Standards FAQ Details | Joint Commission
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Monday 9:08 CST, February 8, 2016

Standards FAQ Details


Medical Staff (MS) (Critical Access Hospitals / Critical Access Hospitals)

Primary Source Verification of Education for Licensed Independent Practitioners
Updated | November 24, 2008
Q.  When credentialing licensed independent practitioners, can verification of a current licensure suffice for verification of the education in lieu of performing primary source verification of the education since a defined level of education is required to receive the license, e.g., a medical license requires completion of medical school, a dental license requires completion of dental school, a podiatric license requires completion of podiatric school, etc?

A. The issues that can relate to verification vary and include but are not limited to:

  • the date of the education
  • the name of the educational institution and its reputation
  • the location of the educational institution.

If the date of the education is important to know to determine how the practitioner has kept current with changes in their field, then primary source verification would be required.  For example, if the education was at some time in the distant past, e.g., twenty or thirty years, then additional information on subsequent training might need to be obtained before granting privileges or assigning job responsibilities.

If it is important to the organization to be able to market the educational status of their practitioners, e.g., having graduates of specific institutions, then primary source verification would be required.

If it is important to know the location of the school. e.g., U.S. vs. foreign to determine if there could be a difference in level of the education or possible language barrier issues that need to be considered, then primary source verification would be required.

If none of these issues are of importance then, verification of licensure alone could suffice of evidence that the individual had completed the requisite education. In addition, there may be an occasion when the educational institution is no longer in existence and the information does not appear on the AMA profile or ECFMG. 

In those instances verification of licensure would suffice since the licensing board would have had to verify the education before granting the license.