1. Clinical Governance

Credentialing and scope of clinical practice

Action 1.23

The health service organisation has processes to:

a. Define the scope of clinical practice for clinicians, considering the clinical service capacity of the organisation and clinical services plan

b. Monitor clinicians’ practices to ensure that they are operating within their designated scope of clinical practice

c. Review the scope of clinical practice of clinicians periodically and whenever a new clinical service, procedure or technology is introduced or substantially altered

Intent

Clinicians are appropriately skilled and experienced to perform their roles safely, and to provide services within agreed scope of clinical practice.

Reflective questions

What processes are used to ensure that clinicians are working within the agreed scope of clinical practice when providing patient care?

How does the health service organisation match the services provided with the skills and capability of the workforce?

How does the health service organisation assess the safety and quality of a new clinical service, procedure or technology?

Key tasks

  • Verify that the organisation has adopted and implemented an evidence-based process for defining scope of clinical practice for all clinicians, including those with independent decision-making authority or working under supervision

  • Consider whether the process for defining scope of clinical practice is appropriately designed, resourced, maintained and monitored.

  • Incorporate periodic review of the organisation’s process for defining scope of clinical practice into audit programs, with a focus on consistency with adopted standards, performance measures and outcomes.

Strategies for improvement

Hospitals

Scope of clinical practice processes are key elements in ensuring patient safety. The purpose is to ensure that only clinicians who are suitably experienced, trained and qualified to practise in a competent and ethical manner can practise in health service organisations.1

All clinicians providing care in a health service organisation must have their scope of clinical practice clearly defined. The processes for defining scope of clinical practice may include developing a position description, conducting a credentialing process or describing the clinician’s role in a contract for services. Regardless of the form, the process describes the mutual commitment between the organisation and each member of the clinical workforce to provide safe, high-quality care.

The governing body should ensure that processes are in place for monitoring and maintaining effective processes for defining scope of clinical practice. The governing body is responsible for ensuring that compliance is monitored and reported, and that variations are investigated.

Define scope of clinical practice

The Standard for Credentialling and Defining the Scope of Clinical Practice2 describes structures and processes that ensure:

  • Clear definition of clinicians’ scope of clinical practice in the context of the organisation’s needs and capability
  • Regular review of clinicians’ scope of clinical practice
  • Safe and appropriate introduction of new clinical services, procedures and other technologies
  • Appropriate supervision of clinicians, when necessary
  • Effective processes for reviewing clinicians’ competence and performance
  • Procedures to be followed if a concern arises about the capability of a clinician.

Outline policies for junior clinicians

Junior clinicians routinely provide services under supervision. The number of junior clinicians is large, their skills are developing, and their employment may be transient as they move through training programs. Therefore, individualised approaches to defining the scope of clinical practice for junior clinicians may be impracticable. Although some organisations may choose to include junior clinicians in their general credentialing and scope of clinical practice processes, most organisations adopt policies that set clear limits on the scope of clinical practice of junior clinicians of varying levels. These policies define the scope of clinical practice for varying levels of seniority, and the requirements for effective supervision and support at each level.

Supervising all junior clinicians according to their assessed capabilities and consistent with organisational policies is a key safeguard of the safety and quality of care. Define clinical supervision responsibilities in senior clinicians’ employment contracts.

Examples of evidence

Select only examples currently in use:

  • Policy documents about the scope of clinical practice for clinicians in the context of the organisation’s needs and capability
  • Committee and meeting documents that include information on the roles, responsibilities, accountabilities and monitoring of scope of clinical practice for the clinical workforce
  • Audit results of position descriptions, duty statements and employment contracts against the requirements and recommendations of clinical practice and professional guidelines
  • Audit results of diagnosis-related groups cared for by clinicians compared with their granted scope of clinical practice and the organisation’s clinical services capability framework
  • Reports of key performance indicators for clinicians
  • Audit results of signatures and role designation in patient healthcare records
  • Workforce performance appraisal and feedback records that show a review of the scope of clinical practice for the clinical workforce
  • Peer-review reports
  • Evaluation of the health service organisation’s clinical services targets
  • Procedure manuals or guidelines for new services, procedures and technologies
  • Defined competency standards for new services, procedures and technologies
  • Planning documents to introduce new services (including workforce, equipment, procedures, scope of clinical practice applications and approval for licensing)
  • Training documents about new clinical services, procedures and technologies
  • Communication to the workforce that defines the scope of clinical practice for new clinical services, procedures or technologies.
Day Procedure Services

Scope of clinical practice processes are key elements in ensuring patient safety. The aim is to ensure that only clinicians who are suitably experienced, trained and qualified to practise in a competent and ethical manner can practise in health service organisations.1

All clinicians providing care in a health service organisation must have their scope of clinical practice clearly defined. The processes for defining scope of clinical practice may include developing a position description, conducting a credentialing process or describing the clinician’s role in a contract for services. Regardless of its form, the process describes the mutual commitment between the organisation and each member of the clinical workforce to provide safe, high-quality care.

