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 Policies and Procedures
Colorado Health Care Professional Credentials Application Information Requirements:
  1. Identifying Information
  2. Current Practice Setting(s)
  3. Call Coverage Information
  4. Licenses/Registrations/Certificates
  5. Education Information (since high school)
  6. Board and Professional Certificatoin/Recertification
  7. Current Hospital and Other Facility Affiliations
  8. Professional Work History
  9. Peer References
  10. Professional Liability Insurance
  11. Health Plan Information
  12. Attestation Information

Click HERE for Initial Credentialing Document List

The following materials will be requested during the credentialing process (if applicable):
  1. State Professional License(s)
  2. Federal Narcotics License (DEA Registration)
  3. Diplomas and/or certificates of completion
  4. Diplomat of National Board of Medical Examiners or Education Commission for Foreign Medical Graduates (ECFMG) Certificate (if applicable)
  5. Specialty/Subspecialty Board Certification or letter from Board(s) stating your status (if applicable)
  6. Certificate of Insurance
  7. Military Discharge Record (if applicable)
  8. Certificates for Basic Life Support (BLS), Advanced Cardiac Life Support (ACLS), Advanced Trauma Life Support (ATLS, Pediatric Advanced Life Support (PALS) and Neonatal Resuscitation Program (NRP)
Upon submitting an application, Parkview will:

• Provide the applicant a receipt in written or electronic form within seven days.

• Promptly determine whether the application is complete. If it is determined that the application is incomplete, the applicant must be notified in writing or by electronic means that the application is incomplete within 10 calendar days after the date the application was received. The notice must describe the items that are required to complete the application.

• If a completed application is received but the organization fails to provide the applicant a receipt in written or electronic form within seven calendar days after receiving the application, the applicant is considered to be a participating physician, effective no later than 53 calendar days following the receipt of the application.

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 Health System 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 Measures

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.

Antibiotic Stewardship

AntiBiogram Data

Empiric Therapy Guidelines

Jim Caldwell, MD

Picture of Dr. James Caldwell

Chief Medical Officer/VP of Medical Affairs

Teresa Braden, MD

Vice President of Quality/Chief Quality Officer


Annette Saccomano

Executive Assistant

Medical Staff Coordinator



Lenéy Stonum

Jessica Espinoza

Bridgett Podhirny

Jodi Lopez

CME Coordinator

Andrea Quintana, RN-BSN

Quality Assurance Analyst