BACKGROUND this document This document details the requirements to be followed in the process of credentialing and defining clinical privileges for senior medical practitioners and dentists employed or appointed by NSW Public Health Organisations. Following the provisions contained in this policy will ensure the alignment of competencies of a medical or dental practitioner with the needs of a health care facility, and ensure that the right clinicians are providing the right services in the right facilities. Key definitions Appointment – the process of appointing a preferred applicant to a position. ACSQHC Standard - the 2004 publication by the Australian Council for Safety and Quality in Health Care (now Australian Commission on Safety and Quality in HealthCare) – Standard for Credentialing and Defining the Scope of Clinical Practice: National Standard for credentialing and defining the scope of clinical practice of medical practitioners, for use in public and private hospitals. AHPRA –the Australian Health Practitioner Regulation Agency responsible for the administration of the National Registration and Accreditation Scheme. Clinical Academic – is a medical practitioner holding general or conditional specialist registration who is employed as a member of staff of a NSW university’s school of medicine; and who accepts an offer of employment under the arrangements set out in the NSW Health policy on clinical academics (PD2010_036). Clinical privileges – the kind of clinical work (subject to any restrictions) that the PHO determines a practitioner is to be allowed to perform at a given health facility. This definition is synonymous with the way the term “scope of clinical practice” is used in the ACSQHC standard. See paragraph 3.4.1 for more detail regarding the meaning of clinical privileges in NSW. Credentialing – the process of assessing and verifying a practitioner’s credentials. Credentials – documented evidence of a person’s formal qualifications, training, experience and clinical competence. Credentials (Clinical Privileges) Subcommittee - a subcommittee of the Medical and Dental Appointments Advisory Committee which is responsible for advising on the delineation of a practitioner’s clinical privileges. eCredential – A state-wide, web-based system that allows Local Health Districts and Networks (LHDNs) to support the administrative and managerial aspects of credentialing and clinical privileging and to provide an electronic record to authorised individuals of the clinical privileges of senior medical practitioners and dentists within NSW Health.
Medical and Dental Appointments Advisory Committee - a committee of a PHO Board that provides advice, and where appropriate recommendations, to the Chief Executive on the appointment of practitioners and the clinical privileges that should be granted to those persons. Model By-laws – means the (Local Health Districts District by-laws [Model By-laws]) made under the Health Services Act 1997 and published in the Government Gazette on 1 March 2012, as amended or substituted from time to time. Public Health Organisation (PHO) – the Health Services Act 1997 (NSW), means a local health district, a statutory health corporation or an affiliated health organisation in respect of its recognised establishments and services. Re-credentialing – the formal process of reviewing and reconfirming a practitioner’s qualifications, experience and other professional attributes. Recruitment and Selection Policy – NSW Health Policy Directive 2015 -02 Recruitment and selection of staff to the NSW Health Service, or any replacement policy. Role delineation – the level of clinical services that can be provided safely and is appropriately supported within a health facility as determined by the available support services, staffing profile, minimum safety standards and other requirements. Reference should be made to the NSW Health Guide to the Role Delineation of Clinical Services 2016 to determine the role delineation of health services. Scope of clinical practice – see clinical privileges. Senior dental practitioner - a person appointed or employed by a PHO as a senior dental practitioner who has specialist registration with the Dental Board of Australia. Senior medical practitioner – a person appointed by a PHO as a Staff Specialist, Clinical Academic or Visiting Practitioner. Specialist – a medical practitioner employed at a PHO as a staff specialist under the Staff Specialist (State) Award. Verification – the process of formally validating the authenticity of the credentials submitted by a practitioner. Visiting Practitioner – a medical practitioner or dentist who is appointed under Chapter 8 of the Health Services Act by a PHO (otherwise than as an employee) to practise as a health practitioner in accordance with such conditions of appointment at any of its public hospitals or health services as may be specified in an appointment. Visiting Practitioner Appointment Policy – NSW Health Policy Directive 2016_052 Visiting Practitioner Appointments in the NSW Public Health Service or any replacement policy.