Annual Renewal of Health Practitioner Registration-Allied Health

/ DGD16-024

ACT Health

Procedure

Annual Renewal of Health Practitioner Registration – Allied Health

Contents

Purpose

Scope

Procedure

Guiding Principles

Acceptable evidence of registration

Responsibilities

Evaluation

Related Legislation, Policies and Standards

Terminology/Definitions

Attachments

Attachment 1 - Notification Form for Conditions on Health Practitioner Registration

Purpose

This procedure sets out the requirements for the annual renewal of registration of those allied health practitioners employed by ACT Health whose practice is regulated by the Australian Health Practitioner Regulation Agency (AHPRA), and should be read in conjunction with the ACT Health Annual Renewal of Health Practitioner Registration policy.

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Scope

Allied health practitioners employed by ACT Health whose practice is regulated by the Health Practitioner Regulation National Law (ACT) Act 2010 (the National Law), asspecified at Table 1, page 2, this document.

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Procedure

Guiding Principles

Relevant knowledge, skills and maintaining competence, are integral to the quality and safe provision of health care by all ACT Health allied health practitioners;
Regulated allied health practitioners are responsible and accountable for maintaining their registration with the relevant National Board and for promptly informing ACT Health of any changes to their registration status;
Regulated allied health practitioners are strongly encouraged to maintain a level of registration over periods of approved long term leave and/or when undertaking non-clinical roles;
Non-practising registration is a category of registration that can be used to provide a minimum level of registration over periods of long term leave however staff cannot practice within their profession if they hold non-practising registration;
All regulated allied health practitioners are required to provide acceptable evidence of annual renewal of registration on or before 30 November each year.

Acceptable evidence of registration

In addition to the original of a practitioner’s certificate, the following forms of evidence available from the Australian Health Practitioner Regulation Agency (AHPRA) are considered acceptable evidence.

Print-out from the ‘Registers of Practitioners-View Details’ screen confirming Registration Number, type, expiry date and conditions or notations;
Print-out from the ‘Registers of Practitioners-Check the status of your renewal application’ screen-verifies that the registration renewal application has been submitted, is being processed and that the practitioner can continue to practice in good faith;
Postal or email correspondence from AHPRA advising that the practitioner is able to practise in good faith whilst registration renewal being processed.

Table 1: Allied Health Practitioners regulated under the National Law[1]

Profession / Protected title(s) / Renewal date
Aboriginal and
Torres Strait
Islander Health
Practice / Aboriginal and Torres Strait Islander health practitioner
Aboriginal health practitioner
Torres Strait Islander health practitioner / 30 November
Dental / Dental therapist
Dental hygienist
Dental Prosthetist
Oral health therapist / 30 November
Medical Radiation Practice / Medical radiation practitioner
Diagnostic radiographer
Medical imaging technologist
Radiographer
Nuclear medicine scientist
Nuclear medicine technologist
Radiation therapist / 30 November
Occupational Therapy / Occupational therapist / 30 November
Pharmacy / Pharmacist
Pharmaceutical chemist / 30 November
Physiotherapy / Physiotherapist
Physical therapist / 30 November
Podiatry / Podiatrist
Chiropodist / 30 November
Psychology / Psychologist / 30 November

Responsibilities

Individual Employee

It is the individual employee’s responsibility to:

Ensure they meet the registration requirements as outlined by the relevant National Boardincluding those pertaining to Continuing Professional Development (CPD)and recency of practice;
Comply with the credentialing and re-credentialing procedures as described in the

ACT HealthProcedure for Credentialing and Defining the Scope of Clinical Practice for Allied Health Professionals;

Consistent with the above, work within their defined scope of clinical practice and conditions of registration;
Advise their Profession Lead (or nominated representative) of any changes in their registration status including conditions, restrictions, limitations, suspension or cancellation;
Consider the registration implications of long term leave, particularly in relation to recency of practice requirements;
Provide acceptable evidence of current practising registration status, confirming that they are able to practice their profession, on or before returning to duty after long term leave.

Note: New employees:

New starters are required to provide evidence of registration both as part of their initial credentialing application prior to commencement of clinical duties, and again, on or before 30 November each year in compliance with this procedure.

