Credentialling process

How does the credentialling process work?

There are 3 distinct steps in the process of credentialling and defining the scope of practice for medical practitioners.

Initial credentialling

  • Verification of credentials: initial review and verification of a medical practitioner’s:
    • qualifications
    • skills
    • experience
    • competencies.

See section 3.1 on page 4 of the WA Health Policy for Credentialling and Defining the Scope of Clinical Practice for Medical Practitioners (OD 0177/09) (external site).

  • Defining the scope of clinical practice: delineation of the scope of clinical practice for a medical practitioner within a specific health care facility. (Defining the scope of clinical practice, also known as delineation of clinical privileges – see Section 3.2 on page 6.)

Defining the scope of clinical practice involves the following steps:

Step 1: review the scope of clinical practice required by the particular health service and requested by the applicant, using one of the above approaches

Step 2: determine the issues to be considered in making a recommendation (See Appendix 4 for a list of potential issues to be considered)

Step 3: recommend the scope of clinical practice for the applicant.

Verification of credentials and defining the scope of clinical practice must be completed prior to appointment/engagement of the medical practitioner.


Formal review of credentials and the scope of clinical practice occurs to confirm the medical practitioner has maintained his/her qualifications, skills and competencies and that the particular health care facility still requires and is able to support the defined scope of clinical practice.

There are 2 types of re-credentialling:

  • planned
  • unplanned.

Planned re-credentialling must occur as part of an area/statewide health service and hospital/health service’s strategy to ensure medical practitioners’ credentials remain current and relevant.

This also ensures that the medical practitioner remains competent to provide the defined scope of clinical practice.

Reasons for undertaking unplanned re-credentialling include:

  • new technology/procedure is introduced outside scope of practice
  • new clinical intervention introduced in health facility
  • the medical practitioner acquires enhanced skills
  • sub-standard performance of medical practitioner
  • a complaint is made to Medical Board or Office of Health Review about the medical practitioner’s performance.

What information must be considered during initial credentialling process?

  • Confirmation of the medical practitioner’s registration with the Medical Board of WA
  • Confirmation that the medical practitioner’s undergraduate qualifications have been verified by the US Educational Commission for Foreign Medical Graduates (ECFMG) (external site)
  • Verification of the medical practitioner’s postgraduate qualifications
  • Review of at least 2 professional referees reports
  • Review of the applicant’s curriculum vitae
  • Verification of accreditation or endorsement of specialist medical colleges for the provision of specific clinical services, procedures or other interventions
  • Review of evidence of the applicant’s compliance with the requirements of a specialist medical college’s fellowship program.

How long does a medical practitioner’s scope of clinical practice last?

The scope of clinical practice shall be defined for a period commensurate with the term of the medical practitioner’s employment/engagement, or if ongoing every 3 years, but in no circumstances more than 5 years.

How long do a medical practitioner’s credentials last?

A medical practitioner’s credentials should only be renewed for a period commensurate with the term of his/her employment/engagement and in no circumstances shall exceed more than 5 years.

To see a flowchart of the above process download:

More information

  • Office of the Chief Medical Officer
  • Nursing and Midwifery Office
Produced by

Quality Improvement and Change Management Unit