The governing body should ensure that processes are in place for monitoring and maintaining effective systems for defining scope of clinical practice. The governing body is responsible for ensuring that compliance is monitored and reported, and that variations are investigated.

Define scope of clinical practice

The Standard for Credentialing and Defining the Scope of Clinical Practice2 describes structures and processes that ensure:

  • Clear definition of clinicians’ scope of clinical practice in the context of the organisation’s needs and capability
  • Regular review of clinicians’ scope of clinical practice
  • Safe and appropriate introduction of new clinical services, procedures and other technologies
  • Appropriate supervision of clinicians, when necessary
  • Effective processes for reviewing clinicians’ competence and performance
  • Procedures to be followed if a concern arises about the capability of a clinician.1

Examples of evidence

Select only examples currently in use:

  • Policy documents about the scope of clinical practice for clinicians in the context of the organisation’s needs and capability
  • Committee and meeting documents that include information on the roles, responsibilities, accountabilities and monitoring of scope of clinical practice for the clinical workforce
  • Audit results of position descriptions, duty statements and employment contracts against the requirements and recommendations of clinical practice and professional guidelines
  • Audit results of diagnosis-related groups cared for by clinicians compared with their granted scope of clinical practice and the organisation’s clinical services capability framework
  • Reports of key performance indicators for clinicians
  • Audit results of signatures and role designation in patient healthcare records
  • Workforce performance appraisal and feedback records that show a review of the scope of clinical practice for the clinical workforce
  • Peer-review reports
  • Evaluation of the health service organisation’s clinical services targets
  • Procedure manuals or guidelines for new services, procedures and technologies
  • Defined competency standards for new services, procedures and technologies
  • Planning documents to introduce new services (including workforce, equipment, procedures, scope of clinical practice applications and approval for licensing)
  • Training documents about new clinical services, procedures and technologies
  • Communication to the workforce that defines the scope of clinical practice for new clinical services, procedures or technologies.
MPS & Small Hospitals

MPSs or small hospitals that are part of a local health network or private hospital group should implement and use the established processes for defining scope of clinical practice.

Small hospitals that are not part of a local health network or private hospital group should develop or adapt processes to:

  • Verify that the organisation has implemented an evidence-based process for defining scope of clinical practice for all clinicians, including those with independent decision-making authority or working under supervision
  • Consider whether the process for defining scope of clinical practice is appropriately designed, resourced, maintained and monitored
  • Incorporate periodic review of the organisation’s process for defining scope of clinical practice into audit programs, with a focus on consistency with adopted standards, performance measures and outcomes.

Scope of clinical practice processes are key elements in ensuring patient safety. The aim is to ensure that only clinicians who are suitably experienced, trained and qualified to practise in a competent and ethical manner can practise in health service organisations.1

The Standard for Credentialling and Defining the Scope of Clinical Practice2 describes structures and processes that ensure:

  • Clear definition of clinicians’ scope of clinical practice in the context of the organisation’s needs and capability
  • Regular review of clinicians’ scope of clinical practice
  • Safe and appropriate introduction of new clinical services, procedures and other technologies
  • Appropriate supervision of clinicians, when necessary
  • Effective processes for reviewing clinicians’ competence and performance
  • Procedures to be followed if a concern arises about the capability of a clinician.

Examples of evidence

Select only examples currently in use:

  • Policy documents about the scope of clinical practice for clinicians in the context of the organisation’s needs and capability
  • Committee and meeting documents that include information on the roles, responsibilities, accountabilities and monitoring of scope of clinical practice for the clinical workforce
  • Audit results of position descriptions, duty statements and employment contracts against the requirements and recommendations of clinical practice and professional guidelines
  • Audit results of diagnosis-related groups cared for by clinicians compared with their granted scope of clinical practice and the organisation’s clinical services capability framework
  • Reports of key performance indicators for clinicians
  • Audit results of signatures and role designation in patient healthcare records
  • Workforce performance appraisal and feedback records that show a review of the scope of clinical practice for the clinical workforce
  • Peer-review reports
  • Evaluation of the health service organisation’s clinical services targets
  • Procedure manuals or guidelines for new services, procedures and technologies
  • Defined competency standards for new services, procedures and technologies
  • Planning documents to introduce new services (including workforce, equipment, procedures, scope of clinical practice applications and approval for licensing)
  • Training documents about new clinical services, procedures and technologies
  • Communication to the workforce that defines the scope of clinical practice for new clinical services, procedures or technologies.

Action 1.24

The health service organisation:

a. Conducts processes to ensure that clinicians are credentialed, where relevant

b. Monitors and improves the effectiveness of the credentialing process

Intent

A formal process is used to ensure that clinicians have the appropriate qualifications, experience and skills to fulfil their delegated roles and responsibilities.

