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  • Privileging and credentialing

    According to the "National Standard for Credentialing and Defining the Scope of Clinical Practice for Medical Practitioners", credentialing is defined as, "the formal process used to verify the qualifications, experience and professional standing of medical practitioners for the purpose of forming a view about their competence, performance and professional suitability to provide safe, high quality health care services within specific organisational environments."

    It is important that you and your practice staff are appropriately credentialed and have a defined scope of practice or clinical privileges that are consistent with the national standard.

    Improving your practice

    Privileging and credentialing should be thought of as a process for the initial granting or approval of clinical privileges for all health care professionals and the ongoing re-validation and review of those clinical privileges.

    All new and existing clinical staff employed in the practice should be appropriately qualified and experienced to perform their role, and should be able to provide evidence of the same.

    • All relevant clinical staff associated with the practice, including but not limited to, medical and nursing staff, should undergo an initial and ongoing credentialing and privileging process in accordance with the National Guidelines for Credentials and Clinical Privileges prior to employment and at least annually.
    • All staff associated with the practice will be appropriately qualified by having an acceptable level of knowledge, skills, attitudes and competence consistent with standards established by their registering professional body (or equivalent), and are currently practicing safely.
    • The credentialing and privileging process will consider previous and ongoing performance and reflect on the constraints and supports imposed by the available resources, including staff, equipment and physical resources available within the practice.
    • All staff will be required to provide evidence of their qualifications regularly, including registration and/or equivalent training, experience and current competence in the delivery of professional health care services for which clinical privileges are requested, as per state and national requirements.
    • The initial and ongoing process should be documented. It is the responsibility of the practice to keep the record up to date and treated in a highly confidential manner.
    • The process should encompass the National Guidelines for Credentials and Clinical Privileges, including:
      • Definitions
      • General principles
      • Definitions
      • Committees
      • Privileges Appeal Tribunal
      • Credentialing process
      • Duration of clinical privileges
      • Review of clinical privileges
      • Appeals process
      • Termination of clinical privileges
       

    The public register of practitioners available on the AHPRA website can provide high-level information about the status of all health practitioners who are registered to practise in Australia. The register provides information on the specialty of practice that the practitioner is registered to practice and any endorsements or conditions on their registration.

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    Tools and Resources

    Download the Privileging & Credentialing checklist

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    References

    Australian Council for Safety and Quality in Health Care (2005), Credentialing and Defining the Scope of Clinical Practice Handbook

    Australian Commission on Safety and Quality in Health Care, Credentialing for Health Professionals