Local Health Network Procedure

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1 Local Health Network Procedure Adelaide Local Health Networks CREDENTIALING AND DEFINING SCOPE OF CLINICAL PRACTICE- ALLIED HEALTH Effective Date 1 July 2011 Approval Authority Chief Executive Officer Next Review Date 1 July 2012 Policy Sponsor Local Health Network Director of Allied Health Last updated 1 June 2011 Version: Overview/Procedure Description The primary objective of this procedure is to ensure the Local Health Networks and other clinical services have systems in place that provide allied health clinicians and managers with clear guidelines for credentialing and determining appropriate scope of practice by Demonstrating a clear understanding of roles, responsibilities and accountability regarding adherence to the SA Health Authenticating Allied & Scientific Health Professionals Credentials Policy and Guidelines for Regional Implementation Recognising and acknowledging the range of training, experience and competency criteria required for different allied health professions Monitoring the range and quality of services provided by enabling regular review of credentialing and scope of practice. 2. Areas of Responsibility The Local Health Network Director of Allied Health or equivalent is accountable to the Chief Executive Officer for ensuring systems are established within the Local Health Network or other clinical service, in order for the Credentialing and Defining Scope of Clinical Practice policy and procedure for allied health to be implemented, monitored and evaluated. Allied health discipline managers, senior allied health professional (AHP3 and above) or service managers are accountable for ensuring administrative compliance with the SA Health Authenticating Allied & Scientific Health Professionals Credentials Policy and Guidelines for Regional Implementation, and the associated Adelaide Local Health Networks Credentialing and Defining Scope of Clinical Practice Allied Health procedure by: ensuring all job and person specifications detail the appropriate credentials and required scope of clinical practice prior to recruitment assessing credentials of all new appointments (permanent, temporary and casual contracts) based on the credentialing procedure and recommendations from the recruitment panel assessing credentials of current allied health employees assessing re-credentialing applications. Clinicians are responsible for the provision of all information required (as per the Credentialing Procedure and Application Form) to ensure appropriate credentialing can be verified and scope of practice determined. 3. Definition/who is covered by this policy and procedure Allied Health includes tertiary qualified professionals who have completed accredited or recognised university degrees or other qualification, enabling them to obtain State or National registration, a licence/accreditation to practise or to be eligible for membership of a professional association, as listed below. (*for exceptions see pt 3 below) This includes those who provide clinical services, clinical support services, those who supervise staff and students who provide clinical services, and those in professional leadership roles. This also includes non-sa Health allied and scientific health professionals who require an approved

2 Access Appointment 1 to work within SA Health sites. Where allied health services are provided by an external contractor, the employing Agency is responsible for ensuring the credentialing of allied health staff. Minimum standards for credentialing as determined by the SA Health Authenticating Allied & Scientific Health Professionals Credentials Minimum Requirements Checklist need to be demonstrated by external providers as part of the employment contract. It is the responsibility of the relevant Local Health Network/clinical service operations manager to ensure these requirements have been met by the external agency. The policy recognises three categories of Allied Health Professional roles: 1. Registered Professionals must satisfy the requirements of registration, a legal process that bestows recognition of a minimum standard of training in a particular field. Registration is the responsibility of the National or State registration board. Allied and Scientific Health Professionals seeking registration will not be credentialed until proof of registration is substantiated. As at July 2011 these disciplines include; Dental Hygiene, Therapy & Prosthetics 2 Occupational Therapy Pharmacy Physiotherapy Podiatry & Podiatric Surgery Psychology 2. Self Regulated Professionals hold a qualification from an accredited University course/training program providing eligibility for membership of a Professional Association that sets and maintains standards of practice. Accredited membership status awarded for participation in an accredited continuing professional development program is desirable for professionals with clinical responsibilities. As at July 2011 self-regulated professions include: Art Therapy Audiology Dietetics Exercise Physiology Medical Radiation (including Radiography, Sonography, Radiation Therapy and Nuclear Medicine) 3 Music Therapy Orthotics and Prosthetics Social Work Speech Pathology 3. Those employed under a Grandparent Clause do not hold a qualification listed in the Commissioner s Standard but are classified under the Allied Health Professional (AHP) classification stream in the South Australian Government Wages Parity (Salaried) Enterprise Agreement 2010 by virtue of an industrial agreement on a present position, present incumbent only basis. These staff are unable to demonstrate eligibility for membership of a professional association but must meet the remaining criteria detailed below and in the application form in order to be credentialed. 4. Procedure Detail 4.1 Credentialing new appointments All new appointments are to be made in accordance with Attraction, Recruitment and Selection Policies. Pre-employment declarations are to be completed as part of the recruitment process. Credentialing new appointments is to be undertaken as part of the recruitment process and may be initiated as part of e-recruitment. 1 A separate Access Appointment policy for Allied and Scientific Health professions is currently under development by the Allied and Scientific Health Office. In the interim as a minimum requirement, evidence of Professional Indemnity Insurance, criminal history check and signed request of the service by the patient/consumer are required. 2 These practitioners may be equivalently covered by the SA Health Policy Directive & Guidelines on Credentialing and Defining Scope of Clinical Practice for Medical & Dental Practitioners. 3 The Medical Radiation disciplines will be covered by National registration in 2012.

