Risk Management

Scope of practice and credentialing
As practice managers, it is
imperative that you are aware of and understand the standards for scope of
practice and credentialing to ensure that you and your practice staff possess
the appropriate qualifications and experience for your roles. According to the
National Standard for Credentialing
and Defining the Scope of Clinical Practice credentialing is defined as,
"the formal process used to verify the qualifications, experience and
professional standing of medical practitioners for the purpose of forming a
view about their competence, performance and professional suitability to
provide safe, high quality healthcare services within specific organisational
environments."
The formal process
All
Australian ministers of health signed up to the National Privileging and
Credentialing standard in 2007. This standard outlines the need to clarify
skills and abilities of clinical personnel, and requires a defined scope of
practice (reference: Australian
Commission on Safety and Quality in Health Care).Appropriate credentials
It is important that you,
your practitioners and your practice staff are appropriately credentialed and
have a defined scope of practice or clinical privileges that are consistent
with the national standard. Practices are advised to clearly articulate
individual scope of practice for all clinical personnel. Failure to ensure
required staff are appropriately registered/credentialed may deem professional
and practice indemnity policies void.
Whilst there is no formal
credentialing for practice managers, the AAPM has established a voluntary
program for Certified Practice Manager (CPM) and the AAPM Fellowship
program. As a professional, you should be aware of, and aim to comply with,
these standards.
Improving your practice
Practice managers should see credentialing as a process for the
initial granting or approval of clinical privileges for all healthcare
professionals and the ongoing review of those clinical privileges.
All
new and existing clinical staff employed in your practice should be
appropriately qualified and experienced to perform their role, and should be
able to provide evidence of the same.
You should retain evidence of
appropriate documentation as part of the personnel file.
- All
relevant clinical staff associated with the practice, including but not
limited to, medical and nursing staff, should undergo an initial and ongoing
credentialing and privileging process in accordance with the National
Guidelines for Credentials and Clinical Privileges prior to employment and at
least annually.
- All staff associated with the practice will be
appropriately qualified by having an acceptable level of knowledge, skills,
attitudes and competence consistent with standards established by their
registering professional body (or equivalent), and are currently practising
safely.
- The credentialing and privileging process will consider
previous and ongoing performance and reflect on the constraints and supports
imposed by the available resources, including staff, equipment and physical
resources available within the practice.
- All staff will be required
to provide evidence of their qualifications regularly, including registration
and/or equivalent training, experience and current competence in the delivery
of professional healthcare services for which clinical privileges are
requested, as per state and national requirements.
- The initial and
ongoing process should be documented. It is the responsibility of the practice
to keep the record up to date and treated in a highly confidential manner.
- The process should encompass the National Guidelines for Credentials and
Clinical Privileges, including:
- definitions
- general
principles
- definitions
- committees
- privileges appeal
tribunal
- credentialing process
- duration of clinical
privileges
- review of clinical privileges
- appeals process
- termination of clinical privileges
The public
register of practitioners available on the AHPRA website can provide
high-level information about the status of all health practitioners who are
registered to practise in Australia. The register provides information on the
specialty of practice that the practitioner is registered to practice and any
endorsements or conditions on their registration.
Next page
Adverse event reporting
- Adverse events and near misses
- What is an adverse event?
- What is a near miss?
- What to do to manage your risk
- Root cause analysis
- The ‘Swiss cheese’ model of hazards and losses
- Seven steps to incident management (adapted from the NSW Guide to Incident Management)
- Tips for effective adverse event and near miss management
- What should you do if an adverse event or near miss occurs
- Patients and family