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Canberra Hospital and Health ServicesOperational ProcedureCredentialing and Defining the Scope of Clinical Practice for Allied Health ProfessionalsContents

Contents....................................................................................................................................1

Introduction..............................................................................................................................2

Purpose.....................................................................................................................................2

Scope........................................................................................................................................ 2

Roles and Responsibilities.........................................................................................................3

Process......................................................................................................................................5

1. Initial Credentialing and Scope of Clinical Practice............................................................5

2. Re-credentialing and Review of Scope of Clinical Practice................................................8

Appeals process...................................................................................................................... 11

Reporting................................................................................................................................ 11

Monitoring and Compliance................................................................................................... 12

Related Policies, Procedures, Guidelines and Legislation.......................................................13

References.............................................................................................................................. 13

Definition of Terms................................................................................................................. 14

Appendices............................................................................................................................. 15

Doc Number Version Issued Review Date Area Responsible PageCHHS16/060 1.1 12/05/2016 01/04/2019 Chief Allied Health

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Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register

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Introduction

ACT Health is committed to the delivery of safe, appropriate and high quality allied health clinical services. This is supported through best practice credentialing and defining scope of clinical practice processes, and routine re-credentialing, by ensuring allied health professionals are appropriately qualified and experienced to perform the roles for which they are employed.

The National Safety and Quality Health Service Standards provide a framework to ensure quality and safe care. Under this framework, health care organisations are to implement processes for credentialing and defining the scope of clinical practice to support safe, high quality health care as an essential component of patient safety. This procedure ensures ACT Health has a system to define and regularly review the scope of clinical practice of allied health professionals, and provides guidance on mechanisms to monitor these processes.

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Purpose

This procedure defines the process for credentialing and defining the scope of clinical practice for allied health professionals working within ACT Health facilities, and ensures that credentialing is professionally led. It provides a standardised governance process for verifying and monitoring the qualifications, experience, professional standing and other relevant professional attributes of allied health professionals, and provides that allied health professionals have a defined scope of clinical practice.


Scope

This procedure applies to independent allied health professionals who practise within ACT Health facilities, including allied health professionals who provide direct clinical care or supervise staff providing direct clinical care.

ACT Health recognises two categories of allied health professionals:

Registered Allied Health ProfessionalsDental prosthetists, dental therapists, nuclear medicine technologists, occupational therapists, oral health therapists, pharmacists, physiotherapists, podiatrists, psychologists, radiation therapists and radiographers.


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Self-regulated Allied Health ProfessionalsAllied health assistants, art therapists, audiologists, cardiac perfusionists, cardiac scientists, counsellors, dietitians, exercise physiologists, genetic counsellors, medical physicists, neurophysiology technologists, orthoptists, prosthetists and orthotists, respiratory scientists, sleep scientists, social workers, sonographers and speech pathologists.

Allied health professionals deemed out of scope for this procedure include: analytical scientists, biomedical engineers, environmental health scientists, medical laboratory scientistsand public health nutritionists. However, the Profession Lead or delegate for each of these disciplines may adopt elements of this procedure that are appropriate for their particular profession.

Allied health professionals engaged in research, clinical supervision, professional governance or duties involving no direct patient care or clinical responsibility are also not required to undergo this credentialing and scope of clinical practice process.


Roles and Responsibilities

Position ResponsibilitiesAllied Health Profession Lead Forum

Provides the governance structure for credentialing and defining the scope of clinical practice for allied health professionals.

Oversees performance monitoring and reporting, ensuring that all identified allied health professionals are appropriately qualified, trained and experienced to undertake clinical services within ACT Health facilities.

Allied Health Credentialing Committee

Functions as the appeal panel for any disputed credentialing and scope of clinical practice matters.

Convened as required by the Chief Allied Health Officer. Membership includes: the Chief Allied Health Officer (Chair); a

Director of Allied Health representative; a Profession Lead representative; a People and Culture Branch representative; a health care consumer representative, and co-opted subject matter experts where required.

Chief Allied Health Officer

Accountable as the primary decision-maker for credentialing and defining the scope of clinical practice for allied health professionals in ACT Health, and endorses confidential tabled credentialing reports as the Chair of the Allied Health Profession Lead Forum.

Ensures that systems are established, implemented, monitored and reported for the credentialing process.

Delegates the role of approving credentialing and scope of clinical practice applications to the Profession Lead for each respective profession.


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Directors of Allied Health

Responsible for ensuring administrative compliance and accountability for credentialing and scope of clinical practice for allied health professionals within their Division.

Report the outcome of the credentialing applications within their respective Division to their Executive Director as required, and to the Chief Allied Health Officer via the Allied Health Executive.

Profession Leads Responsible for ensuring administrative compliance and accountability for credentialing within their respective profession.

Assesses, verifies and approves credentialing and scope of clinical practice applications and re-credentialing applications for all allied health professionals within their profession who provide direct clinical care.

Informs the applicant’s Line Manager of the outcome of the application, and of the scope of clinical practice granted.

Provide status reports for credentialing and scope of clinical practice for each relevant division to the Allied Health Profession Lead Forum as required.

Profession Leads may delegate the credentialing and scope of clinical practice approval process to a senior allied health professional(s) within their discipline.

Provide a copy of the credentialing application to the applicant if requested.

Hiring Managers/Line Managers

Responsible for supporting the credentialing and scope of clinical practice process.

Ensure allied health professionals they manage adhere to the credentialing process and submit all applications and documentation on time.

Overseeing the collation of all applications within the team they manage and submit to the Profession Lead for each respective allied health discipline.

Provide advice and recommendation to the Profession Lead or delegate on the assessment and verification of the applicant’s credentials and the appropriateness of the requested scope of clinical practice.

Informs the Divisional Director of Allied Health of the outcome of the application, and the scope of clinical practice granted, who is to then inform the Divisional Executive Director.

Line Managers may not necessarily be from the applicant’s professional allied health discipline.

