Primary Source Verification of

Health Care Professionals:

A Risk Reduction Strategy for
Patients and Health Care Organizations
A White Paper by Joint Commission International

Sponsored by
 Primary Source Verification of Health Care Professionals: A Risk Reduction Strategy for Patients and Health Care Organizations

AUTHORS
Derick P. Pasternak, MD, MBA, FACPE, Senior Consultant, Joint Commission International
Bonny Chen, MD, FACEP, CPHIT, Surveyor, Joint Commission International

DISCLAIMER
This white paper was supported in part by funding from DataFlow. All content in this white paper was
created and controlled only by Joint Commission International (JCI). You are solely responsible for any
decision to use the white paper as a guideline for assisting your health care organization in establishing
primary source verification practices. It is only a guideline, and you would have to make the decision as to
whether it needs to be tailored to fit the practices and settings at your individual institution. JCI’s provision
of this white paper, as funded by DataFlow, is on a non-exclusive basis, and is not an endorsement of that
company or its products or services; it is also not a statement that DataFlow’s expertise or products or
services are superior to those of other comparable companies. JCI, as a matter of policy, does not endorse
products or services. JCI may make available all the subject matter contained in this white paper to any
other party interested in furthering JCI’s efforts to help improve quality and safety.

JOINT COMMISSION INTERNATIONAL

A DIVISION OF JOINT COMMISSION RESOURCES, INC.
The mission of Joint Commission International (JCI) is to improve the safety and quality of care
in the international community through the provision of education, publications, consultation, and
evaluation services.

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treatment in, or confidential information about, the accreditation process.

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 Primary Source Verification of Health Care Professionals: A Risk Reduction Strategy for Patients and Health Care Organizations

Foreword

W
hy is primary source verification of a health care why Joint Commission International (JCI) accreditation—and
professional’s credentials so important? Not only some governments around the world—requires primary source
does this crucial step in your process help pro- verification, with numerous JCI standards specifically address-
tect your organization, but more important, it also protects ing the need to verify credentials from the primary source.
your patients. We are all familiar with reports from around This white paper provides more information about the im-
the globe about patients being harmed by care received from portance of primary source verification. It also clarifies JCI’s
a health care provider whose credentials were obtained fraud- standards addressing primary source verification, and it pro-
ulently. Is your organization willing to take this risk? vides solutions on how your organization can perform this
Protecting your patients and avoiding this risk are just some necessary step as part of your management processes.
of the reasons your organization should commit to p ­ rimary JCI hopes you find this white paper informative and prac-
source verification. Trusting in your physicians’ and other tical. We share your commitment to protecting your patients,
health care providers’ skills and experience is also critical. This is your staff, and your organization.

Paula Wilson
President/CEO, Joint Commission International

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 Primary Source Verification of Health Care Professionals: A Risk Reduction Strategy for Patients and Health Care Organizations

