Physician Credentialing
A year ago, I read a Gulf News article
1 about a health care problem that continues to threaten the safety of patients in our region—credentialing of health care professionals. The Ministry of Health in Saudi Arabia discovered 4,000 forged certificates for various medical specializations after reviewing 20,870 certificates. That means approximately one in five health care professionals (doctors, nurses, technicians, etc.) in Saudi Arabia was not qualified to pursue the professional work for which they were engaged.
As I visit hospitals and talk with regulators, I am reminded that this forgery problem continues to occur. Because of the devastating impact unqualified professionals have on the quality and safety of care, it is critical that hospitals quickly identify all of their staff who are practicing with forged credentials, practicing in an area outside of their training.
While JCI does not accredit medical personnel - we only accredit health care organizations such as hospitals, polyclinics, and other service delivery facilities – we have built into all of our accreditation standards a number of requirements that reduce their risk of having unqualified professionals. JCI standards require health care organizations to:
• Verify each credential with the primary source – the organization that awarded the diploma, certificate, or other credential;
• Assign privileges to ensure doctors only practice within their competency sphere (these privileges must limit doctors to practicing only in areas where they received training);
• Ensure that nurses and other professionals are assigned according to their credentials and demonstrated competencies;
• Have an ongoing professional performance review instead of a periodic review, which will to quickly identify those whose actions render patients unsafe;
While the Middle East has become an oasis of expansion for health care, fraudulent credentials for health care professionals continues to be a major issue endangering patients. For more information on physician, nurse and other professional credentialing, please visit the Staff Qualifications and Education (SQE) standards found in the 3rd Edition of JCI’s Accreditation Standards for Hospitals, pages 204 – 212 (printed version, including detail) or 28-29 on free access to standards only.2
[1] Al Hakeem, Mariam. “Shameless.” Gulf News. February 15, 2007.
[2] http://www.jointcommissioninternational.org/common/pdfs/jcia/Standards_Only-Hosp_3rd_ed.pdf