Allied health professionals

Ensure all required information is submitted on time for credentials to be verified and scope of clinical practice determined.

Disclose the status of registration or professional membership eligibility, including any conditions, past or present suspensions,


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reprimands or undertakings, limitation on scope of clinical practice by another health care facility or any other matter that could reasonably be expected to be disclosed in order to make an informed decision on credentials and scope of clinical practice.

Comply with re-credentialing and review of scope of clinical practice in a timely manner.

At all times act in good faith.

Chief Allied Health Office

Provide support and guidance to allied health managers and allied health professionals undertaking the credentialing and defining scope of clinical practice process.


Process

1. Initial Credentialing and Scope of Clinical Practice

Application by Allied Health ProfessionalStep 1 – Submission of the application The Allied Health Professional applies for credentialing and a scope of clinical practice

on the relevant form: Allied Health Initial Credentialing Form (for new appointments and existing allied health professionals) or Allied Health External Credentialing Form (for external allied health professionals not-employed by ACT Health). For new employees, submission of the application needs to occur before the commencement of clinical duties.

The Allied Health Professional attaches a complete set of documentation (credentials) to the application. It is the obligation of the Allied Health Professional to advise the Profession Lead or delegate of any conditions, undertakings or other restrictions on registration, limitations on scope of clinical practice by another health service or any other matter that the Profession Lead or delegate could reasonably expect to be disclosed in order to make an informed decision on credentials and scope of clinical practice.

Allied Health Professionals who are new appointments or external to ACT Health must submit at least one referee report from a discipline peer who is independent of the applicant, holds no conflict of interest, and who can attest to the applicant’s clinical performance within the previous two years. For new graduate applicants, the Profession Lead or delegate may use discretion as to the acceptable number and type of referees. The applicant should provide reasons if the report is not from a discipline peer. The Credentialing Referee Report template is provided in the Appendices.

The Allied Health Professional forwards the completed application to their Line Manager for initial checking and onward submission to the Profession Lead or delegate for the relevant profession. For new appointments, the credentialing process will be initiated by the hiring manager in consultation with Employment Services, Canberra Hospital and Health Services. External Allied Health Professionals are to submit applications to the Line Manager who will forward to the Profession Lead or delegate for their discipline.


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Receipt and preparation of application by the Line ManagerStep 2 – Collation of application package for Profession Lead The Line Manager reviews the completeness of the application package, and ensures the

Allied Health Professional has submitted all material before collating and forwarding to the Profession Lead or delegate for consideration.

Consideration by the Profession LeadStep 3 – Verification of credentials and essential documentation The Profession Lead or delegate must review and verify the following:

Applicant’s completed form: Initial Credentialing Form (for new appointments and existing allied health professionals) or External Allied Health Professional Credentialing Form (for external allied health professionals not-employed by ACT Health).

Confirm with Employment Services, Canberra Hospital and Health Services that the applicant’s identity in accordance with a national police check (for all new appointments as part of recruitment and external allied health professionals only) has been carried out.

Applicant’s registration status in the appropriate category with AHPRA for registered allied health professionals; or professional association membership eligibility for self-regulating allied health professionals. Any decision regarding the applicant’s scope of clinical practice must take into account any conditions or undertakings on their registration or eligibility for professional association membership.

Note: It is the obligation of the applicant to advise the Profession Lead or delegate of any conditions, undertakings or other restrictions on registration, limitation on scope of clinical practice by another health service or any other matter that the Profession Lead or delegate could reasonably expect to be disclosed in order to make an informed decision on credentials and scope of clinical practice. This must be documented on the ‘Notification Form for Conditions on Health Practitioner Registration’.

Applicant’s curriculum vitae (for new appointments and external allied health professionals only).

Applicant holds the primary allied health qualification mandatory to the position. Postgraduate qualifications are required only if clinically relevant to the scope of clinical practice requested. Degree qualifications or equivalent must be sighted, with a copy for secure filing.

In some cases applicants may be required to demonstrate as part of initial credentialing Continuing Professional Development (CPD) consistent with registration or professional association requirements, or evidence of a self-managed CPD portfolio consistent with professional requirements. Verification of CPD is non-punitive, and the Profession Lead or delegate may use discretion as to what is appropriate for their profession. For allied health professions that do not specify


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minimum CPD requirements, the Profession Lead or delegate may use discretion as to the acceptable level and type of CPD activities undertaken. For new graduates, the Profession Lead or delegate may use discretion as to what is appropriate CPD. Where evidence of CPD is required as part of initial credentialing the applicant will be notified of this.

Professional Indemnity Insurance (for external allied health professionals only). Referee report (for new and external allied health professionals only; or those

seeking an extended scope of clinical practice) provided by the applicant (must submit at least one credentialing referee report from a discipline peer who is independent of the applicant, holds no conflict of interest, and who can attest to the applicant’s clinical performance within the previous two years). For new graduate applicants, the Profession Lead or delegate may use discretion as to the acceptable number and type of referees. The applicant should provide reasons if the report is not from a discipline peer. The Credentialing Referee Report template is provided in the Appendices.

A Working with Vulnerable People Check for self-regulated applicants where the positions requires it.

Other licensing requirements or credentials as determined by the Profession Lead or delegate (for example, a radiation licence for relevant professions).

Applicants are required to sign a completed declaration regarding employment, registration and membership restrictions, and the accuracy of information provided.

Step 4 – Profession Lead approval of initial credentialing and scope of clinical practice The Profession Lead or delegate should request further information from the applicant

where there is insufficient information to support the requested scope of clinical practice.

The Profession Lead or delegate considers all aspects of the application, and if satisfied, the applicant’s credentials and requested scope of clinical practice will be approved in relation to: Scope of Clinical Practice

The approval must reflect any conditions or undertakings imposed on the applicant by AHPRA, or by the relevant professional association.

Duration of Scope of Clinical PracticeThe approval must include a specified period for the scope of clinical practice of not more than eighteen months and with a defined end date.