I
n the American film “Catch Me If You Can” (2002), the publication on the subject by the UNESCO Council for
confidence man Frank Abagnale poses as an emergency Higher Education Accreditation.5
physician, among other professions, while he had the Yet another problem is that some medical schools and
qualifications for none of them. The film depicts a true ­story. hospitals falsely claim to have qualified or accredited train-
Indeed, many individuals around the world have posed as ing programs. Reuters disclosed Indian government records
physicians, nurses, and other health care professionals. While showing that since 2010, at least 69 Indian medical colleges
fortunately most patients have suffered no long-term harm and teaching hospitals have been accused of such transgres-
from their ministrations as far as we know, every now and sions or other significant failings, including rigging entrance
then, there is a Dr. Jayant Patel (“Doctor Death,” as they exams or accepting bribes to admit students.6 This raises a
called him in Australia) who was repeatedly proven in court special challenge, because if a university actually acquires na-
to have been responsible for multiple patients’ deaths and sus- tional accreditation through fraudulent means, that may be
pected of many more.1 Some of Dr. Patel’s professional edu- especially difficult to detect.
cation and background were real, but no one verified his U.S. To prevent fraudulent representation of individuals’ qual-
licenses before he arrived in Australia.2 In fact, he went to ifications and experience, health care organizations and those
Australia because multiple U.S. states had revoked his license in other fields began verifying credentials from the “primary
due to demonstrated incompetence. source,” that is, the university or other institution. The ser-
Health care professionals are in short supply in several vice of credentials verification grew out of background checks
countries, and these countries therefore import professionals performed in a variety of industries for many decades. Many
from elsewhere. But even in countries with adequate home- governments have also sought information about individu-
grown talent, the size and complexity of the educational and als’ backgrounds through the security clearance process. The
training systems make it easy for a determined fraudster to health care professions were actually latecomers to this pro-
claim having been trained in an institution not familiar to cess, but by the late 1990s, the Joint Commission on Ac-
prospective employers and health care organizations. These creditation of Healthcare Organizations (the then-current
fraudsters can easily create documentation through modern name of The Joint Commission as well as the parent of Joint
technology to support their claimed credentials. Commission International [JCI]) required primary source
There is even a “solution” for the technologically chal- verification for “licensed independent practitioners,” mean-
lenged. In May 2015, police in Karachi, Pakistan, arrested ing physicians and dentists who practiced in U.S. acute care
Shoaib Ahmed Shaikh, owner and president of Axact, a com- hospitals.7 Soon thereafter, nurses’ credentials were subjected
pany that was manufacturing diplomas from several dozen to the same requirement. JCI followed suit in its hospital ac-
institutions that exist in name only. Since 1997, Axact pro- creditation standards.8 JCI’s requirement was later extended
vided fake diplomas to professionals and non-professionals to ambulatory care9 and to other health care professionals in
throughout the world.3 A recent investigative report by The these settings.10
New York Times unearthed websites of 145 non-existent uni- Absent such verification, the majority of honest applicants
versities among other fake institutions from which Axact pro- for a position cannot be distinguished from the small num-
vided “credentials.”4 The problem of diploma mills has long ber of fraudulent ones. Just how big a problem can this be? In
attracted international attention, as evidenced by a special the mid-2000s, the Saudi Commission of Health Specialties

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 Primary Source Verification of Health Care Professionals: A Risk Reduction Strategy for Patients and Health Care Organizations

embarked on a thorough audit of health care professionals’ physician was triggered by adverse patient outcomes. Patients
credentials. It reviewed support documentation of a number must rely on a health care organization’s due diligence to en-
of expatriate doctors, nurses, and other professionals, concen- sure that staff members are qualified to attend to their health
trating on documentation from selected sources. While the care needs. Patients do not have the knowledge to assess the
statistic cannot be extrapolated to all expatriates in the King- competence of health care professionals. Thus, the responsi-
dom of Saudi Arabia, more than 20% of documents submit- bility rests squarely on the shoulders of hospital leaders, as
ted from these sources by individuals claiming to be physicians determined by a U.S. court in 1980, when hospital manag-
and other health care professionals proved unverifiable or out- ers attempted to evade their responsibility by claiming that
right false.11 More recently, DataFlow, an international compa- doctors were “independent practitioners.”15 But are hospital
ny specializing in primary source verification and background managers in any better position than patients to assess pro-
checks, found that since 2013, an average of 2.3% of creden- fessional competence? One can argue that the answer is yes.
tials submitted by health care professional applicants could After all, hospital managers have among them professionals in
not be verified, but there has apparently been a surge of “neg- human resource management, whose training includes back-
ative” reports since early 2015 (see Figure 1, below). ground checking. The responsibility cannot be transferred to
While the Middle East is a focus because of the large others, such as government licensing bodies or medical or
number of expatriate professionals, this phenomenon is by other professional societies.
no means confined to that region. It was already mentioned However, we now have technology that can produce au-
that the most prominent hospital accrediting organization in thoritative-looking facsimiles of official documents. Technol-
North America, The Joint Commission, found it important ogy has upped the counterfeiter’s game. As a recent analysis
to require verification of credentials in the late 20th century; of currency counterfeiting noted, “The modern PC can now
in addition, case reports flow from Europe13 and South Asia,14 readily handle gigabyte-size images, more than enough storage
to name a few. for the captured image of an FRN [Federal Reserve Note, the
Statistics on this subject are difficult to come by. Health currency of the U.S.A.] scanned at 4,000 pixels per inch.”16
care institutions do not like to disclose adverse findings about Diplomas and licenses are a great deal less complex than cur-
their staff, fearing litigation or other consequences, while con- rency. What, then, must health care managers do in order to
sultants are generally bound by non-disclosure agreements. ensure that the doctors, nurses, pharmacists, and others on
What does all this mean for patients and health care or- their staff are qualified to practice their profession? First, they
ganizations? As the cited articles from the press emphasize, have to develop criteria that an applicant must meet in or-
every anecdote that led to a publication about an unqualified der to be considered as a credible candidate for the position.