3 Job and person specifications must define the credentials and scope of practice required for the position. This information will be used by the allied health discipline manager or senior allied health professional when verifying credentials and scope of practice of the preferred applicant. The allied health discipline manager or senior allied health professional must ensure that at the time of an offer of a formal interview that the preferred applicant is provided with the following, and that the credentialing application form is completed: SA Health Authenticating Allied & Scientific Health Professionals Credentials Policy and Guidelines for Regional Implementation (Appendix 1) Adelaide Local Health Networks Credentialing and Defining Scope of Clinical Practice Procedure - Allied Health. Adelaide Local Health Networks Allied Health Credentialing/Re-Credentialing Application Form Adelaide Local Health Networks Allied Health Credentialing Information Sheet The relevant completed application form is to be returned to the allied health discipline manager or senior allied health professional for assessment in accordance with the credentialing procedure. This information will be reviewed in conjunction with the selection panel report. Recommendations are then forwarded to the relevant service director for approval as part of the usual recruitment process In situations where: there is no allied health discipline manager or more senior allied health professional of that discipline for the Local Health Network/clinical service, the credentialing and defining scope of clinical practice application involves a sole practitioner for the Local Health Network/clinical service, the recruitment panel must include senior representation for that allied health discipline from another Local Health Network/clinical service in order to verify credentials for the required scope of practice. 4.2 Initial credentialing of current clinicians/existing staff The credentialing process applies to all clinicians not just those who are newly appointed. All existing allied health clinicians currently working within Adelaide Local Health Networks or other clinical services, irrespective of skills, knowledge, experience and position who have not been credentialed in accordance with the SA Health Authenticating Allied & Scientific Health Professionals Credentials Policy and Guidelines for Regional Implementation and the Adelaide Local Health Networks Credentialing and Defining Scope of Clinical Practice procedure Allied Health, are required to complete the credentialing process. All allied health clinicians should be provided with the following: SA Health Authenticating Allied & Scientific Health Professionals Credentials Policy and Guidelines for Regional Implementation Adelaide Local Health Networks Credentialing and Defining Scope of Clinical Practice Procedure - Allied Health. Information regarding the Administrative Grievance Procedure in accordance with Part 3 of the SA Health (Health Care Act) Human Resource Manual Adelaide Local Health Networks Allied Health Credentialing Application Form Adelaide Local Health Networks Allied Health Credentialing Information Sheet The completed application form is to be returned to the allied health discipline manager or senior allied health professional for assessment in accordance with the credentialing procedure. In situations as outlined when credentialing current staff, systems are to be established to ensure applications are verified by a senior allied health professional in another Local Health Network or clinical service for that discipline or if the scope of clinical practice being sought is not provided within that service. 4.3 Completion of Initial Credentialing Application New appointments and current clinicians/existing staff. All applications must be completed in full. For registered professions a number of the credentialing requirements listed below will be met through the registration process (& for new applicants as part of the recruitment process) minimising duplication.