Variation recommended by the Profession LeadWhere the Profession Lead or delegate proposes to make a recommendation that a scope of clinical practice is to be changed from that applied for and the change is likely to be detrimental to the Allied Health Professional, the Profession Lead or delegate will provide to the applicant, in writing if requested, the reasons for the proposed change and afford them the opportunity to make a submission within fourteen (14) days about the proposed change.

The Profession Lead or delegate should establish appropriate processes to maintain relevant credentialing data and accurate file records for information management, retrieval and auditing purposes.


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The Profession Lead or delegate must notify the Chief Allied Health Officer and the applicant’s Line Manager of the decision in relation to the outcome of initial credentialing and scope of clinical practice. The Line Manager will then notify the Divisional Director of Allied Health, who will notify the Divisional Executive Director of the credentialing outcome as and when required.

The Profession Lead or delegate will table credentialing and scope of clinical practice application approvals at the Allied Health Profession Lead Forum for endorsement. This will include any proposed limitations (such as supervision requirements, conditions or undertakings on registration or professional membership eligibility) and will specify the period until planned re-credentialing and review of scope of clinical practice is due.

Credentialing applications for Profession Leads and for allied health professionals who are sole practitioners within their discipline will be administered through the Chief Allied Health Office. The Chief Allied Health Officer or their delegate will source a suitable discipline-specific senior allied health professional to undertake the assessment of credentials and determine scope of clinical practice. Where necessary, an external profession-specific senior allied health professional may be approached to undertake the assessment of credentials.

2. Re-credentialing and Review of Scope of Clinical Practice

Planned re-credentialing and review of scope of clinical practice for allied health professionals occurs annually. Re-credentialing for registered allied health professionals occurs in November each year in line with the Annual Renewal of Registration for allied health professionals covered by the National Registration and Accreditation Scheme. For self-regulated allied health professionals, re-credentialing occurs in May. Re-credentialing and review of scope of clinical practice provides that the credentials for each allied health professional remains current and relevant and that the Allied Health Professional remains competent to provide the defined scope of clinical practice.

Notification by the Profession Lead of Planned Re-credentialing DateStep 1 – Reminder to the Allied Health ProfessionalEight (8) weeks prior to the planned re-credentialing date, the Profession Lead or delegate notifies the Allied Health Professional of the date by which planned re-credentialing is to be completed.

Allied Health Professional applies for re-credentialing and review of scope of clinical practiceStep 2 – Submission of application The Allied Health Professional applies for re-credentialing and review of scope of clinical

practice on the form: Allied Health Re-credentialing Application Form (for existing allied health professionals previously credentialed). External Allied Health Professionals are to use the Allied Health External Application Form.

The planned re-credentialing application must be fully completed, signed and include current evidence of CPD as well as any other information pertinent to review of credentials.


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Non-compliance with planned re-credentialing and review of scope of clinical practice will be referred to the Chief Allied Health Officer. For the purpose of this procedure, non-compliance is defined as: no response within thirty (30) days past the scheduled review date.

The Allied Health Professional forwards the completed application to their Line Manager for initial checking and onward submission to the Profession Lead or delegate for the relevant profession. External Allied Health Professionals are to submit applications to the Line Manager who will forward to the Profession Lead or delegate for their discipline.

Receipt and preparation of application by the Line ManagerStep 3 – Collation of application package for Profession Lead The Line Manager reviews the completeness of the application package, and ensures the

Allied Health Professional has submitted all material before collating and forwarding to the Profession Lead or delegate for consideration.

Consideration by the Profession LeadStep 4 – Re-credentialing The Profession Lead must review and verify the following:

Applicant’s completed form: Allied Health Re-credentialing Application Form (for existing allied health professionals) or Allied Health External Application Form (for external allied health professionals not employed by ACT Health).

Applicant’s registration status in the appropriate category with AHPRA for registered allied health professions; or professional association membership eligibility for self-regulated allied health professions. Any decision regarding the applicant’s scope of clinical practice must take into account any conditions or undertakings on their registration or eligibility for professional association membership.

Note: It is the obligation of the applicant to advise the Profession Lead or delegate of any conditions, undertakings or other restrictions on registration, limitation on scope of clinical practice by another health service or any other matter that the Profession Lead or delegate could reasonably expect to be disclosed in order to make an informed decision on credentials and scope of clinical practice. This must be documented on the “Conditions or Undertakings on Practice Notification Report”.

Applicant is to demonstrate Continuing Professional Development (CPD) consistent with registration or professional association requirements, or evidence of a self-managed CPD portfolio consistent with professional requirements. Verification of CPD is non-punitive, and the Profession Lead or delegate may use discretion as to what is appropriate for their profession. For allied health professions that do not specify minimum CPD requirements, the Profession Lead or delegate may use discretion as to the acceptable level and type of CPD activities undertaken.

Professional Indemnity Insurance (for external allied health professionals only).


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A Working with Vulnerable People Check for self-regulated applicants where the positions requires it.

Other licensing requirements or credentials as required and determined by the Profession Lead or delegate (for example, current radiation licence for the relevant professions).

Applicants are required to sign a completed declaration regarding employment, registration and membership restrictions, and the accuracy of information provided.

Note: Applicant’s curriculum vitae, post graduate qualification(s) gained or referee reports are only required at re-credentialing if a change to scope of clinical practice is requested (for example, an application for extended scope of clinical practice).

Step 5 – Profession Lead approval of re-credentialing and review of scope of clinical practice The Profession Lead or delegate should request further information from the applicant

where there is insufficient information to support the requested scope of clinical practice.

The Profession Lead or delegate considers all aspects of the re-credentialing application, and if satisfied, the applicant’s re-credentialing and requested scope of clinical practice will be approved in relation to: Scope of Clinical Practice

The approval must reflect any conditions or undertakings imposed on the applicant by AHPRA, or by the relevant professional association.

Duration of Scope of Clinical PracticeThe approval must include a specified period for the scope of clinical practice of not more than one (1) year with a defined end date.

