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: 13 September 2023

Review Date: 13 September 2026

Supersedes: Version 5

On this page:

1. Purpose
2. Scope
3. Requirements
4. Human Rights
5. Supporting documents
6. Review
7. Approval and implementation
8. Definitions
9. Appendix 1: Credentialing process

1. Purpose

This guideline supports Hospital and Health Services (HHS) in the implementation of the Credentialing and defining the scope of clinical practice Health Service Directive (HSD) (QH-HSD-034: 2014).

The guideline provides recommendations for the:

• credentialing of allied health professionals identified in QH-HSD-034: 2014, including those wishing to perform extended scope practices
• provision of professional support to allied health professionals working within Queensland Health.

These recommendations are supported by the Allied Health Clinical Governance Framework which draws together clinical governance principles, structures, policies, and processes, as they apply to allied health professionals and services in Queensland Health, to provide a systematic and consistent approach to delivering quality clinical care across Queensland Health.

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 within the scope of this guideline is provided in Table 1. Credentialing for professions and defining the scope of practice for individual allied health practitioners who are not included within the scope of this guideline is at the discretion of each HHS.

Compliance with this guideline is not mandatory; recommendations may be applied at the discretion of each HHS based on each HHS’s requirements and analysis of their associated risks. HHSs must apply sound reasoning when departing from the recommendations within this guideline.

Table 1. Allied health professions categorised by method of regulation/ registration

3. Requirements

3.1 Credentialling

Credentialing is 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.

Credentialing occurs at the point of employment within Queensland Health HHS as a component of the recruitment process and includes the verification of:

• qualifications
• status of registration (if applicable, verified via the Australian Health Practitioner Regulation Agency (AHPRA) online register) and/or eligibility for membership of, or accreditation/ certification by a relevant professional association recognised by Queensland Health (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.

Alternate or additional credentialing processes may be required to be undertaken by an HHS in instances where allied health professionals have not undergone a Queensland Health recruitment process (for example, external allied health professionals).

Additional credentialing processes are required by an HHS where an allied health professional wishes to perform a task or clinical practice that is not recognised as being within their profession’s core scope of practice (known as extended scope of practice).

Credentialing recommendation 1

It is recommended that alternate or additional credentialing processes would not be required for:

• 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.
• external allied health professionals:
  • who are currently employed by another government department (e.g., Education Queensland, the Australian Defence Force Service) for a substantially similar position, who have undergone a government recruitment process
  • registered to provide care with a government agency (e.g. Workcover Queensland)
  • who are employed by organisations/agencies where an agreement or contract with Queensland Health exists stating that the agency is accountable and responsible for credentialing their employees through mutually agreed processes
  • employed in non-clinical positions
  • conducting research 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)
  • working in private facilities accepting referrals for public patients from HHS practitioners
• students and allied health professionals who are practising under a formal supervision arrangement (e.g. clinical placement, work experience, formal re-entry arrangements)

It is recommended that alternate or additional credentialing processes would be required for external 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
• who are self-employed and are providing direct clinical services within HHS facilities
• who provide supervision to HHS employees as part of the requirements of the employee’s registration with a National Board.

Credentialing recommendation 2

Credentialing processes for external allied health professionals should be undertaken by the delegate who has human resources (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.

Credentialing recommendation 3

Credentialing is required for all allied health professionals who wish to undertake extended scope practices (including Queensland Health and non-Queensland Health employees/external allied health practitioners).

The credentialing process must verify that individuals are competent to provide the extended scope practice.

Credentialing recommendation 4

Credentialing is not required for tasks or practices which are otherwise regulated under the Health Practitioner Regulation National Law (e.g. prescribing by optometrists or podiatrists with national scheduled medicines endorsement).

Credentialing recommendation 5

When credentialing is determined to be required, HHS credentialing processes should align with the processes outlined in appendix 1, including the application of mutual recognition processes for allied health professionals undertaking clinical practice in multiple HHSs.

Credentialing recommendation 6

When credentialing is determined to be required for a practitioner employed by Queensland Health as part of a statewide service (provision of the statewide services requires the practitioner to provide services in multiple other HHSs, as specified in Schedule A of QH-HSD-034: 2014), health practitioners are eligible to be credentialed (and have an appropriate scope of clinical practice defined) for the service by the HHS responsible for providing the service.

