Institutional Privileging for Vascular Access: Building a Defensible Framework

Framework for building an institutional vascular access privileging program: scope of practice delineation, privilege categories, competency documentation, re-privileging, medical staff credentialing vs. nursing competency, and TJC compliance.

guide•Feb 2026•Credentialing

Institutional Privileging for Vascular Access: Building a Defensible Framework

Institutional privileging defines which clinicians are authorized to perform which vascular access procedures within a given institution. A robust privileging framework protects patients (by ensuring only qualified clinicians perform procedures), protects the institution (by creating a documented, defensible competency record), and enables quality oversight (by linking privileges to ongoing outcome data).

This guide provides a framework for building or auditing an institutional vascular access privileging program.

Parent guide: Vascular Access Credentialing: Complete Reference

Credentialing vs. Privileging vs. Competency: Key Distinctions

These three terms are related but distinct:

Credentialing: Verification of a clinician’s professional qualifications — licensure, education, certifications, training program completion. Credentialing asks: “Does this person have the background qualifications to request privileges?”

Privileging: The institution’s authorization for a specific clinician to perform specific procedures or provide specific patient care services. Privileging asks: “Is this person authorized to perform procedure X at this institution?” Privileges are institution-specific.

Competency: Ongoing demonstration that a clinician can perform a procedure or skill to defined standards. Competency asks: “Can this person perform this procedure safely right now?”

Relationship: Credentialing (qualifications) + demonstrated competency → institutional privileges. Privileges are then maintained through annual competency validation.

Regulatory Framework

The Joint Commission (TJC): Accredited hospitals must have a medical staff credentialing and privileging process (MS chapter) and a nursing competency program (HR chapter). TJC does not prescribe a specific format for vascular access privileging but expects institutions to have documented processes for advanced clinical procedures.

CMS Conditions of Participation: Hospitals must ensure clinical staff competency; procedures that require specialized training must have documented evidence of that training.

State nursing practice acts: Define the scope of practice for RNs, LPNs, APRNs, and other clinicians. Vascular access privileges must be consistent with state scope of practice law — institutions cannot grant privileges beyond the legal scope of a clinician’s license.

Privilege Categories for Vascular Access

A complete vascular access privileging framework should define privileges for each procedure tier:

Tier 1: Peripheral IV Insertion (PIV)

Standard bedside skill: Not typically formally privileged; included in nursing orientation and annual skills validation.

US-guided PIV: May require a supplemental credentialing record given the specialized skill involved. See Ultrasound Credentialing Requirements.

Tier 2: Midline Catheter Insertion

Eligible roles: Credentialed RN (typically, same training baseline as PICC), APRN, MD/DO.

Minimum requirements:

  • Completion of PICC/midline insertion didactic training (same curriculum)
  • Minimum proctored midline insertions (5–10)
  • Competency checklist sign-off

Tier 3: PICC Insertion (Bedside)

Eligible roles: RN with specific training (VAT nurse); APRN; IR-trained PA/NP.

Minimum requirements:

  • Completed PICC insertion training program (didactic + simulation + proctored cases)
  • Minimum 10–15 proctored insertions
  • Competency checklist signed by approved proctor
  • Annual maintenance: 12 PICCs/year minimum

Documentation in privileging record:

  • Training program completion certificate or letter from program director
  • Proctored case log with proctor signatures
  • Competency checklist copies
  • Specialty certification (VA-BC) if held — not required for privileges but should be documented as evidence of expertise

Tier 4: Non-Tunneled CVC (IJ, Subclavian, Femoral)

Eligible roles: MD, DO, PA, NP (with hospital-granted privileges); not typically within RN scope of practice for IJ/subclavian/femoral access.

Requirements: Medical staff privileging process via medical staff office; training documentation per specialty training requirements.

Tier 5: Port Access

Eligible roles: Trained RN (VAT or designated IV therapy nurses); APRN.

Minimum requirements:

  • Specific port access training (anatomy of port system, Huber needle technique, ANTT for port access)
  • Minimum 5–10 proctored port accesses
  • Annual competency: minimum access frequency (typically 6–12 port accesses per year)

Building the Privileging Documentation File

For each clinician with vascular access privileges, maintain a file containing:

At initial credentialing:

  1. Training program completion documentation
  2. Proctored case log with proctor attestation
  3. Knowledge assessment score and pass date
  4. Simulation competency sign-off
  5. Current nursing license copy
  6. Specialty certification (VA-BC, CRNI) if applicable
  7. CV/resume for clinical experience

Annual: 8. Annual case volume log (procedure counts per year) 9. Annual competency assessment documentation 10. Current license renewal copy 11. Certification renewal documentation

Privilege delineation form: A signed form specifying exactly which procedures the clinician is authorized to perform (e.g., “PICC insertion, bedside, US-guided; midline insertion; port access”). This form should be signed by both the clinician and a designated approver (department director, medical director).

Privilege Renewal and Suspension

Annual Renewal

Privileges should be formally renewed annually with verification that:

  • License remains active and in good standing
  • Case volume meets minimum threshold
  • Annual competency assessment completed with passing result
  • No patient safety events or quality concerns pending review

Suspension or Restriction

Privileges should be suspended or restricted when:

  • Patient safety event or complication pattern is identified
  • Volume falls below minimum and retraining has not been completed
  • License is under investigation or suspended
  • Clinician voluntarily requests supervised practice

Suspension process:

  1. Identify issue (outcome review, incident report, direct observation)
  2. Notify clinician of privilege suspension
  3. Conduct root cause analysis or performance review
  4. Determine remediation plan (retraining, proctoring, supervision)
  5. Document remediation completion and restore privileges or determine permanent restriction

Medical Staff Credentialing vs. Nursing Competency

Important distinction: Physicians, PAs, and NPs with hospital medical staff privileges go through the medical staff credentialing office for privileging. This process is separate from nursing competency programs.

For MD/PA/NP:

  • CVC, surgical cutdown, IR procedures → medical staff privileging process
  • PICC insertion (if MDs insert PICCs at the institution) → medical staff privilege for PICC, with documentation of training

For RNs:

  • VAT PICC, midline, port access → nursing competency program with HR documentation
  • RNs do not go through medical staff credentialing; they are validated through the nursing competency program

The institutional vascular access privileging program should address BOTH tracks and ensure consistent standards across clinical roles.

Linking Privileges to Quality Outcomes

A mature privileging program connects individual clinician privileges to outcome data:

Individual-level quality metrics:

  • First-attempt success rate by inserter
  • Catheter malposition rate by inserter
  • CLABSI rate attributable to lines placed by individual inserter (challenging but informative)
  • Bundle documentation compliance rate

How to use outcome data:

  • Present aggregate data to all credentialed inserters for transparency and benchmarking
  • Identify outliers (significantly below benchmark) for focused review and re-proctoring
  • Recognize high performers as mentors or proctors
  • Trend individual performance over time as volume increases

Related guides:

Related policies:

References

  1. Gorski LA, et al. (2021). INS Infusion Therapy Standards of Practice (Standard 13). J Infus Nurs, 44(Suppl 1).
  2. The Joint Commission. (2024). Hospital Accreditation Standards: MS Chapter (Medical Staff); HR Chapter (Human Resources). Oakbrook Terrace, IL: TJC.
  3. AVAR. (2023). Vascular Access Position Statements on scope of practice and credentialing. Retrieved from avar.org.