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Credentialing and defining the scope of clinical practice


Directive number: QH-HSD-034: 2014

Effective date: 24 November 2021

Review date: 24 November 2024

Supersedes: Version 2.1

On this page:

Purpose

This Health Service Directive (HSD) supports the delivery of safe and high quality health care by requiring Hospital and Health Services (HHSs) to implement a policy framework to ensure that health professionals, identified in the specific professional stream mandatory requirements, are credentialed and have a defined scope of clinical practice (SoCP).

It also outlines statewide and regional clinical services which require health professionals to have a statewide or regional SoCP (refer to Schedule A).

Scope

This HSD applies to all HHSs and is relevant to health professionals identified in the professional stream requirements section of this document.

Health professionals employed within the Department of Health (the department) should refer to the appropriate policy, standard and/or guideline.

Principles

  • Credentialing and SoCP supports patient safety and clinical governance. It ensures health professionals practise within the bounds of their role/position, education, training, experience and competence, and within the capacity, capability and available support of the facility or service in which they are practising.
  • Recommendations and decisions are made with due care and diligence. Credentialing and SoCP is a non-punitive process underpinned by accountability, procedural fairness, natural justice and transparency.
  • Applicants are treated equally and without discrimination. All recommendations and decisions are based on the professional competence of the health professional and the capacity and capability of the relevant service.
  • A risk management approach is adopted when developing and implementing a policy framework which details the processes, accountabilities and requirements that best reflect the risk profile and organisational needs of the HHS.
  • National standards are used as the benchmark for developing and implementing a HHS policy framework.

Outcomes

HHSs shall achieve the following outcomes:

  • HHSs will have a local policy framework for credentialing and defining the SoCP
  • Health professionals identified in this directive who are employed or engaged by the HHS will be credentialed and have a defined SoCP in accordance with the HHS’s local policy framework
  • Health professionals employed or engaged to provide a statewide or regional service will be credentialed and have a defined SoCP appropriate to that service
  • HHSs will meet the current National Safety and Quality Health Service Standards assessment criteria relevant to credentialing and defining SoCP.

Mandatory requirements

HHSs shall:

  • maintain a policy framework for credentialing and defining the SoCP for identified health professionals that:
    • identifies positions, roles and/or specific procedures or practices within the HHS that are required to undergo formal credentialing and defining the SoCP processes
    • describes the roles and responsibilities of health professionals, committees and decision-makers in the credentialing and defining the SoCP processes
    • defines the maximum duration of a SoCP and the process for renewing a SoCP
    • details the mandatory core requirements for a credentialing application including evidence to support safe practice, including currency of practice and clinical outcomes relevant to the requested SoCP
    • includes a process to mutually recognise a health professional’s credentialing and SoCP from another HHS or the department
    • includes a process for approving temporary SoCP
    • describes how a health professional or the HHS can modify the health professional’s SoCP
    • affords health professionals the right to request the review of or to appeal a decision regarding their SoCP.
  • ensure that delegations for credentialing and SoCP decision making, represented in the HHS HR Delegations Manual: HRM Functions of the Director-General or Instruments of Delegation, as amended from time to time, are reflected in the HHS policy and local human resources delegation frameworks
  • ensure the process for reviewing credentials and defining the SoCP is led or informed by relevant health profession specific peers and includes input from a multidisciplinary team
  • have an established and maintained process which regularly monitors and improves the effectiveness of the HHS credentialing and SoCP process
  • have a process in place which monitors health professionals’ practices to ensure the health professional practises within their defined SoCP
  • provide an immediate report, by briefing to the Chief Health Officer and Deputy Director-General, Prevention Division, in their capacity as custodian of this HSD, where credentialing and SoCP may be a contributing factor in a clinical incident that:
    • may result in media attention which may require a response by the department
      OR
    • was rated as a high risk or a SAC 1 event.
  • publish an up-to-date register of health professionals who are credentialed and have a defined SoCP
  • recognise the approved statewide and regional SoCPs for services listed in Schedule A
  • conduct an annual self-assessment against this HSD and submit their compliance statement to the HSD custodian by the end of each financial year to assist with HSD compliance monitoring.

Specific mandatory professional stream requirements

1. Medical practitioners

HHSs shall ensure:

  • all senior medical officers and visiting medical officers employed or otherwise engaged by the HHS have a current documented SoCP covering all work performed
  • all medical practitioners undertaking licenced private practice within a Queensland public health facility have a current documented SoCP covering all work performed
  • a process is in place, following the principles of risk management, to identify independently practising medical practitioners:
    • not listed above who are required to have a current documented SoCP covering all work performed
      OR
    • that are listed above but may be exempt from credentialing and SoCP in specific circumstances.

2. Nurses

HHSs shall ensure:

  • nurse practitioners are credentialed and have a current documented SoCP covering all work performed
  • nurses undertaking specific procedures or practices that require specific training or qualifications have a current documented SoCP
  • privately practicing nurses working within Queensland public health facilities, but not employed by Queensland Health, are credentialed and have a current documented SoCP covering all work performed.

