Guideline for Nurse Practitioner Organisational Credentialing

Guideline number: QH-HSDGDL-034-2

Effective Date: 27 March 2025

Review Date: 27 March 2028

Supersedes: New Guideline

On this page:

1. Introduction
2. Purpose
3. Scope
4. Guideline for Nurse Practitioner Organisational Credentialing
5. Human Rights
6. Aboriginal and Torres Strait Islander considerations
7. Supporting and related documents
8. Abbreviations
9. Glossary
10. Organisational Credentialing Matrix
11. Approval and implementation
12. Version control

1. Introduction

Nurse practitioners are integral to Queensland’s public health system and enable the delivery of timely health outcomes for local communities. All nurse practitioners must be credentialed and have a documented scope of clinical practice (SoCP) covering all clinical work performed. Credentialing is the formal process of verifying the qualifications, experience, and professional attributes of a health professional to confirm their competence, performance and professional suitability to provide a safe, high-quality healthcare service within specific environments. SoCP is the extent of an individual health professional’s approved clinical practice within an organisation. It ensures health professionals practise within the bounds of their role/position, education, experience, competence, and authority and within the capacity, capability and available support of the facility or service in which they are practising.

Nurse practitioners are autonomous primary treating clinicians who are highly trained and experienced nurses. They provide comprehensive, holistic, and self-directed nursing interventions for patients across a wide range of conditions and presentations. Nurse practitioners assess, diagnose and treat patients/clients/consumers, this includes ordering and interpreting diagnostic investigations with the ability to prescribe therapy and refer to other healthcare providers. Nurse practitioners are uniquely placed within nursing in that they are accountable for complete episodes of care recognised in current health service funding models. The value of nurse practitioner-led care lies in its integration of nursing philosophy, which combines bioscience with psychosocial, patient-centred care. This approach emphasises the holistic synthesis of patient information, focusing not only on the illness or disease but also on the patient's needs, choices, values, and overall health journey. Nurse practitioners work independently, without supervision from other professions, and are fully accountable for the care they provide. They engage in continuous self-assessment to ensure the highest standards of practice.

During the development of the Guideline, the Sunshine Coast Hospital and Health Service (SCHHS) project team undertook an analysis of the nurse practitioner organisational credentialing processes in the 16 Hospital and Health Services (HHSs) within Queensland Health (QH), revealing that all contained the requisite elements of credentialing; however, there were many variations in the approach and length of credentialing, and some had additional credentialing requirements. Health Q32 identifies the need for connected services and an agile workforce. Supporting streamlined credentialing of nurse practitioners aligns with this vision.

The principles of a Nurse Practitioner Organisational Credentialing Guideline that may be applied across all HHSs:

• Meets Health Service Directive QH-HSD-034 Mandatory Requirements
• Streamlined credentialing processes for nurse practitioners and credentialing committees.
• Standardised processes and forms that may be applied in individual HHSs and mutually recognised by other HHSs whilst also being applicable to state-wide services.

The Nurse Practitioner Organisational Credentialing Guideline will:

• Provide a definition of the types of organisational credentialing and recommend time periods for credentialing.
• Rationalise the provision of documentation components of the nurse practitioner organisational credentialing process.
• Align with other health professional organisational credentialing processes as per QH-HSD-034.

2. Purpose

This guideline provides recommendations for Hospital and Health Services (HHS) regarding best practice in the implementation of the Credentialing and defining the scope of clinical practice Health Service Directive (HSD) (QH-HSD-034).

The Guideline has been developed to adhere to national standards and guidelines, QH directives, policies, and standards, as well as align with best practice guidelines for credentialing other health practitioners in Queensland Health (QH).

It supports the premise that credentialing is a non-punitive process underpinned by accountability, procedural fairness, natural justice, and transparency and that applicants are treated equally and without discrimination. Ensuring all credentialing recommendations and decisions are based on the professional competence of the health professional and the capacity and capability of the relevant service.

To develop a streamlined approach to organisational credentialing of nurse practitioners in QH, incorporating mandatory criteria whilst meeting minimum state and national credentialing standards.

The principles and processes identified in this guideline can be applied to any nurse practitioner where credentialing processes are required by a QH jurisdiction or QH HHS organisation.

3. Scope

This Guideline applies to all Hospital and Health Services.

This Guideline applies to nurse practitioners who are registered with the Australian Health Practitioner Agency (Ahpra) and are employed by QH.

