Protect Your Practice

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:
    1. definitions
    2. general principles
    3. definitions
    4. committees
    5. privileges appeal tribunal
    6. credentialing process
    7. duration of clinical privileges
    8. review of clinical privileges
    9. appeals process
    10. 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

This publication is proudly brought to you by Avant Mutual Group. The content was authored by Brett McPherson, reviewed by Colleen Sullivan and Avant Mutual Group.

This publication is not comprehensive and does not constitute legal or medical advice. You should seek legal or other professional advice before relying on any content, and practice proper clinical decision making with regard to the individual circumstances. Persons implementing any recommendations contained in this publication must exercise their own independent skill or judgment or seek appropriate professional advice relevant to their own particular practice. Compliance with any recommendations will not in any way guarantee discharge of the duty of care owed to patients and others coming into contact with the health professional or practice. Avant is not responsible to you or anyone else for any loss suffered in connection with the use of this information. Information is only current at the date initially published. © Avant Mutual Group Limited 2014.

IMPORTANT: Professional indemnity insurance products and Avant’s Practice Medical Indemnity Policy are issued by Avant Insurance Limited, ABN 82 003 707 471, AFSL 238 765. The information provided here is general advice only. You should consider the appropriateness of the advice having regard to your own objectives, financial situation and needs before deciding to purchase or continuing to hold a policy with us. For full details including the terms, conditions, and exclusions that apply, please read and consider the policy wording and PDS, which is available at or by contacting us on 1800 128 268. Practices need to consider other forms of insurance including directors’ and officers’ liability, public and products liability, property and business interruption insurance, and workers compensation and you should contact your insurance broker for more information. Cover is subject to the terms, conditions and exclusions of the policy. Any advice here does not take into account your objectives, financial situation or needs. You should consider whether the product is appropriate for you before deciding to purchase or continuing to hold a policy with us.