Joint Commission SQE Medical Staff

http://www.jointcommission.org/

Primary Source Verification Medical Staff

Excerpts from Joint Commission International Accreditation Standards for Hospitals, Third Edition

The Joint Commission is an independent, not‐for‐profit organization, The Joint Commission accredits and certifies more than 19,000 health care organizations and programs in the United States. Joint Commission accreditation and certification is recognized nationwide as a symbol of quality that reflects an organization’s commitment to meeting certain performance standards.

Mission: To continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value.

Vision Statement: All people always experience the safest, highest quality, best‐value health care across all settings.

Medical Staff

SQE.9 The organization has an effective process for gathering, verifying, and evaluating the credentials (license, education, training, and experience) of those medical staff permitted to provide patient care without supervision

Intent of SQE.9

Physicians, dentists, and others who are licensed to provide patient care without clinical supervision represent those primarily responsible for patient care and care outcomes (also see Glossary). Thus, the organization has the highest level of accountability to ensure that each of these practitioners is qualified to provide safe and effective care and treatment to patients.

The organization assumes this accountability by

• Verification of the essential information such as current registry or licensure, especially when such documents are periodically renewed, and any certification and evidence of completion of postgraduate education.

The organization needs to make every effort to verify essential information, even when the education took place in another country and a significant time ago. Secure Web sites, documented phone confirmation from the source, written confirmation, and third parties, such as a designated, official governmental or nongovernmental agency, can be used.

Nursing Staff

SQE. 12.

The organization has an effective process to gather, verify, and evaluate the nursing staff’s credentials (license, education, training, and experience).

Intent of SQE.12 The organization needs to ensure that it has a qualified nursing staff that appropriately matches its mission resources, and patient needs. The nursing staff are responsible for providing direct patient care. In addition, nursing care contributes to the overall patient outcomes. The organization must ensure that nurses are qualified to provide nursing care and must specify the types of care they are permitted to provide if not identified in laws or regulations. The organization ensures that each nurse is qualified to provide safe and effective care and treatment to patients by

• understanding the applicable laws and regulations that apply to nurses and nursing practice;

• • • •

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gathering all available credentials on each nurse, including at least evidence of education and training; evidence of current licensure; evidence of current competence through informarion from other sources in which the nurse was employed; and also letters of recommendation and or other information the organization may require such as health, history, pictures, verification of the essential information such as current registry or licensure, especially when such as documents are periodically renewed, and any certifications and evidence of completion of specialized or advanced education.

Other Health Professional Staff

SQE.15 The organization has a standardized procedure to gather, verify, and evaluate other health professional staff members’ credentials (license, education, training, and experience).

Intent of SQE.15

Health care organizations employ or may permit a variety of other health professionals to provide care and services to their patients or participate in patient care processes (also see Glossary). For example, these professionals include nurses, midwives, surgical assistants, emergency medical care specialists, pharmacists, and pharmacy technicians.

In some countries or cultures, this group also includes traditional healers or those considered to provide services that complement or provide alternatives to traditional medical practice (for example, acupuncture, herbal medicine). Often, these individuals do not actually practice in the organization instead, they refer to the organization or provide continuing or follow‐up care for patients in the community. Many of these professionals complete formal training programs and receive a license or certificate or are registered with local or national authorities. Others may complete less formal apprentice programs or other supervised experiences.

For those other health professionals permitted to work or practice in the health care organization, the organization is responsible for gathering and verifying their credentials, The organization must ensure that other health professional staff are qualified to provide care and treatments and must specify the types of care an treatment they are permitted to provide if not identified in laws or regulations. The organization ensures the other health professionals are qualified to provide safe and effective care and treatment to patients by • understanding the applicable laws and regulations that apply to such practitioners;

• gathering all available credentials on each individual including at least evidence of education and training, evidence of current licensure or certification when required; and • verification of the essential information such as current registry licensure, or certification.