This may also apply to nurses and midwives required to undergo credentialing for advanced clinical practices or activities that demand specific training or qualifications, as well as privately practising or privately employed nurse practitioners. These individuals, while not employed by QH, may be temporarily engaged by QH or a HHS to address a specific healthcare need for a defined period.

This guideline does not apply to Nurse Practitioner Candidates.

This guideline does not specify requirements for registration or endorsement under the National Law.

4. Guideline for Nurse Practitioner Organisational Credentialing

4.1 Clinical Governance

Clinical governance refers to processes and practices that ensure frontline clinicians, managers, and members of governing bodies are providing accountability to patients and the community, assuring the delivery of health services that are safe, effective, high quality and continuously improving.

Clinical governance in Australia is provided by national, state, and local governing bodies. These come in the form of directives, policies, standards, frameworks, and guidelines.

Documentation pertaining to nurse practitioners and credentialing is provided below.

National:

• The Australian Commission on Safety and Quality in Health Care (ACSQHC), National Safety and Quality Health Service Standards (NSQHSS), 2^nd Edition.
• National Model Clinical Governance Framework (ACSQHC), 2017
• Credentialing health practitioners and defining their scope of clinical practice: A guide for managers and practitioners – ACSQHC, 2015.
• Registration Standard: Endorsement as a Nurse Practitioner – Nursing and Midwifery Board of Australia (NMBA), 2016
• Safety and Quality Guidelines for Nurse Practitioners – NMBA, 2021
• Guidelines: For Nurses applying for endorsement as a Nurse Practitioner – NMBA, 2022

Queensland Health:

• Credentialing and defining the scope of clinical practice (QH-HSD-034), 2024.
• Credentialing and defining the scope of clinical practice. Department of Health Policy (QH-POL-390), 2023
• Credentialing and defining the scope of clinical practice process. Department of Health Standard (QH-IMP-390-2), 2023

HHS:

• Refer to local HHS policy, procedure, and guideline documentation for credentialing of nurse practitioners.

The ACSQHC, NSQHSS Clinical Governance Standard (Standard 1) requires health service organisations to have systems for establishing, maintaining, and improving the reliability, safety and quality of the health services it delivers. Partnering with Consumers (Standard 2) provides the framework for effective clinical governance, including the requirement for organisations to have processes for credentialing, for setting and monitoring the appropriateness of a clinician’s SoCP and providing feedback to clinicians on their clinical performance, participate in review of their clinical practice and act on variation in expected health outcomes of their patients.

4.2 Organisational Credentialing

Organisational credentialing and SoCP supports patient safety and clinical governance. It ensures health professionals practise within the bounds of their role/position, education, training, experience, and competence and within the capacity, capability, and available support of the facility in which they are practising.

There are multiple components to consider during the credentialing process. One term often used interchangeably with SoCP is Model of Care (MoC). The MoC is separate from SoCP and is the framework that a nurse practitioner practices within. Nurse practitioners, in partnership with any employing HHS, are required to develop a local MoC tailored to the clinical service capability of the health services and profile of that region’s population demographic and health needs.

A nurse practitioner is expected to have a core SoCP. These are the aspects of clinical practice that can reasonably be expected to be undertaken by all nurse practitioners endorsed by Ahpra. The specialty SoCP, however, is individual to the nurse practitioner practising within each MoC. A nurse practitioner's specialty SoCP is based on the individual nurse practitioner's skills, knowledge, performance, and professional suitability in keeping with the needs and service capability of the organisation.

The formal process of credentialing a nurse practitioner remains the responsibility of the nurse practitioners employing HHS, where credentialing applications are reviewed by the relevant credentialing committee and recommendations are made by the committee to the nominated decision maker who approves a nurse practitioner’s full SOCP.

If a nurse practitioner has a secondary appointment in another HHS, the Guideline provides guidance to enable consistency of the credentialing content and process to facilitate recognition of the primary credentialing approval (mutual recognition – see below).

4.3 Organisational Credentialing Types

4.3.1 Temporary

Temporary SoCP may be used in circumstances when the services of a nurse practitioner without SoCP are required at very short notice or where it is not possible to complete a full application process. This includes interim, as well as disaster/major emergency and clinical emergency credentialing.

i.     Interim

Interim credentialing may be necessary to appoint a nurse practitioner prior to formal review by the relevant credentialing committee. This may occur when a nurse practitioner commences work prior to completing the full credentialing committee process. An interim SoCP needs to be in place prior to commencement of employment and cover the period up to when the credentialing committee considers the full application. Once an application has been considered the interim SoCP is no longer valid.

