Medical Staff

Ask the expert: What are the Joint Commission requirements for checking post-graduate training at initial appointment?

Medical Staff Leader Connection, April 15, 2010

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The Joint Commission requires verification from the primary source(s). This requirement encompasses internship, residency, and fellowship programs, as well as other relevant experience (e.g., military training). Accepted “designated equivalent sources” for United States and Puerto Rico postgraduate training are the American Medical Association Physician Masterfile and the American Osteopathic Association Physician Database.

In certain instances, foreign institutions will not or cannot verify training. In that case, efforts to obtain primary source verification should be documented. The organization may be able to verify training and experience with individuals who trained with the applicant who are now practicing in the United States.
When an organization cannot obtain verification from the primary source, The Joint Commission standards permit use of a “reliable secondary source.” Such a source can be another hospital that has a documented primary source verification of the credential.

This week’s question and answer are from Verify and Comply: A Quick Reference Guide to Credentialing Standards by Carol S. Cairns, CPMSM, CPCS.
 



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