Action 1.23

Scope of clinical practice processes are key elements in ensuring patient safety. The purpose is to ensure that only clinicians who are suitably experienced, trained and qualified to practise in a competent and ethical manner can practise in health service organisations.¹

All clinicians providing care in a health service organisation must have their scope of clinical practice clearly defined. The processes for defining scope of clinical practice may include developing a position description, conducting a credentialing process or describing the clinician’s role in a contract for services. Regardless of the form, the process describes the mutual commitment between the organisation and each member of the clinical workforce to provide safe, high-quality care.

The governing body should ensure that processes are in place for monitoring and maintaining effective processes for defining scope of clinical practice. The governing body is responsible for ensuring that compliance is monitored and reported, and that variations are investigated.

Define scope of clinical practice

describes structures and processes that ensure:

• Clear definition of clinicians’ scope of clinical practice in the context of the organisation’s needs and capability
• Regular review of clinicians’ scope of clinical practice
• Safe and appropriate introduction of new clinical services, procedures and other technologies
• Appropriate supervision of clinicians, when necessary
• Effective processes for reviewing clinicians’ competence and performance
• Procedures to be followed if a concern arises about the capability of a clinician.

Outline policies for junior clinicians

Junior clinicians routinely provide services under supervision. The number of junior clinicians is large, their skills are developing, and their employment may be transient as they move through training programs. Therefore, individualised approaches to defining the scope of clinical practice for junior clinicians may be impracticable. Although some organisations may choose to include junior clinicians in their general credentialing and scope of clinical practice processes, most organisations adopt policies that set clear limits on the scope of clinical practice of junior clinicians of varying levels. These policies define the scope of clinical practice for varying levels of seniority, and the requirements for effective supervision and support at each level.

Supervising all junior clinicians according to their assessed capabilities and consistent with organisational policies is a key safeguard of the safety and quality of care. Define clinical supervision responsibilities in senior clinicians’ employment contracts.

Examples of evidence

Select only examples currently in use:

• Policy documents about the scope of clinical practice for clinicians in the context of the organisation’s needs and capability
• Committee and meeting documents that include information on the roles, responsibilities, accountabilities and monitoring of scope of clinical practice for the clinical workforce
• Audit results of position descriptions, duty statements and employment contracts against the requirements and recommendations of clinical practice and professional guidelines
• Audit results of diagnosis-related groups cared for by clinicians compared with their granted scope of clinical practice and the organisation’s clinical services capability framework
• Reports of key performance indicators for clinicians
• Audit results of signatures and role designation in patient healthcare records
• Workforce performance appraisal and feedback records that show a review of the scope of clinical practice for the clinical workforce
• Peer-review reports
• Evaluation of the health service organisation’s clinical services targets
• Procedure manuals or guidelines for new services, procedures and technologies
• Defined competency standards for new services, procedures and technologies
• Planning documents to introduce new services (including workforce, equipment, procedures, scope of clinical practice applications and approval for licensing)
• Training documents about new clinical services, procedures and technologies
• Communication to the workforce that defines the scope of clinical practice for new clinical services, procedures or technologies.

Scope of clinical practice processes are key elements in ensuring patient safety. The aim is to ensure that only clinicians who are suitably experienced, trained and qualified to practise in a competent and ethical manner can practise in health service organisations.¹

All clinicians providing care in a health service organisation must have their scope of clinical practice clearly defined. The processes for defining scope of clinical practice may include developing a position description, conducting a credentialing process or describing the clinician’s role in a contract for services. Regardless of its form, the process describes the mutual commitment between the organisation and each member of the clinical workforce to provide safe, high-quality care.

The governing body should ensure that processes are in place for monitoring and maintaining effective systems for defining scope of clinical practice. The governing body is responsible for ensuring that compliance is monitored and reported, and that variations are investigated.