In alignment with national standards and QH governance, it is recommended that an interim SoCP not exceed 3 calendar months, it cannot be renewed or extended, it cannot be used to extend a formal SoCP that is due to expire, and it does not apply to mutual recognition.

ii.      Disaster/Major Emergency: In some situations, nurse practitioners may be required to provide limited short-term care in times of disaster, major emergencies, or major community events – must not exceed 14 days.

iii.   Clinical Emergency: In the case of a clinical emergency a health professional is expected to do everything possible to save a patient's life or save the patient from serious harm – must not exceed 24 hours.

Recommendations for minimum requirements for a temporary scope of practice include:

• Proof of identity (using the 100-point identification check)
• Verification of registration and endorsement as a nurse practitioner with the NMBA – noting any conditions or undertakings
• Verification that the practitioner holds the mandatory qualifications and has the training and skills required for the SoCP
• A recommendation from a Nursing Director (line manager) acknowledging all required HR requirements have been completed prior to an offer of employment in the specified position – including referee checks.

4.3.2 Initial/Renewal

The first formal process is undertaken by the primary HHS credentialing committee. The formal process verifies the qualifications, experience, professional standing, and other relevant professional attributes of the Nurse Practitioner for the purpose of making a decision about their competence, performance and professional suitability to provide safe, high-quality care within the HHS practising to the specified SoCP within the MoC.

A SoCP must be renewed within an appropriate timeframe to make sure the SoCP does not lapse to ensure there are no gaps/breaks in the nurse practitioners SoCP.

All components of the initial credentialing process may not be required for the renewal credentialing process. See: HHS Organisational Credentialing Matrix for requirements of initial and renewal of SoCP.

This also applies to the renewal of statewide or regional SoCP, which is managed by the designated HHS or the department. If a statewide SoCP is not renewed by the designated HHS or the department but the nurse practitioner continues to deliver care/services in a primary HHS/department, a new SoCP application must be submitted to the employing HHS.

In alignment with national standards and QH governance the maximum duration of SoCP (initial and renewal) that can be recommended is 5 years.

This maximum duration may be limited by the credentialing committee if appropriate. Reasons include a defined period of employment or contract.

4.3.3 Mutual Recognition

Mutual recognition is an alternative process to a new application when a nurse practitioner has an appropriate and current SoCP in another department, division, or HHS within QH. This process can be used when a nurse practitioner will be working in multiple locations or transferring employment. Mutual recognition requires the secondary HHS to recognise the SoCP granted by the primary HHS. Mutual recognition of SoCP can only be recognised against the primary HHS/department/division and must not be secondary to another mutual recognition SoCP.

The credentials and SoCP at the primary HHS/department/division must be consistent with the secondary HHS/department/division Clinical Services Capability Framework (CSCF). The secondary HHS/department/division must review the credentials and SoCP from the primary HHS/department/division to determine if it is consistent with the secondary HHS/department/division CSCF. Where the CSCF for the primary HHS differs to the CSCF for the secondary HHS the decision to approve or reject the SoCP for mutual recognition is made by the delegated decision maker at the secondary HHS/department/division.

Current QH processes refer to mutual recognition requirements, including:

• The primary HHS/department division must provide documents requested by the secondary credentialing committee to facilitate mutual recognition, subject to privacy and confidentiality obligations.
• The secondary HHS/department division must obtain a copy of the approved SoCP and committee recommendations from the primary HHS/department division and verify current registration and endorsement as a nurse practitioner with the NMBA.
• The secondary HHS/department division must notify the primary HHS/department division that the nurse practitioner has been granted a SoCP under mutual recognition.

In alignment with national standards and QH governance, the maximum duration of a mutual recognition SoCP must align with and not exceed the date of the primary credentialing process.

4.3.4 Statewide and Regional Services – Schedule A

Statewide and regional services are coordinated by the department or an HHS and are provided to multiple other HHSs across Queensland. For a service to be eligible to approve statewide or regional SoCP, the services must meet the criteria as outlined in Schedule A of the Health Service Directive.

The provision of these services requires nurse practitioners to travel to facilities in other HHSs and are therefore eligible to have an appropriate defined SoCP relevant to the service. HHSs responsible for coordinating and managing a service listed in Schedule A can approve the relevant and appropriate statewide or regional SoCP.

Schedule A lists the statewide and regional services and the designated credentialing committee responsible for assessing the SoCP applications for those services. Only the designated credentialing committee may make recommendations regarding a statewide or regional SoCP to the relevant decision maker.

