Guideline for Credentialing and admitting access for private practice midwives

Guideline number: QH-HSDGDL-034-3

Effective Date: 18 August 2025

Review Date: 18 August 2028

Supersedes: New HSD Guideline

On this page:

1. Introduction
2. Purpose
3. Scope
4. Guideline for Credentialing and admitting access for private practice midwives
4.1 Governance
4.2 Credentialing
4.3 PPM admitting access
5. Human Rights
6. Aboriginal and Torres Strait Islander considerations
7. Supporting and related documents
8. Authorising Health Service Directive
9. Forms and templates
10. Related National Safety and Quality Standards
11. Glossary of terms
12. Approval and implementation
13. Version Control

1. Introduction

Private practice in the Queensland public health sector facilitates patient choice, helps to attract, and retain a highly skilled clinical workforce and enhances the overall sustainability of the public health system. Although admitting rights for private practice midwives (PPMs) is relatively new in many HHSs across Queensland, arrangements for Queensland Health clinicians to participate in private practice have been in operation since 1986. The purpose, principles, and many processes within the Private practice in the Queensland public sector Health Service Directive (QH-HSD-044) and Private practice in the Queensland public health sector framework are applicable to Private Practice Midwives (PPMs).

Private practice arrangements aim to:

• Provide a means to address public sector workforce shortages
• Facilitate private patient choice in the public health sector, consistent with the National Health Reform Agreement and successive National Healthcare Agreement obligations
• Optimise third party funding sources (Medicare Benefits, Private Health Insurance etc.) enabling reinvestment into improving healthcare services
• Optimise the efficient utilisation of public health sector infrastructure.

A PPM is a midwife who provides direct clinical care, education and/or midwifery advice to women and their families in a private capacity. PPMs can be sole practitioners, work in partnership models, operate their own business, be employed by a private midwifery business, be contracted by a private business or practise in a voluntary capacity[1].

The PPM model of care offers women the option of comprehensive midwifery care with a private midwife, which may be rebated by Medicare. PPMs who are credentialled and have an access agreement with a health service, can provide private midwifery care to a woman that is admitted to the health service as an inpatient (i.e. intrapartum care). Whilst providing private midwifery services in this capacity, the PPM is not an employee of the health service.

Queensland is the national leader of the PPM model with the largest number of public hospitals that have access agreements with PPMs. Additionally, Queensland Health has provided the largest number of Medicare rebated midwifery items to inpatients. Historically, processes and requirements for credentialing and access agreements for PPMs has been inconsistent across Queensland public maternity services. Implementing a consistent statewide approach to credentialing and access agreements will ensure that Hospital and Health Services (HHSs) and PPMs, have a clear understanding of the documentation and processes required. Additionally, implementing a consistent statewide approach supports access to safe, high-quality care by enabling women’s informed decision making, and right to choose her birth setting and preferred regulated maternity care provider.

This document is a supporting guideline for the implementation of Health Service Directive QH-HSD-034 Credentialing and defining scope of clinical practice for HHSs engaging with private practice midwives (PPMs). Credentialing health professionals to provide care within a defined scope of clinical practice (SoCP) supports patient safety and ensures health professionals practice 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 (HSD QH-HSD-034). HSD QH-HSD-034 mandates HHSs shall ensure:

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.

[1] NMBA (2023). Guidelines: Safety and quality guidelines for privately practicing midwives.

2. Purpose

This guideline provides recommendations for HHSs regarding best practice in Credentialing and defining the scope of clinical practice for PPMs and informs the process for a PPM to be granted admitting access to Queensland Health birthing facilities to provide safe care to their private patients, whilst working collaboratively with the wider maternity team. The document also outlines the governance, Nursing and Midwifery Board of Australia (NMBA) registration standard, and scope for Endorsement for schedule Medicines for midwives.

The guideline has been developed to adhere to national standards and guidelines, QH directives, policies, and standards, as well as align with best practice guidelines for credentialing other health practitioners in Queensland Health (QH).

3. Scope

This Guideline applies to all Hospital and Health Services.

This Guideline applies to all midwives registered with the Australian Health Practitioner Agency (Ahpra) exercising a right of private practice within a Queensland public hospital.

4. Guideline for Credentialing and admitting access for private practice midwives

4.1 Governance

The Nursing and Midwifery Board of Australia (NMBA) develops registration standards, professional codes, guidelines, and standards for practice which together establish the requirements for the professional and safe practice of nurses and midwives in Australia.

The midwife, as registered by the NMBA, is recognised as a responsible and accountable professional who works in partnership with women to give the necessary support, care, and advice before conception, during pregnancy, labour, birth, and the postpartum period, and to provide care for the newborn, and the infant. This includes consultation with, and referral to, medical care or other appropriate assistance; and implement emergency measures where necessary.

