Credentialling & Defining Scope of Clinical Practice

Credentialing and defining scope of practice of medical staff policy documents

Policy Statement
Monash Health will ensure that the health care professionals it employs or engages are appropriately credentialed and have their scope of clinical practice defined.

Purpose and Rationale
To inform Monash Health medical staff of the process of credentialing and defining scope of clinical practice for delivering safe, effective and person
centred care.

This policy covers the following aspects:

  1. Responsibilities
  2. Reporting & auditing
  3. Recredentialing and planned review of individual scope of practice
  4. Temporary Service
  5. Emergency Situations
  6. New Clinical/Interventional Procedure or Technology
  7. Unplanned Review of Credentials and/or Scope of Practice
  8. Suspension of defined scope of practice
  9. Appeals Process
  10. Credentialing of registrars and fellows (working in procedural areas) for independent practice

Submission of Application for Committee

Please complete application and scope of practice templates as required and provide signed/approved applications to Monash Doctors Workforce: or contact our office (03) 9594 2547.

Monash Doctors Credentialing & Appointments Committee

The Monash Doctors Credentialing and Appointments Committee is established to ensure that Monash Health’s Senior Medical Staff (SMS) comply with the clinical governance strategy outlined in our strategic goal ‘We put our patients first.’

This committee will act at all times in compliance with common law and legislation including the rules of natural justice and procedural fairness. It will ensure that equity and merit are to form the basis of all phases of the credentialing and defining scope of clinical practice process.

Private and confidential information should not be recorded in the committee minutes, but should be documented separately in a memorandum addressed to the Monash Health Corporate Counsel seeking legal advice, so that such documented information is protected under legal professional privilege. Members are also protected by Monash Health’s defamation insurance coverage.

Terms of Reference – Monash Doctors Credentialing & Appointments Committee (July 2019)


Scope of Practice Templates