Advisory GP23/02: Requests for extensions and appeals

10 October 2024

To clarify the requirements for accrediting agencies and general practices to request for extensions and appeals under the National General Practice Accreditation (NGPA) Scheme.

Advisory details

Item	Details
Advisory number	GP23/02
Version number	2.0
Trim number	D24-53647
Publication date	10 October 2024
Replaces	GP23/02 version 1.0 published 22 August 2023
Compliance with this advisory	Mandatory
Information in this advisory applies to	All approved accrediting agencies All general practices
Key relationship	Practice Incentives Program (PIP) Workforce Incentive Program (WIP) – Practice Stream (PS) MyMedicare
Attachment	Not applicable
Notes	General practices and accrediting agencies can both refer requests for extensions and appeals to the Commission for consideration.
Responsible officer	Margaret Banks Director, National Standards Phone: 1800 304 056 Email: AdviceCentre@safetyandquality.gov.au
To be reviewed	October 2026

Purpose

This advisory sets out the Australian Commission on Safety and Quality in Health Care’s (the Commission) processes for accrediting agencies and general practices:

Requesting additional time for assessment processes
Requesting extensions to the accreditation expiry date
Requesting retrospective extensions to a lapsed accreditation expiry date
Seeking to appeal a decision by the Commission relating to a, b and c above
Seeking to appeal on the basis the accrediting agency has not followed processes set out in the NGPA Scheme.

Issue

General practices that successfully complete an assessment to the Royal Australian College of General Practitioners (RACGP) Standards for General Practices and RACGP Standards for point-of-care are awarded accreditation for a period of three years. In some limited instances, general practices may wish to:

Seek an extension to the timeframe of the assessment process;
Seek an extension to their period of accreditation awarded, either in advance of the expiry date or retrospectively;
Appeal a decision by the Commission relating to its decision to withhold an extension or additional assessment time; or
Appeal on the basis the accrediting agency has not followed processes set out in the National General Practice Accreditation Scheme.

Type of request

Additional time for assessment processes

Circumstances	Requirements
When a general practice is experiencing significant delays in the reaccreditation process due to extenuating circumstance(s)* but is not at risk of the current accreditation lapsing	Accompanied by evidence to substantiate claims of extenuating circumstance(s)* Accompanied by evidence that the general practice was implementing the requirements of the NGPA Scheme and complying with accreditation processes at the time the extenuating circumstance(s)* occurred A second or subsequent request for an extension in the same accreditation cycle may be considered where the extenuating circumstances are different to the initial submission and a further extension has not been expressly prohibited by the Commission.

Circumstances

Requirements

When a general practice is experiencing significant delays in the reaccreditation process due to extenuating circumstance(s)* but is not at risk of the current accreditation lapsing

Accompanied by evidence to substantiate claims of extenuating circumstance(s)*
Accompanied by evidence that the general practice was implementing the requirements of the NGPA Scheme and complying with accreditation processes at the time the extenuating circumstance(s)* occurred
A second or subsequent request for an extension in the same accreditation cycle may be considered where the extenuating circumstances are different to the initial submission and a further extension has not been expressly prohibited by the Commission.

Extension to the accreditation expiry date

Circumstances	Requirements
When a general practice is experiencing significant delays in the reaccreditation process due to extenuating circumstance(s)* and is at risk of the current accreditation lapsing	Submitted no more than five months before the general practice’s current accreditation expiry date Accompanied by evidence to substantiate claims of extenuating circumstance(s)* Accompanied by evidence that the general practice was implementing the requirements of the NGPA Scheme and complying with accreditation processes at the time the extenuating event occurred A second or subsequent request for an extension in the same accreditation cycle, may be considered where the extenuating circumstances are different to the initial submission and a further extension has not been expressly prohibited by the Commission.

Circumstances

Requirements

When a general practice is experiencing significant delays in the reaccreditation process due to extenuating circumstance(s)* and is at risk of the current accreditation lapsing

Submitted no more than five months before the general practice’s current accreditation expiry date
Accompanied by evidence to substantiate claims of extenuating circumstance(s)*
Accompanied by evidence that the general practice was implementing the requirements of the NGPA Scheme and complying with accreditation processes at the time the extenuating event occurred
A second or subsequent request for an extension in the same accreditation cycle, may be considered where the extenuating circumstances are different to the initial submission and a further extension has not been expressly prohibited by the Commission.