The decision maker at the secondary HHS/department division (in this case, the recipient of the designated statewide or regional service) is responsible for deciding whether to accept the statewide or regional SoCP awarded by the primary HHS/department division and determining the nurse practitioner's local SoCP to deliver care within the defined MoC.

The secondary HHS/department division must notify the primary HHS/department division of their acceptance of the nurse practitioners statewide or regional SoCP, and they must document the details of the credentialing, including the approved SoCP and noting any conditions.

4.4 Requirements

Organisational credentialing requirements are separate to recruitment and HR requirements. These should be completed during the recruitment process and adhere to the QH Recruitment and Selection HR Policy B1 (QH-POL-212). These may include:

• General criminal history check
• Aged care criminal history check
• Working with children check
• Citizenship and visa check
• Vaccination check

The requirements for registration and endorsement as a nurse practitioner with the NMBA, as well as the HR requirements as outlined above, should not be duplicated for the credentialing process.

Monitoring a nurse practitioner's compliance with SoCP should be part of regular performance reviews and management processes. Requirements should be consistent across all professional streams within the HHS. Guidance should be included in local HHS policy. It should include advice for clinical/line managers who identify concerns about noncompliance with a SoCP. It should also include information about how and to whom to escalate concerns and ensure procedural fairness is provided to the nurse practitioner. This should be a continuous process included in the routine performance and development processes and proactively managed as per the positive performance management principles outlined in Human Resources Policy G9. It is not required to be part of the credentialing process.

4.4.1 Application

An application for new or renewal of a defined SoCP must be completed. The application will detail the requirements and requested evidence to support the credentialing application. This must meet national standard requirements and must be completed and signed by the applicant. The application also requires a recommendation from the relevant/appropriate Nursing Director (delegated line manager/s). Any concerns, complaints or issues that are identified through routine governance processes must be documented for consideration by the relevant credentialing committee. Once completed, the application and supporting documentation are submitted to the relevant HHS-nominated credentialing committee where the nurse practitioner is primarily employed to review and, if required, request further supporting documentation to be able to make a recommendation to approve, reject or limit the SoCP for the applicant.

https://qheps.health.qld.gov.au/__data/assets/word_doc/0034/3258718/Nurse-Practitioner-Organisational-Credentialing-Application-and-Recommendation_TEMPLATE_FINAL_v1.0.docx

4.4.2 Model of Care (MoC) and Scope of Clinical Practice (SoCP)

Organisational and service needs and capabilities must be known (and appropriately documented) so that nurse practitioners’ skills, knowledge and qualifications can be matched to their SoCP within the MoC. Delineating the level and type of services to be provided within a health service is an essential component of determining SoCP for a practitioner. The MoC and SoCP document has been developed to support the application for credentialing and SoCP for approval by the credentialing committee.

The MoC is designed to outline organisational and clinical service needs that are provided based on the clinical service capability of the health services and the profile of that region’s population demographic and health needs. The SoCP is individual to the applicant and outlines the approved clinical practice for the applicant within the bounds of their qualifications, education, training, current experience and competence, and within the capability of the organisation and the clinical service in which they are working.

https://qheps.health.qld.gov.au/__data/assets/word_doc/0033/3258717/Model-of-Care-and-Scope-of-Clinical-Practice_TEMPLATE_FINAL_v1.0.docx

4.4.3 Proof of identity

Proof of identity is required for the initial credentialing process in accordance with the protocol outlined in Recruitment and Selection Human Resources (HR) Policy B1. Current original or certified copies of three identity documents from the list below to satisfy proof of an applicant’s name, date of birth, and signature must include at least one type of photographic ID and one type that contains a signature and date of birth.

• Australian citizenship certificate
• Australian driver’s licence
• Australian student photo ID
• Australian proof of age card
• Birth certificate
• Passport
• Health care card
• Medicare card
• Pension concession card
• Utility bill (e.g. water, gas, electricity)
• Working with children check (Blue Card)

Where an Aboriginal and Torres Strait Islander person is unable to provide proof of identity documentation (e.g. an older person who does not have a birth certificate or those living in remote communities), consideration is to be given to alternative confirmation of proof of identity documents, including a statement by an authorised referee. Examples of acceptable authorised referees include:

• Chairperson, Secretary or CEO of an incorporated Indigenous organisation
• School principal
• Minister of religion
• Treating health professional
• Manager Aboriginal medical service
• Other government employee of at least five years

When the name shown on the documents differs from the person’s current name, the person is to provide sufficient evidence of their name change (e.g., a certified copy of the marriage certificate).

Previously submitted identification documents submitted as part of the applicant's pre-employment screening may be obtained through the HHS HR department.

