CHHS18/113

Canberra Hospital and Health ServicesOperational Procedure AHPRA Medical Practitioner Registration Conditions/NotationsContents

Contents....................................................................................................................................1

Purpose.....................................................................................................................................2

Alerts.........................................................................................................................................2

Scope........................................................................................................................................ 2

Section 1 – Changes to AHPRA Registration..............................................................................2

Section 2 – Internal Notification of changes to AHPRA Registration.........................................3

Implementation........................................................................................................................ 4

Related Policies, Procedures, Guidelines and Legislation.........................................................4

Definition of Terms...................................................................................................................5

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CHHS18/113

Purpose

The purpose of this procedure is to provide Canberra Hospital and Health Services (CHHS) staff with information on the process to notify and enact limitations on Medical Practitioners Scope of Clinical Practice following changes to individual Australian Health Professional Regulatory Agency (AHPRA) registration conditions.

The National Safety and Quality Health Services Standards provides a framework to ensure quality and safe care. Adherence to this framework ensures ACT Health has a system to manage medical practitioners with limitations and/or restrictions attached to their professional registration when employed at CHHS.

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Alerts

The CHHS Medical Officer, Support, Credentialing, Employment and Training Unit (MOSCETU) receive daily notifications of changes to Australian Health Practitioner Regulation Agency (AHPRA) registration through an automated system linked to AHPRA. Any amendments to individual registration will be notified to CHHS through the automated AHPRA Practitioner Information exchange (PIE) system.

All clinicians are also advised of changes to their registration status prior to these changes being made to the public register. It is the professional responsibility of all medical practitioners to alert changes in their registration status through to their Unit Directors and/or the Director of MOSCETU as soon as they become aware of any changes.

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Scope

This document applies to: CHHS Medical Officers (Senior and Junior) CHHS Executive and Management Staff

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Section 1 – Changes to AHPRA Registration

Procedure

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CHHS18/113

Medical practitioners must all hold relevant AHPRA registration to practice medicine in Australia. Throughout the course of time that a clinician holds registration, they may have notations, notifiable conduct, conditions, restrictions and/or limitations attached to their registration.

Any of these restrictions may be placed on a clinician’s registration following an investigation into the practice, competency or mental and/or physical limitations of the clinician. Enforcements of such restrictions does not mean that the clinician can no longer be employed, merely that their scope of clinical practice is required to be reviewed and managed in line with the detailed restrictions.

More detailed descriptions of the various limitations that may be enforced can be found at http://www.ahpra.gov.au/Support/Glossary.aspx#P

When a change is made to a clinician’s registration, the clinician is notified in writing by AHPRA. At this time the clinician has a professional responsibility to advise their employer of imposed changes to their registration.

MOSCETU receives daily notifications of any changes to AHPRA registrations of those clinicians with appointment to or employed by CHHS.

When notified of changes to AHPRA registration, the below process is to be undertaken.

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Section 2 – Internal Notification of changes to AHPRA Registration

Procedure When notified by either a clinician or through advice from AHPRA (either directly or through PIE), the following procedure is to be undertaken: MOSCETU will notify the Deputy Director General (DDG) CHHS, Executive Director (ED) of

the relevant division, Unit Director, and Director of Pharmacy (if required); Executive staff and Unit Directors are to manage the restrictions of Junior Medical

Officers (JMO) within their Division in line with restrictions detailed by AHPRA. If the restrictions relate to a JMO, Unit Directors are to develop an action plan in

response to restrictions, review rostering of the JMO to allow adequate supervision, and ensure the JMO is well supported in carrying out the remainder of their duties.

If the restrictions relate to a Senior Medical/Dental Practitioner (SMDP), the credentialing unit within MOSCETU will raise the issue with the Medical and Dental Appointments and Advisory Committee (MDAAC) to review the clinician’s scope of clinical practice.

MDAAC will notify the Executive Director of the respective unit and the Unit Director, if applicable, to ensure restrictions are adhered to immediately.