Retrospective extensions to a lapsed accreditation expiry date

Circumstances	Requirements
When a general practice’s current accreditation was awarded past the previous accreditation expiry date resulting in a gap between accreditations	Submitted no more than three months after the period in which the general practice was not accredited Accompanied by evidence to substantiate claims of extenuating circumstance(s)* Accompanied by evidence that the general practice was implementing the requirements of the NGPA Scheme and complying with accreditation processes at the time the extenuating event occurred.

To appeal a decision by the Commission

Circumstances	Requirements
When a general practice has previously submitted a request for additional time for assessment processes, an extension, or a retrospective extension but is not satisfied by the outcome determined by the Commission	Submitted no more than 20 business days after receiving the decision on an extension from the Commission Accompanied by additional evidence that the general practice was implementing the requirements of the NGPA Scheme and complying with accreditation processes at the time the extenuating circumstance(s)* occurred

To appeal against an approved accrediting agency

Circumstances	Requirements
When a general practice has undertaken accreditation, and the accrediting agency has not followed the processes set out in the NGPA Scheme	Submission of an appeal can only occur once all avenues of review or appeal have been exhausted with the general practice’s accrediting agency Submitted no more 20 business days of the general practice receiving the final report from the accrediting agency Accompanied by evidence of: a breach of Policy – Approval under the National General Practice Accreditation (NGPA) Scheme to conduct assessments the accreditation assessment was not conducted within the timeframes as stipulated in the Accreditation cycle flow chart for the NGPA Scheme the general practice was not afforded due process to appeal the assessment outcome with the accrediting agency.

Circumstances

Requirements

When a general practice has undertaken accreditation, and the accrediting agency has not followed the processes set out in the NGPA Scheme

Submission of an appeal can only occur once all avenues of review or appeal have been exhausted with the general practice’s accrediting agency
Submitted no more 20 business days of the general practice receiving the final report from the accrediting agency
Accompanied by evidence of:
- a breach of Policy – Approval under the National General Practice Accreditation (NGPA) Scheme to conduct assessments
- the accreditation assessment was not conducted within the timeframes as stipulated in the Accreditation cycle flow chart for the NGPA Scheme
- the general practice was not afforded due process to appeal the assessment outcome with the accrediting agency.

*An extenuating circumstance is defined as:

An extensive and critical occurrence outside a general practice’s control which results in prolonged loss, damage, or absences of access to facilities, records, critical equipment, utilities and/or technology. This may be due to but not limited to, severe weather, natural disaster, fire, accident, or emergencies such as a pandemic
Recent personal hardship or tragedy experienced by key practice personnel which has or is likely to significantly impact the operation for the general practice over an extended period of time. This includes but is not limited to severe illness or death of practice principals or manager.

The Commission will not consider a request for extension to the accreditation expiry date under the following circumstances:

A general practice has not allowed sufficient time to finalise administration of accreditation decisions despite the accrediting agency’s guidance. For example:
- Delaying response to communication sent by the accrediting agency
- Postponing contracted obligations to the accrediting agency such as finalising payment, submitting documents, and agreeing to assessment dates
- Delaying completion of remedial actions
A general practice has transferred to an alternative accrediting agency. It is a requirement that the receiving accrediting agency* accepting the practice as a client maintain the general practice’s existing accreditation cycle and schedule of assessment (refer to Advisory GP18/02)
A general practice had a prolonged gap in hiring key personnel.

*A receiving accrediting agency is an accrediting agency that a general practice applies to for future accreditation services.

After the request has been submitted

Following the submission of a request, the Commission will review all the evidence submitted, collect further evidence from the general practice’s accrediting agency if required, and may seek advice from other relevant parties such as the General Practice Accreditation Coordinating Committee, prior to determining the outcome of the request.

Requests can take 10 to 20 business days to be processed, dependent on the type of request submitted, evidence provided, and the need to seek further information.

Outcome of request

Should the Commission approve an extension to a general practice’s accreditation expiry date, the Commission will assign a revised accreditation expiry date and notify the relevant general practice, the accrediting agency, and Services Australia.

If the general practice is not satisfied with the outcome, it may seek an appeal via the general practice application form. Once the Commission has issued a determination of the appeal, there is no further avenue of appeal.

For accrediting agencies

Accrediting agencies must advise the Commission of any issues that relate to their obligations as an approved accrediting agency to complete assessments of general practices as outlined in Clause 3 of the Policy – Approval under the National General Practice Accreditation (NGPA) Scheme to conduct assessments.

The Commission does not consider delays that result from the operational issues of the accrediting agency as a sufficient reason to grant an extension to a general practice’s accreditation.

An accrediting agency must not backdate or change the date of commencement of a new accreditation cycle.

Topics

General practice