Line Managers

It is the responsibility of the Line Managerto:

Ensure that the credentials and scope of clinical practice for new employees are approved by the Profession Lead prior to commencement of duties;
Sight acceptable evidence of registration renewal of all regulated staff on or before 30 November each year and to provide this information to the relevant Profession Lead to assist with the annual audit of registration compliance;
Immediately advise the relevant Profession Lead of any changes in a staff member’s registration status including conditions, limitations, restrictions, suspension or cancellation.

Profession Lead

It is the responsibility of the Profession Leadto:

Maintain a registration and credentialing information for all ACT Health allied health practitioners employed in theirprofession and to update the information with a high regard for timeliness and accuracy;
Update the information annually (at minimum) in response to any notification from the Chief Allied Health Office that the annual registration audit is commencing-notifications will be emailed in late October each year, approximately one month before the registration expiry date of 30 November;
Ensure administrative compliance with and accountability for operational implementation of this procedure and the related ACT Health Procedure for Credentialing and Defining the Scope of Clinical Practice for Allied Health Professionals;
Maintain a Staff-in-Confidence official file to capture all key decisions and activities pertaining to registration and credentialing , including when a decision is made or an action performed, who made the decision or performed the activity and the basis of their authority;
Provide advice to each Director of Allied Health no later than 15 December each year regarding the registration status of all discipline-specific allied health practitioners in their Division, including any practitioners who have not provided acceptable evidence of renewal and/or practitioners who have had a change in their registration status, necessitating completion of the ACT Health Notification Form for Conditions on Health Practitioner Registration(Attachment 1);
Provide support and advice as required to relevant parties in respect of any practitioners whose registration conditions necessitate a change in either duties, scope of clinical practice or ability to continue practice;
Provide a copy of the registration information to the Chief Allied Health Officer by 30 December each year, confirming the registration status of all practising members of the profession across ACT Health.

Directors of Allied Health-with responsibility for regulated allied health practitioners

It is the responsibility of each relevant Director of Allied Healthto:

Ensure that appropriate governance and reporting systems are in place to monitor and check currency of allied health practitioner registration within theirDivision;
Collate discipline specific registration reports provided by the relevant Profession Leads and prepare a Division-wide report, detailing registration status of all regulated allied health practitioners across the Division including those registrants with conditions on their registration;
Submit the Division-wide report to their Executive Director and Chief Allied Health Office no later than 30 December each year;
Work collaboratively with line managers, the Executive Director, ACT Health People and Culture and the Profession Lead where appropriate to manage situations where acondition on an individual’s registration either limits or otherwise constrains their scope of clinical practice;
Advise the Profession Leads and/or Chief Allied Health Officer of any issues pertaining to the implementation of this procedure.

Chief Allied Health Officer

It is the responsibility of the Chief Allied Health Officer to:

Ensure that appropriate governance systems are in place to monitor and check currency of registration for all regulated allied health practitioners;

Notify Profession Leads of the commencement of the annual renewal of registration audit period;
Notify the Director-General ACT Health of any relevant issues pertaining to the implementation of this procedure and/or related policy;
Provide a report to the Director-General on the registration status of all regulated allied health practitioners, including non-renewals and conditions on practice, no later than five business days after the one month renewal grace period expires on 30 December each year.

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Evaluation

Outcome Measures

AllACT Health allied health practitioners with an occupational requirement to be registered will provide evidence of registration both at the time of appointment and upon the renewal date of 30 November each year.

Method

The Chief Allied Health Officer will ensure governance and reporting systems are established and implemented to examine record and review the credentials of all allied health practitioners, including the registration status of regulated practitioners;
Regular reports will be utilised by the Chief Allied Health Officer to review and audit compliance with this procedure;
An annual report of allied health registration status will be provided to the Director-General no later than five business days after the one month renewal grace period expires on 30 December. The report will include the following:

Total number of regulated allied health practitioners and total percentage who have renewed within the prescribed period;
Total number of regulated allied health practitioners and percentage who have conditions on their registration, including those with proscribed courses of action.