3.2 Professional support for allied health professionals

Professional support is the mechanism within Queensland Health which ensures that allied health professionals continue to develop within the organisation and maintain competency within their practice settings and/or required 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 or environment, career stage, geographical location, or profession.

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.

Professional support recommendation 1

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

• professional supervision (including indirect supervision)
• peer group supervision
• mentoring.

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.

Recommended levels of professional support are outlined in Table 2.

Professional support recommendation 2

Allied health professionals are also encouraged to participate in other forms of professional support that may include peer review, journal clubs, in-service presentations, seminars and workshops and work shadowing.

Table 2. Recommended levels of professional support for allied health professionals

4. Human Rights

Queensland Health must act and make decisions compatible with human rights, in accordance with The Human Rights Act 2019 (the Act). This includes conducting the credentialing process and making decisions with regards to the credentialing of individuals in accordance with the Act.

5. Supporting documents

• Credentialing and defining the scope of clinical practice Health Service Directive (QH-HSD-034:2014)
• Credentialing and defining the scope of clinical practice Department of Health policy (QH-POL-390:2015)
• Queensland Health Human Resources Policy B1 (QH-POL-212:2017): Recruitment and Selection
• Allied Health Clinical Governance Framework in Queensland Health
• Queensland Health Clinical Services Capability Framework

6. Review

7. Approval and implementation

Chief Allied Health Officer

8. Definitions

The following definitions and terms used in this guideline are adapted from the QH-HSD-034: 2014, unless otherwise stated, and apply in the context of this guideline.

Appendix 1: Credentialing Process

1.1 Formation of a committee for credentialing

HHSs have a responsibility to ensure that a system for credentialing 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 to review applications for credentialing and scope of clinical practice within their HHS, or whether an existing credentialing committee will consider these applications.

Where formation of a specific allied health credentialing and defining scope of clinical practice committee is required, the following principles should be applied.

1. The HHS Chief Executive (or delegate) should determine the membership (number and composition) of the allied health credentialing and defining scope of clinical practice committee within their HHS, formally appoint a chairperson and each member to the committee, and establish documented governance for the committee

2. An allied health credentialing and defining scope of clinical practice committee should include, at a minimum:

• the HHS Executive Director Allied Health (or equivalent, such as the 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
• a manager from the profession(s) of the application(s) being considered.

3. An allied health credentialing and defining scope of clinical practice committee should not include clinicians with practice conditions or undertakings attached to their National Board registration and/or 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 that application
• enquire and act with due care and diligence
• ensure all decisions are documented with corresponding reasons to enable review under the Judicial Review Act 1991 if so required.

1.2 Process for credentialing and defining scope of clinical practice of allied health professionals

1.2.1 Lodgement of an application

There are four types of applications that can be lodged by allied health practitioners wishing to be credentialed and/or engage in extended scope tasks or practices:

1. an application from an allied health professional who has not been credentialed within Queensland Health in the previous five years (new application)
2. an application for renewal or review of current scope of clinical practice (renewal/ review application)
3. an application for mutual recognition of current credentialing and scope of clinical practice granted in another HHS (mutual recognition application)
4. an application for scope of practice for a statewide service (to the HHS employing the allied health professional for the service).

1.2.2 Contents of an application

The application for credentialing and scope of clinical practice should include the applicant’s:

• qualifications
• membership (or eligibility for membership) of the appropriate professional association (as determined by Queensland Health) for self-regulated professions
• relevant work and clinical history
• evidence of continuing professional development and recency of practice
• professional referees that can attest to the applicant’s competency and experience in the scope of clinical practice required/ requested.
• 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)

Consideration of an application for an external allied health professional

It is recommended that the credentialing process for external allied health professionals be undertaken by the delegate who has human resources (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:

• 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 applicable) with the relevant National Board
• confirm that the applicant meets the vaccine preventable disease requirements (has a copy of immunisation record or serology results)
• conduct a criminal history check (for self-regulated professions) and confirm that the applicant has a blue card for child related employment and/or a police check for employment in residential and aged care facilities (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
• review the application for completeness and accuracy and seek further information from a senior allied health professional of the same profession as the applicant (where the HR delegate is from a different profession), for confirmation that the applicant:
  • holds the relevant qualifications and capabilities required
  • has evidence of appropriate continuing professional development
  • has appropriate insurance.