For renewal of credentialing, proof of identity is not required unless the nurse practitioner has had a name change.

4.4.4 Registration

The Nurse Practitioner is a registered nurse (RN) endorsed as a nurse practitioner by the NMBA. ‘Nurse Practitioner’ is a protected title under the National Law. A nurse practitioner meets and complies with both the registered nurse as well as the nurse practitioner standards for practice. Undertakings, conditions, or restrictions imposed by the NMBA that place limits on the roles and responsibilities of the clinician may influence the SoCP permitted. These appear on the public register published on the Ahpra website.

For each credentialing process, current details of registration and endorsement as a nurse practitioner are required, including any conditions, undertakings or restrictions. The HHS credentialing committee must conduct an independent search of the NMBA registration and nurse practitioner endorsement on the Ahpra website for confirmation.

It is the obligation of the applicant to advise the committee of any conditions, notations, undertakings, or other restrictions on their registration.

4.4.5 Education, qualifications, formal training

For the initial credentialing process, evidence of formal academic qualifications and training must be provided that supports the SoCP and MoC requested. For renewal applications, only academic qualifications and training obtained since the last credentialing period need to be supplied.

4.4.6 Curriculum Vitae

Based on QH best practice guidelines it is recommended:

1. Initial credentialing – an applicant must submit a current CV.
2. Renewal of SoCP – if the nurse practitioner has remained employed in the same HHS, department and role, then a CV is not required to be submitted for the renewal process – this may be different for nurse practitioners seeking renewal of a statewide or regional SoCP or with mutual recognition.

4.4.7 Continuing Professional Development

The NMBA registration standard: Continuing professional development (CPD) requires nurses and midwives to complete a minimum number of CPD hours/year directly relevant to a nurse or midwife’s context of practice. A nurse practitioner is required to complete the minimum 20 hours required by an RN as well as an additional 10 hours related to the expanded practice of a nurse practitioner, which is inclusive of but not limited to prescribing and administration of medicines, diagnostic investigations, consultation, and referral related to the SoCP.

Evidence of relevant CPD should be documented and verifiable with corroborating data and/or information to ensure adherence with the NMBA registration standard. NMBA guidelines for CPD, supplement the CPD Registration Standard and provide information about the NMBA’s minimum annual CPD requirements and how you can meet these requirements to ensure your CPD is effective.

4.4.8 Professional Indemnity Insurance

Nurse practitioners working within QH are covered by its indemnity policies; however, additional coverage from an external provider (e.g. QNMU) is encouraged.

If held, evidence of current, appropriate professional indemnity insurance must be provided if required by the health service organisation.

4.4.9 Recommendation

A recommendation from the applicants Nursing Director (delegated line manager) needs to accompany the application.

Note: A referee check should be included as part of the HR recruitment process and should not be duplicated for the credentialling process.

https://qheps.health.qld.gov.au/__data/assets/word_doc/0034/3258718/Nurse-Practitioner-Organisational-Credentialing-Application-and-Recommendation_TEMPLATE_FINAL_v1.0.docx

4.4.10 Clinical Practice Peer Review

In addition to CPD and performance development planning, practice-based reflective elements such as clinical audits and peer reviews help maintain, update, and enhance knowledge, skills, and performance to ensure safe and appropriate care delivery. It is recommended to use a standardised process for peer review to support statewide, regional, and mutual recognition of SoCP.

The Clinical Practice Peer Review tool covers 3 functions in the one tool, clinical audit, clinical reference and peer review and is completed annually by a nurse practitioner peer or Senior Medical Officer/Specialist Medical Officer within the same or related clinical specialty. It is conducted alongside the nurse practitioner's review of their Performance and Development Plan (PDP/PaD).

The Clinical Practice Peer Review tool examines the four NMBA Nurse Practitioner Standards:

• Assesses using diagnostic capability.
• Plans care and engages others.
• Prescribes and implements therapeutic interventions.
• Evaluates outcomes and improves practice.

The Clinical Practice Peer Review document is submitted – one per year of practice – for the renewal credentialing process.

It is recommended that newly employed nurse practitioners provide evidence for an initial clinical practice peer review (completed within 3 months of commencement) for the initial credentialing application.

https://qheps.health.qld.gov.au/__data/assets/word_doc/0034/3258709/Clinical-Practice-Peer-Review-Tool_TEMPLATE_FINAL_v1.0.docx

4.5 Outcomes

Once the credentialing committee has reviewed the credentialing application, they are to provide a recommendation regarding credentialing and SoCP for each application within a reasonable timeframe specified in local policy documents, to the HHS Chief Executive (or delegate), who will make the final decision.