Figure 1. Applicants whose credentials were submitted to DataFlow within some of the GCC (Gulf Cooperation Council) countries between
January 2013 and October 2015.12

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 Primary Source Verification of Health Care Professionals: A Risk Reduction Strategy for Patients and Health Care Organizations

It is not enough to examine the candidate’s documentation, guage. Nonetheless, health care management is a field that is
that is, documents attesting to graduation from professional practiced globally; many managers, just as doctors and nurs-
schools, licenses or registrations issued by appropriate govern- es, tend to gravitate toward opportunities where rewards ex-
ment authorities, and, where applicable, evidence of specialty ceed those obtainable in their home countries.
or other special training (for example, surgery for physicians, Once it is understood that “primary source” or “original
intensive care competency for nurses, and so on). It is imper- source” means the organization or government entity that is-
ative to ensure that the documents submitted are indeed what sued the document which supports the credential claimed,
the purported source issued—in other words, primary source there is still the opportunity to mistake a letter issued in ver-
verification. ification of the document and carried by the applicant to be
sufficient in this regard. It has to be very clearly stated that
CHALLENGES AND GAPS IN any communication from or with the original source that is
PRIMARY SOURCE VERIFICATION through a person who is the applicant or his or her agent
Verifying credentials from the primary source is not a sim- (such as a spouse or parent) is unacceptable as primary source
ple matter. Most managers’ first reaction is that they must see verification.
the original documents (for example, diplomas, registration Health care management is complex and time consuming.
certificates, and so on). That by itself can be labor intensive, Verification of credentials adds more time spent away from
because most applicants are not likely to mail or ship those hands-on management. This has caused many health care or-
documents. They must be given time to bring the documents ganizations to look outside themselves to accomplish the task.
for inspection, after which they will want to reclaim the docu- Credentials verification was originally undertaken in the U.S.
ments. Furthermore, in a number of countries that rely heav- by organizations that had been doing background checks for
ily on expatriate travel, health care managers feel pressured to non-health care clients. Eventually, credentials verification
delegate inspection of those original documents either to an organizations (CVOs) developed, many of them concentrat-
agent, such as a recruiter, or to the diplomatic corps that is- ing on health care, but others working with non-health care
sues the work visa to the applicant. The common thought is ­clients, the principal needs of the two types of clients being
that the diplomatic corps would not have issued a work visa essentially the same.
unless it looked at the original document. However, one of During the same period that hospitals embarked on pri-
the authors of this paper has personal experience that work mary source verification, a number of governments conclud-
visas are not carefully vetted. When applying for a short-term ed that the licensing process itself must protect its integrity
work visa, instead of removing his original university diploma and cannot simply rely on documentation submitted by ap-
from its frame, he sent a not-very-professional-looking copy plicants. Since these bodies were even less prepared to investi-
made on his home copying machine. The visa was issued, no gate the sources of documentation than a well-staffed hospital,
questions asked. Surely, this is not the only situation in which some turned to professional and quasi-professional entities,
diplomatic staff did not fully vet qualifications for a work visa. such as the Saudi Commission already mentioned. Others
In some instances, a notary’s stamp on the document is retained the responsibility themselves but turned to one or
accepted as evidence of verification. However, in most coun- another CVO for the actual task of researching the primary
tries, notaries are not in position to do the actual verification, sources. One way or another, the job gets done. But does this
because that is not their role—they verify that an individual’s work meet the needs of hospitals? That remains uncertain.
signature is indeed his or hers, or that the person possessing Governments investigating the backgrounds of physicians,
the document is indeed the person named in the document. nurses, and others seeking professional opportunities may
Even if a notary stamp is affixed to a diploma, it is possible have different goals than hospitals. Many governments simply
that the notary stamp itself is fraudulent. wish to establish that the physician or nurse satisfactorily com-
There is a widespread misunderstanding that original doc- pleted the professional education required by law for issu-
uments are equivalent to primary source. This may have to do ance of a license. In the case of expatriates, governments want
with the fact that the widespread use of the English language to know whether they are licensed in their home countries.
in health care around the world is not accompanied by wide- ­Others take a more nuanced approach, especially for physi-
spread perfect understanding of the language. This may be the cians, and further designate the professionals by status (for
case at all levels of health care management, even in countries example, “consultant,” “specialist,” “registrar,” and so on). On
such as the United States, where English is the primary lan- the other hand, hospitals must be certain that the persons