Variation recommended by the Profession LeadWhere the Profession Lead or delegate proposes to make a recommendation that a scope of clinical practice is to be changed from that applied for and the change is likely to be detrimental to the Allied Health Professional, the Profession Lead or delegate will provide to the applicant, in writing if requested, the reasons for the proposed change and afford them the opportunity to make a submission within fourteen (14) days about the proposed change.

The Profession Lead or delegate should maintain relevant re-credentialing data and accurate file records for information management, retrieval and auditing purposes.

The Profession Lead or delegate must notify the Chief Allied Health Officer and the applicant’s Line Manager of the decision in relation to the outcome of re-credentialing and review of scope of clinical practice. The Line Manager will then notify the Divisional Director of Allied Health, who will notify the Divisional Executive Director of the credentialing outcome as and when required.

The Profession Lead or delegate will table re-credentialing and review of scope of clinical practice application approvals at the Allied Health Profession Lead Forum for endorsement. This will include any proposed limitations (such as supervision requirements, conditions or undertakings on registration or professional membership


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eligibility) and will specify the period until planned re-credentialing and review of scope of clinical practice is due.

Credentialing applications for Profession Leads and for allied health professionals who are sole practitioners within their discipline will be administered through the Chief Allied Health Office. The Chief Allied Health Officer or their delegate will source a suitable discipline-specific senior allied health professional to undertake the assessment of credentials and determine scope of clinical practice. Where necessary, an external profession-specific senior allied health professional may be approached to undertake the assessment of credentials.


Appeals process

An Allied Health Professional who has had their credentialing and scope of clinical practice declined, withheld or varied from the original request, has a right to request a review of the decision in writing to the Chief Allied Health Officer within fourteen (14) days of receipt of the decision.

The Allied Health Professional will be given the opportunity to provide further information that was not previously submitted for consideration which may be relevant to the decision. The Chief Allied Health Officer will convene an Allied Health Credentialing (Appeal) Committee as required to hear the appeal. The appeal process will allow for reconsideration of any decision previously made.


Implementation and Reporting

This procedure will be implemented in a staged fashion. The procedure will be rolled out in the following order – credentialing for: new allied health employees being employed into Canberra Hospital and Health

Services; existing allied health staff from non AHPRA registered groups; existing allied health staff from AHPRA registered groups; and external allied health professionals.

The Chief Allied Health Office is responsible for communicating about the progress of the implementation of this procedure to the allied health workforce and to the Deputy Director-General, Canberra Hospital and Health Services.

The Chief Allied Health Officer via the Allied Health Profession Lead Forum will oversee the monitoring and reporting of credentialing and scope of clinical practice processes. The Profession Lead or delegate for each discipline will provide credentialing status updates for their profession through confidential written reports to the Chief Allied Health Officer for endorsement via the Allied Health Profession Lead Forum, having established appropriate processes to demonstrate accountability for ensuring systems


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are in place for credentialing and scope of clinical practice across the divisions in which their profession is represented.

Following implementation, the Chief Allied Health Officer will provide written advice to the Deputy Director-General, Canberra Hospital and Health Services no later than 5 working days after 30 June outlining the credentialing status of self-regulated allied health professionals; and no later than 5 working days after 30 December outlining the credentialing and registration status of registered allied health professionals.


Monitoring and Compliance

Outcome Measure All identified allied health professionals providing direct clinical care are credentialed

and hold an appropriate scope of clinical practice at initial appointment, and through planned re-credentialing.

Method The Chief Allied Health Officer will ensure processes are established and implemented to

examine, record and review the credentials of allied health professionals providing direct clinical care to patients and consumers.

Regular reports will be utilised by the Chief Allied Health Officer to review compliance with this procedure and any recommendations for improvement.

There will be an annual report of allied health credentialing and scope of clinical practice performance and outcomes. This will include: Total number of registered allied health professionals with annually authenticated

credentials by 30 November each year. Total number of self-regulated allied health professionals with annually

authenticated credentials by 30 May each year.

Compliance All independent Allied Health Professionals providing direct clinical care to patients and

consumers in ACT Health are to have undergone the credentialing process and have a defined scope of clinical practice.

Where an allied health professional refuses to comply with this procedure, the Profession Lead or delegate will advise the Chief Allied Health Officer in writing. The Chief Allied Health Officer will formally write to the applicant requesting submission of their application. The Allied Health Professional will have fourteen (14) days to respond to this request.

If the response is considered unsatisfactory, the Chief Allied Health Officer may recommend to the Deputy Director-General, Canberra Hospital and Health Services, restriction or suspension of the Allied Health Professional’s scope of clinical practice until the necessary documentation is provided. The Chief Allied Health Officer will inform the Allied Health Professional in writing of the determination and of the appropriate Appeals Process.


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Related Policies, Procedures, Guidelines and Legislation

LegislationAustralian Capital Territory Health Professionals Act 2004Australian Human Rights Commission Act 1986Discrimination Act 1991Health Practitioner Regulation National Law 2010 (ACT)Health Practitioner Regulation National Law Act 2009Public Sector Management Act 1994

PoliciesAnnual Renewal of Professional Registration – Allied Health Standard Operating ProcedureAnnual Renewal of Professional Registration PolicyAppeal Mechanism Standard Operating ProcedureConditions or Undertakings on Practice Notification Report FormIntroduction of New Technology PolicyReview of Credentials and Defining of Scope of Clinical Practice prior to the Introduction of New Health Technologies Standard Operating Procedure

Standards Australian Council on Safety and Quality in Health Care, Standard for Credentialing and Defining the Scope of Clinical Practice 2004Public Sector Management Standards 2006

Certified AgreementsACT Public Sector Health Professionals Enterprise Agreement 2013-2017


References

1. Australian Commission of Safety and Quality in Health Care, Safety and Quality Improvement Guideline October 2012, Standard 1: Governance for Safety and Quality in Health Service Organisations.