3. Midwives

HHSs shall ensure:

  • midwives undertaking specific procedures or practices that require specific training or qualifications have a current documented SoCP
  • privately practicing midwives working within Queensland public health facilities, but not employed by Queensland Health, are credentialed and have a current documented SoCP covering all work performed.

4. Allied Health professionals

HHSs shall:

  • ensure all allied health professionals intending to engage in an extended scope of practice are credentialed and have a current documented defined SoCP
  • implement a system to ensure that professional supervision is in place for all allied health professionals with supervisors who have appropriate training, expertise and/or qualifications. Professional supervision is accessed by all allied health professions regardless of an individual employee’s clinical area, career stage, location or profession. For the allied health workforce, professional supervision is the core instrument for providing ongoing review of and managing changes in SoCP.

5. Dental practitioners

HHSs shall ensure:

  • all dental practitioners within the registered divisions of dentist and dental specialist are credentialed and have a current documented SoCP covering all work performed.
  • dental therapists and oral health therapists undertaking specific procedures or practices that require specific training or qualifications are credentialed and have a current documented SoCP.

6. Aboriginal and Torres Strait Islander health practitioners

HHSs shall ensure all Aboriginal and Torres Strait Islander Health Practitioners have an approved Practice Plan, in the approved form, in place covering all work performed.

Telehealth

Credentialing and defining the SoCP is applicable where telephone or videoconferencing technologies are used to conduct a patient consultation where the patient and health professional are not in the same physical location and audio and/or visual information is exchanged in real time.

HHSs providing telehealth services (where the health professional is primarily engaged or employed) shall ensure all health professionals providing telehealth consultations are appropriately credentialed and have a defined SoCP in accordance with the local policy framework.

Where the telehealth service is provided by a contracted service, private provider, or non-government organisation, the HHS receiving the service (where the patient is located) shall ensure credentialing and SoCP requirements and responsibilities are clearly defined in the local policy framework and the contract or service agreement.

Organ retrieval services

DonateLife Queensland coordinates all organ and tissue donor activities across Queensland and is part of the Australian DonateLife network. The clinical governance for organ donation is underpinned by Commonwealth and state legislation, and national clinical guidelines and standards.

Organ retrieval teams, performing organ retrieval surgery on deceased donors, are engaged by recognised transplant units across Australia and New Zealand. A list of recognised transplant units is available in Appendix H of the Transplantation Society of Australia and New Zealand, Clinical Guidelines for Organ Transplantation from Deceased Donors.

Members of Queensland based organ retrieval teams will have an appropriate statewide SoCP approved by the relevant HHS as listed in Schedule A.

Organ retrieval surgery on deceased donors is also undertaken by organ retrieval teams from other jurisdictions, including New Zealand. DonateLife Queensland works with these jurisdictions to coordinate access to Queensland hospitals for the purpose of organ retrieval surgery. These teams will come from recognised transplant units and practice within national clinical governance frameworks and guidelines.

Therefore, no additional local HHS credentialing or SoCP is required for organ retrieval teams coming to a Queensland public health facility to perform organ retrieval surgery on deceased donors.

Declared public health emergencies

A public health emergency declared under Section 362B of the Public Health Act 2005 may require health professionals to undertake functions that would ordinarily require credentialing and SoCP.

An Emergency Order (an order) may be made by the chief executive under section 58 of the Medicine and Poisons Act 2019 in response to the public health emergency. Should an order describe the credentials and define the SoCP for health professionals providing services in accordance with the order, no additional local HHS credentialing and SoCP is required.

Schedule A—statewide and regional services

It is important to note that Schedule A requires the collaboration of both the HHSs and the department to enact. Therefore, the content within Schedule A of this HSD is also incorporated reciprocally in the department’s policy Credentialing and defining the SoCP (QH-POL-390:2015). References to the HHSs and the department within the schedule are relevant.

Statewide and regional services are coordinated by the department or a HHS and provided to multiple other HHSs across Queensland. Examples of these services are listed in HHS Service Agreements, Schedule 2 Funding and Purchased Activity and Services (Section 7), Purchased Services.

For a service to be eligible to approve statewide or regional SoCP the service must require health professionals to travel to other HHSs and meet at least one of the following criteria:

  • a statewide or regional service approved in accordance with the department’s policy Statewide Services (QH-POL-488:2021)
  • listed in a HHS Service Agreement, Schedule 2 Funding and Purchased Activity and Services (Section 7), Purchased Services, as one of the following:
    • state-funded outreach services
    • clinical statewide services
    • clinical support statewide services
    • regional services
    • rural and remote clinical support services
    • prevention services
  • operate an indisputable statewide or regional service by virtue of having a single service and single employer model whereby those health professionals travel across the state or to multiple HHSs.

The provision of these services requires health professionals to travel to facilities in other HHSs. These health professionals are therefore eligible to have an appropriate defined SoCP relevant to the service. HHSs responsible for coordinating and managing a service listed in Schedule A can approve the relevant and appropriate statewide or regional SoCP.