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 Primary Source Verification of Health Care Professionals: A Risk Reduction Strategy for Patients and Health Care Organizations

they hire (including locum tenens physicians), or the indepen- like situation; the CVO receives the query and issues a re-
dent physicians they allow to treat patients within their walls, port, but discourages going into details. Sometimes contracts
have the requisite skills to perform within their environment. even disclaim CVO responsibility for inaccurate reports.
While the hospitals may not be interested in home-country While this situation is by no means universal, where it exists,
­licensing, this is all the same a higher degree of requirement, it creates a major barrier in the hospitals’ ability to satisfy in-
expressed in a variety of ways: hospital and medical staff by- ternational credentialing requirements, which demand trans-
laws, nursing and other professional policies, job descriptions, parency of the process.
and so on. In short, what hospitals require from primary Even if a CVO has disclosed its process and demonstrates
source verification and background checks for health care pro- true transparency at the time of the origin of the contractual
fessionals is more stringent than those of ­governments. relationship, the health care organization has to ensure that
Hospitals that choose to undergo international accredita- the CVO’s modus operandi does not change significantly over
tion have yet another challenge in this sphere. Joint Com- time. No organization is static in the way it conducts its busi-
mission International (JCI), the organization that accredits ness, so health care managers should periodically review how
the largest number of hospitals worldwide, has explicit and the CVO conducts primary source verification. Otherwise,
detailed requirements for how documents have to be veri- the health care organization may not be able to claim fully
fied.17 Other accrediting bodies also address this topic. For reliable primary source verification.
example, “[T]he hospital has an effective process for gath- Hospitals that do not contract with CVOs also may expe­
ering, verifying and evaluating the credentials (registration, rience difficulty in dealing with the primary sources. Insti­
education, training and experience) of those healthcare pro- tutions in countries that have been affected by war (or civic
fessionals who are permitted to provide patient care without upheaval) may not have access to records at all, due to destruc­
supervision,” and “[t]he registration, education, training and tion of facilities. Certain universities and training programs,
experience of these individuals is verified from the original particularly from certain countries in the Middle East and
sources when possible.”18 Thus, it is frequently inevitable that South Asia, may not be able to respond to requests for cre-
primary source verification by governments and that required dentials verification because of war or upheaval. However,
of hospitals do not coincide exactly. recently, many CVOs have been able to establish lines of com-
The lack of congruence between government and hospital munication with these degree- and certificate-granting entities
needs regarding primary source verification is a major cause and have had greater success in receiving answers to queries.
of gaps in actual performance of primary source verification. Another problem is dealing with expatriate staff members
Despite bylaws, policies, or accreditation standards to the who present documents from countries with languages that are
contrary, health care managers, all of whom have inevitable more “niche” (for example, Albanian, Uzbek, and so on). Once
budgetary constraints, often convince themselves that prima- again, CVOs, with broad client base and necessarily broad
ry source verification done by or on behalf of government is ­outreach, are more likely to be able to close the gap by finding
reliable. And even then, relying on government verification competent translators of documents and communications.
is not so easy. For example, until recently, organizations that Another complicating factor is that hospitals may not
operated multiple hospitals in the United Arab Emirates had know how to access information that may actually be in the
a further complicating factor; Emirati hospitals are subject public domain. A number of government entities (such as
to three different government oversight bodies: Health Au- Thailand) and professional associations (for example, the
thority of Abu Dhabi and Dubai Health Authority in those American College of Physicians) maintain websites that may
specific emirates, and the Federal Government for selected be accessed to glean such information, usually upon paying
hospitals in Dubai and Abu Dhabi, as well as all hospitals in a modest fee. These websites may be used to establish the va-
the other five, so-called “northern” emirates. This specific is- lidity of the specific credential presented, since the informa-
sue was resolved when the three authorities agreed in 2013 to tion can be obtained without it passing though the control
set a common baseline for the required qualifications from of the applicant. Care must be exercised, however, because
health professionals (by profession) and engaged the same while some professional associations require examinations or
CVO to conduct primary source verification. verified certifications before they admit candidates to mem-
However, gaps exist in the performance of some CVOs. bership, others simply accept self-declared competence and
The biggest issue is usually a lack of transparency. Contracts payment of a fee. Therefore, any organization relied upon
between hospitals and CVOs sometimes create a black box- for this information must be proven to require demonstrated

