A comprehensive RACGP accreditation checklist covering every documentation area, register, system and operational requirement Australian general practices need to have in place before their survey assessment. Written by an accreditation consultant working directly with practices preparing under the RACGP 5th Edition Standards.
👤 Ben – MedAssure Consulting 🕐 14 min read 📅 Updated May 2026
What's in this guide
RACGP accreditation is one of the most operationally significant undertakings a general practice will face, and one that practices consistently underestimate. The volume of documentation required, the specificity of the evidence assessors are looking for, and the way operational reality must align with documented policy creates a workload that almost always takes longer than expected.
This article provides a comprehensive checklist of what your practice needs to have in place. It is not a substitute for the full RACGP Standards for General Practices (5th Edition), and it is not a step-by-step instruction guide. It is a structured checklist of the major areas you should be addressing, and where most practices encounter difficulty.
RACGP accreditation is the formal process by which an Australian general practice demonstrates that it meets the RACGP Standards for General Practices (5th Edition), the national benchmark for clinical governance, patient safety and practice management in general practice.
Accreditation is conducted by an approved accrediting agency, with AGPAL and QPA being the most commonly used by general practices. While the agencies differ in their administrative processes, all assess practices against the same RACGP Standards.
For most practices, accreditation is also a financial necessity. Maintaining accreditation is required for eligibility to the Practice Incentives Program (PIP) and the Workforce Incentive Program (WIP) under Medicare. Loss of accreditation does not just create operational risk, it can materially affect practice revenue.
The honest answer depends on your practice's starting point. There are three broad scenarios:
If your practice has been through accreditation before and has maintained its policies, registers and quality improvement activities consistently between cycles, preparation can typically begin around three to four months before your renewal survey. The work is largely review, refresh and update.
First-time accreditation requires significantly more lead time. Realistic preparation requires nine to twelve months for most practices. The volume of policies, registers, evidence and quality improvement documentation that needs to be built from scratch is substantially higher than most practice managers expect.
Practices that received conditions in a previous survey, or whose documentation has become outdated, sit somewhere in between. Six to nine months is typical, depending on the gaps identified.
The single most consistent theme across practices that struggle on survey day is that they began structured preparation too late. Compressed preparation almost always produces compressed-quality documentation.
Policies and procedures form the foundation of accreditation evidence. The RACGP Standards require documented policies across a wide range of clinical and administrative areas. Each policy must be practice-specific, as generic templates are identifiable to assessors and consistently flagged as non-compliant.
Core Policy Documentation Required
The challenge with policies is rarely the absence of documentation, it is alignment. A patient privacy policy that describes general principles without reflecting the specific way your practice handles patient records, who has access, how breaches are managed and how patients can request information will not satisfy assessors.
Policies copied from a generic template, or downloaded from another practice, are one of the most consistent sources of non-compliance findings. Assessors interview staff to verify whether documented policies reflect actual practice, and a mismatch is identifiable immediately.
The RACGP Standards require a range of active registers and compliance records. The critical word is active. A register that exists but contains no entries, or only entries created in the weeks before survey, signals to assessors that the register is not being used as intended.
Registers and Records Required
Cold chain monitoring is one of the most scrutinised areas. Logs that show patterns inconsistent with continuous monitoring, for example entries only on weekdays or gaps over weekends and public holidays, are routinely flagged. Cold chain monitoring is required to be continuous, and the log must reflect that.
Staff documentation is where many practices have the foundations in place but lack the rigour assessors are looking for. The challenge is not having documents, it is having current, complete, consistently maintained documents for every individual staff member.
Staff and Workforce Records
CPR training currency for all clinical staff is one of the most frequently cited areas of non-compliance. Most CPR certifications require annual renewal, and a single expired certification at the time of survey is enough to attract a finding.
Quality improvement is the area where most practices struggle, and for a clear reason: meaningful quality improvement evidence takes time to accumulate. A genuine PDSA cycle (Plan, Do, Study, Act) cannot be completed retrospectively in the weeks before a survey.