Amendments to Schedule A

Amendments to Schedule A will require an amendment to the HSD in accordance with the department’s HSD Management Standard (QH-IMP-366-1:2015) and the HSD Consultation Standard (QH-IMP-366-2:2015).

The relevant HHS/department division shall give two months’ notice in writing to the HSD Custodian of any proposed change to services listed in Schedule A.

Following consultation on the amendment, the HSD Custodian shall make a submission to the Director-General for consideration/approval.

Amendments to Schedule A in the HSD are reflected in the department’s credentialing policy.

Accountabilities

The HHS/department division who employs/engages a health professional with a designated approved statewide or regional SoCP shall:

  • ensure applications for credentialing and SoCP are considered and approved within appropriate policy frameworks
  • ensure the health professional has appropriate SoCP for the service provided
  • notify other relevant HHSs/department divisions of the health professional’s statewide or regional SoCP status
  • as the employer, manage any clinical performance issues that may occur with the provision of services listed under Schedule A.

The recipient HHS to the statewide or regional service shall:

  • accept the credentialing and SoCP of health professionals for that service
  • The recipient HHS may undertake additional assurance processes, in consultation with the employing/engaging HHS/department division, to ensure the approved SoCP aligns with the recipient HHS’s Clinical Services Capability Framework (CSCF) and policy
  • continue to exercise due diligence by monitoring the health professional’s SoCP at the local level
  • manage any immediate local patient safety concern/s that may arise with a health professional, and immediately notify the HHS/department division which granted the statewide or regional SoCP of the concerns.

Statewide and regional services include the following:

1. Department of Health

The Department of Health coordinates several statewide services and engages health professionals to undertake roles which have a statewide remit or responsibility.

Some departmental health professionals are engaged to undertake statewide roles that are authorised or delegated to function, as required, by legislation. The following positions do not require a statewide SoCP to enact their relevant statewide role:

  • Chief Health Officer
  • Deputy Chief Health Officer/s
  • Chief Psychiatrist
  • Executive and Medical Directors, Communicable Diseases Branch, Prevention Division

The following department services are recognised as statewide for the purpose of credentialing and SoCP:

  • BreastScreen Queensland
  • Retrieval Services
  • Medical coordination services
  • Pre-hospital and retrieval services
  • Pathology Queensland
  • Forensic Services.

2. Cairns and Hinterland HHS

Regional services as follows:

  • Community Forensic Outreach Service:
    • Services to Cairns and Hinterland and Torres and Cape HHSs.
  • Court Liaison Service:
    • Services to Cairns and Hinterland and Torres and Cape HHSs.
  • North Queensland Forensic Adolescent Mental Health Services:
    • Services to Cairns and Hinterland and Torres and Cape HHSs.
  • Specialist outreach clinical services to Torres and Cape HHS:
    • Anaesthetics
    • Endocrinology
    • Gastroenterology/Endoscopy
    • General Medicine
    • General Surgery
    • Haematology
    • Immunology
    • Infectious Diseases
    • Nephrology
    • Obstetrics and Gynaecology
    • Oncology
    • Orthopaedic Surgery
    • Palliative care
    • Paediatrics and child health
    • Pain Management
    • Plastics and Reconstructive Surgery
    • Psychiatry
    • Respiratory Medicine
    • Urology
    • Vascular surgery
    • Specialist Public Health Unit:
    • Services to Cairns and Hinterland and Torres and Cape HHSs
  • Tuberculosis Services:
    • Services to Cairns and Hinterland and Torres and Cape HHSs.

3. Central Queensland HHS

Regional services as follows:

  • Court Liaison Service:
    • Services to Central Queensland and Central West HHSs.
  • Specialist Public Health Unit:
    • Services to Central Queensland and Central West HHSs.
  • Tuberculosis Services:
    • Services to Central Queensland and Central West HHSs.

4. Children’s Health Queensland HHS

Statewide services are as follows:

  • Consultation Liaison Child and Youth Psychiatry Services
  • Cardiac Surgery for Children and Young People
  • Cardiology Services for Children and Young People
  • Child Development
  • Deadly Ears Program
  • Forensic Adolescent Mental Health Alcohol and Other Drugs Program
  • General Paediatric Medicine
  • Paediatric Allergy and Immunology
  • Paediatric Burns and Trauma
  • Paediatric Haematology
  • Paediatric Infectious Diseases
  • Paediatric Metabolic Medicine
  • Paediatric and Neonatal Surgery
  • Paediatric Nephrology
  • Paediatric Neurosciences
  • Paediatric Oncology
  • Paediatric Ophthalmology
  • Paediatric Oral and Maxillofacial Surgery
  • Paediatric Orthopaedic Surgery
  • Paediatric Otolaryngology
  • Paediatric Psychiatry
  • Paediatric Rehabilitation and Cerebral Palsy Health
  • Paediatric Rheumatology
  • Paediatric Respiratory
  • Paediatric Sleep Medicine
  • Paediatric Urology

