General Practice Accreditation
This guide is a resource for general practices who are undergoing accreditation.
The Australian Commission on Safety and Quality in Health Care (the Commission) has now confirmed that all general practice accreditation will be suspended, taking effect Thursday, 26 March 2020. Read more here.
What is General Practice Accreditation?
Around 80 per cent of General Practices in Australia undergo accreditation. The process requires practices to be assessed against the Royal Australian College of General Practitioners (RACGP) Standards by an independent third party at least every three years, to gain an ‘accredited’ status.
Accreditation uses a peer review model where surveyors must be actively involved in General Practice (including in the areas of practice management) and where at least one of the visiting surveyors is a general practitioner.
The RACGP states that achieving accreditation shows patients that your practice is committed to providing high quality, safe and effective care as determined by the general practice profession.
Why become accredited?
There are many benefits to becoming an accredited General Practice. Some of these include:
- Recognition within the General Practice community that your clinic is performing in accordance to best practice standards
- Proven framework for Quality Improvement and Quality Assurance in General Practice
- Improving Practice efficiency and the practice environment
- Measure how the practice is performing in relation to General Practice benchmarks
- The opportunity to reflect on what’s working well at a practice level and identify areas for improvement
- Access funding from the Practice Incentives Program (PIP), Service Incentive Payments (SIP) and the Practice Nurse Incentive Program (PNIP).
The RACGP standards for General Practice
The Standards for General Practices (5th edition) were developed after three separate consultation phases. RACGP conducted pilot testing, in-depth reviews with General Practice and considered feedback from 135 stakeholders in developing the 5th edition standards. The standards were developed with the purpose of protecting patients from harm by improving the quality and safety of health services.The 5th edition standards differ from the 4th as they move away from “process” focused to more “outcome and patient centered” focused. The standards have also been submitted to seek International Society for Quality in Healthcare accreditation.
The 5th Edition Standards were released in October 2017. After 1 November, 2018 all practices will be assessed under the 5th edition standards.
Each standard is divided into a number of criteria and each criterion has a number of related indicators, which describe what practices need to do to meet the criterion.
Flagged indicators (those marked ►) are considered mandatory. Unflagged indicators are considered discretionary.
Each criterion includes an explanation of what is required to achieve the criterion.
Visit the RACGP website for resources and information relating to accreditation.
On 1 January 2017 the National General Practice Accreditation Standard Scheme came into effect. The scheme was developed by a collaboration of The Australian Commission on Safety and Quality in Health Care and the RACGP. Read about it here: safetyandquality.gov.au
Approved Accreditation Agencies
The following agencies are approved to assess general practices to the RACGP Standards for general practices.
AGPAL Group of Companies. Incorporating Australian General Practice Accreditation Limited (AGPAL) and Quality Innovation Performance Limited (QIP)
Po Box 2058, Milton BC QLD 4064
Tel: 1300 362 111
Quality Practice Accreditation Pty Ltd
136 Mount St, Gundagai, NSW 2722
Tel: 1800 188 088
The Australian Council on Healthcare Standards
5 MacArthur St, Ultimo, NSW 2007
Tel: 02 9281 9955
Tip: These organisations often allocate a support contact to practices undergoing accreditation with them. Make sure you contact your support contact so you can learn about additional resources, support services and information these organisations may offer.
Essential components of accreditation
Policy and Procedure Manual development and update
A Policy and Procedure Manual is a great resource to ensure practice processes are documented and their implementation is consistent across staff members.
A good manual is a valuable reference and training tool so it is important to ensure this is kept up to date.
There should be a formal review of the manual every three years, however it is a good idea to revisit key policies and procedures on a yearly basis and offer staff an opportunity to offer their input.
There are organisations which can provide Policy and Procedure Manual templates, which a practice can customise to suit their needs.
Contact your accreditation provider for more information..
Practice Staff records
There are several accreditation indicators that relate to comprehensive documentation of staff records.
The Staff Training Sheets Resource has been used by many clinics to help plan and organise information about staff members. The resource includes:
- an induction checklist
- a staff immunisation record pro forma, and
- many training sheets that can be used on an ongoing basis as part of in-house education for staff.
Templates and Practice forms
Numerous resources have been developed to support practices going through accreditation. We have included a list of the most common resources below.
Contact your accreditation provider to learn about additional templates and proformas for your practice.
Patient feedback is a great way to measure patient satisfaction with the service and health care your practice provides. Continual and ongoing feedback enables this feedback to shape improvements in the quality of services provided.
RACGP accreditation standards require practices to conduct one patient survey every three years. Practices can select from the following approved validated questionnaire providers:
- Insync’s Patient Satisfaction Instrument (PSI) Ph: 1800 143 733
- CFEP Survey’s Patient Accreditation Improvement Survey (PAIS) Ph: (07) 3855 2093
- Press Ganey Associates Ph: (07) 5560 7400
Self-assessment questionnaire and visit preparation
In order to assist a practice to prepare for the accreditation survey visit, all accreditation bodies provide self-assessments, templates, resources checklists and even web-based training.
Contact your accreditation provider to find out what support is available and what steps may be required prior to your survey visit.
On-site visit and accreditation audit
The onsite visit will usually take place every three years. The visit length will vary depending on the size of the clinic and how many doctors/staff will need to be interviewed.
During the visit, the clinic should remain open to the public so surveyors can witness usual practice operations.
For more information on what will be involved as part of your survey visit, contact your accreditation provider.
Top Accreditation Resources
The following are useful accreditation resources:
- RACGP 5th Edition Standards
- RACGP Infection prevention and control standards (5th edition)
- RACGP Fact Sheets for Accreditation
- RACGP Managing emergencies and pandemics in general practice
- RACGP Sterilisation records suite. Order it from the RACGP
- RACGP schedule 8 medicines record books (practice and doctors bag size). Order it from the RACGP
- RACGP Patient feedback guide: Learning from our patients
- RACGP Computer security guidelines (3rd edition)
- RACGP 10 tips for safer healthcare (poster)
- RACGP Pandemic flu kit
- RACGP Privacy Resources
- RACGP General Practice: a safe place – tips & tools
- The Department of Health National Vaccine Storage Guidelines Strive for Five
- Additional templates from your accreditaion provider
Visit the Office of Australian Information Commissioner on the Australian Privacy Principles: oaic.gov.au
Health Complaints Commissioner
Visit the new Health Complaints Commisoner website: HCC.vic.gov.au
Health Complaints Commissioner
Level 26, 570 Bourke St, Melbourne, VIC 3000
Tel: 1300 582 113
Accreditation checklist from your provider
As the RACGP Standards are comprehensive, it is unlikely that all components will be reviewed during the three-yearly accreditation visit.
However, your accreditation provider will provide a checklist of areas that are considered essential that are always checked as part of the accreditation visit.
You should use this checklist to review what procedures or documentation you may still need to compile to be ready for your survey visit. You can also allocate the responsibility for certain activities to different staff in your practice.
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