Australian Commission assessment outcomes data shows approximately 77% of practices required improvement or remediation before accreditation was awarded. The real risk is not always obvious non-compliance, it is the hidden accreditation gaps practices assume are complete until an assessor asks to see the evidence.
Ben
RACGP Accreditation Consultant, MedAssure Consulting
In This Article
Bottom Line
Most practices eventually achieve RACGP accreditation, but many do not meet every mandatory indicator at the first assessment. The real risk is not only a missing document. It is the overlooked task, outdated register, informal process or half-finished action the practice did not realise was still open.
Understanding why practices fail RACGP accreditation starts with a number most practice managers never see. Australian Commission on Safety and Quality in Health Care assessment outcomes data shows that 23% of practices had all mandatory indicators met at initial assessment, meaning approximately 77% required improvement or remediation before accreditation was awarded.
77%
of Australian general practices required improvement or remediation before accreditation was awarded.
Source: Calculated from Australian Commission on Safety and Quality in Health Care assessment outcomes data, which reports that 23% of practices had all mandatory indicators met at initial assessment. View source.
The real lesson
The dangerous gaps are usually the ones the practice cannot see from the inside. A pre-survey readiness review gives you a fresh set of eyes before the assessor arrives, so you know which policies, registers, staff files, QI records and evidence trails are actually incomplete.
Book a Readiness ReviewIf you spoke to most practice managers, they would tell you their last accreditation went fine. That is true in one important sense: most practices eventually achieve accreditation. But "eventually" is doing a lot of work in that sentence.
The Australian Commission on Safety and Quality in Health Care (ACSQHC) operates the National General Practice Accreditation (NGPA) Scheme, and the most recent published data covers three full years of assessments from April 2023 to April 2026 across thousands of Australian general practices and Aboriginal Medical Services.
The headline finding is one that almost nobody is talking about: 23% of practices had all mandatory indicators met at initial assessment. Put another way, approximately 77% had at least one mandatory indicator that needed improvement or remediation before accreditation could be awarded.
Why this matters
This is not mainly a story about assessors being difficult or practices intentionally ignoring the Standards. In most cases, the problem is that small requirements are assumed to be complete until someone tests them properly: a staff file that was never updated, a policy that was never reviewed, a register that stopped being maintained, or a quality improvement activity that was discussed but never closed out.
The vast majority of practices get there in the end. But "getting there" can involve a 65 business day remediation window that is stressful, expensive, distracting, and often avoidable if the practice identifies its hidden gaps earlier.
This article breaks down the published data on exactly which indicators are causing remediation findings, why busy practices often overlook them, and how a structured readiness review can identify the gaps your team may not realise are still open before the assessor arrives.
Before going further, it is worth being precise about what failure looks like under the current scheme, because the language is often loose.
When an accrediting agency (AGPAL, QPA, or another approved agency) conducts your initial routine assessment, each indicator in the RACGP Standards for general practices is rated as met, not met, not applicable, or not assessed. Any indicator rated "not met" triggers a remediation period of up to 65 business days, during which the practice must produce additional evidence to demonstrate compliance.
There are three tiers of consequence beyond "fully compliant at initial assessment":
The three tiers of failure
A note on realistic expectations: it is uncommon for even well-prepared practices to pass an initial assessment with zero findings. Assessors are thorough and the Standards are detailed. The realistic goal is not zero findings, it is to stay well below the 20% repeat-assessment threshold and to keep the remediation list short enough that 65 business days is more than enough to close it out cleanly.
The Commission publishes the raw count of how many practices were rated "not met" against each indicator across the assessment period. Below are the fifteen indicators practices were most frequently caught on nationally, drawn from the April 2023 to April 2026 reporting window.
| Rank | Indicator | Topic | Practices "not met" |
|---|---|---|---|
| 1 | GP3.1A | Qualifications, education and training of healthcare practitioners | 2,066 |
| 2 | QI2.1B | Health summaries | 1,528 |
| 3 | C3.5B | Work health and safety | 1,505 |
| 4 | C8.1B | Education and training of non-clinical staff | 1,235 |
| 5 | GP3.1C | Qualifications, education and training of healthcare practitioners | 1,145 |
| 6 | QI1.2B | Patient feedback | 1,038 |
| 7 | QI1.2C | Patient feedback | 931 |
| 8 | C3.1C | Business operation systems | 811 |
| 9 | C6.4D | Information security | 770 |
| 10 | QI1.2A | Patient feedback | 738 |
| 11 | QI3.1A | Managing clinical risks | 736 |
| 12 | GP6.1C | Maintaining vaccine potency (cold chain) | 727 |
| 13 | GP5.3A | Doctor's bag | 726 |
| 14 | QI2.2E | Safe and quality use of medicines | 704 |
| 15 | QI3.1B | Managing clinical risks | 687 |
Source: Australian Commission on Safety and Quality in Health Care, Indicators where improvements were required before accreditation was awarded, RACGP Standards 5th edition, reporting period April 2023 to April 2026.
