St. Joseph Credentialing FAQ

The Joint Commission accreditation standards require hospitals have privilege forms that indicate the type of care, treatment and services, or procedures that a practitioner will be authorized to perform.

Upon applying for initial appointment or reappointment, practitioners complete a privilege form indicating what privileges or procedures they want to perform at PeaceHealth St. Joseph.

PeaceHealth St. Joseph’s privilege forms include two types of privileges: (1) Core privileges are those privileges that are routinely taught in most residency programs. Practitioners that meet the threshold criteria for the specialty are qualified to request core privileges; (2) Advanced privileges are procedures that require additional training or special competence. Additional documentation is required to demonstrate competence within the past two years.

Physicians within each specialty assist with the development of privilege forms. For example, a group of family medicine physicians review and make recommendations on the Family Medicine privilege form, cardiologists review and make recommendations on the Cardiac Services form, etc.

The Joint Commission accreditation standards require that hospitals determine a practitioner’s current competency at reappointment. PeaceHealth St. Joseph Medical Center’s privilege form format identifies advanced privileges as those that require additional documentation of competence. Documentation criteria and privilege forms are established by the medical staff.

Credentialing is a term that usually encompasses two separate processes: credentialing and privileging.

• Credentialing: Primary source verification of a healthcare practitioner’s education, training, work experience, license, etc. A variety of resources are used to verify the information involving direct communication from the educational and training institutions, past and current hospital affiliations and employers, peer reference letters, certification boards, licensing agencies and other sources.
• Privileging: Granting approval for an individual to perform a specific procedure or specific set of privileges based on documented competence in the specialty in which privileges are requested.

Each practitioner working in the hospital or PeaceHealth Medical Group clinic setting must be credentialed through PeaceHealth St. Joseph Medical Center’s medical staff process.

Practitioners who are independently responsible for patient care by virtue of their license and hospital authority must be credentialed even if they are employed by PeaceHealth. Licensed independent practitioners who must be credentialed regardless of whether they are PeaceHealth employees or not are physicians, dentists, certified nurse midwives, podiatrists, nurse practitioners, physician assistants and psychologists.

PeaceHealth, like other healthcare organizations, is legally responsible for knowing that individuals providing patient care are qualified and competent to do so. Over the past 30 years there have been multiple legal cases where hospitals were held accountable because they had not done adequate credentialing.

The Joint Commission, the Centers for Medicare and Medicaid Services (CMS), National Committee on Quality Assurance (NCQA), Washington State Department of Health and other oversight organizations require that members of the medical and allied health staff be credentialed and privileged before working in the facility.

No. It is PeaceHealth’s legal obligation to ensure that all practitioners have gone through the credentialing process and have been approved by the regional Board of Directors. A practitioner working at a PeaceHealth entity before the credentialing process is complete places PeaceHealth and the practitioner at significant legal risk and can directly impact accreditation status.

View our online credentialing application, privilege forms and application checklist for more information.

Initial applications require a fee of $350.00. Payment may be made by check and must be received by the PeaceHealth St. Joseph Medical Center Medical Staff Services office before the application is processed.

The Joint Commission is an accrediting organization with a mission to improve the safety and quality of care provided to the public. Hospitals voluntarily submit to the Joint Commission accreditation surveys every three years; the survey is a comprehensive evaluation of the overall quality and safety of the organization. PeaceHealth complies with all of the Joint Commission credentialing standards.

Most healthcare organizations advise submitting an application 90 days before a practitioner’s start date. The average processing time is less than 90 days. Ninety days is a benchmark because it allows extra time when verification sources do not respond in a timely manner or clarification of discrepancies is required.

Credentialing consists of two steps: 1) verification process performed by the PeaceHealth St. Joseph Medical Center Medical Staff Services office; and 2) review of the verified application by the PeaceHealth St. Joseph Medical Staff leadership and approval by the regional Board of Directors.

An application can be completed in less time if peer references and other verification sources promptly respond to Medical Staff Services requests for information, requested documentation is supplied by the applicant in a timely fashion and there are no issues identified in the application process that require further investigation.

Offices such as ours that perform primary source (initiating sources; coming directly from the source issuing the credential) verification of credentialing applications have very little control over process time. The process time is affected by verification sources (other hospitals, training programs, peer references, employers, etc.) responding to our requests for information.

The verification process could be done in 2-3 weeks if all sources respond to first requests for information. If a response is not received, credentialing staff execute additional requests to sources. This causes a significant time delay in completing applications.

Yes! Practitioners can greatly influence the length of processing time by contacting their verification sources and asking each source to mail or fax PeaceHealth’s verification requests back as soon as possible.

When we start processing an application, the practitioner and their credentialing contact receive a letter from our office listing of all verification sources from which we require responses. We ask the practitioner or their credentialing contact to call the sources to prompt responses back to PeaceHealth St. Joseph Medical Center. Responses can be faxed to our office at (360) 715-4134.

The Medical Staff Services office only processes complete applications. All incomplete applications are returned to the practitioner or clinic for completion; this creates a substantial delay in the practitioner credentialing process. Use the application checklist as a guide to identify what forms need to be submitted. See How to Submit an Application for detailed information.

PSV is the process of verifying credentials directly with the source. For example, a credentialing office cannot accept a copy of a medical school degree as evidence that the physician graduated from medical school. The school must be contacted directly to verify the physician’s attendance and graduation.

PSV is required so that hospitals and credentialing offices do not receive fraudulent documents from applicants or other non-primary sources. A credentialing office cannot accept any verification that comes through a third party rather than the primary source. PSV is a requirement by accrediting bodies as well as the cornerstone of a good credentialing process.

Visit the How to Submit an Application page for detailed information.

The privileging process ensures healthcare practitioners meet uniform standards of education, training, experience and demonstrated competence to perform requested practices or procedures. Physicians within each specialty assist in the development of privileging forms and make recommendations regarding appropriate threshold eligibility before practitioners are authorized to render specific patient care services.

Current practitioners applying to another PeaceHealth entity, current practitioners requesting additional privileges and new applicants can request privileges through the Medical Staff Services department. To have the appropriate privilege forms e-mailed to you, simply contact us at the number listed on this page.

Reappointment is the process of re-evaluating a practitioner’s current competency after they have been appointed to PeaceHealth St. Joseph Medical Center’s medical staff.

PeaceHealth has a duty to ensure that all practitioners on staff are currently competent; reappointment is the process of re-evaluating competency. The Joint Commission hospital accreditation standards require all practitioners to complete a reappointment process every 24 months.

If a practitioner does not complete reappointment paperwork on time, the practitioner’s reappointment will expire and they can no longer work or see patients.

If a practitioner’s reappointment expires, the practitioner must then complete the initial application process in order to be appointed to the medical or professional staff and to treat patients at PeaceHealth St. Joseph Medical Center.

Visit our Reappointment page for detailed information.

At PeaceHealth, expirables include a practitioner's license to practice, malpractice insurance, DEA certificate and board-certification.

Visit our Expirables page for detailed information.