Written notification is to be provided to the applicant and facility/department/unit/service manager within a reasonable timeframe specified in local policy documents, of receiving the recommendation from the credentialing committee.

4.6 Request to change SoCP

There may be a variety of reasons to request a change to SoCP. Note: a nurse practitioner may voluntarily request a review of their SoCP at any time; this is to be recognised and encouraged as appropriate professional conduct.

Standard governance processes should be ongoing throughout the credentialing period. If concerns, complaints, or issues are identified through these standard governance processes that would affect the applicant's compliance with the approved scope of clinical practice, the relevant HHS credentialing decision maker needs to be notified immediately.

4.6.1 Additional skills/qualifications

A practitioner may request additional SoCP if they have gained new skills or qualifications. Before the credentialing committee considers making any recommendation regarding expanding the nurse practitioner’s SoCP, the facility must confirm that it has the capability and the need for the nurse practitioner to expand their SoCP.

The nurse practitioner should submit to the credentialing committee:

• a request in writing for the change of SoCP
• reviewed MoC and SoCP document
• evidence to support the additional requested SoCP (e.g. qualification/s)
• references from at least two professional peers who are independent of the applicant, with no conflict of interest, and who can attest to the applicant’s clinical performance in the requested SoCP.

4.6.2 Removal conditions/notations/undertakings

A practitioner may also request a review of their SoCP when conditions, notations, or undertakings on their Ahpra registration that affect the practitioner’s SoCP are removed or reduced.

The nurse practitioner should submit to the credentialing committee:

• a request for the removal of conditions, notations, undertaking on the SoCP,
• reviewed MoC and SoCP document,
• evidence and details of the changes to conditions, suspensions, notations or undertakings on their Ahpra registration,
• references from at least two professional peers who are independent to the applicant, with no conflict of interest, and who can attest to the applicant’s clinical performance in the requested SoCP.

4.6.3 Voluntary reduction

Nurse practitioners may voluntarily, and by mutual agreement with their employer, limit SoCP. Examples include the nurse practitioner no longer having the qualifications required, the HHS no longer having the ability to clinically support the practitioner’s SoCP or the HHS CSCF being redefined.

The nurse practitioner should submit to the credentialing committee:

• a request in writing for the reduction of SoCP
• reviewed MoC and SoCP document

4.6.4 Request for review by decision maker

A direction by the decision maker to the committee that a practitioner’s SoCP requires review.

The nurse practitioner must be advised in writing, within a reasonable time frame outlined in local policy documents, that a review has been requested and an invitation to provide a written submission.

The committee must provide an opportunity for the practitioner to make statements and/or present documents. However, this does not include a right for the practitioner to be present for the entirety of the committee’s proceedings.

The person raising a concern about the specific practitioner is not to be involved in any deliberations or decision-making regarding the practitioner’s SoCP.

4.7 Review of a decision

An applicant may apply for a review of SoCP at the department divisional level where an application is denied, withheld, limited or granted in a different form than requested, including the timeframe that has been granted. It is a requirement under the Health Service Directive that the HHS or department provide local policy or guidelines on how to request a review of a decision.

The steps a nurse practitioner must take in seeking a review of a SoCP decision are:

• Within a reasonable time frame, outlined in local policy documents, of receiving the decision, the nurse practitioner must request a local review of the credentialing and SoCP decision in writing.
• The nurse practitioner should include a submission with their request that includes specific grounds and reasons for requesting a review.
• The nurse practitioner's submission is to be presented to the decision maker.
• The decision maker must consider the nurse practitioner’s request for review and submission and may seek advice from the committee, where appropriate.
• Within a reasonable time frame, outlined in local policy documents, of the receipt of the submission from the nurse practitioner, the decision maker must communicate their decision on the review of the nurse practitioner’s SoCP, including the reason/s for that decision, in writing, to the nurse practitioner. The letter must also outline the process for the nurse practitioner to lodge a formal appeal.

Note: resolution of credentialing and SoCP matters should be exhausted at this level before progressing to the appeals process.

If appropriate, the nurse practitioner’s current approved SoCP remains in effect while deliberations and consideration of any further submissions/appeals are in progress.

4.8 Appeal process

A nurse practitioner whose SoCP has been terminated, suspended, reduced, denied or approved in a different form than that requested has the right to appeal against that decision through a review by an independent appeal committee.

The appeal process is instigated after all possibilities of resolution have been exhausted at the department division level.

