Verification - Primary Source Verification - Definition (AHC)

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 Ambulatory accreditation manual at HR 02.01.03  EP 3,(for training) EP 4 (for license) Also HR 02.01.05 EP2 for Temporary privileges.
Last updated on June 29, 2020
Manual: Ambulatory
Chapter: Human Resources HR

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