The Joint Commission’s Primary Source Verification Requirements
Service : Background Screening
Recent advances in technology have made it far easier for individuals to forge their credentials and qualifications, including educational backgrounds and professional licenses. The risks associated with individuals using such tactics to obtain positions they are not qualified to hold increases significantly in a healthcare setting, where patients’ well-being and lives are on the line.
To alleviate such risks, the Joint Commission requires healthcare organizations to use “primary sources” to verify certain credentials, including medical school diplomas, specialty training or residency certificates, licenses to practice, registration with a medical or dental council or any other credential required by law, regulation or hospital policy, as well as any credentials issued by recognized education or professional entities as the basis for clinical privileges.1 The Joint Commission does not require other verifications, such as professional history, letters of recommendation, criminal background checks, identification verification, immigration and financial documents to be verified from the primary source, unless required by hospital policy.2
Primary Source Verification
Primary source verification means that the individual’s reported credentials and qualifications are verified through the original organization or governmental entity that issued the document or credential, or through a designated equivalent source (i.e. an approved agent of the source that has been determined to maintain specific items of credential information that are identical to the information at the primary source).3 Methods for conducting primary source verification include direct correspondence with the issuing source, such as through a documented telephone conversation or by facsimile, email or letter.4 It is important to note that obtaining original documents is not necessarily equivalent to primary source verification – any communication from or with the original source that is through a person who is the applicant or his or her agent is unacceptable as primary source verification.5
Designated equivalent sources accepted by the Joint Commission include, but are not limited to, the following:
- The American Medical Association (AMA) Physician Masterfile for verification of a physician’s U.S. and Puerto Rican medical school graduation and postgraduate education completion;
- The American Board of Medical Specialties (ABMS) for verification of a physician’s board certification;
- The Educational Commission for Foreign Medical Graduates (ECFMG) for verification of a physician’s graduation from a foreign medical school;
- The American Osteopathic Association (AOA) Physician Database for pre-doctoral education accredited by the AOA Bureau of Professional Education, post-doctoral education approved by the AOA Council on Postdoctoral Training, and Osteopathic Specialty Board Certification;
- The Federation of State Medical Boards for all actions against a physician’s medical license; and
- The American Academy of Physician Assistants (AAPA) Profile for physician assistant education, provided through the AMA Physician Profile Service.
For international verifications, if a secure online database is available to determine the validity of the credentials, this may also be an acceptable source. Some countries or government agencies may have a database that facilitates the retrieval of this information online. For example, Thailand has the government-regulated Medical Council of Thailand and primary-source verifies all physicians trained in Thailand prior to licensing, including their medical training and specialty training. The website allows users to look up the physician in question and contains the most recent licensing information, educational history, dates and a photograph submitted by the university for further accuracy. Belgium has a similar government website for primary source verification of physicians. The Japanese Ministry of Health and Social Welfare website has information about physicians and pharmacists, but not nurses.6
Challenges to Primary Source Verification
There may be instances where primary source verification through a primary source is not possible. For example, when an educational institution is no longer in existence and the information does not appear on the AMA profile or ECFMG. In this situation, verification of licensure would suffice since the licensing board would have had to verify the education before granting the license.7
Verification of credentials received from institutions outside the country may also be challenging, and in some cases not even possible, such as in the event of loss of records in a disaster. There should be evidence of a credible effort to verify the credentials. A credible effort should constitute multiple attempts (at least two within 60 days) by the methods discussed above, with documentation of each attempt, as well as of the results.8 Following such documented attempts, the education/licensure should still be verified either through the licensing board or a designated equivalent source.
Verification Requirements for Other Healthcare Staff
Many healthcare organizations have a credentialing team that handles the verification process for physicians and other practitioners, but face some difficulty and confusion when determining the verification requirements and best practices for other types of staff in the healthcare setting.
First, when determining the required verification procedures for staff other than physicians and practitioners, it is important to note that primary source verification only applies when licensure/certification or registration is required to practice a profession (see HR.01.02.05 EP 1, MS.06.01.03 EP 6 and MS.06.01.05 EP 2).9 When a healthcare organization requires licensure, registration or certification that is not otherwise required by law or regulation, the hospital must still verify the credentials and document such verification, but verification through the primary source is not required.10
Another point of confusion for some organizations when screening staff other than physicians and practitioners is the requirement set forth in HR.01.02.05 EP 3, stating that “[t]he organization verifies and documents that the applicant has the education and experience required by the job responsibilities.” This does not mean that verification via primary source is required. Organizations are required to verify and document education and experience only when specific minimum requirements are written into the job description. For example, if the Nurse Manager job description specifically requires the incumbent to possess a Master’s Degree in Nursing, the organization must verify the individual has this credential. Organizations determine how verification and documentation of education and experience will be managed. Examples may include, but are not limited to:
- Verification directly with schools or employers – either by the organization or a third-party provider;
- Review of a diploma or certification that demonstrates completion of an education course or degree, then retaining a copy as documentation of this education. Organizations also determine if documentation will be retained as “paper” or in an electronic format, such as a scanned document;
- Alternatively, organizations could review (but not copy) such a document and then enter a note of attestation by the person reviewing the document into an HR file. The date the document was reviewed should be documented.11
1Primary Source Verification of Health Care Professionals: A Risk Reduction Strategy for Patients and Health Care Organizations, Joint Commission International 8 (2016), available at http://www.jointcommissioninternational.org/assets/3/7/JCI_White_Paper_Primary_Source_Verif.pdf [hereinafter referred to as “Joint Commission International”].
3 Id. at 6.
4 Id. at 9. In this case, it would be important to ensure that the organization being contacted is a legitimate, accredited organization, since the rise in diploma mills and associated resume fraud deceptions poses an additional challenge during primary source verification. Id.
5 Id. at 6.
6 Id. at 9-10..
7 https://www.jointcommission.org/standards_information/jcfaqdetails.aspx?StandardsFAQId =880&StandardsFAQChapterId=48&ProgramId=0&ChapterId=0&IsFeatured=False&IsNew=Fa lse&Keyword=
8 See Joint Commission International, supra note 1, at 10.
9 https://www.jointcommission.org/standards_information/jcfaqdetails.aspx?StandardsFAQId=1245&StandardsFAQChapterId=66&ProgramId=0&ChapterId=0&IsFeatured=False& IsNew=False&Keyword=
10 2016 Hospital Accreditation Standards, THE JOINT COMMISSION, HR.01.02.05 EP 2.
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