Guideline for Credentialing, defining the scope of clinical practice and professional support for allied health professionals

Guideline number: QH-HSDGDL-034-1:2015

Effective Date: 1 March 2019

Review Date: 1 March 2022

Supersedes: Version 4

On this page:

1. Purpose
2. Scope
3. Credentialing
4. Supporting documents
5. Approval and implementation
6. Version control
7. Definition of terms
8. References
9. Appendix 1: Credentialing process

1. Purpose

The purpose of this guideline is to support Hospital and Health Services (HHSs) in the implementation of the Credentialing and Defining the Scope of Clinical Practice Health Service Directive.

The overall aim is to ensure that healthcare is provided and/or appropriately supervised by suitably qualified and proficient clinicians working within their scope of practice and in line with the clinical services capability of the healthcare facility.

The guideline describes recommendations for:

• credentialing allied health professionals
• the provision of professional support to allied health professionals working within Queensland Health.

These recommendations are in accordance with the Allied Health Clinical Governance Framework.

This document is a guideline only. Any recommendations may be applied at the discretion of HHSs and should be based on individual HHS requirements and analysis of associated risks.

2. Scope

This guideline has applicability to all HHSs, their employees and all organisations and individuals acting as an agent for HHSs (including contractors, consultants and volunteers).

A list of allied health professions included in the scope of this guideline is provided below. Credentialing for professions who are not included within the scope of this guideline is at the discretion of each HHS.

This guideline applies to the following allied health professions:

3. Credentialing

Credentialing is the process of verifying an individual’s qualifications and experience to form a view about their competence, performance and professional suitability to provide high quality care within specific settings and/or scopes of practice. This occurs at the point of employment within Queensland Health through the recruitment process and includes the verification of:

• qualifications
• status of registration (verified via the appropriate Australian Health Practitioner Regulation Agency register) and/or eligibility for membership/accreditation/certification of a relevant professional association (verified via professional association websites)
• employment history (including evidence of practice and ongoing professional development)
• educational and training history
• application demonstrating suitability for the advertised position
• referee reports.

This guideline describes the instances where alternate or additional credentialing processes are, or may be, required.

• Alternate or additional credentialing processes may be required by an HHS in instances where allied health professionals have not undergone a Queensland Health recruitment process (external allied health professionals).
• Additional credentialing processes are required by an HHS where an allied health professional intends to perform practices that are not recognised as being within the scope of their profession (extended scope of practice).

3.1 External allied health professionals

In this context external allied health professionals are defined as allied health professionals who are providing services to current patients of the HHS within HHS facilities and who have not undergone a Queensland Health or similarly rigorous recruitment process. This section provides advice on the instances where additional credentialing processes may/may not be required.

It is recommended that Credentialing processes would not be required for:

• external allied health professionals currently employed by another Government Department (e.g. Education Queensland, the Australian Defence Force Service) who have undergone a Government recruitment process
• external allied health professionals who are registered to provide care with a Government agency (e.g. Workcover Queensland)
• external allied health professionals employed by organisations/agencies where an agreement/contract with Queensland Health exists stating that the agency is accountable and responsible for credentialing their employees through mutually agreed processes
• external allied health professionals with appointments in non-clinical positions
• students and allied health professionals who are practising under a formal supervision arrangement (e.g. work experience, re-entry)
• external allied health researchers where the research involves no patient contact or responsibility, or which has Human Research Ethics Committee (HREC) approval and local HHS Site Specific Approval (SSA)
• external allied health professionals working in private facilities accepting referrals for public patients from HHS practitioners
• allied health professionals who are employed by one HHS and provide services to another HHS, for example providing services through a relief pool, exchange or rotation program or via telehealth.

Credentialing processes are recommended for:

• external allied health professionals employed by organisations/agencies where there is no agreement with the HHS stating that the organisation/agency is responsible and accountable for credentialing its employees
• external allied health professionals who are self-employed and are providing direct clinical services within HHS facilities
• external allied health professionals who provide supervision to HHS employees as part of the requirements of the employee’s registration.