2. National Standard for Credentialing and Scope of Clinical Practice. Australian Council on Safety and Quality in Health Care, 2004.

3. Standard Operating Procedure (SOP): Credentialing and Defining the Scope of Clinical Practice for Senior Medical and Dental Practitioners.


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Definition of Terms

In this procedure, unless otherwise indicated:

Appointment – the employment or engagement of an allied health professional to provide services within an organisation according to conditions defined by general law and supplemented by contract.

Allied Health Professional – this procedure applies to the following allied health professionals who provide direct clinical care within ACT Health facilities.

Registered Allied Health Professionals: dental prosthetists, dental therapists, nuclear medicine technologists, oral health therapists, occupational therapists, pharmacists, physiotherapists, podiatrists, psychologists, radiation therapists and radiographers.

Self-regulated Allied Health Professionals: Allied health assistants, art therapists, audiologists, cardiac perfusionists, cardiac technologists, counsellors, dietitians, exercise physiologists, genetic counsellors, neurophysiologists, orthoptists, prosthetists and orthotists, respiratory scientists, sleep scientists, social workers, sonographers and speech pathologists.

Note: the following ACT Health allied health professional disciplines are outside the scope of the procedure: allied health assistants, analytical scientists, biomedical engineers, environmental health scientists, medical laboratory scientists, medical physicists and public health nutritionists.

Clinical Practice – the professional activity undertaken by allied health professionals for the purposes of investigating patient symptoms and preventing and/or managing illness, together with associated professional activities related to patient care.

Clinician – a healthcare provider, trained as a health professional. Clinicians include registered and non-registered practitioners, or a team of health professionals providing health care who spend the majority of their time providing direct clinical care.

Credentialing – the formal process used to verify the qualifications, experience, professional standing and other relevant professional attributes of an allied health professional for the purposes of forming a view about the competence, performance and professional suitability of the allied health professional to provide safe, high quality health care services within a specific organisational environment.


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Credentials – the qualifications, professional training, clinical experience, research, education, communication and teamwork that contribute to an allied health professionals competence, performance and professional suitability to provide safe, high quality health care services. For the purposes of this procedure, an allied health professional’s history of, and current status with respect to, professional registration, disciplinary actions, indemnity insurance and criminal record are also regarded as relevant to their credentials.

Delegate – is a representative(s) of the Profession Lead’s own choosing, who is authorised to verify and approve the credentials and defined scope of clinical practice of allied health professionals in their own discipline.

Defining the Scope of Clinical Practice – delineating the extent of an individual allied health professionals clinical practice within a particular organisation based on the individuals credentials, competence, performance and professional suitability, and the needs and capability of the organisation to support the allied health professional’s scope of clinical practice.

Extended Scope of Clinical Practice – is the range of evidence-based roles and tasks that maximise the health professional’s scope of clinical practice, involving extending the scope of clinical practice of specific professions; it describes a discrete knowledge and skill base in addition to the recognised core scope of a profession and the regulatory context of a particular jurisdiction.

Professional Standing – is the recognition of a health practitioner to be of good professional repute and character; practicing a high degree of ethical conduct; widely respected by peers; and demonstrates a commitment to continuing professional development and clinical practice advancement.

Re-credentialing – the formal process used to reconfirm the qualifications, experience and professional standing (including history of current status with respect to professional registration, professional association eligibility, disciplinary actions, indemnity insurance and criminal record) of allied health professionals, for the purpose of forming a view about their ongoing competence, performance and professional suitability to provide safe, high quality health care services within specific organisational environments.

Scope of Clinical Practice – the authorised extent of an individual allied health professional’s clinical practice within a particular organisation based on the individual’s credentials, competence, performance and professional suitability and the needs and capability of the organisation to support the clinician’s scope of clinical practice.


Appendices


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Appendix 1: Initial Application FormAppendix 2: Re-credentialing Application FormAppendix 3: External Application FormAppendix 4: Credentialing Referee Report

Disclaimer: This document has been developed by Health Directorate, Canberra Hospital and Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.

Date Amended Section Amended Approved By25 Oct 2016 Appendices – Alert Added noting

the forms are currently under review

Manager – Policy, Data and Quality Assurance Team

11 Dec 2017 Minor updates Jo Morris, Ag Chief Allied Health Officer


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Application for new appointments and existing Allied Health Professionals within ACT Health

The ACT Health Procedure for Credentialing and Defining the Scope of Clinical Practice for Allied Health Professionals recognises two categories of Allied Health Professionals that are required to complete the application process for initial credentialing and scope of clinical practice:

1. Registered Allied Health Professionals must satisfy the requirements of a National Board to practise clinically or provide clinical supervision. The relevant ACT Health Allied Health Professions include: Dental Prosthetics, Dental Therapy, Nuclear Medicine Technology, Occupational Therapy, Oral Health Therapy, Pharmacy, Physiotherapy, Podiatry, Psychology, Radiation Therapy and Radiography.

2. Self-Regulated Allied Health Professionals hold a relevant allied health qualification providing eligibility for membership of a Professional Association. The relevant ACT Health Allied Health Professions include: Art Therapy, Audiology, Cardiac Science, Counselling, Dietetics, Exercise Physiology, Genetic Counselling, Neurophysiology Technology, Orthoptics, Prosthetics and Orthotics, Respiratory Science, Sleep Science, Social Work, Sonography and Speech Pathology.

OFFICE USE ONLY

Application recorded: Yes No Date: / /Name:Position:Signature:

Appendix 1

ACT HEALTH ALLIED HEALTH PROFESSIONALS

Credentialing and Scope of Clinical Practice – Initial Application Form

Please note that this form is a sample only. Please contact [email protected] for the latest version of the allied health credentialing form that is relevant to your individual circumstances.

mailto:[email protected]

SECTIONS 1 – 7: TO BE COMPLETED BY THE APPLICANT

SECTION 1 – APPLICANT’S DETAILS

Note: Please ensure that your name(s) reflects that which is published on any national register for your profession.