Reflective question

What processes are used to ensure that clinicians have the appropriate qualifications, experience, professional standing, competencies and other relevant professional attributes?

Key tasks

  • Ensure that the processes for credentialing clinicians are documented in the organisation’s policies, procedures or protocols.

  • Review results of audits and system evaluation reports for compliance with the credentialing policies, procedures or protocols.

Strategies for improvement

Hospitals

Health service organisations are required to appoint clinicians who are suitably experienced, skilled and qualified to practise in a competent and ethical manner, taking into account service needs and organisational capability. Organisations have several processes to ensure that clinicians are suitably credentialed before they start work.

These are detailed in the Commission’s Credentialing Health Practitioners and Defining their Scope of Clinical Practice: A guide for managers and practitioners.1

Collect evidence of credentials

Collect evidence of minimum credentials as part of any recruitment process, and reconsider the evidence when there is a change in circumstances or a change in role for clinicians. Verify the information submitted by, or on behalf of, a clinician for determining scope of clinical practice, even when a recruitment agency is used to source applicants and they perform some verification processes.

Collect evidence for each of the following areas1:

  • Education, qualifications and formal training
  • Previous experience, including relevant clinical activity and experience in similar settings to the relevant scope of clinical practice
  • Clinician references and referee checks
  • Continuing education that relates to a role in which the clinician is engaged and that is relevant to the scope of clinical practice
  • Current registration with the relevant national board
  • Professional indemnity insurance
  • Other documentation and pre-employment checks, such as
    • a current curriculum vitae
    • an applicant’s declaration
    • proof of identity (100-point identity check)
    • passport and copies of relevant visas (for overseas-trained practitioners)
    • a police or working with children check
  • The applicant having no registration board restrictions or conditions on their registration, no criminal history, no report of professional misconduct against them, no report of unsatisfactory professional conduct and no outstanding complaints
  • Permission to contact previous facilities or organisations where the clinician has been employed.

The credentialing process requires submission and review of a number of supporting documents. If the originals are not supplied or previously verified through other processes, organisations may require certification by a Justice of the Peace or similar recognised certifying agent.

Given the diversity of skills and experience of internationally qualified clinicians, it is important that the references and checks on education, training, competencies and experience are thorough and diligent. Consider any added support, supervision or training that may be required by international clinicians to ensure that their practices are safe.1

Improve the credentialing process

Monitoring and improving the effectiveness of the credentialing process may involve:

  • Setting up credentialing committees with clear terms of reference, and ensuring that committee members understand their responsibilities, and have the required knowledge and skills to fulfil their responsibilities
  • Reviewing and validating the processes for credentialing, defining and managing scope of clinical practice, and ensuring that these are diligent and effective
  • Verifying (and periodically re-verifying) each clinician’s credentials following defined organisational policy.

Examples of evidence

Select only examples currently in use:

  • Policy documents that describe the formal credentialing processes for health practitioners
  • Committee and meeting records for the credentialing committee
  • Register of workforce qualifications and areas of credentialed practice
  • Documented recruitment processes that ensure that clinicians are matched to positions, and have the required skills, experience and qualifications to perform their roles and responsibilities
  • Employment documents that define the roles of clinical supervisors and trainees undertaking regular clinical supervision
  • Evidence that the health service organisation has verified clinicians’ qualifications before employment
  • Documented use of a checklist for scope of clinical practice
  • Documented performance reviews or peer reviews for the clinical workforce
  • Audit results of clinical documentation for compliance with guidelines, policies, procedures or protocols
  • Documented process for identifying clinicians to be credentialed.
Day Procedure Services

Health service organisations are required to appoint clinicians who are suitably experienced, skilled and qualified to practise in a competent and ethical manner, taking into account service needs and organisational capability. Organisations have several processes to ensure that clinicians are suitably credentialed before they start work.

These are detailed in Credentialing Health Practitioners and Defining their Scope of Clinical Practice: A guide for managers and practitioners.3

Collect evidence of credentials

Collect evidence of minimum credentials as part of any recruitment process, and reconsider the evidence when there is a change in circumstances or a change in role for clinicians. Verify the information submitted by, or on behalf of, a clinician for determining scope of clinical practice, even when a recruitment agency is used to source applicants and they conduct some verification processes.

