RACMA Guide to Credentialing and Scope of Clinical Practice Processes

RACMA Fellows and Associate Fellows have key roles in clinical governance in our organisations. Their expertise in this area means that they are in a position to provide expert advice and leadership in all areas of clinical governance. One of the specific areas where such leadership is of significant importance to health service organisations is in the development, maintenance and improvement of processes that lead to appropriate credentialing and defining the scope of clinical practice of medical staff both within the health service organisation and for medical staff who may be affiliated with that organisation.

This practical guide (which was first published in 2015) has been developed and updated to ensure that all RACMA members have a consistent way of functioning as the guardian and that there is agreement about the factors that need to be considered in any process that is adopted. The guide has been developed to be complimentary to the guidelines provided by jurisdictions as those guides provide a regulatory framework for specific jurisdictions with less of the practical details of how to go about setting up processes, maintaining processes or making improvements.

This guide is aimed at providing RACMA members with a “how to” in relation to setting up appropriate processes, indicating how the processes can be monitored and by whom, what issues need to be considered in the processes of appropriate credentialing and defining scope of clinical practice and how these may be ascertained. The objective is that all of us as RACMA members will ensure that our systems provide a high level of safety in medical staff practice and support quality of clinical practice.

It is important that medical administrators ensure that there is a documented change in organisation policy from a governing body (e.g. your CEO, Board, Department, Government) which provides authorisation for any changes in your actions from usual practice.