3.2 Allied health professionals wishing to perform extended scope practices

Credentialing is required for all allied health professionals who plan to undertake extended scope practices (including Queensland Health and non-Queensland Health employees). The process must verify that individuals are competent to provide the extended scope practice. Credentialing is not required for practices which are otherwise regulated under the Health Practitioner Regulation National Law (e.g. prescribing by optometrists or podiatrists with national scheduled medicines endorsement).

Appendix 1 details the recommended processes for both credentialing of external allied health professionals and for allied health professionals wishing to perform extended scope practices.

3.3 Mutual recognition

Some allied health professionals undertake clinical practice in multiple facilities, HHSs or Department of Health divisions and may wish to apply for mutual recognition of credentialing processes across these areas. It is recommended that HHSs apply mutual recognition processes as detailed in Appendix 1.

3.4 Professional support for allied health professionals

Professional support is the mechanism within Queensland Health which ensures that allied health professionals continue to develop both personally and professionally and maintain their competency within their practice settings and/or scope of practice. Allied health professionals' participation in professional support is central to the safety of patients and the quality of services, regardless of clinical area, career stage, location or profession.

It is recommended that all allied health professionals should participate in at least one of the following:

• professional supervision
• peer group supervision
• mentoring.

Allied health professionals are also encouraged to participate in other components of professional support, including peer review, journal clubs, in-services and work shadowing.

Where a line manager is not of the same profession as the allied health professional, the allied health professional and their line manager should consult with a profession-specific manager when fulfilling their professional support requirements.

The recommended levels of professional support are based on the allied health professional’s clinical experience and are described below.

These recommendations apply to all temporary and permanent employees and should commence within 3 months of employment.

Supervision requirements for allied health professionals employed in Queensland Health Mental Health Services are contained within the Human Resources Policy G5 (QH-POL-192:2008) Practice Supervision in Allied Mental Health and the Queensland Health Clinical Supervision Guidelines for Mental Health Services 2009. This Guideline does not replace the principles, definitions or requirements as outlined in mental health-specific policy.

4. Supporting and related documents

Authorising Health Service Directive

• Credentialing and Defining the Scope of Clinical Practice Health Service Directive (QH-HSD-034:2014)

Policy and standard/s

• Allied Health Clinical Governance Framework
• Clinical Services Capability Framework for Public and Licensed Private Health Facilities V3.2
• Queensland Health HR Policy B1 (QH-POL-212:2017): Recruitment and Selection
• Queensland Health HR Policy B46 (QH-POL-250:2014): Citizenship, Residency, Visas and Immigration

Procedures, guidelines and protocols

• Professional Support Resources for Allied Health, available at https://qheps.health.qld.gov.au/cunningham-centre/html/ah-resources.

5. Approval and implementation

Guideline Custodian: Chief Allied Health Officer

Approving Officer: Dr John Wakefield, Deputy Director-General, Clinical Excellence Queensland

Approval date: 14/02/2019

Effective from: 01/03/2019

6. Version control

7. Definition of terms

8. References

1. The Australian Council on Healthcare Standards 2004, ACHS News, Vol12 1-2, ACHS Sydney.

9. Appendix 1: Credentialing Process

1.1 Formation of a Committee for credentialing

HHSs have a responsibility to ensure that a credentialing system exists for all identified allied health professionals.

The HHS Chief Executive (or delegate) should determine whether an allied health-specific Credentialing and Defining Scope of Clinical Practice Committee is required within their HHS, or whether these tasks can be undertaken by an existing credentialing committee.

Where formation of an Allied Health Credentialing and Defining Scope of Clinical Practice Committee is required, the following process should apply.