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 Primary Source Verification of Health Care Professionals: A Risk Reduction Strategy for Patients and Health Care Organizations

competence. Again, this knowledge is more likely to reside in different chapter in those standards manuals.
an internationally-oriented CVO than in any single hospital. The primary source verification requirements make up the
A very special situation exists in the case of hospitals that basis of several standards in the Hospital SQE chapter. For
form a chain or system and share medical staff with others in medical staff, standards SQE 9.1, 9.2 and SQE 12 reference
the chain. In situations such as this, credentials verified by the primary source verification requirement. For nursing staff,
one hospital, if accredited, may be accepted by the others in the requirement is included in SQE 13, and for other health
the chain. However, notwithstanding the fact of accredita- care practitioners, the requirements are in SQE 15, and both
tion of the index organization, this sharing of information is refer to the parameters found in the intent of SQE.9.
acceptable only if the applicable standard(s) has (have) been The designation “medical staff” refers to all physicians,
fully met. This requirement may escape the attention of the dentists, and other professionals who are licensed to practice
medical managers and therefore a gap is created. Situations without supervision. This includes all categories of medical
such as this seldom apply to nursing staff, since nurses are staff, including those who are employed by the hospital and
more likely working in a single location only. visiting, contract, honorary, or private community staff mem-
Nonetheless, a different special situation arises if the hos- bers. The term “visiting staff” includes those who are locum
pital uses a staffing agency to complement its nursing or other tenens, invited experts, and others who are allowed to pro-
professional workforce. The credentials of “contract nurses” vide patient care services temporarily. House officers, or ­junior
and other nurses and professionals who are not permanent doctors, who are no longer in training but are permitted by
employees but serve at longer or shorter temporary intervals the hospital to practice independently, will also fall under the
(for example, employees of independent physicians who prac- classification of medical staff. In countries where traditional
tice at the hospital) must be verified from the original source, medicine practitioners such as acupuncturists, chiropractors,
just as the credentials of locum tenens doctors. If the contract- and others are permitted to practice independently, these prac-
ing agency asserts that it has performed this verification, it be- titioners are also included in the designation of medical staff.
comes the equivalent of a CVO and its process has to be able Independent practitioners who provide patient care services
to withstand the hospital’s scrutiny. Without such transpar- in the facilities of the hospital, but are not employees or mem­
ency, the verification becomes the responsibility of the hospi- bers of the clinical staff, must also be credentialed and privi-
tal, which it may once again contract to an actual CVO. leged in the same manner as other medical staff, which includes
A final note of caution, especially applicable to physicians the primary source verification of credentials (GLD 6.2).
who travel to other organizations in order to acquire new JCI requires certain credentials to be primary-source ver-
skills: When a medical member presents a certification related ified. These credentials include those such as medical school
to an advanced degree or advanced specialty training, the new diplomas, specialty training or residency certificates, licenses
credential should be immediately verified from the original to practice, registration with a medical or dental council, or
source.19 This requirement for JCI accreditation may escape any other credential required by law, regulation, or hospital
the attention of health care managers. In fact, even if a CVO policy, as well as an credentials issued by recognized educa-
has been contracted, this special verification may fall outside tion or professional entities as the basis for clinical privileges