Surname

Given name(s)

Previous name(s)

Date of birth

Place of birth

Postal address

Phone

Mobile

Email

SECTION 2 – PRE-EMPLOYMENT CHECKS AND QUALIFICATIONS Confirm Provided

National Police Check: (For new appointments only)

Application made as part of recruitment process: Application not yet made:

Working with Vulnerable People Check: (Where required for self-regulated professions)

Application made as part of recruitment process: Application not yet made:

Evidence of qualifications*Certified copy of primary allied health qualification or equivalent (if not previously provided) and postgraduate qualifications (where relevant).*For new graduates who have not yet graduated, a letter from your academic institution is required confirming that you have satisfied all requirements for the award for which you studied.

N/A

N/A

NON-AUSTRALIAN RESIDENTS ONLY:

Do you require a Work Visa to practise in Australia?

No

Yes Yes

18

SCOPE OF CLINICAL PRACTICE

Please list the profession(s) in which you are seeking core scope of clinical practice:

__________________________________________________________________________________________________

__________________________________________________________________________________________________

REGISTRATION OR PROFESSIONAL ASSOCIATION MEMBERSHIP ELIGIBILITY:

RegisteredProfession(s): _________________________________________________________________

Registration Number: ___________________ Registration Type: ________________________

Expiry Date: / / Endorsements: __________________________

FOR MEDICAL RADIATION/DENTAL/SONOGRAPHY PROFESSIONS:

Location Specific Practice Number recorded: __________________

Current radiation licence number: __________________________

Australian Sonographer Accreditation Registry (ASAR) registration number: ________________

Self-RegulatedProfession(s): _______________________________________________________________

Professional Association: ______________________________________________________

Eligible for Membership: Yes No:

Membership Number (if a member): ____________________________________________

Expiry Date: / /

Are you accredited with a professional association: Yes No

(Please specify): ____________________________________________________________

__________________________________________________________________________

Expiry Date: / /

SECTION 3 - ADDITIONAL INFORMATION Confirm Provided

Current Practising Status:Does your position or the position for which you have applied include any clinical responsibility (e.g. direct patient care or clinical supervision)?

Yes No

Curriculum Vitae: (For new appointments only if not previously provided) N/A

Continuing Professional Development:

Please provide evidence of completed CPD over the past 12 months as part of registration requirements, professional association requirements, or as part of a self-managed CPD portfolio consistent with professional requirements.

Credentialing Referee Report (For new appointments only; or those seeking extended scope of clinical practice)

Please attach a credentialing referee report from a discipline peer as part of your application.

Attached: Yes No Comments: _____________________________________________

N/A

19

SECTION 4 – EXTENDED SCOPE OF CLINICAL PRACTICE

Only include details of clinical practice specific to extended scope of clinical practice that you are qualified to perform (provide copies qualifications where relevant).

N/A

Areas of clinical practice Qualification completed Datecompleted

Copy provided

SECTION 5 – LIMITED SCOPE OF CLINICAL PRACTICE

Has your scope of clinical practice been limited, or do you wish to limit your scope of clinical practice for any reason? If yes, please specify why:

Yes No

SECTION 6 – CONFIDENTIAL PROFESSIONAL INFORMATION

Have you ever been denied registration or professional association membership?

Are there any restrictions or special conditions placed on your registration or professional association membership?

Have any claims, investigation or lawsuits for malpractice been made against you?

Has your scope of clinical practice or appointment at any health service been reduced, suspended or revoked, or have you had any conditions attached to your previous appointments for any reason?

Is there any other information regarding your ability to practise that should be declared?

If yes to any of the above, please attach details.

Yes

Yes

Yes

Yes

Yes

No

No

No

No

No

SECTION 7 – DECLARATION BY APPLICANT

To the best of my knowledge, the information provided in this application is true and correct. I understand that any incorrect statement may result in refusal in granting or the withdrawal of existing credentials. I authorise my Profession Lead or delegate to seek information relating to my credentials and experience as relevant to my application.

I agree to inform ACT Health of any complaint made about my professional conduct or of any change in my registration or professional membership eligibility status.

I understand that the information referred to in this application will be securely stored, and can be accessed as required by the Profession Lead and Chief Allied Health Officer or nominated delegates.

Signature: ________________________________________ Date: / /

Name: ___________________________________________ Position: _________________________________________

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SECTIONS 8 – 9: TO BE COMPLETED BY PROFESSION LEAD OR DELEGATE

SECTION 8 – CONFIRMATION OF CREDENTIALS Confirm Received

Registered Professions

Copy of relevant qualifications received

National Board registration confirmed on AHPRA website:Date of sighting: / /

Has the National Board placed any restrictions on the applicant’s practice or registration?

If yes, provide details:_______________________________________________

_________________________________________________________________


Location Specific Practice Number recorded

Current radiation licence sighted and number recorded

Australian Sonographer Accreditation Registry (ASAR) registration number recorded

Yes No

Self-regulating professions

Copy of relevant qualifications received

Eligible for Professional Membership

Professional Membership details received

YesNo

YesNo

YesN/A

Continuing Professional Development

Has the applicant demonstrated CPD as part of their registration requirements, professional association requirements, or as part of a self-managed CPD portfolio consistent with professional requirements.

Comments:_________________________________________________________

__________________________________________________________________

Yes No

Credentialing Referee Report (For new appointments; and those seeking extended scope of clinical practice)

A credentialing referee report has been received from the applicant’s referee.

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PART 9 - APPROVAL BY PROFESSION LEAD OR DELEGATE

On completion of all aspects of the Procedure for Credentialing and Defining the Scope of Clinical Practice for Allied Health Professionals, I am satisfied that the applicant has the appropriate credentials and registration or professional membership eligibility to undertake the scope of clinical practice for the position for which they are being employed or are currently employed within ACT Health.

