Advisory GP18/02: Transferring accreditation between accrediting agencies

Advisory details

Purpose

This advisory sets out the Australian Commission on Safety and Quality in Health Care’s (the Commission) requirements when a general practice transfers accrediting agencies during its registration or accreditation cycle.
 

Issue

General practices can choose from approved accrediting agencies when seeking assessment. They may also choose to change their accrediting agency at the end of a contracted period, or during a registration or accreditation cycle.

For the purpose of this advisory the:

• initial accrediting agency is the accrediting agency that currently provides accreditation services
• receiving accrediting agency is the accrediting agency the general practice wishes to engage as its future accreditation service provider
• registration cycle is the 12-month period during which a general practice that has never been accredited should achieve accreditation, commencing when the general practice enters into a contract with an accrediting agency
• accreditation cycle is the three-year period for which a general practice is awarded accreditation
• assessment cycle is the period from when a general practice undertakes an initial assessment to when the accrediting agency determines the assessment outcome.

General practices should not be prevented from transferring between accrediting agencies during a registration or accreditation cycle. However, a transfer must not occur during an assessment cycle where a general practice is dissatisfied with the initial assessment outcomes and does not wish to complete the assessment process.

Transfers must also not compromise the continuity of risk oversight through the loss of relevant accreditation information. Where identified gaps, assessment findings or other critical information are not preserved or made available to the receiving accrediting agency, there is an increased risk that the receiving accrediting agency will not have a complete understanding of the general practice’s risk profile. This may result in inconsistent assessment decisions and delayed or inadequate management of previously identified risks, thereby increasing the potential for patient harm.
 

Requirements

The general practice may transfer accrediting agencies during its registration or accreditation cycle where the following requirements are met.

1. The general practice must ensure that:
   1. the transfer does not occur during an assessment cycle
   2. a contract with the receiving accrediting agency is signed before, or immediately after, cancellation of its client agreement with the initial accrediting agency, and that there are no outstanding actions or obligations owed to the initial accrediting agency
   3. if previously assessed, a copy of the most recent routine assessment report, and any other assessments conducted following the routine assessment, is provided by the general practice to the receiving accrediting agency
   4. the existing registration or accreditation expiry date and assessment schedule are maintained.
2. The receiving accrediting agency must:
   1. maintain the general practice’s existing registration or accreditation expiry date
   2. not issue a replacement registration or accreditation certificate for the existing registration or accreditation cycle
   3. where previous assessments have been conducted, refer to the general practice’s previous assessment reports to understand its risk profile and ensure continuity of risk oversight
   4. notify the Commission within 48 hours if there is reasonable cause to believe that the general practice is seeking a transfer during an assessment cycle.
3. The initial accrediting agency must:
   1. where previous assessments have been conducted, provide the general practice with a copy of its most recent routine assessment report and any other assessments conducted following the routine assessment
   2. notify the Commission within 48 hours if there is reasonable cause to believe that the general practice is seeking a transfer during an assessment cycle.

The Commission will continue to recognise any registration or accreditation certificates awarded by the initial accrediting agency until their expiry date.

For general practices wishing to transfer accrediting agencies during an assessment cycle, they must submit a written request to the Commission and provide evidence that the accrediting agency has:

• breached the Policy - Approval under the National General Practice Accreditation (NGPA) Scheme to conduct assessments; and/or
• not complied with the Commission’s NGPA Scheme fact sheets and/or advisories.
   

Costs

All costs associated with transferring accrediting agencies are the responsibility of the general practice.