Regional services are as follows:

  • Assertive Mobile Youth Outreach Service (AYMOS):
    • Services to Children’s Health Queensland, Metro North and Wide Bay HHSs.
  • e-Child and Youth Mental Health Service:
    • Services to Cairns and Hinterland, Central West, Children’s Health Queensland, Mackay, North West, and Townsville HHSs.
  • Mental Health, Alcohol, Tobacco and Other Drugs Service:
    • Services to Brisbane Youth Detention Centre (Metro South HHS) and Children’s Health Queensland HHS.
  • Mental Health, Alcohol, Tobacco and Other Drugs Indigenous Transition Service:
    • Services to Children’s Health Queensland, Darling Downs, Gold Coast, Metro North, Metro South and West Moreton HHSs.

5. Darling Downs HHS

Statewide services as follows:

  • Senior Medical Officer Relieving Program
  • Queensland Country Relieving Doctors Program.

Regional services as follows:

  • Aboriginal and Torres Strait Islander Child and Youth Care Coordination:
    • Services to Darling Downs, Gold Coast, Metro South, South West and West Moreton HHSs, and Mater Public Hospitals.
  • Specialist Public Health Unit:
    • Services to Darling Downs and South West HHSs.

6. Gold Coast HHS

Regional services as follows:

  • Eating Disorder Service:
    • Services to Darling Downs, Gold Coast, Metro South, South West, and West Moreton HHSs.

7. Metro North HHS

Statewide services as follows:

  • Alcohol and Drug Service
  • Burns
  • Cardiology (including Indigenous Cardiac Outreach Program (ICOP))
  • Clinical Genetics
  • Forensic Psychiatry
  • Heart Transplantation Service
  • Lung Transplantation Service
  • Neonatology (including NeoRESQ)
  • Nuclear Medicine
  • (including Positron Emission Tomography (PET), specifically PET radiopharmaceutical production and manufacturing)
  • Otolaryngology
  • Queensland Eating Disorder Service
  • Respiratory Medicine (including Indigenous Respiratory Outreach Program (IROC))

Regional services as follows:

  • Community Forensic Outreach Service:
    • Services to Central Queensland, Darling Downs, Gold Coast, Metro North, Metro South, Sunshine Coast, West Moreton and Wide Bay HHSs.
  • Court Liaison Program:
    • Services to Darling Downs, Gold Coast, Metro North, Metro South, Sunshine Coast and West Moreton HHSs.
  • Dual Disability Program:
    • Services to Central Queensland, Central West, Children’s Health Queensland, Metro North, Sunshine Coast and Wide Bay HHSs.
  • Tuberculosis Service:
    • Services to Gold Coast, Metro North, Metro South, Sunshine Coast, West Moreton and Wide Bay HHSs, and to the communities of Cherbourg and Kingaroy (Darling Downs HHS).

8. Metro South HHS

Statewide services as follows:

  • Deafness and Mental Health Service
  • Liver Transplantation Service
  • Kidney Transplantation Service
  • Oral Medicine and Oral and Maxillofacial Pathology
  • Spinal Outreach Team
  • Transcultural Mental Health Service

Regional services as follows:

  • Dual Disability Program:
    • Services to Gold Coast, West Moreton, Darling Downs, South West, Children’s Health Queensland and Metro South HHSs.
  • Tuberculosis Service:
    • Services to Gold Coast, Metro North, Metro South, Sunshine Coast, West Moreton and Wide Bay HHSs, and to the communities of Cherbourg and Kingaroy (Darling Downs HHS).

9. South West HHS

Regional services as follows:

  • Flying Specialist Service (specialist Obstetrics and Gynaecology, General Surgery and Anaesthetic services):
    • Services to Central West, Darling Downs and South West HHSs.

10. Torres and Cape HHS

Statewide services as follows:

  • Royal Flying Doctor Service general practice and primary health care.

11. Townsville HHS

  • Regional services as follows:
    • Community Forensic Outreach Service
    • Services to Mackay, North West and Townsville HHSs.
  • Dual Disability Program:
    • Services to Cairns and Hinterland, Mackay, North West, Torres and Cape, and Townsville HHSs.
  • North Queensland Forensic Adolescent Mental Health Services:
    • Services to Cleveland Youth Detention Centre, Cairns and Hinterland, Mackay, North West, Torres and Cape, and Townsville HHSs.
  • Secure Mental Health Rehabilitation Unit
    • Services to Cairns and Hinterland, Mackay, North West, Torres and Cape, and Townsville HHSs.
  • Specialist Public Health Unit:
    • Services to North West and Townsville HHSs.
  • Tuberculosis Service:
    • Services to Mackay, North West and Townsville HHSs.

12. West Moreton HHS

Statewide services as follows:

  • High Security Mental Health Inpatient Service
  • Specialist Mental Health Intellectual Disability Service.