Collect evidence for each of the following areas3:

  • Education, qualifications and formal training
  • Previous experience, including relevant clinical activity and experience in similar settings to the relevant scope of clinical practice
  • Clinician references and referee checks
  • Continuing education that relates to a role in which the clinician is engaged and that is relevant to the scope of clinical practice
  • Current registration with the relevant national board
  • Professional indemnity insurance
  • Other documentation and pre-employment checks, such as
    • a current curriculum vitae
    • an applicant’s declaration
    • proof of identity (100-point identity check)
    • passport and copies of relevant visas (for overseas-trained practitioners)
    • a police or working with children check
  • The applicant having no registration board restrictions or conditions on their registration, no criminal history, no report of professional misconduct against them, no report of unsatisfactory professional conduct and no outstanding complaints
  • Permission to contact previous facilities or organisations where the clinician has been employed.

The credentialing process requires submission and review of a number of supporting documents. If the originals are not supplied or previously verified through other processes, organisations may require certification by a Justice of the Peace or similar recognised certifying agent.

Given the diversity of skills and experience of internationally qualified clinicians, it is important that the references and checks on education, training, competencies and experience are thorough and diligent. Consider any extra support, supervision or training that may be required by international clinicians to ensure that their practices are safe.3

Improve the credentialing process

Monitoring and improving the effectiveness of the credentialing process may involve:

  • Setting up credentialing committees with clear terms of reference, and ensuring that committee members understand their responsibilities, and have the required knowledge and skills to fulfil their responsibilities
  • Reviewing and validating the processes for credentialing, defining and managing scope of clinical practice, and ensuring that these are diligent and effective
  • Verifying (and periodically re-verifying) each clinician’s credentials following defined organisational policy.

Examples of evidence

Select only examples currently in use:

  • Policy documents that describe the formal credentialing processes for health practitioners
  • Committee and meeting records for the credentialing committee
  • Register of workforce qualifications and areas of credentialed practice
  • Documented recruitment processes that ensure that clinicians are matched to positions, and have the required skills, experience and qualifications to perform their roles and responsibilities
  • Employment documents that define the roles of clinical supervisors and trainees undertaking regular clinical supervision
  • Evidence that the health service organisation has verified clinicians’ qualifications before employment
  • Documented use of a checklist for scope of clinical practice
  • Documented performance reviews or peer reviews for the clinical workforce
  • Audit results of clinical documentation for compliance with guidelines, policies, procedures or protocols
  • Documented process for identifying clinicians to be credentialed.
MPS & Small Hospitals

Health service organisations are required to appoint clinicians who are suitably experienced, skilled and qualified to practise in a competent and ethical manner, taking into account service needs and organisational capability.

MPSs or small hospitals that are part of a local health network or private hospital group should implement and use the established credentialing system, when relevant.

Small hospitals that are not part of a local health network or private hospital group should develop or adapt a system for credentialing and:

  • Ensure that the processes for credentialing clinicians are documented in the organisation’s policies, procedures or protocols
  • Review results of audits and system evaluation reports for compliance with the credentialing policies, procedures or protocols.

Organisations could form partnerships to jointly conduct credentialing processes.

Organisations will need to collect evidence of minimum credentials as part of any recruitment process, and reconsider the evidence when there is a change in circumstances or a change in role for clinicians. Collect evidence for each of the following areas1:

  • Education, qualifications and formal training
  • Previous experience, including relevant clinical activity and experience in similar settings to the relevant scope of clinical practice
  • Clinician references and referee checks
  • Continuing education that relates to a role in which the clinician is engaged and that is relevant to the scope of clinical practice
  • Current registration with the relevant national board
  • Professional indemnity insurance
  • Other documentation and pre-employment checks, such as a curriculum vitae, proof of identity, and a police or working with children check.

For more information, refer to Credentialing Health Practitioners and Defining their Scope of Clinical Practice: A guide for managers and practitioners.1

Examples of evidence

Select only examples currently in use:

  • Policy documents that describe the formal credentialing processes for health practitioners
  • Committee and meeting records for the credentialing committee
  • Register of workforce qualifications and areas of credentialed practice
  • Documented recruitment processes that ensure that clinicians are matched to positions, and have the required skills, experience and qualifications to perform their roles and responsibilities
  • Employment documents that define the roles of clinical supervisors and trainees undertaking regular clinical supervision
  • Evidence that the health service organisation has verified clinicians’ qualifications before employment
  • Documented use of a checklist for scope of clinical practice
  • Documented performance reviews or peer reviews for the clinical workforce
  • Audit results of clinical documentation for compliance with guidelines, policies, procedures or protocols
  • Documented process for identifying clinicians to be credentialed.
Last updated 21st June, 2018 at 10:43pm
BACK TO TOP
References

Australian Commission on Safety and Quality in Health Care. Credentialing health practitioners and defining their scope of clinical practice: a guide for managers and practitioners. Sydney: ACSQHC; 2015.

Australian Council for Safety and Quality in Health Care. Standard for credentialling and defining the scope of clinical practice: a national standard for credentialling and defining the scope of clinical practice of medical practitioners, for use in public and private hospitals. Canberra: Australian Council for Safety and Quality in Health Care; 2004 (accessed Sep 2017).