This policy specifies the processes for the credentialing and defining of scope of practice for Grampians Health (GH) health professionals.

The existence of a sound process of credentialing and defining the scope of clinical practice is an essential component of the quality and safety framework of the health service and ensures the delivery of a patient centered, safe environment for both GH employees and the consumers of the health service.

This policy and the related procedures describes the requirements and processes to ensure that clinical credentials are checked, including appropriate registration, for GH health care professionals in line with legislative requirements and the National Standard for Credentialing and Defining the Scope of Clinical Practice.

This process is also designed to ensure GH health professionals that are appointed, and are providing patient care within GH, are competent, possess the appropriate level of skills, experience and qualifications, and are able to fulfil the tasks and responsibilities of their appointment.

Credentials represent the formal qualifications, training, experience and clinical competence of the health care professional.

Credentialing refers to the formal process used to verify the qualifications, experience, professional standing and other relevant professional attributes of health care professionals to form a view about their competence, performance and professional suitability to provide safe, high quality health care services within the specific organisational environment of GH.

Defining the scope of clinical practice follows on from credentialing and involves delineating the extent of an individual health care professionals clinical practice within GH, based on the individual's credentials, competence, performance and professional suitability and the needs of the capability of GH to support the health care professional scope of clinical practice.

Scope of practice defines the authorised extent of a health care professional's clinical practice within GH; this information is made known to the health care professional and the relevant GH departments.

Health care professionals are staff employed or engaged by Grampians Health to provide clinical care to patients within the areas of Medicine, Nursing, Allied Health, Medical Imaging and Pharmacy including employees on fixed terms, casual or ongoing contracts, external agency staff and contractors deployed at Grampians Health, honorary staff and visiting specialists.

Professional registration means recognition of fulfillment of requirements of the relevant professional registration Board to obtain required registration with that Board.

APPOINTMENTS

All health care professionals who provide patient care services in the context of clinical care within GH will be appointed in accordance with the GH Recruitment Policy (POL0141) and the protocol for Engagement of Locum and External Agency Staff (NCP0158). These appointments are subject to routine review, incorporating the health care professionals credentials and definition of scope of practice.


RESPONSIBILITIES

Individual
The individual health care professional has a responsibility to ensure:

1. They have the appropriate credentials for their position.

2. They are duly registered with the appropriate Board and inform GH of any specific conditions on their practice as soon as operational.

3. They deliver health care as per their individually defined credentialing and scope of clinical practice.

Management
Each line manager is responsible for ensuring that health care professionals within their unit/department/program are appropriately credentialed and they only deliver care within their defined scope of clinical practice.

Each professional discipline will undertake an audit at least annually to confirm the AHPRA registration of its employees engaged at GH.

Organisation
GH is responsible for implementing an appropriate clinical governance system that ensures delivery of safe, effective and patient centered care, and that the health care professionals that it engages or employs are appropriately credentialed and have their scope of clinical practice defined.


PROFESSIONAL DISCIPLINE REPORTING

The following committees are involved in the credentialing and scope of clinical practice processes for health care professionals across GH:

Medical and Dental Professionals

• Medical Credentials and Dental Credentialing and Scope of Clinical Practice Committee

Nursing Professionals

• Nursing and Midwifery Credentialing and Scope of Practice Committee

Allied Health Professionals

• Allied Health Credentialing and Scope of Practice Committee