Part 2: Standard process for credentialing and defining scope of clinical
14. Renewal of credentialing and scope of clinical practice process 29
Scheduled re-credentialing and renewal of a practitioner’s SoCP must occur as a part of an organisational strategy to ensure each practitioner’s credentials remain current and relevant, and that the practitioner remains competent to provide the defined SoCP. Renewal of SoCP must occur at a maximum of five-year intervals. There is no
obligation on a particular public healthcare facility to maintain the SoCP previously granted.
The committee MUST, as a minimum, examine the following information:
a) A completed and signed the application form11 for credentialing and SoCP (refer to Appendix 4).
b) In checking the application for SoCP, should an applicant respond ‘yes’ to any questions under ‘applicant’s declaration and authorisation’, principles of natural justice and procedural fairness must be applied before making an adverse decision against the applicant based on the information provided by the applicant. It is the obligation of the practitioner to advise the committee of the following:
• limitation on SoCP by another public health facility;
• any other matter the committee could reasonably expect to be disclosed in order for the committee to make an informed decision on credentials and SoCP. Failure to fully inform the committee may result in suspension and a review of the applicant’s SoCP (refer to Part 4).
c) Verification of the practitioner’s registration status in the appropriate category with AHPRA. Any decision regarding a practitioner’s SoCP must take into account any conditions, notations or undertakings on their registration. For example, if a practitioner has given an undertaking to AHPRA that they will refrain from
performing a particular procedure, then their SoCP in every public health facility at which they work should reflect the exclusion of the procedure from their SoCP. NB: It is the obligation of the practitioner to advise the committee of any conditions, undertakings, notations or other restrictions on their registration; or
Failure to fully inform the committee may result in suspension and a review of the applicant’s SoCP (refer to Part 4).
d) The committee may request the applicant’s current curriculum vitae, the preferred format being the AHPRA standard format.
NB: any employment gaps greater than three calendar months require explanation.
e) Documented evidence of participation in relevant professional development activities (CPD/ CME/ PDP/ MOPS) in the requested SoCP. This includes, but is not limited to a range of activities to meet individual learning needs, including practice-based reflective elements, such as clinical audit, peer-review or
11
NB: under the Electronic Transactions (Queensland) Act 2001, “due to the applicant’s signature on the Application for scope of clinical practice form being required to be witnessed by another person, an electronic signature is not able to
performance appraisal, as well as participation in activities to enhance knowledge, such as courses, conferences and online learning. It is expected, at a minimum, that applicants will meet the requirements established by AHPRA and the colleges. For applicants who have obtained a Fellowship within the past 12 months, the Fellowship certificate/letter from the college confirming fellowship will be considered to be sufficient evidence of professional development at the time of application only.
f) If the practitioner is employed by the HHS/DoH division, at least one reference from their clinical line manager or their director is required. In all other cases (such as locums, medical practitioners treating patients in aged public health facilities etc) two references are required.
A referee should be independent of the applicant with no conflict of interest, and who can attest to the applicant’s clinical performance within the previous 12 calendar months.
NB: Referee reports must be taken into account, however they should not replace the committee’s duty to enquire and act with due care and diligence.
g) In determining SoCP, consideration should be taken in regards to resources and the needs of the public health facility to ensure consistency with the CSCF service level(s) to support the clinical work undertaken.
h) Check and retain a copy of the ‘internet search’ conducted in accordance with the protocol in Recruitment and Selection HR Policy B1.
14.1 Other information relevant to safe practice
The committee may consider any other material they believe is reasonably relevant to safe practice, including, but not limited to:
reports from, the Office of the Health Ombudsman, AHPRA and/or Medicare Australia
patient and staff complaints
medical indemnity history and status, including audits of litigation matters clinical review and audit information
information made available from any Queensland Health investigations.
14.2 Recommendation and approval of scope of clinical
practice
The following processes and management for the renewal of credentialing and SoCP are the same as the standard application for credentialing and SoCP.
Refer to:
Requests for further information (refer to Part 2, Section 4.3). Duration of scope of clinical practice (refer to Part 2, Section 4.4). Credentialing Committee recommendation (refer to Part 2, Section 4.5). Decision of HSCE/division CE or delegate (refer toPart 2, Section 4.6).