Regional services as follows:

  • Prison Mental Health Service:
    • Services to Southern Queensland Correctional Centre (West Moreton HHS), Wolston Correctional Centre (Metro South HHS), Arthur Gorrie Correctional Centre (Metro South HHS), Brisbane Correctional Centre (Metro South HHS), Brisbane Women’s Correctional Centre (Metro South HHS), Woodford Correctional Centre (Metro North HHS), Borallon Training and Correctional Centre (West Moreton HHS).
  • Secure Mental Health Rehabilitation Unit:
    • Services to Metro North, Metro South, Gold Coast and West Moreton HHSs.

13. Coronavirus (COVID-19) pandemic response

On 29 January 2020, under Section 362B of the Public Health Act 2005, the Minister for Health and Minister for Ambulance Services made an order declaring a public health emergency in relation to coronavirus disease (COVID-19).

As part of Queensland Health’s response to the Coronavirus (COVID-19) pandemic the following medical practitioners are deemed to have a statewide SoCP:

  • Infectious Diseases Physicians
  • Public Health Physicians.

Statewide SoCP will be extended to medical practitioners with a defined SoCP in the above-named specialties which have been approved by a delegated decision maker for credentialing and SoCP of a HHS or the department.

Statewide SoCP for Infectious Diseases Physicians and Public Health Physicians will remain valid while the public health emergency declaration is in effect.

  • Acts Interpretation Act 1954 (Qld)
  • Anti-Discrimination Act 1991 (Qld)
  • Australian Organ and Tissue Donation and Transplantation Authority Act 2008 (Aus)
  • Health Act 1937 (Qld)
  • Health Employment Directive: Senior medical officers: Special remuneration arrangements (No. 02/15)
  • Health Employment Directive: Visiting Medical Officers: Employment framework (No. 05/18)
  • Health Ombudsman Act 2013 (Qld)
  • Health Practitioners and Dental Officers (Queensland Health) Award – State 2015
  • Health Practitioners and Dental Officers (Queensland Health) Certified Agreement (No.3) 2019
  • Health Practitioner Regulation National Law Act 2009 (Qld)
  • Health Service Directive: Patient Safety (QH-HSD-032:2014)
  • Hospital and Health Boards Act 2011 (Qld)
  • Hospital and Health Boards Regulation 2012 (Qld)
  • Human Rights Act 2019 (Qld)
  • Information Privacy Act 2009 (Qld)
  • Judicial Review Act 1991 (Qld)
  • Major Events Act 2014 (Qld)
  • Medical Officers (Queensland Health) Award – State 2015
  • Medical Officers’ (Queensland Health) Certified Agreement (No.5) 2018
  • Medicine and Poisons Act 2019 (Qld)
  • Medicine and Poisons (Medicines) Regulation 2021 (Qld)
  • Mental Health Act 2016 (Qld)
  • Nurses and Midwives (Queensland Health) Award – State 2015
  • Nurses and Midwives (Queensland Health and Department of Education) Certified Agreement (EB10) 2018
  • Public Health Act 2005 (Qld)
  • Transplantation and Anatomy Act 1979 (Qld)
  • Aboriginal and Torres Strait Islander Health Practitioner, Clinical Governance Guideline
  • Aboriginal and Torres Strait Islander Health Practitioner, Scope of Practice Guideline
  • Best practice guide to clinical incident management.
  • Credentialing and defining scope of clinical practice, Department of Health Policy (QH-POL-390:2015)
  • Credentialing and defining scope of clinical practice for medical practitioners and dentists in Queensland – a best practice guideline (QH-GDL-390-1-1:2017)
  • Employees to Notify Supervisor if Charged with or Convicted of an Indictable Offence Human Resources Policy E4 (QH-POL-127:2014)
  • Guideline for credentialing, Defining the Scope of Clinical Practice and Professional Support for Allied Health Professionals (QH-HSDGDL-034-1:2015)
  • Health Funding Policy and Principles.
  • HHS Services Service Agreements.
  • HHS HR Delegations Manual: HRM Functions of the Director-General
  • Indemnity for Queensland Health Medical Practitioners Human Resources Policy I2 (QH-POL-153)
  • Practice Plan - Aboriginal and Torres Strait Islander Health Practitioner
  • Public Service Commission, Queensland Government Indemnity Guideline
  • Recruitment and Selection, Human Resources Policy B1 (QH-POL-212:2014)
  • Statewide Services Policy (QH-POL-488:2021)

Supporting documents

Business area contact

  • Medical Advisory and Prevocational Accreditation Unit
  • Chief Medical Officer and Healthcare Regulation Branch
  • Prevention Division

Review

This directive will be reviewed at least every three years.