1. The HHS Chief Executive should:
• determine the number and composition of the Allied Health Credentialing and Defining Scope of Clinical Practice Committees within their HHS
• appoint a Chairperson and members for each Committee
• establish documented governance of the Committee
• formally appoint members of the Allied Health Credentialing and Defining Scope of Clinical Practice Committee.
2. An Allied Health Credentialing and Defining Scope of Clinical Practice Committee should include, at a minimum:
   • the Executive Director Allied Health (or equivalent such as Director Allied Health or Team Leader Allied Health)
   • one senior allied health professional
   • one medical officer nominated by the Executive Director Medical Services
   • one nursing officer nominated by the Executive Director Nursing and Midwifery Services
   • when considering applications from a specific profession, the profession-specific manager from that profession.
3. An Allied Health Credentialing and Defining Scope of Clinical Practice Committee should not include clinicians with disciplinary conditions or undertakings attached to their own scope of clinical practice.
4. The Chair and members of the Allied Health Credentialing and Defining Scope of Clinical Practice Committee at a minimum should:
   • declare any actual or perceived conflicts of interest regarding an application and withdraw from deliberations of the application
   • enquire and act with due care and diligence
   • document all decisions with corresponding reasons as decisions are reviewable under the Judicial Review Act 1991.

1.2 Process for credentialing and defining scope of clinical practice of allied health professionals wishing to engage in extended scope practices

This section applies to all allied health professionals wishing to engage in extended scope practice including both internal and external applicants.

Lodgement of an application

There are three types of applications that can be lodged for consideration.

1. an application from an allied health professional who has not been credentialed by an HHS in the previous five years (new application)
2. an application from an allied health professional for review of current credentialing and scope of clinical practice (review application); and
3. an application by an allied health professional for mutual recognition of current credentialing and scope of clinical practice (mutual recognition application).

The application should include information from the facility/department/unit/service where the applicant intends to work regarding the areas of practice that will be required of the applicant and the applicant’s:

• qualifications
• registration (if applicable)
• evidence of continuing professional development and recency of practice
• evidence of professional indemnity insurance (required for external applicants only)
• pre-employment checks as required by the role (external allied health professionals only - e.g. working with children check; vaccine preventable disease requirements)
• work history
• professional referees.

Consideration of an application

All applications for credentialing and defining scope of clinical practice for allied health professionals wishing to engage in extended scope of practice require review by a credentialing committee.
The Credentialing Committee, as a minimum, should:

• review the application for completeness and accuracy, and ensure the applicant has provided sufficient evidence to demonstrate that they have the required competencies to match the requested scope of practice
• request further information from the allied health professional where there is insufficient information to support the requested scope of clinical practice
• verify the applicant’s registration status (if appropriate) with the relevant Board
• ensure the applicant holds the relevant qualifications
• ensure the applicant has provided evidence of appropriate continuing professional development
• obtain references from at least one professional referee who is independent of the applicant, with no conflict of interest, and who can attest to the applicant’s clinical performance within the previous two years
• consider the needs of the HHS, the Clinical Services Capability Framework, the available resources within facilities, and relevant recommendations of professional associations
• consider any conditions or undertakings on the applicant’s registration, which may arise out of impairment, disciplinary or registration concerns.

The Credentialing Committee may also consider other material including:

• reports from registration boards
• patient and staff complaints
• professional indemnity history and status including audits of litigation matters
• clinical review and audit
• information made available from HHS and/or Department of Health investigations
• any other information pertinent to the capacity of the applicant to provide high quality care.

Recommendation of the Credentialing Committee

The Credentialing Committee should provide a recommendation relating to the applicant’s credentials and/or scope of clinical practice to the HHS Chief Executive (or delegate) within thirty business days of receiving an application.

Decision by the Chief Executive

When the application has been considered and recommendations made by a Credentialing Committee, the final decision should be made by the HHS Chief Executive (or delegate).
In responding to the recommendation, the HHS Chief Executive (or delegate) should consider:

• all aspects of the application
• the referee report/s
• the applicant’s registration and supervision needs
• the needs and resources of the facility/service to ensure the recommendation is consistent with the Clinical Services Capability Framework as it applies to that facility/department/unit/service.