Midwives who have NMBA endorsement for scheduled medicines are recognised under the Health Practitioner Regulation National Law (Queensland), section 94 as being qualified to administer, obtain, possess, prescribe, sell/supply or use a medicine for midwifery practice.  EMs can also apply for and receive a Medicare provider number to access the Medicare Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS).

The registration standard: Endorsement for schedule medicines for midwives requirement includes:

1. Completion of an approved prescribing course.
2. Three years full time (5000 hours) experience in the past six years that is either across the continuum of care, or in a specified context of practice.
3. Successful completion of an NMBA-approved program of study leading to endorsement for scheduled medicines, or a program that is substantially equivalent to an NMBA-approved program of study leading to endorsement for scheduled medicines as determined by the NMBA (NMBA, 2017).

NMBA also administer standards, policies, and guidelines for nurses and midwives.   These may be consistent across all health practitioners such as the standard for Professional Indemnity Insurance or they may be specific to privately practicing midwives, such as Safety and quality guidelines for privately practising midwives. In 2018, the NMBA conducted a mass audit of all PPMs, requiring PPMs to provide evidence of compliance with the safety and quality guidelines for privately practice midwives.

4.2 Credentialing

Credentialing health professionals to provide care within a defined scope of clinical practice (SoCP) supports patient safety and ensures health professionals practice 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 (HSD QH-HSD-034).

Health Service Directive QH-HSD-034 Credentialing and defining scope of clinical practice supports the delivery of safe and high-quality health care by requiring HHSs to implement a policy framework to ensure that relevant health professionals are credentialed and have a defined SoCP (HSD QH-HSD-034). This directive applies to all HHSs and is applicable to health professionals including Medical Practitioners, Nurses, Midwives, and Allied Health Professionals employed or otherwise engaged by Queensland Health.

4.2.1 Principles

Patient safety — minimise risk to patients by ensuring PPMs have the right skills, qualifications, and experience with the respective healthcare facility for the clinical services being provided.

Consistency — the practice of all PPMs, intending to engage in a specific scope of clinical practice SoCP aligns with National Safety and Quality Health Service Standards and enables a reduction in red-tape across the HHSs.

Natural justice and procedural fairness — credentialing and SoCP processes are underpinned by natural justice and procedural fairness.

Due care and diligence — all parties act with due care and diligence to support natural justice and procedural fairness. Credentialing and defining SoCP processes are underpinned by transparency and accountability.

Equity — applicants are to be treated equally and without discrimination. All decisions shall be based on the professional competence of the applicant and the capability of the relevant service.

4.2.2 HHS Responsibilities

HHSs are responsible for ensuring there is a framework and procedure in place for credentialing and defining SoCP (QH-IMP-390-2). Health Service Directive QH-HSD-034 Credentialing and defining the scope of clinical practice(the Directive) stipulates all identified health professionals are credentialed and have a defined SoCP.

The Health Service shall:

• Ensure that the local Human Resources Delegations Manual aligns to the full suite of credentialing and SoCP delegations that are represented in the Department of Health HR Delegations Manual (refer to Section 3.2). It is important to note that the decision maker, with delegation to approve SoCP, must not participate in the credentialing committee process or its deliberations (with the exception of approving temporary SoCP).
• Ensure all health professionals working within Queensland Health, but not employed by Queensland Health, are credentialed and have a current documented SoCP (see Appendix One).
• Ensure credentialing decisions are professionally led with appropriate relevant health professional representation (i.e. for PPM - midwifery led and/or appropriate midwifery representation).
• The committee shall recommend SoCP for a specified period, but which must not exceed five years. SoCP shall be subsequently renewed within an appropriate timeframe to ensure there are no gaps/breaks in the health professionals SoCP.
• Have a process in place which affords health professionals the opportunity to have a decision regarding their SoCP reviewed or appealed (refer to sections 3.1, 3.8 and 3.10 DoH Delegations Manual).
• Acknowledge ‘mutual recognition’ as an alternative process to a new application when the health professional has an appropriate and current SoCP in another department division or a HHS. (This process can be used if the PPM will be working in multiple locations or transferring employment).

Publish, on QHEPS, an up-to-date register of health professionals who are credentialed and have a defined SoCP.

4.2.3 Documentation management

Development of a digital passport aims to support the mobility of staff across the Queensland public health system and create a mutually beneficial statewide approach to information sharing, specifically human resources, mandatory training, and credentialing data. Although a minimum viable product has been developed, a statewide digital health passport is not yet available. Instead, there are two different processes currently in use across Queensland:

1. Local internal electronic systems: documentation is collected manually from the applicant via email submission. Documents are then emailed to the credentialling committee for review and are stored locally.
2. Commercial digital solution: an electronic portal/digital pathway to collect, verify and maintain data that integrates with internal and external healthcare data systems.