The ED and Unit Director will develop and action plan in response to the restrictions on the SMDP, review on-call arrangements of the SMDP to ensure appropriate supervision

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CHHS18/113

of JMO’s in respect to prescribing (if required). The ED and Unit Director will ensure the SMDP is well supported in carrying out the remainder of their duties.

The SMDP will be offered and advised to seek assistance through the Employee Assistance Program for counselling and support.

When a clinician’s scope of clinical practice is restricted, the clinician must be informed and acknowledge the restrictions in writing by either MDAAC (SMDP) or their supervisor (JMO).

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Implementation

All medical staff and new staff will be made aware of this procedure on commencement at CHHS.

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Related Policies, Procedures, Guidelines and Legislation

Policies Health Directorate Complaints or Concerns about the Clinical Competence of a Doctor or

Dentist Policy Health Directorate Performance Development and Review of Doctors and Dentists Policy ACT Public Service Performance Framework Policy ACT Health Conflict of Interest Procedure

Procedures CHHS Credentialing and Defining the Scope of Clinical Practice for Senior Medical and

Dental Practitioners Procedure

Legislation Health Act 1993 (ACT) Discrimination Act 1991 Health Practitioner Regulation National Law 2010 (ACT) Health Records (Privacy and Access) Act 1997 Human Rights Act 2004 Work Health and Safety Act 2011 Public Sector Management Act 1994

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Definition of Terms

Appointment - means the employment or engagement of a doctor or dentist to provide services within an organisation according to conditions defined by general law and supplemented by contract. (Australian Commission on Safety and Quality in Health Care (ACSQHC), 2004).

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CHHS18/113

Clinical practice - means the professional activity undertaken by doctors or dentists for the purposes of investigating patient symptoms and preventing and/or managing illness, together with associated professional activities related to patient care (ACSQHC, 2004).

Credentialing - means the formal process used to verify the qualifications, experience, professional standing and other relevant professional attributes of a doctor or dentist for the purpose of forming a view about the competence, performance and professional suitability of the doctor or dentist to provide safe, high quality health care services within a specific organisational environment (ACSQHC, 2004).

Defining the scope of clinical practice - means delineating the extent of an individual doctor’s or dentist’s clinical practice within a particular organisation based on the individual’s credentials, competence, performance and professional suitability, and the needs and the capability of the organisation to support the doctor’s or dentist’s scope of clinical practice (ACSQHC, 2004).

Junior Medical Officer - means an Intern, Resident Medical Officer (RMO), Career Medical Officer (CMO), Registrar, Senior Registrar or Fellow level appointment.

Senior Medical and Dental Practitioner – means a Specialist, Senior Specialist and Visiting Medical Officer (VMO) engaged by a public health facility in the ACT but not a medical officer at an Intern, Resident Medical Officer (RMO), Career Medical Officer (CMO), Registrar, Senior Registrar or Fellow level appointment.

Scope of Clinical Practice - means the authorised extent of an individual doctor’s or dentist’s clinical practice within a particular organisation. See “defining the Scope of clinical practice” (ACSQHC, 2004).

Specialist - means a person who a) is a registered medical practitioner; andb) After full registration has spent not less than five years in the practice of medicine; andc) Has spent not less than three years in supervised specialist training and/or experience; andd) Has obtained an appropriate higher medical qualification in his or her speciality acceptable to the Health Directorate.

References

1. Australian Commission on Safety and Quality in Health Care, 2004. Credentialling of Clinicians. [Online] Available at: https://www.safetyandquality.gov.au/wp-content/uploads/2012/01/credentl1.pdf

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Disclaimer: This document has been developed by ACT Health, Canberra Hospital and Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.

Policy Team ONLY to complete the following:Date Amended Section Amended Divisional Approval Final Approval 16/03/2018 Whole document Jeff Fletcher, CMO CHHS Policy

Committee Chair23/05/2018 Whole document Jeff Fletcher, CMO CHHS Policy

Committee

This document supersedes the following: Document Number Document Name

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Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register