the scope of that contract, in which case the responsibility re- (SQE.9.1 ME 1 & 2).
verts to the hospital. This situation would also be applicable Other verification, such as professional history, letters of
to nurses, pharmacists, therapists, and others. recommendation, criminal background check, identification
verification, immigration, and financial documents, are not
JOINT COMMISSION INTERNATIONAL required by JCI to be verified from the primary source, un-
(JCI) STANDARDS FOR PRIMARY less required by hospital policy. These verifications should be
SOURCE VERIFICATION highly considered by the hospital, though, because they are
JCI recognizes the importance of primary source verification, best practices and can prevent a potentially harmful situa-
and has included standards supporting this into its accredita- tion resulting from appointment of a practitioner who pro-
tion manual. The requirement of primary source verification vided fraudulent credentials. Recalling the case of Dr. Jayant
is found in the “Staff Qualifications and Education” chapter ­Patel, otherwise known as “Doctor Death,” the tragedy of
(SQE) of the 5th edition of the JCI Accreditation Standards for those multiple patient deaths could have been averted if the
Hospitals. Primary source verification is also required for other ­hospitals had verified his U.S. licenses prior to his employment.
JCI designations, such as ambulatory care, and will appear in a The term “nursing staff” includes all nurses employed by

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 Primary Source Verification of Health Care Professionals: A Risk Reduction Strategy for Patients and Health Care Organizations

Figure 2. Sources of misrepresentation by some applicants.20

or contracted to a hospital. Other health care practitioners in- methods, including directly contacting the organization from
clude those such as pharmacists, pharmacy technicians, nurse which the credential was issued. This may be done through
midwives, surgical assistants, physical therapists, nutrition- methods such as documenting a telephone conversation with
ists, radiographers, laboratory technicians, perfusionists, re- the issuing source, or by facsimile, email, or letter. In this
spiratory therapists, or emergency medical care specialists. In case, it would be important to ensure that the organization
some countries, practitioners such as those who provide ser- being contacted is a legitimate, accredited organization, since
vices such as herbal medicine or acupuncture also fall under the rise in diploma mills and associated resume fraud de-
this category. Primary source verification applies only to those ceptions (see Figure 2, above) poses an additional challenge
professionals who work or practice in the hospital. during primary source verification.
During an initial JCI accreditation survey, primary source In the case where a secure online database is available to de-
verification must be performed for all medical staff and nurs- termine the validity of the credentials, this is also acceptable.
ing staff who joined the hospital within the 12 months prior Some countries or government agencies may have a data­base
to the survey. All other medical staff must have their prima- that facilitates the retrieval of this information online. For
ry source verification completed within 12 months of the example, Thailand has the government-regulated Medical
initial survey. For other health care practitioners, primary Council of Thailand and primary-source verifies all physi-
source verification should be carried out for those practi- cians trained in Thailand prior to licensing, including their
tioners who joined the hospital beginning 4 months prior medical training and specialty training. The website allows
to the initial accreditation survey, and then all practitioners one to look up the physician in question and contains the
must be verified through the original source in the next three most recent licensing information, educational history and
years post-survey. dates, and a photograph submitted from the university for
Primary source verification can be achieved through s­ everal further accuracy. Belgium has a similar government website