1.3 Process for credentialing of external allied health professionals

This section provides recommendations for HHSs who wish to undertake credentialing for external allied health professionals (i.e. allied health professionals who are providing services to current patients of the HHS within HHS facilities and who have not undergone a Queensland Health or similarly rigorous recruitment process).

Lodgement of an application

There are three types of applications that can be lodged for consideration.

1. an application from an allied health professional who has not been credentialed by an HHS in the previous five years (new application)
2. an application from an allied health professional for review of current credentialing and scope of clinical practice (review application)
3. an application by an allied health professional for mutual recognition of current credentialing and scope of clinical practice (mutual recognition application).

The application should include information regarding the applicant’s:

• qualifications
• registration (if applicable)
• evidence of continuing professional development and recency of practice
• evidence of professional indemnity insurance (required for external applicants only)
• pre-employment checks as required by the role (external allied health professionals only - e.g. working with children check; vaccine preventable disease requirements)
• work history
• professional referees.

It is recommended that the credentialing process for external allied health professionals be undertaken by the delegate who has HR delegation responsibilities for authorising and approving decisions related to recruitment activities and appointments most relevant to the allied health professional seeking to be credentialed. Any perceived or actual conflict of interest should be declared by the person undertaking the credentialing process and, where this exists, an alternate HR delegate should be identified to manage the application.

The HR delegate, as a minimum should:

• review the application for completeness and accuracy, and seek further information where required
• verify the applicant’s identity in accordance with the protocol in Queensland Health HR Policy B1: Recruitment and Selection – QH-POL-212:2017
• verify the applicant’s registration status (if appropriate) with the relevant Board
• confirm the applicant holds the relevant qualifications and capabilities required
• confirm the applicant has provided evidence of appropriate continuing professional development
• confirm that the applicant has appropriate insurance
• confirm that the applicant has a copy of immunisation record or serology results and meets vaccine preventable disease requirements
• confirm the applicant has submitted the criminal history check documentation (for self-regulated and non-regulated professions)
• confirm that the applicant has a Working with Young Children and/or Aged Care clearance if relevant to the scope of clinical practice
• obtain references from at least one professional referee who is independent of the applicant, who has no conflict of interest, and who can attest to the applicant’s clinical performance within the previous two years
• consider relevant profession-specific input where the HR delegate is from another profession.

1.4 Period of authorised practice

The standard period of authorised practice for external allied health professionals and extended scope practice is five years.
If a decision is made to approve an application for a period of less than five years, reasons for the shorter period should be provided to the applicant in writing.

1.5 Advice on application outcome

For applications which have been reviewed by a credentialing committee, written advice should be provided to the applicant and facility/department/unit/service manager within ten business days of receiving the recommendation from the Credentialing Committee.

The outcome of applications which have not been reviewed by a credentialing committee but have been reviewed by a HR delegate (e.g. external allied health professionals not performing extended scope practices) should be provided in writing to the applicant within 30 business days of submitting the application. Where an application is denied, withheld, limited or granted in a different form to that which was requested, applicants should be informed in writing that they may appeal the outcome of the review within twenty business days from the date of the correspondence.

1.6 Lodgement of an appeal

The following process should be followed for managing an appeal.

• the Credentialing Committee or HR Delegate must notify the HHS Chief Executive (or delegate) of the appeal within two business days of receiving the appeal request
• the HHS Chief Executive may progress the appeal through existing appeal mechanisms within the HHS or by establishing an Allied Health Appeals Committee
• the Appeals Committee should include allied health representation and should not include members involved in the original credentialing decision for the application being considered. Representation may be sought from another HHS
• the HHS Chief Executive (or delegate) should provide written advice of the outcome of the appeal to the appellant and the relevant professional and facility/department/unit/service managers within fifty business days of the date of the appellant’s correspondence.

1.7 Mutual recognition of credentials and scope of clinical practice

In granting mutual recognition to applicants with credentials and scope of practice approved in another facility/service the following information should be considered:

• advice about the applicant’s practice from the applicant’s current facility/department/unit/service
• documentation relating to the applicant’s credentials and scope of clinical practice.

