Manual:
Hospital and Hospital Clinics
Chapter:
Medical Staff MS
Topic:
Verification - Primary Source Verification - Definition
What is Primary Source Verification and to whom does it apply ?
Any examples are for illustrative purposes only.
Primary Source Verification (PSV) is required for confirming that an individual possesses a valid license, certification or registration to practice a profession when required by law or regulation. It is the responsibility of the accredited organization to complete PSV, not the licensed individual. The glossary of The Joint Commission Accreditation Manual defines PSV as:
"Verification of an individual practitioner's reported qualifications by the original source or an approved agent of that source. Methods for conducting primary source verification of credentials include direct correspondence, documented telephone verification, secure electronic verification from the original qualification source, or reports from credentials verification organizations (CVOs) that meet Joint Commission requirements. See also credentials verification organization (CVO)." The definition of a CVO may be found in the glossary of the accreditation manual.
Selected agencies that have been determined to maintain a specific item(s) of credential(s) information that is identical to the information at the primary source are referred to as a 'designated equivalent source'. The glossary of the accreditation manual provides examples of such sources. Organizations are responsible for determining what method will be used to document that PSV was completed and must include the date the verification was conducted, who conducted the verification, what was specifically verified and the results of the verification. At the time of survey, surveyors evaluate compliance with completing primary source verification of licensure, certification, etc. Simply presenting a copy of a license in lieu of evidence that primary source verification was complete by the organization does not meet the intent of the requirement.
The requirements for completing PSV are found in the Human Resources chapter of the accreditation manuals at HR.01.01.01. For the Behavioral Health program, see HRM.01.02.01. The Hospital and Critical Access Hospital manuals contain a Medical Staff (MS) chapter that also require PSV of the applicant's relevant training and current competence. These requirements are found at MS.06.01.03 EP 6 and MS.06.01.05 EP 2.
Primary Source Verification (PSV) is required for confirming that an individual possesses a valid license, certification or registration to practice a profession when required by law or regulation. It is the responsibility of the accredited organization to complete PSV, not the licensed individual. The glossary of The Joint Commission Accreditation Manual defines PSV as:
"Verification of an individual practitioner's reported qualifications by the original source or an approved agent of that source. Methods for conducting primary source verification of credentials include direct correspondence, documented telephone verification, secure electronic verification from the original qualification source, or reports from credentials verification organizations (CVOs) that meet Joint Commission requirements. See also credentials verification organization (CVO)." The definition of a CVO may be found in the glossary of the accreditation manual.
Selected agencies that have been determined to maintain a specific item(s) of credential(s) information that is identical to the information at the primary source are referred to as a 'designated equivalent source'. The glossary of the accreditation manual provides examples of such sources. Organizations are responsible for determining what method will be used to document that PSV was completed and must include the date the verification was conducted, who conducted the verification, what was specifically verified and the results of the verification. At the time of survey, surveyors evaluate compliance with completing primary source verification of licensure, certification, etc. Simply presenting a copy of a license in lieu of evidence that primary source verification was complete by the organization does not meet the intent of the requirement.
The requirements for completing PSV are found in the Human Resources chapter of the accreditation manuals at HR.01.01.01. For the Behavioral Health program, see HRM.01.02.01. The Hospital and Critical Access Hospital manuals contain a Medical Staff (MS) chapter that also require PSV of the applicant's relevant training and current competence. These requirements are found at MS.06.01.03 EP 6 and MS.06.01.05 EP 2.
Last updated on February 04, 2022
with update notes of: Review only, FAQ is current
First Published Date: April 11, 2016
Last Reviewed Date: February 04, 2022