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Q&A: What does the Joint Commission say about getting data on physicians from healthcare facilities that have closed?

Credentialing & Verification Update, June 18, 2008

Circumstances may not always allow information to be requested or received directly from a primary source. For instance, a healthcare facility may close or the applicant’s records may have been lost or destroyed. Verification of education or training completed in a foreign country may not be accessible.

Examples of secondary-source information include written statements from individuals who were in leadership positions in the closed organization or statements from a successor organization. Usually, if a hospital has closed, the medical staff records will have been transferred to another facility. If the hospital is part of a healthcare system, the system’s main office or another system hospital can provide information about the location of files. Also, the medical staff office of other hospitals in the same city often will have information concerning the location of these records.

The Joint Commission allows use of reliable secondary sources after a documented attempt to contact the primary source is made. A footnote in the standards allows another hospital with documented primary-source verification of the applicant’s credentials to serve as this secondary source.

Notably, the AOA-HFAP and Medicare Conditions of Participation do not address this issue.

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