1.8 Interim scope of clinical practice

Where the standard credentialing and defining scope of clinical practice process cannot be completed prior to the date the applicant commences clinical services or engages in extended scope practice, an interim scope of clinical practice may be granted.
An interim scope of clinical practice should only be granted after the relevant decision maker (Chief Executive or delegate or for external applications, the relevant HR delegate) reviews evidence of the applicant’s registration with the appropriate Board (if applicable) or evidence that the applicant possesses the appropriate qualifications. For external allied health professionals, they must also possess appropriate indemnity insurance.

The decision maker should provide written advice to the applicant and department/unit/facility/service prior to the commencement of duty if an interim scope of clinical practice is granted. An interim scope of clinical practice should exist for a maximum of ninety business days and should not be renewed or extended.

The applicant should submit a full application within sixty business days of when the decision regarding interim scope of clinical practice is made by the decision maker.

1.9 Review of credentials or authorised scope of clinical practice

Applicants should apply for a review of their credentials or scope of clinical practice two months prior to the expiry date. The same scope of clinical practice is not automatically granted.

Requirements for an unscheduled review

Unscheduled reviews should be managed by a Credentialing Committee, even if the original application was assessed by a HR Delegate (i.e. in the case of external allied health professionals). The process for managing an unscheduled review requires:

• lodgement by a third party of a request for an unscheduled review
• consideration and recommendation by the Credentialing Committee
• decision by the HHS Chief Executive (or delegate)
• advice on outcome of unscheduled review.

Lodgement of an unscheduled review request

An unscheduled review is triggered when a third party lodges an unscheduled review request. The Chair of the Credentialing Committee should notify the HHS Chief Executive (or delegate) within two business days of receiving a request for an unscheduled review.

At short notice, and in emergency situations, the Chair of the Credentialing Committee, after consulting with the profession-specific manager, may reduce or suspend a scope of clinical practice immediately if they have reasonable belief that there is a risk to the safety of patients. The allied health professional should be informed of this decision, and the reasons for the decision, verbally and in writing within two business days. Such action is interim pending unscheduled review by the Credentialing Committee.
The Chair of the Credentialing Committee should determine not to proceed with a review when:

• the concern has previously been investigated and no new information is available
• the request is assessed as a vexatious complaint.

The Chair of the Credentialing Committee should provide the following advice to the allied health professional verbally and in writing, within ten business days of receiving the request:

• the process for managing the review (where the Credentialing Committee is convened and makes a recommendation to the HHS Chief Executive (or delegate) who is the decision maker for appeal processes)
• the subject of the review
• reasons for review
• copies of all available documents which the committee should consider
• the time and date of proposed review meeting
• the possible outcome of deliberations
• a request for a written submission from the allied health professional
• an offer to the allied health professional to make an oral presentation to the committee.

The allied health professional should be provided twenty business days to respond.

Consideration and recommendation by the Credentialing Committee

The Credentialing Committee should provide a recommendation, with reasons, in writing to the HHS Chief Executive (or delegate) within ten days of the committee meeting. The HHS Chief Executive (or delegate) may request that the committee provide further advice.

Advice of outcome of the unscheduled review

Within ten business days of receiving the Committee’s recommendation, the HHS Chief Executive (or delegate) should:

• advise the allied health professional, in writing, of the review outcome, including reasons for the decision
• advise the relevant professional and department/unit/facility/service managers, in writing, of the review outcome, including reasons for the decision
• amend details (where necessary) of the allied health professional’s credentials and scope of clinical practice to the facility Intranet web site (where available).

1.10 Forms and templates

Templates and resources for HHSs to use or modify for use to suit their local needs are available on the Allied Health Professions’ Office of Queensland (AHPOQ) intranet page using tab to clinical governance: http://qheps.health.qld.gov.au/alliedhealth/home.htm.