Standards FAQ Details | Joint Commission
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Friday 8:56 CST, February 5, 2016

Standards FAQ Details

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


Verifying Affiliations/Privlege or Work History at other Healthcare Organizations
Current | March 24, 2010
Q. Are organizations required to verify affiliations at other health care organizations, and if yes, for how many years back must the verifications be done?

A. There is no standards requirement to verify hospital/other healthcare organization affiliations or privileges/clinical responsibilities or work history for any applicant. The hospital MS.06.01.05 and MS.06.01.13 and the HR.02.01.03 requirements are to evaluate:

  • voluntary or involuntary relinquishment of any license or registration
  • voluntary or involuntary termination of medical staff membership
  • voluntary or involuntary limitation, reduction, or loss of clinical privileges

Simply verifying affiliations would not meet these requirements.

If you ask the questions of the applicant, usually in the application, and the applicant's answers do not conflict with the information obtained when you query the NPDB, then there is no need to contact the other facilities or licensing/registration bodies. You would only need to contact them if the information conflicts.

In addition a statement indicating that a practitioner is in "good standing" without knowing the criteria for someone being placed in "good standing or bad standing" would be meaningless information. In many organizations practitioners can have numerous performance issues and the organization would never indicate that the individual's status is anything other than in "good standing".

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