Consideration of an application for extended scope

All applications for credentialing and scope of clinical practice for allied health professionals wishing to engage in extended scope of practice should be reviewed by a credentialing committee.

At a minimum, the credentialing committee, 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, including verification that the applicant holds the relevant qualifications
• 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 National Board
• 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, including in relation to the extended scope practice being requested
• consider the needs of the HHS, the Clinical Services Capability Framework (CSCF), the available resources within facilities, and relevant recommendations of professional associations
• consider any conditions or undertakings on the applicant’s registration and how they may impact on the ability of the allied health professional to perform the extended scope tasks required.

If warranted, for example if concerns about the practitioner’s ability to perform the extended scope are raised during the credentialing process, the credentialing committee may also request other material or information on a case-by-case basis that they consider to be pertinent to the capacity of the applicant to perform the requested scope, 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.

1.2.3 Committee recommendation and decision by the chief executive

The role of the credentialing committee is to provide a recommendation regarding credentialing or scope of practice for each application to the HHS Chief Executive (or delegate) who will make the final decision. This committee’s recommendation should be provided to the HHS Chief Executive within 30 business days.

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.

When deciding whether to accept the committee’s recommendation, the HHS chief executive (or delegate) should also consider all aspects of the application, including the referee report(s), the applicant’s National Board registration (if applicable) and supervision requirements, and the needs and resources of the facility/service to ensure the recommendation is consistent with the Clinical Services Capability Framework (CSCF) as it applies to that facility/department/unit/service.

1.2.4 Notification of application outcome

Applications reviewed by a credentialing committee

For applications that have been reviewed by a credentialing committee, written advice should be provided to the applicant and facility/department/unit/service manager within 10 business days of receiving the recommendation from the credentialing committee.

Applications reviewed by a HR delegate

The outcome of applications that have been reviewed by a HR delegate (e.g., external allied health professionals not performing extended scope practices) and not reviewed by a credentialing committee, should be provided in writing to the applicant within 30 business days of the application submission.

1.2.5 Lodgement of an appeal

Where an application is denied, withheld, limited, or granted in a different form to that which was requested, including if a period of less than five years of scope of practice are granted, applicants should be informed in writing that they may appeal the decision within 20 business days from the date of the written notification of the outcome of their application.

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 a specific 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 if required.
• 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 50 calendar days of the date of the appellant’s correspondence.

1.2.6 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
• up to date documentation relating to the applicant’s credentials and scope of clinical practice, including verification of registration with the National Board (if applicable).

1.2.7 Interim scope of clinical practice

Where the standard credentialing and defining scope of clinical practice process outlined above cannot be completed prior to the date the applicant is required to commence employment, provision of clinical services or engagement in extended scope practice, an interim scope of clinical practice may be granted by the HHS Chief Executive (or delegate), or the relevant HR delegate for external applicants.

At a minimum, the appropriate delegate must review evidence of the applicant’s registration with the appropriate board (if applicable) and evidence that the applicant possesses the appropriate qualifications. External allied health professionals 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 employment or practice if an interim scope of clinical practice is granted. An interim scope of clinical practice may be in place for a maximum of 90 business days and should not be renewed or extended.

The applicant should submit a full application as soon as practicable, and no later than 60 business days from the date the interim scope of clinical practice is granted by the decision maker.

1.2.8 Review/ renewal of credentials or scope of clinical practice

Scheduled review/ renewal

Applicants should apply for a review of their credentials or scope of clinical practice and submit an application no later than two months prior to the expiry date. The same scope of clinical practice is not automatically granted.

1.2.9 Unscheduled review of credentials or scope of clinical practice

Lodgement of an unscheduled review request

An unscheduled review is triggered when an appropriate 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 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.

Requirements for an unscheduled review

Unscheduled reviews should be managed by a credentialing committee, regardless of whether the original application was assessed by a HR delegate (i.e. in the case of external allied health professionals) or a credentialing committee. The process for managing an unscheduled review requires:

• lodgement of a request for an unscheduled review by an appropriate and relevant third party e.g. the allied health professional’s line manager
• consideration and recommendation by the credentialing committee
• decision by the HHS chief executive (or delegate)
• advice on outcome of unscheduled review.

The chair of the credentialing committee should provide the following advice to the allied health professional and their line-manager verbally and in writing, within 10 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 20 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 business 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).

1.2.10 Forms and Templates

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