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 Primary Source Verification of Health Care Professionals: A Risk Reduction Strategy for Patients and Health Care Organizations

for primary source verification of physicians. The Japanese the hospital should have confidence in the completeness, ac-
Ministry of Health and Social Welfare website has informa- curacy, and timeliness of that information. In order to achieve
tion about physicians and pharmacists, but not nurses. this level of confidence, the hospital should initially evaluate
In some cases, verification of credentials received from the agency providing the information, as well as periodically
institutions outside the country may be challenging, and in thereafter, to ensure that JCI standards continue to be met.
some cases not even possible, such as in the event of loss of Appointments of medical staff are not to be made until,
records in a disaster. There should be evidence of a credible at a minimum, the licensure or registration has been veri-
effort to verify the credentials. A credible effort should con- fied from the primary source. Until all credentials required
stitute multiple (at least two within 60 days) attempts by the by laws and regulations have been verified, the medical staff
methods discussed above, with documentation of each at- member should provide patient care services only under su-
tempt, as well as of the results. pervision (standard SQE.9.2 ME 2).
Primary source verification may be accomplished by a Primary source verification is considered complete fol-
third party, such as a government agency or a nongovern- lowing the above processes, unless the medical staff member
ment agency (such as a CVO). When a third party is used for has obtained subsequent credentials in the period following
verification, JCI requires the hospital to verify that the third the initial appointment. In this case, the credentials must be
party implements the verification process as described in pol- verified from the primary source before use in modifying or
icy or regulations and that the process meets the expectations adding to clinical privileges (standard SQE.12 ME 3). In ad-
described in the intent of standard SQE.9.1 ME 3. This could dition, all practitioners’ subsequent licenses must also be pri-
include attaining a letter from the third party, detailing the mary-source verified following renewal.
procedure used for verification, or obtaining equivalent in-
formation on the third party’s website. It is also important to CONCLUSION
confirm that the third party has verified all the required docu- JCI recognizes the importance of primary source verifica-
ments. For example, in the case of medical staff, this includes, tion of practitioner credentials. Patients expect that the cre-
at a minimum, verifying medical school education through to dentials held by their practitioners represent the experience,
the most recent training. knowledge, and skills needed to provide quality patient care.
There are three situations in which there is an acceptable A practitioner who does not possess the credentials required
substitute for a hospital performing primary source verifica- to provide appropriate patient care could cause harm to the
tion of credentials. The first is applicable to those hospitals patient, which could ultimately lead to serious risk manage-
directly overseen by government bodies. In this case, the gov- ment issues, negative publicity for the health care organiza-
ernment’s verification process, supported by the availability tion, as well as potential liability actions. Protecting the public
of published government regulations about its method of pri- is a top priority of health care organizations. While the process
mary source verification, can be acceptable. As before, this is of primary source verification is not without its challenges, we
dependent upon the hospital’s own verification that the gov- hope that this white paper has detailed the necessity for prima-
ernment verification process meets the expectations described ry source verification and the potential pitfalls, the JCI stan-
in the JCI standards. dards requirements, and solutions that health care organiza-
The second situation applies to those hospitals seeking pri- tions may use to successfully accomplish this critical endeavor.
mary source verification for a candidate who is currently af-
filiated with a hospital with current JCI accreditation, with References
full compliance on its verification process found in standard 1. Taylor, J: “Bundaberg surgeon Jayant Patel barred from ever practising
SQE.9.1, ME 1 and 2. Full compliance indicates that all the medicine again in Australia.” 14 May 2015. www.abc.net.au/news/2015-05
-15/jayant-patel-barred-from-practising-medicine-again-in-australia
measurable elements are fully met, or that any not met or /6472234. Accessed 15 December 2015.
partially met measurable elements that were required to be 2. “Australia’s ‘Dr. Death’ linked to 87 fatalities.” 26 May 2005. www.nbcnews
addressed by a Strategic Improvement Plan (SIP) have been .com/id/7991906/ns/health-health_care/t/australia’s-dr-death-linked
-fatalities/#.VnCtbPkrLIU. Accessed 15 December 2015.
addressed and are now in full compliance. 3. “FIA raids Axact’s offices, computers confiscated.” Daily Pakistan Global
The last situation is relevant in the case of an indepen- 19 May 2015. en.dailypakistan.com.pk/fia-raids-axacts-offices-seals-records
dent third-party verifier, such as a designated, official, govern- -765. Accessed 2 Jan 2016.
4. Walsh, D: “Fake Diplomas, Real Cash: Pakistani Company Axact Reaps
ment, or nongovernment agency. As previously mentioned, Millions.” The New York Times 17 May 2015.
in the situation where a hospital uses a third-party verifier, 5. UNESCO Council for Higher Education Accreditation: “Toward Effec-