Date of last review: 15 November 2021

Supersedes: Version 2.1

Approval and implementation

Directive Custodian

Chief Health Officer and Deputy Director-General Prevention Division

Approval by Chief Executive

Director-General, Queensland Health

Approval date: 24 November 2021

Issued under section 47 of the Hospital and Health Boards Act 2011

Version control

VersionDate Prepared byComments
1 01/07/2013 Office of Principal Medical Officer New HSD
1.1 18/07/2013 Office of Principal Medical Officer Minor updates incorporated resulting from feedback from second round of statewide consultation.
1.2 10/04/2014 Office of Principal Medical Officer Minor inclusions following statewide consultation, feedback, Credentialing Officers Network and alignment with the draft Credentialing and defining scope of clinical practice for medical practitioners and dentists in Queensland guide
Consultation has occurred with the:
  • Acting Chief Dental Officer
  • Nursing and Midwifery Office, Queensland
  • Allied Health Professions’ Office, Queensland.
2.0 1/06/2017 Office of the Chief Medical Officer Inclusions following the review of the Credentialing and defining SoCP for medical practitioners and dentists in Queensland; a best practice guide, June 2014.
Inclusion of approved ‘statewide/ multi HHS’ services (Schedule A) category pertaining only to medical practitioners and dentists.
Consultation has occurred with the:
  • All HHS Chief Executives through the Chief Executive Forum
  • Multiple EDMSs
  • Credentialing Officers
  • Office of the Chief Nursing and Midwifery Officer
  • Allied Health Professions’ Office of Queensland
  • Office of the Chief Dental Officer.
  • Credentialing Health Service Directive Advisory Committee
V2.1 06/05/2020 Chief Medical Officer and Healthcare Regulation Branch Addition of statewide SoCP for infectious diseases physicians and public health physicians for COVID-19 response.
V3.0 15/11/2021 Chief Medical Officer and Healthcare Regulation Branch Comprehensive review to address issues raised and feedback received relating to previous versions.

The HSD purpose is for HHSs to establish a policy framework for credentialing and SoCP which ensures health professionals identified in the HSD are credentialed and have a documented SoCP.

Dental Practitioners separated from Medical Practitioners.

Inclusion of dental therapists and oral health therapists.

Nursing and midwifery split into separate professions.

Inclusion of Aboriginal and Torres Strait Islander Health Practitioners.

Requirements defined for telehealth, organ retrieval services and declared public health emergencies.

Statewide and regional SoCP redefined as services and aligned with HHS Service Agreements and the Department Policy: Statewide Services.

Definitions expanded for greater clarity.

Definitions

Term Definition / explanation / detailsSource

Aboriginal and Torres Strait Islander Health Practitioner

An Aboriginal and Torres Strait Islander Health Practitioner is registered by the Aboriginal and Torres Strait Islander Health Practice Board of Australia under the Health Practitioner Regulation National Law. The Aboriginal and Torres Strait Islander Health Practitioner is a primary health care professional providing high-quality, culturally-safe, clinical care services to Aboriginal and Torres Strait Islander people and communities.

An Aboriginal and Torres Strait Islander Health Practitioner may also be known as an Aboriginal Health Practitioner, or a Torres Strait Islander Health Practitioner.

Aboriginal and Torres Strait Islander Health Practice Board of Australia. Registration Standard: Aboriginal and/or Torres Strait Islander Health Practitioners

Allied Health Professionals

The allied health workforce in Queensland Health is comprised of a diverse group of independent and distinct professions. These include professions that are registered by a relevant National Board under the Health Practitioner Regulation National Law, professions that are self-regulated and professions that are unregulated.

Registered professions: Medical Radiation Practice, Occupational Therapy, Optometry, Pharmacy, Physiotherapy, Podiatry and Psychology.

Self-regulated professions: Art Therapy, Audiology, Clinical Physiology, Dietetics/ Nutrition, Exercise Physiology, Genetic Counselling, Leisure Therapy, Music Therapy, Orthoptics, Orthotics and Prosthetics, Medical and Health Physics, Social Work, Sonography (including echo-sonography) and Speech Pathology.
Unregulated professions: Rehabilitation Engineering.

Allied Health Professions’ Office of Queensland

Core scope of clinical practice

Aspects of clinical practice that can be reasonably expected to be undertaken by all health professionals who are registered or hold a particular qualification.

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. December 2015.

Credentialing

The formal process used to verify and review the qualifications, experience, professional standing and other relevant professional attributes of health professionals for the purpose of forming a view about their competence, performance and professional suitability to provide a safe, high quality healthcare service within specific environments.

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. December 2015.

Credentials

The practical experience, qualifications, professional awards and statements of competency issued by an authorised and recognised body that attest to a health professional’s education, training and competence and relevant practical experience.

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. December 2015.

Dentist

A dental practitioner registered by the Dental Board of Australia under the Health Practitioner Regulation National Law within the division of dentist.

An independent practitioner who is legally able to practice within the definition of dentistry and within their scope of practice.
Dentists treat patients of all ages and can undertake all activities within the definition of dentistry.

Dental Board of Australia. Guidelines for Scope of Practice, 1 July 2020.