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Related Legislation, Policies and Standards

Legislation:

Australian Human Rights Commission Act 1986
Health Practitioner Regulation National Law (ACT) Act 2010

Medicines, Poisons and Therapeutic Goods Act 2008
Public Sector Management Act 2006

Policy:

ACT Health Policy-Annual Renewal of Health Practitioner Registration

Procedures

ACT Health Procedure for Credentialing and Defining the Scope of Clinical Practice for Allied Health Professionals

Standards

National Safety and Quality Health Service Standards
Public Sector Management Standards 2006
Standards of Practice for ACT Health Allied Health Professionals, Publishing Services, Publication No 15/1289
Professional Standards- refer to for information on professional standards relating to each National Board.

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Terminology/Definitions

In this procedure, unless otherwise indicated:

Regulated allied health practitioner-as set out under the National Law and as summarised at Table 1 this document.

Appointment-the employment or engagement of an allied health practitioner to provide allied health services within ACT Health according to conditions defined by general law and supplemented by contract.

Credentialing-the formal process used to verify the qualifications, experience, professional standing and other relevant professional attributes of an allied health practitioner for the purpose of forming a view about the competence, performance and professional suitability of the individual to provide safe, high quality health care services within a specific organisational context.

(Re)Credentialing- the formal process used to re-confirm a practitioner’s competence, performance, professional suitability and registration where applicable.

Defining the Scope of Clinical Practice-delineating the extent of an individual allied health practitioner’s clinical practice within a particular organisation based on the individual’s credentials, competence, performance and professional suitability, including the capacity of the organisation to support the practitioner’s scope of clinical practice.

Scope of Clinical Practice-the authorised extent of an individual allied health practitioner’s clinical practice within a specific organisational context, based on the individual’s credentials, competence, performance and professional suitability, and the needs and capacity of the organisation to support same.

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Attachments

Attachment 1- ACT Health Notification Form for Conditions on Health Practitioner Registration

Disclaimer: This document has been developed by ACT Health 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
16/02/2018 / Attachment 1 added / CAHO / Policy Advisory Committee

This document supersedes the following:

Document Number / Document Name

Attachment 1 - Notification Form for Conditions on Health Practitioner Registration

STAFF-IN- CONFIDENCE

Purpose

Consistent with the ACT Health Annual Renewal of Health Practitioner Registration, the purpose of this form is to identify and manage any registered nursing, midwifery or allied health practitioner whose scope of practice and/or capacity to practice is subject to any of the following:

Restricted or limited by a Board imposed cancellation, suspension, condition, undertaking, notation or reprimand which limits, restricts or prevents their practice;
Limited or bound by supervision requirements including those relating to provisional registration, recency of practice and/or those that apply to area of practice endorsement.

Timely and routine completion of this form helps ACT Health identify and manage risks in relation to scope of clinical practice and to patient safety and quality.

1: Practitioner Details (one form per staff member)

Name: / Profession:
Registration No. / Area employed:
Registration Type: / Timeframe of condition:

2: Detailsof Practice Restriction

Please print off and attach the practitioner’s Registration Details at the “View Details” page on the AHPRA Registers of Practitioners. See below

3: Profession Lead/DON, Line Manager and ACT Health People and Culture where relevant.

Please outline the action taken or proposed for managing the practitioner’s registration conditions in the workplace, including in response to any restrictions or limitations to their scope of practice (response not limited by size of text box). Please ensure you include the name of person/s providing supervision for the required 3 months full-time equivalent as per Condition on Registration.

4: Profession Lead

Name and title
Title / Discipline / Phone number / Email

5: Line Manager

Name and title
Title / Discipline / Phone number / Email

6: ACT Health People and Culture (if applicable)

Name and title
Title / Phone number / Email
Notification Form for Conditions on Health Practitioner Registration

Forward a completed copy of this form to the Chief Allied Health Office

Chief Allied Health Office

Date Received / Action/Comment
Review date

Reporting Person:

Name:

Position:

Signature and date:

NOTE: This form is referenced in the following related documents:

ACT Health Policy-Annual Renewal of Health Practitioner Registration
ACT Health Procedure Annual Renewal of Health Practitioner Registration-Allied Health
Canberra Hospital and Health Services Procedure for Credentialing and Defining the Scope of Clinical Practice for Allied Health Professional

Doc Number / Version / Issued / Review Date / Area Responsible / Page
DGD16-024 / 1 / 01/10/2016 / 01/10/2019 / Chief Allied Health Office / 1 of 10
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

[1] Ref: