Credentialling and defining the scope of clinical practice

What is credentialling?

Credentialling is the formal process used to verify the qualifications, experience and professional standing of medical practitioners for the purpose of ascertaining their competence, performance and professional suitability to provide safe, high quality health care services within specific organisational environments.1,2

Credentialling involves the:

  • determination of the essential criteria of a position
  • identification of the appropriate qualification, experience and expertise (i.e. credentials) that could be used to provide evidence against the essential criteria
  • verification of those credentials.

Defining the scope of clinical practice is the process of delineating the extent of an individual medical practitioner’s clinical practice within a particular organisation based on the individual’s credentials, competence, performance and professional suitability, and in consideration of the needs and capabilities of the health facility itself.1,2

It defines the clinical practice that a medical practitioner is permitted to conduct at a particular health care facility.

Defining the scope of clinical practice is sometimes referred to as clinical privileges.

Does it apply to me?

Medical practitioners

The WA Health Policy for Credentialling and Defining the Scope of Clinical Practice for Medical Practitioners (OD 0177/09) (external site) applies to all independent medical practitioners practising in public health care facilities in Western Australia, and includes:2

  • consultants/specialists
  • health service medical practitioners
  • senior medical practitioners
  • clinical academics
  • senior registrars/fellows who have conditional registration with the Medical Board of WA
  • vocational registered general practitioners seeking admitting rights to a public health facility
  • unsupervised overseas trained doctors, unsupervised international medical graduates (IMGs), and unsupervised overseas trained specialists (OTS)
  • medical practitioners with a right of private practice in a public hospital
  • medical practitioners undergoing a supervised clinical assessment prior work in rural hospitals/health services
  • medical practitioners providing telehealth services
  • private medical practitioners providing care to residents of publicly operated residential care facilities, nursing homes or multi-purpose sites
  • medical administrators and non-specialist qualified medical administrators who may have direct patient contact or provide clinical services.

The credentialling policy does not apply to:

  • interns (PGY 1s)
  • resident medical officers (PGY2, PGY3)
  • registrars (PGY3+)
  • senior registrars
  • fellows enrolled in:
    • a recognised training program
    • working under supervision in a WA hospital.

Nurses and Midwives

OD 0505/14 Credentialing and Defining Scope of Clinical Practice for Health Professionals (Nursing and Midwifery) in WA Health Services – A Policy Handbook(external site) applies to all Eligible Midwives and Nurse Practitioners with independent responsibility for client care or clinical supervision in WA and provides guidance for a uniform system of credentialing and defining the scope of clinical practice

What do I have to do?

If credentialling and defining the scope of clinical practice relates to you (refer above), then you are required to cooperate with the health service in which you are working (either employed or engaged) to ensure that the necessary documentation is provided in a timely manner.

Initial credentialling will be conducted during your first appointment and re-credentialling will occur at regular intervals (about every 3 years).


  1. Australian Council for Safety and Quality in Health Care (2004). Standard for Credentialling and Defining the Scope of Clinical Practice. A National Standard for Credentialling and Defining the Scope of Clinical Practice of Medical Practitioners, For Use in Public and Private Hospitals. Note: the Council has since become the Australian Commission on Safety and Quality in Health Care.
  2. Western Australian Department of Health 2009. Policy for Credentialling and Defining the Scope of Clinical Practitioners for Medical Practitioners.

More information

  • The director of medical services at your hospital/health service who oversees the credentialling process.
  • Nursing and Midwifery Office
  • Office of the Chief Medical Officer


Produced by

Quality Improvement and Change Management Unit