Dentistry

Dentistry involves assessing, preventing, diagnosing, advising on, and treating any injuries, diseases, deficiencies, deformities or lesions on or of the human teeth, mouth or jaws or associated structures. It includes restricted dental acts listed in Section 121 of the National Law.
The broadest range of activities dental practitioners can undertake.

Dental Board of Australia. Guidelines for Scope of Practice, 1 July 2020.

Dental Specialist

A dental practitioner registered by the Dental Board of Australia under the Health Practitioner Regulation National Law within the division of dental specialist.

An independent practitioner who is legally able to practice within the definition of dentistry and within their scope of practice.
A dentist who has completed specialised training and education plus at least two years of general dental practice and is registered in one or more of the 13 specialties listed below:

  • dento-maxillofacial radiology
  • endodontics
  • forensic odontology
  • paediatric dentistry
  • periodontics
  • prosthodontics
  • public health (community) dentistry
  • oral and maxillofacial pathology
  • oral and maxillofacial surgery
  • oral medicine
  • oral surgery
  • orthodontics
  • special needs dentistry.

Dental Board of Australia. Guidelines for Scope of Practice, 1 July 2020.

Dental Therapist

Dental therapists focus on oral health and provide assessment, diagnosis, treatment, management, prevention services. Services may include restorative treatment, fillings, tooth removal, promotion of oral health, other oral care.

Dental therapists predominantly treat children, however, can treat adults with appropriate education and training.

Dental Board of Australia. Guidelines for Scope of Practice, 1 July 2020.

Engaged

Used in conjunction with employed, this refers to health professionals who provide services in a Queensland public health facility but are not employed by a HHS or the Department. This may include, but is not limited to:

  • Contracted services
  • Third party providers
  • Outreach and visiting clinical services
 

Extended scope of practice

Any task or clinical practice that falls outside the recognised scope of practice of the specific allied health profession.

Ministerial Taskforce on health practitioner expanded scope of practice: final report 2014.

Health professional

Health professional means:

  • a person registered under the Health Practitioner Regulation National Law;
  • or a person, other than a person referred to in paragraph (a), who provides a health service, including, for example, an audiologist, dietitian or social worker.

Hospital and Health Boards Act 2011

Independently practicing

The medical practitioner has full responsibility for patient care. The level of responsibility may be related to for example (not an exhaustive list), registration, qualifications, role description, pay scale or contract requirements. It also includes using professional knowledge in a non-clinical relationship with patients where the position requires the practitioner to be a registered medical practitioner.

Medical Board of Australia. Guidelines: supervised practice for international medical graduates.

Medical Practitioner

A person registered and legally able to practice, within the scope of their registration, as a medical practitioner and/or medical specialist by the Medical Board of Australia.

Medical Board of Australia. Statement: Medical registration - what does it mean? Who should be registered?

Midwife

A person with prescribed educational preparation and competence for practice who is registered as a midwife by the Nursing and Midwifery Board of Australia under the Health Practitioner Regulation National Law.

Nursing and Midwifery Board of Australia. Framework: Decision-making framework for nursing and midwifery.

Nurse

A person who has completed the prescribed educational preparation and competence for practice, who is registered as an enrolled nurse or registered nurse by the Nursing and Midwifery Board of Australia under the Health Practitioner Regulation National law.

Nursing and Midwifery Board of Australia. Framework: Decision-making framework for nursing and midwifery.

Nurse Practitioner

A registered nurse educated and authorised to function autonomously and collaboratively in an advanced and extended clinical role.

A nurse practitioner is an advanced practice nurse endorsed as a Nurse Practitioner by the Nursing and Midwifery Board of Australia, who has direct clinical contact and practices within their scope under the legislatively protected title ‘nurse practitioner’ under the National Law.

Nursing and Midwifery Board of Australia. Registration standard: Endorsement as a nurse practitioner.

Oral Health Therapist

Oral health therapists focus on oral health and have qualifications in dental therapy and dental hygiene and include assessment, diagnosis, treatment, management, prevention services. Services may also include restorative treatment, fillings, tooth removal, periodontal treatment, other oral care to promote healthy oral behaviours.

Oral health therapists can treat patients of all ages.

Dental Board of Australia. Guidelines for Scope of Practice, 1 July 2020.

Organ retrieval team

An organ retrieval team will include key team members from cardio-thoracic, liver or renal transplant units and may include surgeons, physicians, anaesthetists, nurses and perfusion technicians.

The donation specialist coordinator also attends the retrieval surgery to assist with logistic arrangements, organ packaging, documentation of the process, and care of the deceased post donation.

Transplantation Society of Australia and New Zealand (TSANZ), Clinical Guidelines for Organ Transplantation from Deceased Donors

Policy framework

Broadly covers a range of documents that set out the HHS’s policy and processes. This may include, but is not limited to:

  • Policies
  • Procedures
  • Protocols
  • Implementation Standards
  • Guidelines
 

Practice Plan

The Practice Plan defines the individual Aboriginal and Torres Strait Islander Health Practitioner’s scope of practice. The plan is to be reviewed on an annual basis, taking into consideration the professional growth of the individual and role requirements, but may be reviewed at any time.

