Editorial

JCI Standards Address Physician Competencies

Editorial
Our standards require they continually look for any data suggesting a physician has a high number of undesirable outcomes such as a large number of patients with surgical complications, returns to the surgical suite, or post-operative infections, and determine the cause of these problems immediately.

In the third edition of the JCI standards, which became effective in January 2008, we strengthened our standards for verifying credentials of medical personnel.  We now require hospitals to verify the credential with the primary source – the organization that awarded the credential.  This requirement is designed to better help hospitals catch forged credentials, which are unfortunately too common in the medical field.

Here are some recent reports showing the magnitude of the forgery problem:

  • The Delhi Medical Association pledged in 2004 to work to make the capital free of frauds after determining that as many as 40,000 unqualified persons with fraudulent credentials may be practicing medicine in the city.  The association speculated at the time that every 10 minutes a patient in Delhi loses his life or undergoes irreparable damage to his health at the hands of a fraud.
  • In January 2007, the Health Ministry in Saudi Arabia discovered 4000 forged certificates for various medical specializations after reviewing 20, 870 certificates.

JCI does not accredit medical personnel; we only accredit health care organizations, such as hospitals.  We have built into our standards, however, a number of requirements that help hospitals reduce their risk of having unqualified doctors. Because of the devastating impact unqualified doctors have on the quality and safety of care, it is critical that hospitals quickly identify doctors who are practicing with forged credentials, practicing in an area outside of their training, or simply practicing unsafe medicine.

To ensure doctors only practice within their competency sphere, we have standards that require hospitals to assign privileges.  These privileges must limit doctors to practicing only in the areas where they have received training.  To help hospitals quickly identify physicians practicing unsafe medicine, we require hospitals to have an ongoing professional practice review instead of a periodic review.  


Our standards require they continually look for any data suggesting a physician has a high number of undesirable outcomes such as a large number of patients with surgical complications, returns to the surgical suite, or post-operative infections, and determine the cause of these problems immediately.  Our standards aim to ensure these problems don’t just accumulate in a file and go unnoticed by hospital administration.

We encourage all persons seeking care anywhere to research the physician they are considering using.  Patients should ask their referring physician about the doctor, research the doctor on the Internet, and ask the hospital for comparative information.  Hospitals should be able to tell patients if the procedure they are receiving is a common procedure performed by the physician and if there is any data suggesting this physician has a high number of undesirable outcomes, such as post-operative infections.

But the reality is that the medical traveler may have a more difficult time getting this type of information and find it harder to determine if he has chosen or been assigned a competent physician.  That’s why it is important that the medical traveler choose a JCI-accredited hospital.  It is one of the best tools he has to reduce his risk of having an unqualified doctor perform his surgery.

There will always be risks in medical care, but many hospitals around the world are working hard to reduce risk and improve care.  Finding these hospitals is the medical traveler’s best bet.  For more information on JCI-accredited hospitals, visit www.jointcommissioninternational.org.


Karen Timmons is President and CEO of Joint Commission International.

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