Department of Health

Professional standards in private health service establishments

Key messages

  • Credentialling and defining the scope of clinical practice helps match medical staff to their role and organisation.
  • Accreditation to National Safety and Quality Health Service (NSQHS) Standards is a condition of registration for private health facilities.
  • Private health facilities have to comply with the Child Safe Standards, the Reportable Conduct Scheme and requirements for the Working with Children Check.

These clinical practice resources will assist you in understanding the requirements of registration of a private health facility.

Credentialing and defining the scope of clinical practice

Credentialling is the formal process of verifying a medical practitioner’s qualifications, experience, professional standing and other relevant professional attributes. It assesses their competence and suitability to provide safe, high quality health care services in a specific organisational environment.

Defining the scope of clinical practice (also known as privileging) follows on from credentialling. It delineates the scope of a medical practitioner’s clinical practice within a particular organisation.

Safer Care Victoria'sCredentialling and defining the scope of clinical practice for medical practitionersExternal Link contains more information.

National Safety and Quality Health Service Standards

The Australian Commission on Quality and Safety in Health Care has developed 8 National Safety and Quality Health Service Standards to improve the quality of health care in Australia. They provide a nationally consistent statement about the level of care consumers can expect from health service organisations.

Accreditation to the 8 national standards is required for registered private health service establishments.

The second edition of the national standardsExternal Link was released in November 2017. Registered private facilities will be assessed to the second edition from January 2019.

Health service establishment protocols for quality and safety

For the purpose of ensuring the quality and safety of health services provided at a health service establishment, the proprietor must prepare protocols (sometimes called by-laws) in accordance with the Regulations.

Reviewed 04 April 2025

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Contact details

Postal address: GPO Box 4541, Melbourne 3001

Private Hospitals Unit Department of Health

privatehospitals@health.vic.gov.au
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