Completion of the Practice Plan in the approved form is required under the Health (Drugs and Poisons) Regulation 1996/Medicines and Poisons Regulation 2021.

Aboriginal and Torres Strait Islander Health Practitioner, Scope of Practice Guideline

Privately practicing midwives

Midwives who practice as a sole practitioner, in partnership or in self-employed models and working on their own account.

Nursing and Midwifery Board of Australia. Fact sheet: Professional indemnity insurance arrangements.

Privately practicing nurses

Nurses who practice as a sole practitioner, in partnership or in self-employed models and working on their own account.

Nursing and Midwifery Board of Australia. Fact sheet: Professional indemnity insurance arrangements.

Professional supervision

Professional supervision is a formal working alliance between two allied health professionals with the primary intention to ensure alignment of practice capabilities to the supervisee’s role and setting and to enhance the knowledge, skills and attitudes of the supervisee

Allied Health Clinical Governance Framework.

Queensland Health

Queensland Health refers to the public sector healthcare system, incorporating the Department of Health and HHSs.

 

Regional scope of clinical practice

A SoCP which is valid in defined group of HHSs. The SoCP aligns with the regional service.

 

Regional service

A clinical service, which is the responsibility of a lead HHS or department division, that is delivered to a defined group of HHSs and locations.

 

SAC 1

Severity Assessment Code (SAC) 1 incidents are incidents causing death or likely permanent harm which is not reasonably expected as an outcome of healthcare.

Best practice guide to clinical incident management.

Scope of clinical practice (SoCP)

The extent of an individual health professional’s approved clinical practice within an organisation based on the individual’s credentials, competence, performance and professional suitability and the needs and capability of the organisation to support the health professional’s SoCP.

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. December 2015.

Scope of practice

The full spectrum of roles, functions, responsibilities, activities and decision-making capacity that individuals within that profession are educated, competent and authorised to perform.

Nursing and Midwifery Board of Australia. Framework: Decision-making framework for nursing and midwifery.

Senior Medical Officer (SMO)

A registered medical practitioner employed in:

  • any position in a classification level L13 (C1-1 only) to L29 under clause 2.6.3 of the Medical Officers (Queensland Health) Certified Agreement (No. 5) 2018 (MOCA 5)
  • any position classified and remunerated as a Medical Officer with Private Practice, Medical Superintendent with Private Practice or Senior Medical Superintendent with Private Practice.

Senior Medical Officers include a diverse group of independent practitioners which includes, but is not limited to:

  • General practitioners
  • Staff specialists
  • Career hospital doctors
  • International medical graduates (IMGs) offered a staff grade position
  • Clinical managers and medical managers

Health Employment Directive: Senior medical officers: Special remuneration arrangements (No. 02/15)
Medical Officers (Queensland Health) Award – State 2015

Specific procedures or practices

Specific procedures or practices are those where it cannot be reasonably assumed to be within the health professional’s core scope of clinical practice or competency and require specific training or qualifications.

See also: Core scope of clinical practice

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. December 2015.

Statewide scope of clinical practice

A SoCP which is valid across all Queensland Health facilities. The SoCP aligns with the relevant statewide service.

 

Statewide service

A clinical service, which is the responsibility of a lead HHS or a department division and is provided to multiple locations across all of Queensland. These services are typically highly specialised clinical services.

Statewide Services Policy (QH-POL-488:2021)

Telehealth

The use of telephone or videoconferencing technologies to conduct a patient consultation where the patient and health professional are not in the same physical location and audio and/or visual information is exchanged in real time.

Telehealth is a modality of care not a scope of clinical practice.

Ahpra and National Boards. Telehealth guidance for practitioners. July 2020.

Temporary SoCP

Temporary SoCP may be used in circumstances when the services of a health professional without SoCP are required at very short notice or where it is not possible to complete a full application process prior to the health professional commencing.

This process strikes a balance between risks of patient harm which arise from a failure to provide an appropriately skilled health professional in a timely manner, and risks of patient harm arising from processes with reduced credentialing requirements and with less checks and balances in place.

Credentialing and defining the scope of clinical practice for medical practitioners and dentists: a best practice guideline (QH-GDL-390-1:2017)

Visiting Medical Officer (VMO)

A person who is registered under the Health Practitioner Regulation National Law to practice in the medical profession and who incurs ongoing private practice costs. This includes:

  • a visiting general practitioner (VGP)
  • a VGP with FRACGP
  • a VGP with FRACGP and/or Vocational Registration
  • a visiting senior specialist, or, a visiting specialist registered with the Medical Board of Australia under the provisions of the Health Practitioner Regulation National Law Act 2009 (Qld).

VMOs are specialists that have their own private practice or general practitioners who choose to consult within public and private hospitals on a part time basis.

Health Employment Directive: Visiting Medical Officers: Employment framework (No. 05/18)

Last updated: 24 November 2021