Accreditation under the NGPA Scheme

A self-assessment is not a formal requirement of the NGPA Scheme. However, accrediting agencies may require general practices to complete a self-assessment to assist general practices determine their level of compliance with the RACGP Standards for general practices (the Standards) and prepare for the initial assessment.

At the initial assessment, the accrediting agency will:

• Undertake an assessment of a general practice either on site for general practices with dedicated physical premises or virtually for general practice without dedicated physical premises
• Review the general practice's compliance against the relevant indicators in the Standards through a visual inspection, interviews with key personnel, and a review of documents
• Award a rating for each indicator
• Advise the general practice of any indicators rated ‘not met’
• Provide an initial report to the general practice within five business days of the conclusion of the initial assessment.

Where one or more relevant indicators assessed have been rated ‘not met’, the general practice has a remediation period of up to 65 business days to implement changes to demonstrate all requirements of the specified indicators have been met.

A final assessment is conducted when the general practice has met all relevant indicators or at the end of the remediation period, whichever occurs earlier.

At the final assessment, the accrediting agency will determine if the indicators rated 'not met' at initial assessment have been remediated.

Accrediting agencies then have 20 business days to provide the general practice with a final report and determine if accreditation is awarded.

Accreditation will be awarded and an accreditation certificate will be issued for general practices that meet all relevant indicators in the Standards.

Accreditation is awarded for three years.

For newly accredited general practices, the accreditation expiry date is three years from the date the accrediting agency determined the accreditation outcome.

For previously accredited general practices, the new accreditation expiry date is three years from the previous accreditation expiry date unless the accreditation outcome was determined past the previous expiry date.

The flow chart provides an overview of the steps involved in the assessment and reporting process.

Accreditation cycle flow chart for the National General Practice Accreditation Scheme

2024

Other resource

General practices that are not accredited should consult an accrediting agency to coordinate an assessment process.

Accredited general practices should ensure compliance with the Standards throughout the accreditation cycle and may commence coordination of assessment processes between 12 to 18 months from their accreditation expiry date.

The initial assessment should be undertaken at least four months and no more than eight months prior to their accreditation expiry date to minimise the risk of the expiry date lapsing. This ensures accrediting agencies and general practices comply with the timelines of the NGPA Scheme.

If a general practice seeks to undertake an assessment earlier than eight months prior to the accreditation expiry date, approval must be obtained from the Commission before the assessment commences.

Under the National Health Reform Act 2011, the Australian Commission on Safety and Quality in Health Care (the Commission) is responsible for coordinating the National General Practice Accreditation (NGPA) Scheme, which provides for accreditation of general practices to the Royal Australian College of General Practitioners (RACGP) Standards for general practices (the Standards). The Commission is introducing a range of strategies to reduce potential and real conflicts of interest that are associated with accreditation processes.

General practice consultants not to participate in assessments

General practices may engage a variety of consultants to support the operation of their general practice and prepare for assessment to the Standards, including the self-assessment if required.

Such consultants have been previously observed to respond directly to enquiries from assessors on behalf of the general practice at an assessment.

Consultants engaged by a general practice to prepare the general practice for an assessment, are not permitted to attend or participate in the assessment process under the NGPA Scheme.

General practice accreditation consultants will however be able to complete and submit self-assessments on behalf of a general practice and also assist the general practice with corrective actions.

A general practice accreditation consultant is a person who meets one of more of the following criteria:

• Is not identified on the organisational chart
• Is not an employee
• Has no line management responsibilities in the organisation
• Does not provide regular and ongoing technical support for the delivery of patient care.

This strategy is specifically aimed at consultants whose work in a general practice is primarily to achieve accreditation, who do not provide or support direct patient care, and who do not have as a primary part of their role the transfer of expert knowledge and/or skill to the organisation’s workforce.

This requirement does not apply to consultants who may be engaged by general practices to support clinical care or provide ongoing technical advice and expertise.

Accrediting agencies are required to notify general practices of these requirements before commencing an assessment.

Accrediting agencies consulting on the RACGP Standards for general practices

A known conflict of interest exists in situations where an accrediting agency or an assessor both support a general practice to implement the Standards, and then assess them against those Standards.

To reduce the likelihood of this conflict of interest occurring, accrediting agencies are to:

• Have in place processes to ensure assessors who provide general practice accreditation consulting services do not review the organisations where they have consulted
• Provide the Commission with information on how they manage conflicts of interest occurring when assessors provide consulting services on the Standards and assess to the Standards.

Accrediting agencies must ensure that there is no conflict of interest, or bias, on the part of the accrediting agency or its assessors in conducting assessments and awarding accreditation. Any conflict of interest must be immediately acknowledged and addressed by the accrediting agency.

Initial assessments must be conducted on-site for general practice with dedicated physical premises and virtually for general practices without dedicated physical premises.

The requirements of a virtual assessment are outlined in Conducting a virtual assessment under the NGPG Scheme.

In limited circumstances, the Commission may grant approval for assessments to be conducted via a hybrid assessment, where part of an accreditation assessment team is on site, and part of an assessment team is present using virtual access digital technology.

The requirements of a hybrid assessment are outline in Conducting a hybrid assessment under the NGPG Scheme.

Accrediting agencies are required to refer to the below when considering non-applicability of RACGP Standards for general practices mandatory indicators. The individual circumstances of general practice should be considered in determining whether specific indicators are not applicable.

At the time a general practice is assessed against the Standards, assessors will assess evidence of compliance to relevant indicators and award a rating. These are described below.

Accrediting agencies and general practices are required to adhere to the requirements stipulated in Advisory GP18/04: Notification of significant risk.

Repeat assessments apply to general practices with 20% or more mandatory indicators rated ‘not met’ following the initial assessment.

Accrediting agencies and general practices are required to adhere to the requirements stipulated in Advisory GP23/03: Standardised repeat assessment of general practices.

Accrediting agencies and general practices are required to adhere to the requirements stipulated in Advisory GP23/02: Requests for extensions and appeals. For more information on how to apply for an extension request, see submission forms page.

Accreditation is not awarded if a general practice does not meet one or more relevant indicators in the Standards.

General practices may reapply to be accredited with an accrediting agency of their choice.

For general practices that wish to appeal the accreditation assessment outcome decision, they are required to adhere to the requirements stipulated in Advisory 23/02: Requests for extensions and appeals.

Accrediting agencies and general practices are required to adhere to the requirements stipulated in Advisory GP18/02: Transferring accreditation between accrediting agencies.

Accrediting agencies and general practices are required to adhere to the requirements stipulated in Advisory GP24/01: Assessment following relocation of physical premises by an accredited general practice.