Department of Health

Key messages

  • Credentialing is the formal process of verifying the qualifications and experience of senior medical staff.
  • Credentialing ensures ensure the skills and experience of senior medical staff match consumers’ clinical needs.
  • Victoria has a strict credentialing policy that ensures all senior medical staff have a defined scope of clinical practice.
  • Victoria’s credentialing policy is being expanded to include nurses, midwives, allied health clinicians and dentists.

All senior medical staff who have an independent responsibility for patient care in Victoria’s public health services must have their qualifications and experience ‘credentialled’ according to strict statewide guidelines.

The Department of Health & Human Services policy Credentialling and defining the scope of clinical practice for medical practitioners ensures that health services provide the highest standards of clinical care from a safe, skilled and competent workforce.

History of credentialing

Since 2007, the department has developed a range of policies and initiatives to encourage health services to build stronger relationships with their senior staff, and to actively involve them in the improvement of their shared clinical practice.

  • Victoria’s credentialling policy has been updated to provide world-class processes and tools for reviewing the experience and performance of senior medical staff at regular intervals across a five-year ‘credentialling cycle’.
  • The credentialling policy was expanded to include private midwives who are eligible to provide care in public hospitals, and senior doctors who provide services to residents of publicly operated residential aged care facilities.
  • Collaborating with the Australian Dental Association, Dental Health Services Victoria, and the Dental Practice Board of Victoria, the department has developed guidelines for credentialling and defining the scope of practice of dentists working in public health services.
  • The Understanding clinical practice toolkit provides tools that enable senior doctors, their peers and medical leads (medical directors or unit heads) to better understand and monitor clinical practice.
  • Partnering for Performance is a performance development and support framework that supports senior doctors and health services to regularly review their standards of clinical care and identify areas for service improvement.

What is credentialing?

Credentialing is the formal process of verifying the qualifications, experience and professional attributes of senior medical staff to confirm their competence and suitability to provide safe, high-quality healthcare services within specific organisational environments.

Defining the scope of clinical practice - also known as ‘privileging’ - follows on from credentialling and involves delineating the scope of a medical practitioner’s clinical practice within a particular organisation’s clinical needs and capabilities.

The department’s policy has been developed with the assistance of the Clinical Engagement Advisory Group (CEAG), an expert working group comprising representatives from across the health sector, which consulted closely with senior doctors, medical associations and specialist medical colleges. The policy was released in 2007 and updated in 2009 and 2011.

The department is currently working with a number of other health professional groups, including nurse practitioners, midwives, allied health clinicians and dentists to ensure that the policy’s resources align with their credentialing and scope of practice needs.

Why is credentialing important?

Credentialing and defining the scope of clinical practice are part of broader quality and risk management processes that protect and improve the safety of health service consumers by ensuring that:

  • senior doctors appointed by public health services have been through a thorough process to ensure their skills and experience match consumers’ clinical needs
  • doctors practise within the scope of their training and competency, and within the capabilities of the organisation in which they work
  • health services are properly supporting their doctors and clinical staff by providing the resources and professional development they need to deliver high-quality services.

What does credentialing mean for doctors?

The department’s credentialing policy ensures that:

  • where doctors have a scope of practice to undertake a certain activity, they are properly and fully supported in the provision of that activity
  • doctors are actively involved in service planning and development by ensuring that clinical services match community needs, organisational capacity, and individual medical capabilities
  • doctors’ interests are represented in credentialing and scope of practice processes, through independent peer involvement in committee and organisational processes
  • doctors have access to appropriate independent appeals processes where necessary.

What does credentialing mean for health services?

The department’s policy provides health services with a baseline or minimum standard for their processes for credentialling and defining the scope of practice of their senior medical staff. The policy provides benefits to organisations by:

  • promoting more active engagement by senior doctors in the strategic planning and development of health services
  • ensuring that service delivery is a shared activity, supported by both health services and medical staff
  • providing reassurance that doctors appointed to hospitals and health services have the appropriate skills, and undergo regular reviews to ensure their scope of practice continues to match organisational needs and capabilities.

Reviewed 05 October 2015


Contact details

Consumer Partnerships and Quality Standards Department of Health & Human Services

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