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Medical Staff Services

To support the Mission/Vision/Values of Parkview Medical Center, the Medical Staff Services/Accreditation Department coordinates the credentialing and privileging process for more than 300 members of the Parkview Medical Staff, including MDs, DOs, Dentists, Podiatrists as well as credentialing/privileging for other allied health professionals who provide clinical services at Parkview Medical Center.

The Medical Staff Services professionals exceed the credentialing standards mandated by the federal government, state government and regulatory agencies. Parkview has maintained Accreditation through The Joint Commission (TJC) and Certification as a Credentials Verification Organization through the National Committee for Quality Assurance (NCQA). In addition to credentialing, the department oversees and coordinates the processes for Accreditation through TJC and Medicare Certification through Centers for Medicare and Medicaid Services (CMS).

Medical Staff Services professionals offer physicians and allied health professionals support services including orientation to the facility, CME opportunities, meeting coordination/support for all committees and departments of the Medical Staff, monthly Physician Resource Newsletter, physician recognition program, CMS/TJC Core Measure data collection/analysis/education, American College of Cardiology data registries/support, Society of Thoracic Surgeons data registry/support, National Surgical Quality Improvement Program data registry/support.

Credentialing

Contact our Credentialing Coordinator for assistance in the Physician Application process.

Pay Your Medical Staff Application/Credentialing Fees Online

The Credentialing Staff acts as the primary contact point for physicians and allied health professionals to provide information, support and coordination of credentialing, privileging and membership to Parkview Medical Center.

It is also the Credentialing Staff’s responsibility to review and maintain accurate files to ensure primary source verification of licensure, education, post-graduate clinical training, board verification, malpractice history, and disciplinary actions, as well as other professional sanctions. The Credentialing Staff will also identify potential issues; generate reports and present findings to the various Department Qualifications Committees, the Credentials Committee, the Medical Executive Committee, and the Medical Relations Committee to facilitate recommendations for approval.

Continuing Medical Education

Parkview Medical Center is accredited by the Colorado Medical Society to provide continuing medical education for physicians. Accreditation is a voluntary system that assures the public and the medical community that accredited CME is a strategic partner in health care quality and safety initiatives, providing physicians with relevant, effective education that meets their learning and practice needs. Accreditation standards ensure that CME is designed to be independent, free of commercial bias, and based in valid content.

Parkview’s CME Coordinator arranges for CME programs and coordinates Performance Improvement (PI) CME projects.  For a schedule of upcoming programs please contact the CME Coordinator. Additionally, Parkview offers online CME access 24/7 from any location again; contact the CME Coordinator for more information.

Support / Administrative

The Medical Staff Coordinator is responsible for coordinating monthly medical staff department meetings and various committee meetings. This involves mailing meeting calendars and agendas, meeting arrangements, transcribing/distribution of all meeting minutes, as well as assisting with other miscellaneous medical staff projects and duties. The bi-annual General Medical Staff (GMS) meeting is also organized by the Medical Staff Coordinator. Various medical staff and hospital topics are discussed and voted upon at this meeting, including hospital bylaw revisions.

  • Physician voting eligibility at the GMS meeting is based upon meeting attendance requirements of at least 50% of department meetings and 50% of the GMS meetings.

Clinical Database Supervisor

Manages and oversees all data collection and submission to include the following:

  • Support clinical data collection activities on a number of variables, including the areas of administrative, demographic, admission status, history and risk factors, cardiac status, cath lab visits, for both visits for diagnostic and PCI information, lesion and treatment information, operating room visits for both coronary artery bypass graft and valve surgeries, adverse events, and discharge status. Data are collected through chart review then validated, and submitted for the following databases:
    • The Society for Thoracic Surgeons/Lumedx Apollo Database
    • National Cardiovascular Data Registry/CathPCI Registry and ICD Registry

Quality Core Measure Team

Core Measure Analyst: 719.584.4915
Abstractors: 719.584.4037

Parkview Medical Center is pleased to be a part of the Hospital Inpatient Quality Reporting Program. This program focuses on data from several different Quality Measures that are collected by our team of analysts and abstractors. These Quality Measures include Acute Myocardial Infarction, Heart Failure, Pneumonia and the Surgical Care Improvement Project. These measures are collected to ensure quality health care and patient safety.

The Analysts assist physicians and the organization by providing current data, the Abstractors also assist by keeping current on Quality Measure requirements and submitting data to CMS/Joint Commission.

Parkview strives to meet or exceed the Hospital Inpatient Quality Reporting Programs expectations set forth by CMS/Joint Commission. Our team interacts on a daily basis with the physicians and staff to assure the standards are being implemented and address any concerns at the point of care.

These measures are publicly reported; please see the following web sites for additional information:

Quality Assurance

The Quality Assurance Analysts identify, review and coordinate all aspects of physician related quality issues. This includes peer review and, as needed, external review.

The process of identifying quality issues entails screening numerous sources daily. An Ongoing Professional Practice Evaluation is prepared for each physician and presented biannually to assure that both obvious opportunities to improve and "trends" are identified and addressed.

The QA Analyst also coordinates all new physicians’ "provisional review" process in which random patient visits are screened by a physician peer for quality of care.

ACS NSQIP

The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) is a risk-adjusted data collection mechanism that provides participating hospitals with the tools and opportunity to develop quality initiatives to improve surgical care. ACS is continually interacting with key entities such as the Leapfrog Group, the National Quality Forum (NQF), the Agency for Healthcare Research and Quality (AHRQ), the Centers for Medicare and Medicaid (CMS), and The Joint Commission with regard to the ACS NSQIP. The Joint Commission awards ACS NSQIP hospitals a Merit Badge on their Quality Check public website. ACS NSQIP has recently implemented several changes that have led to unprecedented growth. As of May 2011, there are 350+ sites participating in the U.S. with fifteen sites in three Canadian provinces, one in Lebanon and one in the United Arab Emirates. Parkview Medical Center has been a participant since June 2006. A Surgical Clinical Nurse Reviewer, trained by ACS NSQIP personnel and certified annually, is responsible for all data collection and transmission of data to the central servers maintained by the American College of Surgeons.

Antibiotic Stewardship

AntiBiogram Data

Empiric Therapy Guidelines

Steve Nafziger, M.D.

Picture of Dr. Steve Nafziger

Vice President Medical Affairs
719.584.4999

Terry Frazier, RN, CPHQ

Director Accreditation Medical Staff Services
719.584.7309

Karen Sanchez

Administrative Assistant
719.584.4590

Megan Lujan

CVO Credentialing Specialist
719.584.4708

Linda Duvall, RN

CME Coordinator
719.584.4692

Darlene Baca

Medical Staff Coordinator
719.584.7399

Bobbie Blood

Clinical Database Supervisor
719.584.4335

Vicky Knutson, RN

Quality Assurance Analyst
719.584.4331

Barbara Daveline, LPN

SCNR
719.584.7368

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400 West 16th Street, Pueblo, CO 81003

719.584.4000