Applicants should be informed in writing that they may appeal the decision within a reasonable time frame, outlined in local policy documents, from the written notification of their application/review outcome.

The steps a nurse practitioner must take in seeking a review of a SoCP decision are:

• The nurse practitioner should include a submission with their request that includes specific grounds and reasons for requesting a review.
• The credentialing committee or HR delegate must notify the HHS Chief Executive (or delegate) of the appeal within a reasonable timeframe of receiving the appeal request
• The HHS Chief Executive may progress the appeal through existing appeal mechanisms within the HHS or by establishing a specific appeals committee, which must be convened within a reasonable time frame, outlined in local policy documents, of the date the notification is made to the relevant decision-maker
• To maintain the integrity of the appeal process, the decision maker for the outcome of an appeal MUST NOT be the same decision maker who made the original SoCP decision
• The appeals committee should include nursing representation and should not include members involved in the original credentialing decision for the application being considered
• The appeals committee must consider all information presented and make recommendation/s, including the reasons for the recommendation/s
• The appeal committee is only able to make recommendations and is not a delegated decision-maker
• The appeal committee chair must forward the committee recommendation/s in writing to the relevant decision maker within a reasonable time frame, outlined in local policy documents, of the final convening of the appeal committee
• Once the relevant decision maker has received the appeal committee’s recommendation/s, they must make a decision on the nurse practitioner’s appeal of their SoCP. This includes agreeing with the recommendations, disagreeing with the recommendations, make a decision that includes conditions being attached to the nurse practitioner's SoCP
• The relevant decision maker should provide written advice on the outcome of the appeal to the appellant, the chair of the appeal committee and the departmental credentialing committee
• The decision, with comprehensive reasons, must be communicated in writing to the appellant within a reasonable time frame, outlined in local policy documents, of the last day that the appeal committee convenes
• The appeal is then closed.

A nurse practitioner may also, as a separate process, seek a judicial review of any SoCP decision through the Supreme Court. Applications for judicial review under the Judicial Review Act 1991 of a credentialing/ SoCP decision. A request can be made by the nurse practitioner generally within 28 days of the decision that has impacted them being made (section 26 of the Judicial Review Act 1991). Applicants may also request the reasons for a decision that has adversely affected them. This may occur during or after the SoCP appeal process.

4.9 Termination of SoCP

A SoCP for a nurse practitioner may be terminated based on a recommendation of the HHS Chief Executive (or delegate) following a review or appeal process.

If a nurse practitioner is no longer employed within the HHS, their nurse practitioner credentialing and SoCP is terminated. A process needs to be outlined in local policy documents to ensure the credentialing committee are notified and accurate records maintained.

If a nurse practitioner holding mutual recognition credentials ceases employment with the primary HHS but continues to be employed by the secondary HHS, the credentialing committee of the primary HHS must notify the credentialing committee of the secondary HHS, as a new application will be required for the secondary HHS.

If the nurse practitioner is seconded to another position within QH and maintains continuous employment, their credentialling and SoCP can be temporarily suspended. The nurse practitioner must remain registered and endorsed as a nurse practitioner with the NMBA during this time and must meet the requirements for recency of practice. The period lapsed must not exceed the expiry date of their last approved credentialing period.

4.10 Credentialing Committee

The HHS/department division needs to ensure that local policy adheres to the requirements outlined in the Queensland Health, Health Service Directive Credentialing and defining the scope of clinical practice, QH-HSD-034.

The HHS Chief Executive (or delegate) should determine whether a nurse/nurse practitioner-specific credentialing and defining scope of clinical practice committee is required to review applications for credentialing and scope of clinical practice within their HHS or whether an existing credentialing committee will consider the applications. If there isn’t a nurse-specific credentialing committee, then committee membership shall include a multidisciplinary team and relevant health profession-specific peers or have a process to seek input from a relevant profession-specific peer.

Where a nurse/nurse practitioner-specific credentialing committee is required, then the following should apply:

• The HHS Chief Executive (or delegate) should determine the membership (number and composition) of the nurse/nurse practitioner credentialing committee within their HHS, formally appoint a chairperson and each member to the committee and establish documented governance for the committee.
• It is recommended that a nurse/nurse practitioner credentialing committee membership include:
  • Director of Nursing and Midwifery
  • Relevant Nursing and/or Midwifery Service Director/s – a representative from each division in the HHS
  • Nurse Practitioner
  • Senior Medical Officer
  • Allied Health (pharmacy, radiology, etc.) if relevant.

Other attendees

• Non-members of the committee attending should be discussed with the chair at least 24 hours before the meeting.