Some HHSs are using the commercial digital solution ‘Cgov’ to manage administration of the credentialing process due to the benefits of digital workflow and digital integration. Data can be inbound (pulled into Cgov from other systems), outbound (pushed from Cgov to other systems) or bi-directional (flowing both to and from Cgov to other systems).

Cgov digital workflow- This system provides a digital workflow that can be customised to match organisational needs including:

• Creation of online forms to simplify submission of credentials and evidence
• Customised and automated workflows to alert and remind when action is needed.

Cgov digital integration - Integration with internal systems (e.g. human resources management systems) reduces the need for manual management of data across multiple systems providing efficiency and reducing errors. Integration with external healthcare data systems, including AHPRA, means the system can retrieve AHPRA data using the midwife’s unique AHPRA registration number, and receive daily alerts if there are any changes to the midwife’s registration status.

4.2.4 Initial Credentialing process

Step One: The PPM seeking credentialing contacts the local HHS Office of the Nursing and Midwifery Service Director (however named) and completes the Endorsed midwife credentialing application form (see ‘Forms and templates’).

Step Two: The PPM submits their application for SoCP, accompanied by a complete set of documentation (credentials) as outlined in the credentialing application form (see ‘Forms and templates’), including qualifications, education and practice status, through one of the following:

1. Locally – The local office of the Nursing and Midwifery Director (however named) provides the PPM with an email address to return the completed application and supporting documents to.
2. Digitally – When the digital passport becomes available for endorsed midwives, this process would be recommended. Currently, the main digital platform in use is The Patient Safety Company “CGov” software program which generates a unique link to the relevant credentialing and SoCP application form for the midwife to complete and upload.

Step Three: The Credentialing Committee review and consider the completed application and supporting documentation. Members of the Committee have individual personal accountability for ensuring they review all provided documentation before the meeting.

The credentialed scope of clinical practice will be:

• Consistent with the midwife’s registration status
• Within the Clinical Services Capability Framework (CSCF) level of the facility where they will be providing services
• For the period of three (3) years or as defined by the Nursing and Midwifery Credentialing and Scope of Clinical Practice (SoCP) Committee
• Reviewed if the midwife’s role and responsibilities change, or the midwife requests a review.

The Committee makes recommendations to the decision maker who has delegation to approve SoCP for endorsement (see DoH HR delegations manual). Once SoCP is endorsed, the midwife can take on those clinical practices / activities, listed in their SoCP, within the HHS.

The Committee will send Correspondence to the midwife within 10 days of the meeting, notifying them of the decision, and providing details of the timeframe and conditions for maintaining SoCP. The midwife’s name and details pertaining to the approved duration and SoCP will be recorded on HHS Nursing and Midwifery credentialing register.

When there is a decision not to grant a SoCP, correspondence to the applicant will include reasons why this decision was made and outline the process for the applicant to appeal the decision if applicable.

4.2.5 Renewing Credentialing status

Step One: The PPM will be invited to reapply via a renewal reminder three to six months before the expiry of their SoCP with an application form either linked or attached.

Step Two: The PPM completes and returns the SoCP application form (see ‘Forms and templates’) including all required documentation and must return it no later than six weeks before the expiry date, to allow sufficient time for administrative processing, committee review, and endorsement. The midwife is responsible for meeting these timelines to avoid expiration of their approved SoCP.

4.2.6 Mutual recognition of authorisation and SoCP

A Mutual recognition process may be undertaken by the HHS to grant a mutual recognition SoCP if the PPM already works under the requested SoCP in another Queensland HHS. The HHS must obtain a copy of the:

1. Originating HHS application form

2. Signed minutes of the meeting when the SoCP was granted

3. Applicants’ SoCP approval letter.

If SoCP is approved by way of mutual recognition, the SoCP expiry date will be the same as the primary SoCP.

4.2.7 Appealing a decision

To appeal a decision made by the Credentialing Committee, a request for reconsideration must be made in writing by the applicant and submitted to the Committee within 30 days of receipt of Credentialing outcome letter.

The applicant must clearly articulate why a reconsideration of the Committee's decision is requested and provide evidence to support the request.

The individual midwife should not undertake practice within the defined specific SoCP until the outcome of an appeal has been determined.

During each stage of the credentialing and SoCP processes, compliance with natural justice and procedural fairness must be appropriately managed and adhered to. It is important to note that:

• to maintain the integrity of the appeal process, the decision maker for the outcome of an appeal MUST NOT be the same decision maker who made the original SoCP decision
• the appeal committee is only able to make recommendations and is not a delegated decision maker.

4.2.8 Credentialing breaches

Breaches in credentialing and SoCP may be identified by a supervisor / manager / director in the workplace, during consultation or induction. If there is a breach in credentialing i.e. an identified occurrence of a practitioner having commenced work before credentialing and SoCP has been approved, or a practitioner working outside their current SoCP, the breach is to be immediately reported to the Executive Director Nursing and Midwifery Service (EDNMS).

