TJC Requirements for Verifying Practitioner Identification

PUBLISHED: May 10, 2019
Relevant to: Ambulatory Care, Critical Access Hospitals, Hospitals

The Joint Commission requires that accredited organizations confirm and verify the information for any individual seeking privileges. According to TJC, organizations verifying the credentials of a individual for privileging purposes should view one of the following:

  • A current picture organizational ID card
  • A valid picture ID issued by a state or federal agency (for example, a driver’s license or passport)

The verification (i.e. the viewing of the identification) should be conducted on-site – except in cases involving telemedicine or tele-interpretive services in which case the verification can be conducted at the offsite “distant” location. TJC does not limit when the identification needs to be verified. For example, identification can be verified when an individual picks up an application, is interviewed, arrived to first provide services and/or when photo ID badge picture is taken.

TJC further explains that if an organization has multiple settings, identification verification can take place in any setting that “falls under the scope of the TJC accreditation survey.”

When identification is verified the verification shall be documented in the individual’s credentialing file.

TJC does not encourage or recommend that organizations make a copy of the photo identification for the credentials file because of the risk of identity theft.

Included with today’s notice is an example policy for identification verification for privileging purposes.

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