The Chair and members of the nurse/nurse practitioner credentialing and defining scope of clinical practice committee, at a minimum, should:

• declare any actual or perceived conflicts of interest regarding an application and withdraw from deliberations of that application,
• enquire and act with due care and diligence,
• ensure all decisions are documented with corresponding reasons to enable review under the Judicial Review Act 1991 if so required.

The decision maker with delegations to approve SoCP (HHS CE or delegate) must not participate in the credentialing committee process or its deliberations.

During each stage of the credentialing and SoCP process, it is important that there is compliance with the principles of natural justice and procedural fairness and that any perceived or real conflicts of interest are appropriately managed.

A prime requirement of robust credentialing and defining the SoCP process is ensuring clear accountability for establishing and managing an appropriately convened credentialing committee (the ‘committee’), which manages its business in a timely manner.

The Committee will:

• Ensure they meet at a frequency that ensures applications for credentialing and SoCP are reviewed in a timely manner for new applications and that there are no breaks in ongoing SoCP for renewal applications. This also includes processes to manage out-of-session (flying minute) approvals for urgent applications (should only be used in exceptional circumstances).
• Follow the established terms of reference, protocols, and procedures for evaluation of SoCP and credentialing.
• Undertake assessment and review of all documentation submitted by applicants and seek relevant third-party advice regarding each application for SoCP and credentialing.
• Not consider an incomplete application or make a recommendation about a practitioner’s SoCP pending submission of further information.
• Consider the SoCP in accordance with the CSCF for each service.
• Make a recommendation regarding:
  • the outcome (to approve with or without limitations or not approve the defined scope of clinical practice)
  • the duration of the credentialing period (maximum 5 years – if a period shorter than 5 years is recommended, then a reason for the shorter period needs to be provided)

Where authorised, ensure information regarding a practitioner’s SoCP is accessible at all times to relevant staff. This is done via the publication of HHS and departmental SoCP registers that are accessible on QHEPS (the publication of up-to-date SoCP registers by HHSs and the department are mandatory requirements of the HSD and department standard: Credentialing and defining the scope of clinical practice process (QH-IMP-390:2).

It is recommended to include:

• HHS/Hospital
• Last Name
• First Name
• Ahpra number
• SoCP type (MR/Interim/Formal)
• SoCP status (Approved/Expired/Revoked)
• Approved SoCP
• Subspeciality (if applicable)
• Start Date
• Expiry Date
• Conditions
• Supervision

5. Human Rights

Queensland Health must act and make decisions compatible with human rights, in accordance with The Human Rights Act 2019  (the Act). This includes conducting the credentialing process and making decisions with regards to the credentialing of individuals in accordance with the Act.

6. Aboriginal and Torres Strait Islander considerations

In adhering to this guideline, HHSs must consider the impact this guideline may have on Aboriginal and Torres Strait Islander stakeholders, particularly cultural impacts.

7. Supporting and related documents

• Credentialing and defining the scope of clinical practice (health.qld.gov.au)
• Recruitment and selection (health.qld.gov.au)
• Credentialing and defining the scope of clinical practice for medical practitioners and dentists: a best practice guideline (health.qld.gov.au)
• Clinical services capability framework | Queensland Health

Authorising Health Service Directive

• Credentialing and defining the scope of clinical practice Health Service Directive (QH-HSD-034)

Forms and templates

• Nurse Practitioner Organisational Credentialing Application & Recommendation
• Model of Care and Scope of Clinical Practice
• Clinical Practice Peer Review Tool

The above templates and resources for HHSs to use or modify for use to suit their local needs are available on the Nurse Practitioner QHEPS page, available via the Office of the Chief Nurse Officer (OCNO), Practice Innovation intranet page. Nurse Practitioners | Queensland Health Intranet.

Accreditation references (e.g. EQuIP and other criteria/standards)

• https://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-standards/nurse-practitioner-standards-of-practice.aspx
• https://www.safetyandquality.gov.au/publications-and-resources/resource-library/credentialing-health-practitioners-and-defining-their-scope-clinical-practice-guide-managers-and-practitioners
• https://www.safetyandquality.gov.au/sites/default/files/migrated/Clinical-governance-for-nurses-and-midwives.pdf

8. Abbreviations

9. Glossary

10. Organisational Credentialing Matrix

11. Approval and implementation

Guideline custodian

The Chief Nurse Officer

Approving officer

Deputy Director General, Clinical Excellence Queensland, Queensland Health

Approval date: 27 March 2025

Effective from: 27 March 2025

12. Version control