Credentialing and Scope of Practice for Surgeons (2014)

Credentialing is the process used to verify a surgeon’s qualifications, experience, professional standing and other relevant professional attributes for the purpose of forming a view about their ability to deliver surgical services in a particular health service.

Scope of Practice refers to the range of practice or type of procedures, which an individual can perform. It is important to note that an individual’s scope of practice is dependent upon the local environment, and therefore may vary from institution to institution.

Key principles include:-

• This is an organisational governance responsibility
• Patient safety is paramount
• Quality of care must be ensured
• The capability and role of the health service must be considered
• Processes must be fair, transparent and legally robust
• Credentialing should be reviewed on a regular basis

Committees, which define credentialing, and scope of practice for surgeons

• Should have a core membership of medical practitioners from a range of clinical disciplines.
• Should include or co-opt a member from the relevant surgical discipline.
• Should include non-medical organisational and or community members
• Should be convened prior to the appointment of a surgeon, at least every five years of a surgeon’s appointment, and at times where an unplanned review of a surgeon’s scope of clinical practice is requested.
• Members of the committee must declare any conflicts of interest.
• Members of the committee must be indemnified by the health service.
• There must be an appropriate appeals mechanism
• The College is prepared to provide external advice or assistance.

When reviewing credentials the committee should seek

• Proof of medical registration, indemnity insurance, specialty qualifications and compliance with continuing professional development.
• Evidence of recent practice & experience
• Referee reports
• To understand how a surgeon’s practice will interlink with the roles of the health service
• Assurance about the safety of any proposed procedures in the context of the health service

The Appeals Process committee should:

• Include members with the necessary skills and experience to provide informed and independent advice
• Include no members involved in the original decision
• Follow the rules of procedural fairness
• Provide an independent review of an application
• Include within its memberships at least one surgeon who practises in the field relevant to the scope being reviewed, and preferably from another hospital or health service
• Include a RACS nominee
• Allow the attendance of a support person for the surgeon

Community need

• Surgeons are trained within nine specialities. Their scope of practice will usually be restricted within that specialty. However there are many examples where practice within another surgical specialty is an appropriate response to community need (An example would be a rural general surgeon performing surgery on a child, where there is no paediatric surgical presence).
• Sub-specialisation is an increasing trend. However the scope of practice of a well-trained generalist should not be unduly constrained as a consequence.
• The scope of practice may differ for emergency as opposed to elective care. Emergency care will generally require a wider scope than elective care

Credentialing for individual procedures vs. a range of practice

• In some situations it may be possible to define a scope of practice down to the level of a list of specific surgical procedures. This can cause problems dealing with unexpected emergency cases, and is increasingly difficult the more general is an individual’s practice
• An alternative approach is to credential areas of practice, outlining types or groups of procedures, and thus allowing needed flexibility. This can be too open ended.
• There is no easy answer to this matter. Credentialing committees should be encouraged to develop workable solutions that suit a particular health service.

The role of published guidelines

• A range of organizations and societies have published documents or guidelines on matters such as training or case numbers required to perform various procedures
• Such documents should be regarded as of an advisory nature only, and cannot replace the need for an individual credentialing committee to form its own opinion about any specific matter. The College is able to provide expert advice.

Notification to regulatory authorities

• The MBA & MCNZ have a requirement that medical practitioners report any restrictions imposed on their practice
• By defining a scope of practice, a credentialing committee is effectively placing restrictions on an individuals practice. This is a normal process and does not require notification
• If a credentialing committee uncovers serious concerns about a surgeon this should be reported to MBA/MCNZ.

Introduction of new services

•  Hospitals and health services should have in place policies, structures and procedures for determining how new services should be introduced
  
  
• These determinations should be based on considerations such as safety, support services and staff training
  
  
• Surgeons wishing to incorporate new services within their scope of practice must undergo appropriate credentialing.

Performance appraisal

• Health services should regularly appraise surgeon performance. The College has published a Multi-Source Feedback Tool designed for this purpose. (LINK)
• All surgeons are obligated to participate in a continuing professional development program, which includes appropriate surgical audit.
• Understand the resources required for proposed clinical activities
• Understand the competencies required of a surgeon
• Understand the technical requirements for the proposed clinical activities
• Assess & verify the qualifications, training and experience required of a surgeon to undertake the proposed scope of practice
• Confirm that the surgeon is compliant with CPD requirements
• Be clearly notated as representing the RACS. (Other surgeons on the committee are not official representatives of RACS, but may make decisions on their own behalf.)
• Have no conflict of interest
• Make comment from RACS’ point of view

 The appropriate Regional Office of the RACS can provide advice concerning an appropriate representative.

1. Credentialing and defining the scope of clinical practice for medical practitioners in Victorian health services - a policy handbook. 2007, Victorian Government Department of Human Services: Melbourne.

2. Credentialing Framework for New Zealand Heath Professionals. 2010, New Zealand Ministry of Health: Wellington.

3. Allsop, J. and K. Jones, Quality Assurance in Medical Regulation in an International Context. 2005, Department of Health: England: London.

4. Standard for Credentialing and Defining the Scope of Clinical Practice. 2004, Australian Council for Safety and Quality in Health Care: Canberra.

5. Surgical Competence and Performance: A Guide to aid the assessment and development of surgeons. 2011, Royal Australasian College of Surgeons: Melbourne.

6. National Guidelines for Credentials and Clinical Privileges. 2002, Australian Council for Safety and Quality in Health Care: Canberra.

7. Toward Clinical Excellence - A Framework for the Credentialing of Senior Medical Officers in

New Zealand. 2001, Ministry of Health: Wellington