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Advisory GP23/03: Standardised repeat assessment of general practices

This advisory sets out the standardised repeat assessment processes for accrediting agencies and general practices under the National General Practice Accreditation (NGPA) Scheme.

Advisory details

Item Details
Advisory number GP23/03
Version number 1.0
Trim number D23-39799
Publication date 4 October 2023
Replaces  
Compliance with this advisory Mandatory
Information in this advisory applies to
  • All approved accrediting agencies
  • All general practices
Key relationship
Attachment  
Notes

Repeat assessments apply to general practices who undertake their initial assessments on or after 1 January 2024 and with 20% or more mandatory indicators rated ‘not met’ following the initial assessment.

This process is likely to affect less than 4% of general practices.

Responsible officer Margaret Banks

Director, National Standards

Phone: 1800 304 056

Email: AdviceCentre@safetyandquality.gov.au
To be reviewed October 2025

Purpose

This advisory sets out the standardised repeat assessment processes for accrediting agencies and general practices under the National General Practice Accreditation (NGPA) Scheme.

Issue

Under the current NGPA scheme, general practices that achieve accreditation are next assessed in three years. General practices with a large number of mandatory indicators rated ‘not met’ at initial assessment are unlikely to have sufficient time to fully embed all the changes required by the time accreditation is awarded.

This has led to discretionary application by accrediting agencies in determining the need for repeat assessments of general practices. However, the criteria and the method of implementation of repeat assessments had varied between accrediting agencies.

Requirements

Prior to the repeat assessment

The Australian Commission on Safety and Quality in Health Care’s (the Commission) will determine the need for a repeat assessment using assessment outcome reports and will notify the general practice and accrediting agency.

Criteria

General practices with 20% or more mandatory indicators rated ‘not met’ following the initial assessment.

The accrediting agency must confirm the date of the repeat assessment with the Commission and the general practice within 10 business days of the Commission providing notification. The repeat assessment must be conducted within 6 months of the completion of the recent assessment.

If indicators are not met at repeat assessment, then a remediation period of 20 business days may apply. The assessment and submission of a report to the general practice must be completed within 45 business days of the commencement of the repeat assessment.

During the repeat assessment

The repeat assessment will be conducted as an on-site assessment and must include a review of:

  • All mandatory indicators rated ‘not met’ at the initial assessment.
  • Any recommendations made by assessors at the initial assessment.

Any mandatory indicator that is reassessed can be rated ‘met’ and ‘not met’.

Outcome of the repeat assessment

The accrediting agency will provide an initial report to the general practice within 5 business days of the conclusion of the repeat assessment.

Where all indicators are ‘met’, the general practice’s accreditation award will remain in place and the accreditation expiry date unchanged.

Where one or more indicators are ‘not met’, the general practice will have a 20 business day remediation period to address any of the ‘not met’ indicators. At the end of the remediation period, the accrediting agency will conduct a final assessment to determine if all indicators have been ‘met’.

Accrediting agencies then have 20 business days to provide the general practice with a final report and determine if accreditation is retained. If one or more indicator is rated ‘not met’ at the completion of the repeat assessment, the general practice’s accreditation will be withdrawn.

Withdrawal of accreditation

Following the withdrawal of the general practice’s accreditation:

  • The accrediting agency must notify the Commission of the withdrawal within 48 hours
  • The Commission will notify Services Australia of the withdrawal.

The withdrawal may impact the general practice’s eligibility for Commonwealth incentive programs that require accreditation against the RACGP Standards for general practices, such as Practice Incentives ProgramWorkforce Incentive Program – Practice Stream, and MyMedicare.

General practices that have their accreditation withdrawn can arrange reassessment to the RACGP Standards for general practices in full as soon as the accreditation outcome of the repeat assessment has been determined.

Appeal process

General practices have 20 business days from receiving the final assessment report to submit an appeal. Appeals should be made to the accrediting agency in the first instance. Following the completion of this appeal, practices may appeal to the Commission within 20 business days of receiving the outcome of an appeal to the accrediting agency.

The Commission will only consider appeals where there is evidence that the relevant accrediting agency did not comply with Commission specified policies, processes and/or directions relating to the assessment conducted as detailed in Advisory GP23/02: Request for extensions and appeals.

If the Commission does not determine the general practice’s accreditation should be reinstated, there is no further avenue of appeal.

Costs

All costs of the repeat assessment are the responsibility of the general practice being reassessed.

A flow chart of the standardised repeat assessment process is linked below:

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