4 Where supporting documentation is required, it is to be the original or a certified copy. Requirements as detailed on the allied health credentialing application form: Registration (registered professions) - current registration with the relevant allied health professional board to practise in South Australia, or current registration with the Australian Health Practitioners Regulation Agency (AHPRA). Currency of registration presumes qualifications have been verified by the respective registration board. Employment contracts must be conditional on fulfilment of full registration requirements. Primary allied health qualification (self-regulating professions & staff employed under a Grandparent Clause) - parchment or transcript of academic achievement from an accredited university course (or recognised university course in the case of overseas applicants). Graduation Offices of the respective University may be contacted to confirm the applicant has completed the qualification. Eligibility for professional association membership an allied health qualification from an accredited or recognised university course provides eligibility for membership of the relevant professional association. Curriculum Vitae (on recruitment only) - detailing work history, experience and referees. Referees (as part of Curriculum Vitae) - names and contact details of three current referees who are capable of giving considered opinion regarding the applicant s clinical skills, competence within the past 3 years and suitability for the position. The recruitment panel may consider it appropriate to contact recent employing bodies and clinicians with whom the applicant has worked, in addition to the stated referees in order to verify the applicant s professional standing. The Chair of the recruitment panel, the allied health discipline manager or senior allied health professional may consult, with the consent of the applicant, any relevant person who has knowledge of the training or experience of the applicant, especially in the case of interstate and overseas applicants. In the case of new graduate applicants, the allied health discipline manager or senior allied health professional may use discretion as to the acceptable number and type of referees. Postgraduate qualifications (include higher degree, diploma, certificate, and competency-based training programs). Scope of clinical practice for advanced or extended roles with evidence of additional qualification or evidence of competency to be credentialed to practice. Profession re-entry requirements - demonstration of satisfactory completion of the allied health professional association requirements for re-entry to the profession as applicable. Work Visa -demonstration of satisfactory completion of the allied health professional association recognition requirements and presentation of work Visa for overseas trained professionals as applicable. Completed declaration regarding employment or registration/membership restrictions, accuracy of information provided. Criminal History Report - only if employed in a prescribed position covered by the Aged Care Act 1997 (Commonwealth) or the Children s Protection Act 1993 where criminal history screening is to be undertaking at least every three years. Other information that may be considered relevant to the application. 4.4 Completion of Re-Credentialing Application Re-credentialing is the process used to reconfirm registration, eligibility for professional association membership, experience, continuing professional development, scope of practice and professional standing. Re-credentialing will occur annually and when there is alteration to the scope of clinical practice. The re-credentialing process is to be aligned with verification of registration where required, preventing duplication of processes. All applications must be completed in full. Where supporting documentation is required, it is to be the original or a certified copy.

5 Requirements as detailed on the allied health re-credentialing application form: Registration (registered professions) - current full registration with the relevant allied health professional board to practise in South Australia, or current registration with AHPRA. Eligibility for professional association membership ongoing eligibility without restriction Evidence of completed continuing professional development by way of current registration, professional association CPD point scheme or by evidence of a self-managed portfolio of relevant professional development completed in the past year. Where the CPD cycle is greater than 12 months, the applicant will demonstrate the CPD completed to date. Performance review and development plan evidence of participation in an annual performance review and development process. Professional supervision -evidence of participation in regular intra-professional supervision Advanced/extended scope of practice skill maintenance - evidence of completion of sufficient procedures to maintain skills in advanced or extended roles where applicable Completed declaration regarding employment or registration/membership restrictions and accuracy of information provided. Criminal History Report - only if employed in a prescribed position covered by the Aged Care Act 1997 (Commonwealth) or the Children s Protection Act 1993 where criminal history screening is to be undertaking at least every three years Completion of Amendment to Scope of Clinical Practice application Use re-credentialing application form. Supporting documentation includes: Post-graduate qualifications (include higher degree, diploma, certificate, and competency-based training programs). Details of amendment to scope of clinical practice Skill maintenance schedule as required. 4.5 Processing of Credentialing and Re-Credentialing Applications The allied health discipline manager or senior allied health professional is responsible for: Verifying applications for credentialing and scope of clinical practice Checking registration documentation annually where required Providing recommendation to the service director regarding new appointments Checking with the discipline s professional registration board any restrictions placed on the clinician s practice or if there are any membership restrictions or complaints made about a member to the professional association. Contacting referees to verify the applicant s professional standing (new applicants). Providing the applicant with a completed copy of the application, detailing any restrictions placed on clinical practice. Applicants should be referred to the Appeals Process when required. In situations where there are questions/concerns regarding verification of credentials, an ad hoc Allied Health Credentialing & Scope of Clinical Practice Committee will be formed to determine the most appropriate outcome. This committee will report to the Local Health Network Director of Allied Health. Membership will include 2 senior representatives from the same professional discipline, including one from another Local Health Network or clinical service, one senior allied health representative from a different discipline and the Local Health Network Allied Health Director who will act as chairperson. (Terms of Reference to be drafted) 4.6 Storage of Credentialing Data A centralised Statewide database to store credentialing information of all health professionals is currently under development at the Dept. of Health. In the short-medium term until centralised data entry and storage processes are determined, the allied health manager or senior allied health professional is responsible for keeping local discipline credentialing data, providing an annual status report to the Local Health Network Director of Allied Health by January 31 each year.

