Action 4.04

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

The Clinical Governance Standard has specific actions for credentialing and scope of clinical practice.

• Action 1.23 – scope of clinical practice
• Action 1.24 – credentialing 

Health service organisations should use these established systems and processes to support the implementation of this action.

Processes must be in place to ensure that only clinicians with the requisite authority prescribe, dispense and administer medicines. This authority is defined by both national and state or territory legislation. For many clinicians, this authority will be registration with the Australian Health Practitioner Regulation Agency (AHPRA). In some circumstances, the authority to administer medicines may be given by a state or territory. For example, registered nurses might be able to initiate and administer a limited selection of medicines without a prescription as part of a nurse-initiated medicines list.

The health service organisation may be responsible for establishing the qualifications and competence required by the clinicians and other members of the workforce working in extended roles – for example, nurses qualified to administer chemotherapy, clinicians authorised to administer intrathecal injection of chemotherapy, and nurses authorised to administer medicines against standing orders.

Clinicians’ scope of clinical practice is likely to be defined by their professional background, qualifications, credentials or authority, acknowledged through AHPRA registration or endorsement.

An endorsement of registration recognises that a person has extra qualifications and expertise in an approved area of practice, and/or is provided for scheduled medicines.² See the AHPRA Endorsement of Registration Fact Sheet for more information.

Use organisation-wide credentialing and scope of clinical practice processes to support:

• Identification and description of all areas where specific authorisation is required to prescribe, dispense or administer medicines
• Assessment of qualifications and competencies at recruitment
• Inclusion of a clear definition of scope of clinical practice in job descriptions and contracts of employment
• Development and maintenance of a log or register for individual professions or positions for which an authority is required to prescribe, administer or dispense medicines.

Review organisational policies, procedures and guidelines to ensure regular assessment of qualifications and competence of clinicians to safely prescribe, dispense and administer medicines.

Consider strategies such as:

• Providing extra training and competency assessment when new medicines or formulations are introduced and when implementing electronic medication management
• Using simulation training for members of the workforce when they start work or if they are required to work under supervision.

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

The Clinical Governance Standard has specific actions for credentialing and scope of clinical practice. 

• Action 1.23 – scope of clinical practice
• Action 1.24 – credentialing

Health service organisations should use these established systems and processes to support the implementation of this action.

Processes must be in place to ensure that only clinicians with the requisite authority prescribe, dispense and administer medicines. This authority is defined by both national and state and territory legislation. For many clinicians, this authority will be registration with the Australian Health Practitioner Regulation Agency (AHPRA). In some circumstances, the authority to administer medicines may be given by a state or territory. For example, registered nurses might be able to initiate and administer a limited selection of medicines without a prescription as part of a nurse-initiated medicines list.

The health service organisation may be responsible for establishing the qualifications and competence required by clinicians and other members of the workforce working in extended roles – for example, nurses qualified to administer chemotherapy, clinicians authorised to administer intrathecal injection of chemotherapy, and nurses authorised to administer medicines against standing orders.

Clinicians’ scope of clinical practice is likely to be defined by their professional background, qualifications, credentials or authority, acknowledged through AHPRA registration or endorsement.

An endorsement of registration recognises that a person has additional qualifications and expertise in an approved area of practice, and/or is provided for scheduled medicines.² See the AHPRA Endorsement of Registration fact sheet for more information.

Use organisation-wide credentialing and scope of clinical practice processes to support:

• Identification and description of all areas where specific authorisation is required to prescribe, dispense or administer medicines
• Assessment of qualifications and competencies at recruitment
• Inclusion of a clear definition of scope of clinical practice in job descriptions and contracts of employment
• Development and maintenance of a log or register for individual professions or positions for which an authority is required to prescribe, dispense or administer medicines.

Review organisational policies, procedures and guidelines to ensure regular assessment of qualifications and competence of clinicians to safely prescribe, dispense and administer medicines.

Consider strategies such as:

• Providing extra training and competency assessment when new medicines or formulations are introduced and when implementing electronic medication management
• Using simulation training for members of the workforce when they start work or if they are required to work under supervision.

Examples of evidence

Select only examples currently in use:

• Policy documents about scope of clinical practice for prescribing, dispensing and administering medicines
• List of the individual workforce members with authority to prescribe, dispense or administer medicines
• Employment documents that describe the responsibilities, accountabilities and scope of clinical practice of the workforce in medication management
• Records of competency assessments of the workforce where medication authority requires demonstration of competence
• Audit results of compliance with the authority to prescribe, dispense or administer medicines
• Committee and meeting records in which the scope of clinical practice for medicines was considered.

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

The Clinical Governance Standard has specific actions for credentialing and scope of clinical practice.

• Action 1.23 – scope of clinical practice
• Action 1.24 – credentialing

Health service organisations should use these established systems and processes to support the implementation of this action.

Processes must be in place to ensure that only clinicians with the requisite authority prescribe, dispense and administer medicines. This authority is defined by both national and state and territory legislation. For many clinicians, this authority will be registration with the Australian Health Practitioner Regulation Agency. In some circumstances, the authority to administer medicines may be given by a state or territory. For example, registered nurses might be able to initiate and administer a limited selection of medicines without a prescription as part of a nurse-initiated medicines list.

Use organisation-wide credentialing and scope of clinical practice processes to support:

• Identification and description of all areas where specific authorisation is required to prescribe, dispense or administer medicines
• Assessment of qualifications and competencies at recruitment
• Inclusion of a clear definition of scope of clinical practice in job descriptions and contracts of employment
• Development and maintenance of a log or register for individual professions or positions for which an authority is required to prescribe, dispense or administer medicines.

Review organisational policies, procedures and guidelines to ensure regular assessment of qualifications and competence of clinicians to safely prescribe, dispense and administer medicines.

Consider strategies such as:

• Providing extra training and competency assessment when new medicines or formulations are introduced and when implementing electronic medication management
• Using simulation training for members of the workforce when they start work or if they are required to work under supervision.