The ACSQHC's own analysis is blunt about what is going wrong. For the top three indicators rated "not met," the main reason provided by assessors is the same in almost every case: "documentation not available" at the time of initial assessment.
In other words, the failures are not generally that practices are unsafe or non-compliant in their actual operations. The failures are that practices cannot produce the evidence at the right moment, in the right format, organised in a way the assessor can navigate.
What follows is each of the six dominant failure patterns drawn from the data, paired with the practical steps that reduce the risk of each one.
Most practices do not fail accreditation because they deliberately ignored the Standards. They get caught because small tasks are assumed to be done, split across different staff members, left half-finished, or never checked again after the last accreditation cycle. A readiness review helps identify those hidden gaps before the assessor does.
The problem
GP3.1A and GP3.1C between them cause more failures than any other category in Australian general practice. More than 3,200 practices were rated not met against one of these two indicators across the reporting period. The pattern is consistent: a GP joined the practice 18 months ago, the AHPRA certificate on file has lapsed, the CPR refresher is overdue, the immunisation record was never collected. None of this is hard to fix individually. It is hard to fix systematically, three years after the last accreditation, when no one has been tracking it.
How to reduce the risk
Build a simple checklist of every required document for each staff member: AHPRA registration, CPR, anaphylaxis training, immunisation records, indemnity insurance, and any role-specific certifications. Work through it name by name and tick off each item once you physically have the current document on file. The point is not to produce a register as evidence in itself, the assessor wants to see the actual documents for each staff member, current and on hand. The checklist is just your tool for making sure nothing is missing before survey day. Organise the files by staff member, with a folder for each person containing their current certifications, so any document can be produced the moment it is asked for.
The problem
QI2.1B is one of the most common remediation findings nationally, with 1,528 practices rated not met. The Standards expect practices to maintain current, accurate health summaries for active patients, but with high patient turnover, locum GPs, and competing clinical pressures, summaries drift out of date fast. Practices that have not run a structured health summary audit in the 12 months before assessment almost always get caught.
How to reduce the risk
Run a health summary audit, and use a documented PDSA cycle if you want a clear record of the activity. But be clear on what the assessor is checking: it is not enough to show that an audit happened. They need to see that the health summaries are actually current and complete at the time of assessment. The audit is the mechanism for getting them there, not a substitute for the result. Work through active patient records, bring the summaries up to date, and make sure the improvement is real and visible in the clinical system, not just recorded as a completed task.
The problem
C3.5B is the third-most common remediation finding, with 1,505 practices caught out. WHS sits awkwardly in general practice because no one wakes up thinking about it, but the Standards require evidence of an active WHS system: hazard registers, incident reporting, training records, and review cycles. A WHS policy written in 2022 and never reviewed is not evidence of an active system. Assessors look at the dates.
How to reduce the risk
Review your WHS policy annually and date the review. Maintain a hazard register that captures real items (slip hazards, sharps disposal, ergonomic concerns) rather than reading as a generic template. Document any incidents, however minor, with a clear closure note. Keep WHS as a standing item on practice meeting agendas at least quarterly, and minute the discussion.
The problem
QI1.2A, QI1.2B, and QI1.2C together account for more than 2,700 not-met findings across the reporting period. These three sub-indicators ask three different things: that the practice collects feedback, that it analyses what comes in, and that it uses the analysis to drive improvement. Most practices nail the first one. Plenty get to the second. Very few can show the third leg of that stool in writing.
How to reduce the risk
A feedback box is not enough. Build a simple closed-loop process: feedback is collected, reviewed at a defined cadence (monthly works well), themes are documented, at least one improvement action is recorded against the themes, and the result of that action is reviewed at a later meeting. The evidence is the written trail through that loop, not the volume of feedback collected. Two or three closed-loop improvements per year, properly documented, is stronger evidence than 50 feedback forms with no follow-up.
The problem
C6.4D (information security) is the indicator that has moved most aggressively up the rankings in the past year, reaching 770 failures by April 2026. The reason is straightforward: the regulatory and threat environment has changed, and assessors are now applying a sharper lens to practice-level cyber and data security. A practice with a one-page IT policy from 2022 that does not address access controls, breach response, third-party data handlers, or staff training is unlikely to pass this indicator in 2026.
How to reduce the risk
Update your information security policy to cover, at a minimum: user access controls and password requirements, multi-factor authentication where applicable, data breach response procedures, third-party data handlers and their compliance status, and staff training on information security. A simple monthly IT report from your provider showing patching, backups, and any incidents is evidence of an active system. Run a brief annual review of the policy and date it.
