WA Health credentialling policy on reduction, suspension or termination of clinical practice

The purpose of this document is to provide area health services with guidance on interpreting and implementing Section 12 of the WA Health Policy for Credentialling and Defining the Scope of Clinical Practice for Medical Practitioners (OD 0177/09) (external site). This section relates to the reduction, suspension and termination of clinical practice.1

Hospitals/health services in WA have a duty of care to patients and must manage the performance and conduct of medical practitioners appropriately, in accordance with:

Section 12 of the policy lists some of the circumstances that may result in a medical practitioner’s scope of clinical practice and/or clinical practice being:

  • reviewed
  • suspended
  • terminated.

These circumstances include a medical practitioner:

  • ceasing to be registered with the Medical Board of WA
  • ceasing to have appropriate and adequate medical indemnity cover or insurance
  • being found to have made a false declaration through omission or false information which justifies such action
  • engaging in serious or wilful misconduct
  • presenting a risk to the safety and wellbeing of patients and/or staff
  • departing from generally accepted standards of medical practice in his/her conduct
  • being subject to criminal investigation
  • convicted of a serious crime which could affect his/her ability to provide the defined clinical scope safely and competently.1

The right to initiate disciplinary action, reduce, suspend or terminate the scope of clinical practice of a medical practitioner is held by the appointing officer.

This officer has been delegated by an area health service to oversee the appointment, engagement and management of medical practitioners at a WA hospital/health service.

If the appointing officer believes in good faith that a medical practitioner’s conduct or actions has placed the safety and quality of patients, other staff and the health care facility at risk, he/she may immediately suspend the medical practitioner’s clinical practice.

The appointing officer must then decide whether the medical practitioner’s conduct/performance should be managed under the:

  • credentialling pathway
  • performance management and disciplinary processes outlined in the Public Sector Standards and relevant industrial agreements3
  • Memorandum of Understanding between the Minister for Health and the Australian Medical Association (WA Branch).5

Any performance management and disciplinary taken by the hospital/health service must comply with the conditions outlined in the:

  • Public Sector Management Act (external site) and relevant industrial agreements3
  • Memorandum of Understanding between the Minister for Health and the Australian Medical Association (WA Branch).5

If the appointing officer believes in good faith that the safety and quality of health care in another institution is subsequently at risk, he/she should refer the matter to the:

  • appointing officer of that hospital/health service
  • relevant area health service chief executive or the Director General of Health.

The Director General may refer the matter to a statewide review panel to determine whether it should recommend that clinical privileges at other health care facilities throughout the State be:

  • restricted
  • made conditional
  • varied
  • suspended
  • terminated
  • reinstated.5

References

  1. Western Australian Department of Health 2009, The Policy on Credentialling and Defining the Scope of Clinical Practice for Medical Practitioners (2nd Edition).
  2. Commissioner for Public Sector Standards 2001, Public Sector Standards in Human Resource Management.
  3. Western Australian Industrial Relations Commission 2008, Department of Health Medical Practitioners (Director General) AMA Industrial Agreement 2007
  4. Department of Health 2005, Medical Services Agreement between the Minister for Health and Contracting Medical Practitioners
  5. Memorandum of Understanding between the Minister for Health and the Australian Medical Association (Western Australia) Inc. on Clinical Privileges, Conduct and Governance in Western Australian Government Hospitals and Health Services (2009). On 19 December 2012, the AMA (WA) signed a new MOU with Health Minister Dr Kim Hames and Director General of Health Mr Kim Snowball.

More information

Performance Activity and Quality Division
Phone: 9222 4080
Email: safetyandquality@health.wa.gov.au

Produced by

Performance Directorate