YES NO (If no, provide details) __________________________________________________________

The scope of clinical practice requested is granted for: 1 YEAR LESS THAN 1 YEAR (Specify) ______ months

Approved by the Profession Lead or delegate: YES NO

Signed: ___________________________________________ Date: / /

Name: ____________________________________________ Position: __________________________________________

Note: The duration of the credentialing and scope of clinical practice approval is one year, subject to satisfactory renewal ofregistration or professional membership eligibility where appropriate, or a lesser time as determined by the Profession Leador delegate.

DATE DUE FOR RE-CREDENTIALING: / /

A copy of the application is to be provided to the applicant on request. The original application and associated documents are either to be kept on secure paper file or electronically scanned for monitoring and reporting.

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Application for re-credentialing of allied health professionals

The ACT Health Procedure for Credentialing and Defining the Scope of Clinical Practice for Allied Health Professionals recognises two categories of Allied Health Professionals that are required to complete the application process for re-credentialing:



OFFICE USE ONLY


Appendix 2


Credentialing and Scope of Clinical Practice – Re-credentialing Application Form

Please note that this form is a sample only. Please contact [email protected] for the latest version of the allied health credentialing form that is relevant to your individual circumstances


SECTIONS 1 – 7: TO BE COMPLETED BY THE APPLICANT



Surname

Given name/s

Previous name/s

Date of birth

Place of birth

Postal address

Phone

Mobile

Email address

SECTION 2 – RE-CREDENTIALING DETAILS Confirm Provided

PREVIOUSLY CREDENTIALED: Yes No (Complete the Initial Application Form)

Date of previous approval: / /

NATURE OF RE-CREDENTIALING

1. I wish to re-apply for the defined scope of clinical practice that I was previously granted with no changes

OR

I wish to apply for an extended scope of clinical practice to that which I was previously granted

OR

2. I wish to limit the scope of clinical practice that I was previously granted.

Current Practising StatusDoes your position or the position for which you have applied include any clinical responsibility (e.g. direct patient care or clinical supervision)?

Working with Vulnerable People Check (Where required for self-regulated professions)

Issued: Date of issue: / / Current: Yes No

Yes No

Yes No

Yes No

Yes No

Yes No N/A

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Please list the profession(s) in which you are seeking core scope of clinical practice:

__________________________________________________________________________________________________

__________________________________________________________________________________________________

REGISTRATION OR PROFESSIONAL ASSOCIATION MEMBERSHIP ELIGIBILITY:


Registration Number: ___________________ Registration Type:________________________










Expiry Date: / /


(Please specify): ____________________________________________________________

__________________________________________________________________________

Expiry Date: / /

SECTION 3 – ADDITIONAL INFORMATION Confirm Provided

Curriculum Vitae (only required if requesting a change to scope of clinical practice)



Credentialing Referee Report (For those seeking extended scope of clinical practice only)



N/A

25


Include only details of clinical practice that you are qualified to perform beyond your primary allied health qualification, this includes advanced and extended scopes of clinical practice (provide copies qualifications/training where relevant).

Areas of clinical practice Qualification or training completed DateCompleted

Copy provided



Yes No








Yes

Yes

Yes

Yes

Yes

No

No

No

No

No


To the best of my knowledge, the information provided in this application is true and correct. I understand that any incorrect statement may result in refusal in granting or the withdrawal of existing credentials. I authorise my Profession Lead or delegate to seek information relating to my credentials and experience as relevant to my application.



Signature: ________________________________________ Date: / /

Name: ___________________________________________ Position: _________________________________________

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_________________________________________________________________





Yes No


Eligible for Professional Membership:

Professional Membership details received:

YesNo

YesN/A


Has the applicant demonstrated CPD over the past 12 months consistent with their registration requirements, professional association requirements, or as part of a self-managed CPD portfolio consistent with professional requirements?

Comments:__________________________________________________________

__________________________________________________________________

Yes No

Credentialing Referee Reports (For those seeking extended scope of clinical practice only)


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SECTION 9 – APPROVAL BY PROFESSION LEAD OR DELEGATE

On completion of all aspects of the Procedure for Credentialing and Defining the Scope of Clinical Practice for Allied Health Professionals, I am satisfied that the applicant has the appropriate credentials and registration, or professional membership eligibility to undertake the scope of clinical practice for the position for which they are currently employed within ACT Health.

YES NO (If no, provide details) ________________________________________________________



Signed: ___________________________________________ Date: / /

Name: ____________________________________________ Position: __________________________________________




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Application for external allied health professionals (not-employed by ACT Health) providing clinical services within ACT Health facilities

This form is used for initial credentialing and re-credentialing of external allied health professionals.External Allied Health Professionals working within ACT Health facilities are required to comply with the ACT Health Procedure for Credentialing and Defining the Scope of Clinical Practice for Allied Health Professionals. The procedure recognises two categories of Allied Health Professionals that are required to complete the application process for credentialing and scope of clinical practice:



OFFICE USE ONLY


Appendix 3

ACT HEALTH EXTERNAL ALLIED HEALTH PROFESSIONALS

Credentialing and Scope of Clinical Practice – External Application Form



SECTIONS 1 – 7: TO BE COMPLETED BY EXTERNAL ALLIED HEALTH PROFESSIONAL



Surname

Given name(s)

Previous name(s)

Date of birth

Place of birth

Postal address

Phone

Mobile

Email

PURPOSE OF SEEKING ACCESS TO PROVIDE CLINICAL SERVICES WITHIN ACT HEALTH FACILTIES:

1. Locum or agency allied health professional seeking to provide clinical services to patients within Canberra Hospital and Health Services facilities Yes No

OR

2. Private allied health professional providing clinical services to patients within Canberra Hospital and Health Services facilities Yes No

OR

3. Providing clinical supervision involving direct patient care to staff or students within Canberra Hospital and Health Services Yes No

OR

4. Academic seeking honorary appointment within Canberra Hospital and Health Services Yes No

OR

5. Other ACT Government Directorate employee, non-government organisation, or organisation not otherwise stated seeking to provide clinical services within Canberra Hospital and Health Services Yes No

OR

6. Other Yes No (Please specify): __________________________________________________________________

PREVIOUSLY CREDENTIALED WITH ACT HEALTH: YES NO

Date of previous approval: / /

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SECTION 2 – CRIMINAL HISTORY AND QUALIFICATIONS Confirm Provided

National Police Check:

Application has been made/pending: Application not yet made:

Working with Vulnerable People Check: (Where required for self-regulated professions)

Application has been made/pending: Application not yet made:

Evidence of qualificationsCertified copy of primary allied health qualification or equivalent (if not previously provided) and postgraduate qualifications (where relevant).