The problem
This is often the real reason practices get caught. The team believes the accreditation work is under control because the policies exist, the registers have been started, training has happened informally, or someone was asked to follow something up. But when the evidence is reviewed properly, the gaps are still there: policies are outdated, registers are incomplete, staff records are missing, meeting actions were never closed, feedback was collected but not analysed, or a quality improvement activity was discussed but not documented.
These are not always obvious from inside the practice because everyone is busy keeping the clinic running. The risk is that the practice only discovers the gap when the assessor asks for evidence, by which point the team is working under remediation pressure.
How to reduce the risk
Treat accreditation preparation as a gap review, not just a document hunt. Work through each major area and ask: is it current, complete, implemented, recorded, reviewed, and ready to show? This is where an external readiness review can be valuable. A fresh set of eyes can identify the gaps the practice has become used to, prioritise what needs fixing, and give the team a clear action plan before survey day.
Where MedAssure Helps
MedAssure helps general practices identify overlooked accreditation gaps before they become assessor findings. This includes reviewing policies, registers, staff files, training evidence, quality improvement records, patient feedback processes, meeting actions and survey-readiness documentation. The goal is to show the practice what is actually missing, not just what appears to be on file.
A readiness review does not guarantee accreditation and it does not replace the formal assessment. It gives your practice an independent, practical view of the gaps you may not know you have, with a prioritised action plan before the assessor arrives.
Book a Readiness ReviewThe lesson from the assessment outcomes data is not simply that practices should organise their folders better. Folder structure matters, but the bigger issue is whether the underlying accreditation work has actually been completed, implemented, reviewed and recorded.
The patterns above are the practical gaps your practice will be measured against under the RACGP Standards for general practices. A practice can look prepared from the inside and still have unresolved gaps across staff credentialing, health summaries, WHS systems, patient feedback, information security, quality improvement and evidence trails.
Three practical takeaways
Important compliance note
A consultant can help your practice prepare before assessment, but the formal assessment must remain independent. The role of a readiness review is to identify genuine gaps, prioritise corrective actions and help the practice build evidence properly.
Much of what an assessor reviews is physical and lives inside the practice, not just in a policy folder. Vaccine fridge logs, autoclave records, drug cupboard expiry checks, infection prevention systems and general premises cleanliness are only the obvious examples. The bigger risk is the less obvious onsite gaps practices often miss: expired items, incomplete logs, unchecked equipment, unclear staff processes, and small compliance issues that quietly build up before survey day.
That is why a strong preparation process combines two things: a document and evidence review, and a practical gap review against how the practice actually operates. Done early enough, most accreditation issues are fixable. Done too late, the same issues become remediation pressure.
MedAssure can complete a structured RACGP Accreditation Readiness Review to identify hidden gaps across your policies, registers, staff files, QI evidence, training records and survey-readiness documentation before assessment pressure starts.
Readiness Review
A fixed-fee review to identify overlooked RACGP accreditation gaps before the assessor arrives.
Accreditation Guide
A practical, end-to-end checklist for general practices preparing for RACGP accreditation.
MedAssure Services
Specialist accreditation preparation, gap analysis, and pre-survey readiness reviews for Australian general practices.
An indicator rated not met at initial assessment triggers a remediation period of up to 65 business days. If all indicators are met by the end of that period, accreditation is awarded. If any mandatory indicators remain unmet at the final assessment, accreditation is not awarded. Separately, practices with 20% or more of mandatory indicators rated not met at initial assessment are required to undergo a standardised repeat assessment six months after accreditation is awarded.
According to Australian Commission on Safety and Quality in Health Care assessment outcomes data, 23% of practices had all mandatory indicators met at initial assessment. This means approximately 77% required improvement or remediation before accreditation was awarded.
GP3.1A, which covers qualifications, education and training of healthcare practitioners, is the single most commonly failed indicator nationally in the April 2023 to April 2026 assessment outcomes data. Common issues include missing or unavailable current AHPRA registration, CPR, immunisation, training or credentialing evidence at the time of assessment.
The remediation period can last up to 65 business days. During this period, the practice must produce additional evidence or implement changes to demonstrate compliance with indicators rated not met. A final assessment is then conducted, and the accrediting agency determines whether accreditation is awarded.
An accreditation consultant can provide an external readiness review before survey day. This helps identify overlooked or incomplete gaps across policies, registers, staff files, training evidence, quality improvement records, patient feedback processes, meeting actions, cold chain documentation and other accreditation evidence. A consultant cannot guarantee accreditation or participate in the formal assessment process, but can help the practice understand what is missing and prioritise what needs to be fixed before the assessor arrives.
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. MedAssure helps practices identify genuine gaps, prioritise corrective actions and prepare evidence properly before formal assessment.