Quality Improvement Documentation
The PDSA documentation must show all four stages of the cycle. Many practices document the planning and "doing" stages but provide weak evidence of the study and act stages, measuring outcomes and demonstrating that learnings were embedded into operational practice. This is consistently identified by assessors as an area requiring improvement.
A Pre-Survey Readiness Review identifies gaps before assessors do.
Clinical governance documentation is often where smaller practices have the largest gaps. Informal governance arrangements that exist in practice, but have not been formally documented, will not satisfy assessors.
Governance and Business Documentation
This area covers the operational reality of how the practice runs day to day, and the documentation that demonstrates compliance. Assessors do not just review documentation, they observe the practice during their visit. The walkthrough component of the survey is where the alignment between documented policy and operational reality is tested.
Clinical and Operational Evidence
Survey day is where months of preparation are tested. Even practices with strong documentation can encounter problems on the day if they have not specifically prepared for the assessor visit itself.
Survey Day Preparation
Assessors interview both clinical and administrative staff. If a receptionist cannot articulate the practice's complaint handling process, or a nurse cannot describe the cold chain breach response procedure, the documentation alone will not save the finding. Staff preparation is as important as document preparation.
Downloaded templates, policies inherited from a previous practice manager that have not been updated, or documents written in generic language without practice-specific detail. This is the single most common cause of policy-related findings.
Cold chain logs filled in over a weekend, incident registers with sudden bursts of entries, or training records created in the weeks before survey. Patterns of retrospective documentation are immediately apparent to experienced assessors.
PDSA cycles created retrospectively, patient surveys completed without follow-up action, or clinical audits conducted without genuine analysis. Quality improvement is intended to be an ongoing operational practice, not a documentation task.
Reception staff who do not know where the complaint policy lives, nurses who cannot describe the practice's emergency response procedure, or GPs unable to articulate the credentialing arrangement. Staff preparation is consistently underdone.
Evidence buried across multiple drives, folders, email accounts and physical files. If an assessor cannot find a document during the survey, in practical terms it does not exist for accreditation purposes.
MedAssure works directly with Australian general practices to handle the full accreditation preparation process, including policy development, evidence organisation, quality improvement systems and survey day readiness. Every engagement is scoped and quoted to your practice.
Speak With MedAssure View Our ServicesRACGP accreditation operates on a three-year cycle. Practices need to undergo a full accreditation survey every three years to maintain their accredited status and Medicare incentive program eligibility.
AGPAL (Australian General Practice Accreditation Limited) and QPA (Quality Practice Accreditation) are both approved by the RACGP to conduct accreditation assessments. They assess against the same RACGP Standards but differ in their administrative platforms, application processes and surveyor pools. Some practices have a longstanding relationship with one provider, others choose based on cost or process preference.
Non-compliance findings are categorised by severity. Minor findings typically result in a defined corrective action timeframe. More significant findings can lead to conditional accreditation, requiring re-assessment of specific areas. In the most serious cases, though rare, accreditation can be withheld until corrective work is completed and re-assessed.
Yes. Many practices manage accreditation internally, particularly those with experienced practice managers who have been through the cycle multiple times. External consulting support typically becomes valuable when a practice is preparing for first-time accreditation, has limited internal capacity, has received non-compliance findings previously, or wants confidence rather than uncertainty going into survey.
Accrediting body fees for a single-site general practice typically range from $3,000 to $6,000 or more, depending on practice size and location. This does not include internal staff time, documentation development or any consulting support engaged. Accreditation costs vary depending on the practice size, accreditation body fees, preparation workload and whether external support is required.
The RACGP 6th Edition Standards are the next major revision of the standards. While most practices are currently accredited under the 5th Edition, the 6th Edition will become the assessment basis once the transition window closes. The fundamental categories of evidence (policies, registers, quality improvement, governance) remain, but the specificity of indicators and evidence requirements is expected to increase.
MedAssure provides specialist RACGP accreditation consulting for Australian general practices, including accreditation preparation, policy development, compliance systems and pre-survey readiness reviews for AGPAL and QPA assessments.