N/A

N/A


Please list the profession(s) in which you are seeking the core scope of clinical practice:

__________________________________________________________________________________________________

__________________________________________________________________________________________________

REGISTRATION AND PROFESSIONAL ASSOCIATION MEMBERSHIP ELIGIBILITY:


Registration Number: ___________________ Registration Type:________________________










Expiry Date: / /


(Please specify): ____________________________________________________________

__________________________________________________________________________

Expiry Date: / /

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SECTION 3 – ADDITIONAL INFORMATION Confirm Provided

Current Practising Status:Does your position or the position for which you have applied include any clinical responsibility (e.g. direct patient care or clinical supervision)?

Yes No

Curriculum Vitae

Evidence of appropriate Professional Indemnity Insurance (certificate of currency required)

Insurance Company ___________________________________________________

Policy Type __________________________________________________________

Policy Number _______________________________________________________

Amount ____________________________________________________________

Expiry: / /

Yes No

Continuing Professional Development:


Credentialing Referee Report



NON-AUSTRALIAN RESIDENTS ONLY:

Do you require a Work Visa to practise in Australia?

No

Yes Yes


Only include details of clinical practice specific to extended scope of clinical practice that you are qualified to perform (provide copies qualifications where relevant).

N/A

Areas of clinical practice Qualification completed Datecompleted

Copy provided



Yes No

32








Yes

Yes

Yes

Yes

Yes

No

No

No

No

No


To the best of my knowledge, the information provided in this application is true and correct. I understand that any incorrect statement may result in refusal in granting or the withdrawal of existing credentials. I authorise the Profession Lead or delegate of my discipline to seek information relating to my credentials and experience as relevant to my application.



Signature: ________________________________________ Date: / /

Name: ___________________________________________ Position: _________________________________________

33




Copy of relevant qualifications received:




_________________________________________________________________





Yes No


Copy of relevant qualifications received:

Eligible for Professional Membership:

Professional Membership details received:

YesNo

YesNo

YesN/A


Has the applicant demonstrated CPD as part of their registration requirements, professional association requirements, or as part of a self-managed CPD portfolio consistent with professional requirements.

Comments:_________________________________________________________

__________________________________________________________________

Yes No

Credentialing Referee Report


34

PART 9 – APPROVAL BY PROFESSION LEAD OR DELEGATE

On completion of all aspects of the Procedure for Credentialing and Defining the Scope of Clinical Practice for Allied Health Professionals, I am satisfied that the applicant has the appropriate credentials and registration, or professional membership eligibility to undertake the scope of clinical practice for the position for which they are seeking access to within ACT Health.

YES NO (If no, provide details) ________________________________________________________



Signed: ___________________________________________ Date: / /

Name: ____________________________________________ Position: __________________________________________




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Credentialing and Scope of Clinical Practice Referee Report


CREDENTIALING REFEREE REPORT(This report is for new and external allied health professionals only; or those seeking to extend their scope of clinical practice)

Referee’s DetailsReferee’s Name:

Referee’s Position:

Applicant’s DetailsApplicant’s Name:

Allied Health Profession:

Position applied for:

1. Professional Relationship

How long have you known the applicant?

In what professional capacity have you known the applicant?

When was your last professional contact with the applicant?

Can you comment on the nature of the practice and patient population encountered in the professional practice of the applicant?

2. Clinical Skills and KnowledgeHistory-taking, clinical examination and presentation of findings Poor Adequate Good Excellent Not Observed N/A

Clinical judgement and decision-making skills Poor Adequate Good Excellent Not Observed N/A

Clinical record keeping skills Poor Adequate Good Excellent Not Observed N/A

Clinical skills Poor Adequate Good Excellent Not Observed N/A

Additional comments on clinical skills and knowledge base in the applicant’s requested scope of clinical practice.Please comment on the applicant’s participation in Continuing Professional Development activities related to their requested scope of clinical practice.

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Appendix 4



3. Work EthicPunctuality and reliability (completion of set tasks on time) Poor Adequate Good Excellent Not Observed N/A

Organisational skills Poor Adequate Good Excellent Not Observed N/A

Initiative Poor Adequate Good Excellent Not Observed N/A

Additional comments on work ethic, reliability and punctuality:

4. Communication and Interpersonal Skills

Clarity of written communication Poor Adequate Good Excellent Not Observed N/A

Communication and rapport with patients and consumers Poor Adequate Good Excellent Not Observed N/A

Relationships with other health professionals Poor Adequate Good Excellent Not Observed N/A

Additional comments on the applicant’s interpersonal skills:

5. EmployabilityAre you aware of any medical condition, mental or physical, (including substance abuse or dependence) and which might adversely affect the applicant’s ability to competently and safely practise within their requested scope of clinical practice?

Yes (if yes, please specify) No

Are you aware of any formal complaints, or disciplinary or legal action against the applicant?

Yes (please describe) No

Would you offer the applicant a clinical position in your workplace/clinical area?

Yes No (please specify)

Would you entrust the applicant with the clinical care of a family member?

Yes No (please specify)

6. Conflict of Interest and other commentsDo you have a personal relationship with the applicant or any conflict of interest in providing this referee report?

Yes (please specify) No

Other comments you may wish to make (optional):

7. SignatureName:

Position:

Signature: Date: / /

Contact Number:

Contact Email:

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