If notification is required, a Breach Notification Report Form is to be completed and forwarded to the EDNMS for signing and reporting to the Risk and Compliance Manager. If a breach is identified through a clinical incident that was rated as a high risk or SAC1 event, or an incident which may result in media attention, a brief is to be prepared as soon as possible for the HSCE who will provide an immediate report to the Chief Health Officer.

4.3 PPM admitting access

This section informs the process for a PPM to be able to access Queensland Health birthing facilities to provide safe care to their private patients, whilst working collaboratively with the wider maternity team of the public service. It is assumed that applying for admitting access follows successful completion of a credentialling process.

4.3.1 Principles

Consistency: contracts and agreements regarding private practice in Queensland public health sector facilities are consistent.

Efficiency and value: private practice is conducted in a way that supports overall service sustainability and best use of public resources.

Managed: private practice is actively managed and monitored by Hospital and Health Services.

Simplicity and transparency: obligations, performance criteria and fees for private practice are accessible, clear and consistent.

Patient centred: private practice is conducted in a way that prioritises patients’ needs.

Value for money: private practice is conducted in a way that is financially sustainable in the benefits it creates.

4.3.2 Process

Step One: On completion of the credentialing process (outlined above), the local Credentialing Team will advise the Nursing and Midwifery Management/Executive team and provide relevant information for them to draft the License Agreement (see ‘Forms and templates’). Relevant documentation submitted by the PPM during the Credentialing process includes evidence of:

• Current Professional Indemnity Insurance
• Current Public Liability Insurance
• Unconditional and unrestricted Australian Health Practitioner Regulation Agency (AHPRA) registration with endorsement for schedule medicines
• Vaccine preventable disease check

Step Two: Access license agreement reviewed and signed by the PPM and the HHS representative.

Step Three: Once the Access License Agreement has been finalized by all parties, arrangements are made for the PPM to complete an orientation program and meet the maternity management team and key personnel for each facility that access has been given. This must be completed prior to the PPM commencing care within the facility to ensure the PPM is familiar with the relevant systems and safety mechanisms, and establish relationships required to maintain patient safety at all times.

5. 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 and granting admitting access of individuals in accordance with the Act.

6. Aboriginal and Torres Strait Islander considerations

In adhering to this guideline, HHSs must consider the impact this guideline may have on Aboriginal and Torres Strait Islander stakeholders, particularly cultural impacts.

7. Supporting and related documents

• Credentialing and defining the scope of clinical practice QH-HSD-034
• Credentialing and defining the scope of clinical practice Department of Health Policy QH-POL-390
• Credentialing-health-practitioners-and-defining-their-scope-of-clinical-practice-A-guide-for-managers-and-practitioners-December-2015.pdf (safetyandquality.gov.au)
• Credentialing and defining the scope of clinical practice for medical practitioners and dentists: a best practice guideline (health.qld.gov.au)
• Department of Health HR Delegations Manual.
• Department of Health strategic plan | Queensland Health
• Fact Sheet: Endorsement for scheduled medicines midwives
• General Liability Insurance - Cover Information Pack (health.qld.gov.au)
• HR Policy B1 - Recruitment and selection (health.qld.gov.au)
• NMBA Midwife standards for practice
• NMBA - Fact sheet: Safety and quality guidelines for privately practising midwives (nursingmidwiferyboard.gov.au)
• NMBA registration standard: Endorsement for schedule medicines for midwives
• Medicines and Poisons Act 2019 - Queensland Legislation - Queensland Government
• Midwife PBS Prescribing
• Private practice in the Queensland public health sector framework
• Private practice in the Queensland public sector Health Service Directive
• Professional Indemnity Insurance (health.qld.gov.au)
• Unleashing the potential: An open and equitable health system
• Women Centred care: Strategic directions for Australian maternity services

8. Authorising Health Service Directive

• Credentialing and defining the scope of clinical practice Health Service Directive (QH-HSD-034)

9. Forms and templates

• Application for Credentialing: Private Practice Midwife template (DOCX 107 kB)
• Access Licence Agreement: Private Practice Midwife template (DOCX 145 kB)

10. Related National Safety and Quality Standards

1. Clinical Governance Standard
2. Partnering with Consumers Standard
3. Medication Safety Standard
4. Comprehensive Care Standard
5. Communicating for Safety Standard

11. Glossary of terms

12. Approval and implementation

Guideline custodian
The Chief Midwife Officer

Approving officer
Deputy Director General, Health Workforce Division, Department of Health.
Approval date: 15 August 2025
Effective from: 18 August 2025

This guideline will be reviewed at least every three years.

13. Version control

PRINTED COPIES ARE UNCONTROLLED

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