© 2016 JOINT COMMISSION INTERNATIONAL 10 www.jointcommissioninternational.org

 Primary Source Verification of Health Care Professionals: A Risk Reduction Strategy for Patients and Health Care Organizations

tive Practice: Discouraging Degree Mills in Higher Education.” 2009. 14. Alvi, N: “Court wants action against quacks.” Hindustan Times 25 Feb-
6. MacAskill A, Sacklow S, Miglani S (Reuters): “India’s medical schools are ruary 2007.
plagued with fraud.” 16 Jun 2015. www.businessinsider.com/indias-medical 15. Johnson v. Misericordia Community Hospital, 294 N.W. 2d Wis. Ct.
-schools-are-plagues-with-fraud-2015-6 Accessed 15 December 2015. App. 1980, quoted by Horty Springer & Mattern, P.C. 1998 in “Hospi-
7. Deutsch S, and Mobley CS: The Credentialing Handbook. Aspen, 1999, tal-Medical Staff Relations” chapter of Seminar on Ethical Challenges of
p. 27. Physician Executives, American College of Physician Executives, Indian
8. Joint Commission International Standards for Accreditation of Hospitals, Wells, California, USA, October 2000.
First Edition. Oak Brook, IL: Joint Commission Resources, 1998. Stan- 16. National Academy of Sciences: “Emerging Counterfeiting Technology
dards SQE.7 and SQE.10. Threats,” Chapter 3, in A Path to the Next Generation of U.S. Banknotes:
9. Joint Commission International Standards for Ambulatory Care, First Edi- Keeping them Real. National Academies Press, 2007. Downloaded 15 De-
tion. Oak Brook, IL: Joint Commission Resources, 2005. Standards SQE.7 cember 2015 from www.nap.edu/read/11874/chapter/5.
and SQE.10. 17. Joint Commission International Standards for Accreditation of Hospitals,
10. Joint Commission International Standards for Accreditation of Hospitals, Fifth Edition. Oak Brook IL: Joint Commission Resources, 2013. Standards
Third Edition. Oak Brook, IL: Joint Commission Resources, 2007. Stan- SQE. 9, SQE. 13, SQE 15.
dard SQE.15. 18. COHSASA (The Council for Health Services Accreditation in South-
11. Al Hakeem M: “I don’t know how unqualified doctors get their certifi- ern Africa) Standards for Hospitals, Version 6.7, 2014. Standard 2.5.1 and
cates.” Gulf News (Dubai) 15 February 2007. Criterion 2.5.1.2
12. DataFlow Trend Report 2015. “Document Quality of Medical Profes- 19. Joint Commission International Standards for Accreditation of Hospitals,
sionals in the GCC Region.” Fifth Edition. Oak Brook, IL: Joint Commission Resources, 2013. Intent of
13. Papagallo, M: “Clona l’indentità di un medico e lavora al proto soccor- Standards SQE.9 through SQE.9.2.
so.” Corriere della Sera 15 September 2010. 20. DataFlow.

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