Define scope of clinical practice

describes structures and processes that ensure:

• Clear definition of clinicians’ scope of clinical practice in the context of the organisation’s needs and capability
• Regular review of clinicians’ scope of clinical practice
• Safe and appropriate introduction of new clinical services, procedures and other technologies
• Appropriate supervision of clinicians, when necessary
• Effective processes for reviewing clinicians’ competence and performance
• Procedures to be followed if a concern arises about the capability of a clinician.

Examples of evidence

Select only examples currently in use:

• Policy documents about the scope of clinical practice for clinicians in the context of the organisation’s needs and capability
• Committee and meeting documents that include information on the roles, responsibilities, accountabilities and monitoring of scope of clinical practice for the clinical workforce
• Audit results of position descriptions, duty statements and employment contracts against the requirements and recommendations of clinical practice and professional guidelines
• Audit results of diagnosis-related groups cared for by clinicians compared with their granted scope of clinical practice and the organisation’s clinical services capability framework
• Reports of key performance indicators for clinicians
• Audit results of signatures and role designation in patient healthcare records
• Workforce performance appraisal and feedback records that show a review of the scope of clinical practice for the clinical workforce
• Peer-review reports
• Evaluation of the health service organisation’s clinical services targets
• Procedure manuals or guidelines for new services, procedures and technologies
• Defined competency standards for new services, procedures and technologies
• Planning documents to introduce new services (including workforce, equipment, procedures, scope of clinical practice applications and approval for licensing)
• Training documents about new clinical services, procedures and technologies
• Communication to the workforce that defines the scope of clinical practice for new clinical services, procedures or technologies.

MPSs or small hospitals that are part of a local health network or private hospital group should implement and use the established processes for defining scope of clinical practice.

Small hospitals that are not part of a local health network or private hospital group should develop or adapt processes to:

• Verify that the organisation has implemented an evidence-based process for defining scope of clinical practice for all clinicians, including those with independent decision-making authority or working under supervision
• Consider whether the process for defining scope of clinical practice is appropriately designed, resourced, maintained and monitored
• Incorporate periodic review of the organisation’s process for defining scope of clinical practice into audit programs, with a focus on consistency with adopted standards, performance measures and outcomes.

Scope of clinical practice processes are key elements in ensuring patient safety. The aim is to ensure that only clinicians who are suitably experienced, trained and qualified to practise in a competent and ethical manner can practise in health service organisations.¹

describes structures and processes that ensure:

• Clear definition of clinicians’ scope of clinical practice in the context of the organisation’s needs and capability
• Regular review of clinicians’ scope of clinical practice
• Safe and appropriate introduction of new clinical services, procedures and other technologies
• Appropriate supervision of clinicians, when necessary
• Effective processes for reviewing clinicians’ competence and performance
• Procedures to be followed if a concern arises about the capability of a clinician.

Examples of evidence

Select only examples currently in use:

• Policy documents about the scope of clinical practice for clinicians in the context of the organisation’s needs and capability
• Committee and meeting documents that include information on the roles, responsibilities, accountabilities and monitoring of scope of clinical practice for the clinical workforce
• Audit results of position descriptions, duty statements and employment contracts against the requirements and recommendations of clinical practice and professional guidelines
• Audit results of diagnosis-related groups cared for by clinicians compared with their granted scope of clinical practice and the organisation’s clinical services capability framework
• Reports of key performance indicators for clinicians
• Audit results of signatures and role designation in patient healthcare records
• Workforce performance appraisal and feedback records that show a review of the scope of clinical practice for the clinical workforce
• Peer-review reports
• Evaluation of the health service organisation’s clinical services targets
• Procedure manuals or guidelines for new services, procedures and technologies
• Defined competency standards for new services, procedures and technologies
• Planning documents to introduce new services (including workforce, equipment, procedures, scope of clinical practice applications and approval for licensing)
• Training documents about new clinical services, procedures and technologies
• Communication to the workforce that defines the scope of clinical practice for new clinical services, procedures or technologies.