Action 1.24 states

The health service organisation:

  1.  Conducts processes to ensure that clinicians are credentialed, where relevant
  2.  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

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

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 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 extra 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.

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:

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.

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

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

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 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 extra 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.

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:

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.

Reference

  1. 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.