6 4.7 Mutual recognition Allied health clinicians credentialed by the other Local Health Networks or clinical services within SA Health will be recognised for a 12 month period and will include the term of the Criminal History report. The allied health manager or senior allied health professional must request a copy of supporting credentialing documentation from the relevant Local Health Network or clinical service. Scope of clinical practice may need to be adjusted according to the requirements of the Local Health Network or clinical service. 4.8 Monitoring and Review of Clinical Credentials The allied health discipline manager or senior allied health professional must implement, record and review procedures to: ensure clinicians undertake sufficient practice to maintain their skills in their various areas of practice, record the completion of any additional training by a clinician which may entitle him/her to apply for additional clinical credentials, ensure clinicians regularly undertake continuing education and any special training associated with any conditional granting of clinical credentials, where necessary, identify and investigate reports of any incidents associated with any clinician s treatment or care of patients/consumers within the health service, investigate the outcome of complaints or claims made against any clinician concerning treatment or care of patients/consumers within the hospital or service, bring to the attention of the Local Health Network Director of Allied Health any matter which may reflect on any clinician s continued ability to effectively practise, and bring to the attention of the registration board/professional association, the Local Health Network Director of Allied Health, any matter which may indicate that a clinician s ability to effectively practise is seriously compromised. 4.9 Changes to Clinical Credentials Evidence of loss of expertise or concerns regarding competence must be raised with the allied health discipline manager or senior allied health professional to be addressed through the performance review and development process in the first instance. Where it is believed a clinician from a registered profession has breached his/her professional standards of practice in such a way that constitutes notifiable conduct, practitioners, employers and education providers are mandated by law to report. Notifiable Conduct means the practitioner has a) practised the practitioner s profession while intoxicated by alcohol or drugs; or b) engaged in sexual misconduct in connection with the practice of the practitioner s profession; or c) placed the public at risk of substantial harm in the practitioner s practice of the profession because the practitioner has an impairment; or d) placed the public at risk of harm because the practitioner has practised the profession in a way that constitutes a significant departure from accepted professional standards. Where it believed a clinician from a self-regulated profession or employed under Grandparent Clause has breached professional standards of practice, a complaint can be reported through the relevant professional association if the clinician is a member, or alternatively via the Health & Community Services Complaints Commissioner. There is a requirement on the clinician involved to inform the employer of any complaint or investigation made against him/her. It is the responsibility of the allied health discipline manager or senior allied health professional to limit the clinician s scope of practice in accordance with the recommendations of the registration board, the professional association or the Health & Community Services Complaints Commissioner Compliance In the event an allied health professional refuses to comply with the credentialing procedure, the allied health discipline manager or senior allied health professional will advise the Local Health Network Director of Allied Health in writing. The Local Health Network Director of Allied Health will formally

7 write to the applicant requesting submission of an application. The allied health professional will have fourteen days to respond. If the response is considered unsatisfactory, the Local Health Network Director of Allied Health will recommend to the Chief Executive Officer Restriction or suspension of the allied health professionals scope of practice until the necessary documentation is provided. The Local Health Network Director of Allied Health will inform the allied health professional in writing of the determination and of the appropriate Appeals process Appeals Process In the event the allied health professional is not satisfied with the determination of credentialing or recredentialing, he/she may appeal the decision by: Following the standard appeals procedure that exists within the recruitment process (new applicants only) Requesting a review through a Local Health Network Credentialing Committee. An Allied Health Credentialing and Scope of Clinical Practice Committee will be formed as required to address such concerns Following the Administrative Decision Grievance Procedure in accordance with Part 3 of the SA Health Human Resource Manual 5. References SA Health Authenticating Allied & Scientific Health Professionals Credentials Policy and Guidelines for Regional Implementation (March 2011) AHS Criminal History Reports, Regional Corporate Procedure (January 2011) CNAHS Credentialing and Defining Scope of Clinical Practice Policy (2008) CNAHS Credentialing and Defining Scope of Clinical Practice Procedure (Medical Practitioners, 2008) Approved Signature: Name: Position: Chief Executive Officer Date: Change History Any printed version of this document may have been superseded. Version Effective From Effective To Change Summary /07/ /07/2012

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