarily AMC which resulted in a more homogenous population. Because of these limitations, our survey data may not be representative of the overall status of privileging in pharmacy on a national level. Finally, although pharmacy directors were provided with a background section specifying the definition of privileging for our study, there is still the potential for interpretation variability if pharmacy directors answered based on departmental versus medical staff board privileging. Because we solely focused on all privileging conducted at the level of the medical staff board, our survey did not assess institution specific credentials required for privileging, although this may vary significantly between institutions.

Conclusion

Although the majority of institutions that responded to our survey do not currently have a privileging process in place, institutions without a privileging process are considering implementing one in the next several years. The results from this survey highlight important barriers and keys to success that may be considered when implementing a privileging process. Common barriers included a lack of awareness or understanding of the clinical pharmacist’s training and a lack of time for medical and pharmacy staff. Identifying medical staff champions, appointing a leader to manage the process, and establishing competency standards may contribute to successful implementation. As the pharmacy landscape continues to evolve, privileging will likely play an important role in achieving future goals of the profession. A larger, broader survey is needed to further characterize the state of privileging on a national level.

Appendix

Survey Background

Background: Privileging is the process in which an individual practitioner is granted authority by an institution administrative committee. The privilege is granted following an institution-specific application process completed by all members of the medical staff. For a point of reference, the privileging process for a pharmacist is similar to that of other medical providers. This is in contrast to a credentialing process which documents and validates that a health care professional has obtained the credentials and qualifications to provide care within their designated scope of practice. Through a privileging process, pharmacists may be granted privileges at an institution to conduct specific patient care services. State legislation and institution specific policies dictate the scope of practice granted under the privileging process.

Privileging is the permission or authorization granted by a hospital to a health care professional to render specific diagnostic, procedural, or therapeutic services. An example could be pharmacist X is privileged at institution Y to prescribe and monitor all anticoagulation medication therapy management. An example would NOT be if all pharmacists in a department are given the authority to conduct a specific service without undergoing an individual privileging application process.

This survey is designed to ascertain the status of privileging in both inpatient and outpatient (ambulatory care) settings at your institution. For the purposes of this study, we will focus solely on the privileging process as it relates to an individual pharmacist granted privileges from an institution credentialing committee.