Accreditation under the NGPA Scheme

Completing a self-assessment may be required by an accrediting agency so that a general practice can determine their level of compliance with the standards. However, reporting on the outcome of a self-assessment or submitting documentation to an accrediting agency as part of the self-assessment is not a formal requirement of the NGPA Scheme.

The accrediting agency will:

• Undertake an on-site assessment of a general practice
• Review evidence provided by the general practice to demonstrate they have implemented the relevant indicators in the RACGP Standards for general practices and/or the RACGP Standards for point-of-care testing and 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 relevant indicators assessed have been rated ‘not met’ the general practice will be given 65 business days to implement changes to demonstrate they have met the requirements of the specified indicators.

The accrediting agency will conduct a final assessment, to determine if indicators rated ‘not met’ 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.

The accrediting agency will determine whether the general practice has satisfied the requirements of the assessment. The general practice will be awarded accreditation if all relevant indicators in the RACGP Standards for general practices and/or the RACGP Standards for point-of-care testing are rated as ‘met’. Accreditation is awarded for three years.

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

General practices should commence coordination of assessment processes 12 to 18 months from the accreditation expiry date. The on-site assessment should be undertaken at least four months and no more than eight months prior to the practice’s accreditation expiry date.

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.

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.

Initial assessments must be conducted on-site. In limited circumstances, the Commission may grant approval for assessments to be conducted via a hybrid assessment.

A hybrid assessment is a model of assessment where part of an accreditation assessment team is on site, and part of an assessment team is present using virtual access digital technology.

Prior approval from the Commission must be sought for hybrid assessments. Accrediting agencies and general practices must follow guidance issued by the Commission in relation to hybrid assessments.

At the time a general practice is assessed against the RACGP Standards for general practices and/or RACGP Standards for point-of-care testing, assessors will assess evidence of compliance to relevant indicators and assign a rating. These are described below.

A general practice is accredited if all relevant actions in the RACGP Standards for general practices and/or RACGP Standards for point-of-care testing are rated as ‘met’ at final assessment. Accreditation is awarded for three years.

For general practices who are completing the ‘business as usual’ three-year accreditation cycle, the new accreditation expiry date is three years from the original accreditation expiry date or where applicable, the revised accreditation expiry date issued by the Commission if an extension request is granted.

If accreditation was finalised after the accreditation expiry date, the date of commencement of the new accreditation cycle is the date the accrediting agency formally notifies the general practice the determination of accreditation.

For general practices who were granted 12 months extension to their accreditation expiry date as a result of the suspension in accreditation activities in 2020, the date of commencement of the accreditation period is the date the accrediting agency formally notifies the general practice the determination of accreditation. General practices did not receive an additional 12 months’ accreditation; rather, the benefits of accreditation were extended for that period.

If the requirements of the standards are not met, accreditation is not awarded. General practices may reapply to be accredited with an accrediting agency of their choice.

Services Australia may withhold payments for the Practice Incentives Program (PIP) and Workforce Incentive Program (WIP) – Practice Stream if accreditation has expired. If payments are withheld for three consecutive payment quarters, incentive payments will be forfeited and the practice may be withdrawn from the program(s).

The practice can reapply for PIP and WIP – Practice Stream if it later achieves accreditation, and payments will start from the payment quarter following the date the practice has met all eligibility requirements and are approved for the program(s).

For more information about the PIP or WIP – Practice Stream, contact Services Australia on 1800 222 032.

Accrediting agencies are required to provide each general practice with an accreditation assessment report at the conclusion of the assessment process. Accreditation certificates are issued to general practices that have met all the relevant requirements of the standards.

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

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 the request for approval page.

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 GP18/03: Physical relocation of a general practice to other premises.

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 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 practice and prepare for assessment to the RACGP Standards, including the self-assessment if required.

Such consultants previously have observed at assessment and responded directly to enquiries from assessors.

From the date of issuing this advice, consultants engaged by a general practice to prepare the 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 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 assessor both support a general practice to implement 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 also provide general practice accreditation consulting services do not review 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 RACGP Standards and assess to the RACGP Standards.

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