Practice Accreditation Readiness Checklist

RACGP 5th Edition Accreditation Readiness Checklist

Use this checklist to systematically assess your practice's readiness for accreditation against the RACGP Standards for General Practices (5th edition). Work through each section, marking items as complete, in progress, or requiring action. This checklist covers all five standards and their core criteria.

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Standard 1: Communication and Patient Participation

### Criterion C1.1 — Informed Patients

- [ ] Practice has a current patient information sheet describing services, fees, and appointment procedures - [ ] Information is available in accessible formats (large print, languages other than English where relevant to patient demographics) - [ ] Patients are informed of their rights and responsibilities - [ ] Fee information is clearly displayed and communicated prior to services - [ ] After-hours care arrangements are communicated to patients - [ ] Practice website (if applicable) contains accurate and current information

### Criterion C1.2 — Identifying and Addressing Patient Needs

- [ ] Systems are in place to identify patients who may need additional support (e.g., cultural, linguistic, accessibility) - [ ] The practice can arrange interpreter services when needed - [ ] Patient recall and reminder systems are operational and documented - [ ] Follow-up processes for test results are documented and consistently applied - [ ] Systems exist for managing patients who do not attend scheduled appointments

### Criterion C1.3 — Communication and Patient Participation

- [ ] Patient feedback mechanism is in place (e.g., survey, suggestion box, online feedback) - [ ] Patient feedback is reviewed regularly by the practice team - [ ] Evidence of action taken in response to patient feedback - [ ] Patients are involved in decisions about their care (documented in clinical records) - [ ] Practice has a process for patient involvement in practice improvement activities

### Criterion C1.4 — Health Promotion

- [ ] Practice provides health promotion information and resources relevant to patient population - [ ] Health promotion activities are documented - [ ] Information resources are current and evidence-based

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Standard 2: Rights and Needs of Patients

### Criterion C2.1 — Patient Rights

- [ ] Practice has a documented privacy policy compliant with the Privacy Act 1988 - [ ] Privacy policy is communicated to patients - [ ] Patient consent processes are documented and consistently applied - [ ] Systems ensure confidentiality of patient information (physical and electronic records) - [ ] Staff have received privacy and confidentiality training - [ ] Practice has a process for patients to access their health records

### Criterion C2.2 — Patient Identification

- [ ] Minimum of three patient identifiers are used at each clinical encounter - [ ] Patient identification process is documented in practice policy - [ ] Staff are trained on patient identification procedures - [ ] Systems prevent duplicate patient records

### Criterion C2.3 — Informed Consent

- [ ] Informed consent process is documented in practice policy - [ ] Consent is obtained and recorded before significant procedures or treatments - [ ] Patients are provided with adequate information to make informed decisions - [ ] Consent documentation is stored in the patient record

### Criterion C2.4 — Managing Complaints

- [ ] Practice has a documented complaints management policy and procedure - [ ] Complaints process is communicated to patients (visible signage, written information) - [ ] Complaints are recorded, investigated, and resolved in a timely manner - [ ] Evidence of practice improvement actions arising from complaints - [ ] Staff are aware of the complaints process and their responsibilities

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Standard 3: Clinical Care

### Criterion C3.1 — Clinical Governance

- [ ] Practice has a documented clinical governance framework - [ ] Regular clinical governance meetings are held (with documented minutes and action items) - [ ] Incident reporting system is in place and understood by all staff - [ ] Incidents are investigated and actions taken to prevent recurrence - [ ] Open disclosure process is documented and staff are trained - [ ] Clinical audit activities are conducted regularly with documented findings and improvements - [ ] Significant event analysis is conducted for serious incidents - [ ] Clinical indicators are monitored (e.g., prescribing, referral, investigation patterns)

### Criterion C3.2 — Clinical Performance and Effectiveness

- [ ] GPs participate in continuing professional development - [ ] Clinical staff work within their scope of practice - [ ] Evidence-based guidelines inform clinical decision-making - [ ] Referral pathways are documented and current - [ ] Diagnostic imaging and pathology ordering follows established criteria - [ ] Prescribing practices are monitored and reviewed

### Criterion C3.3 — Continuity of Care

- [ ] Clinical records contain comprehensive and current patient information - [ ] Systems support continuity when patients see different clinicians within the practice - [ ] Handover processes are in place for clinical staff transitions (leave, departure) - [ ] Correspondence management system ensures timely review and action on incoming clinical information - [ ] Follow-up systems for referrals, investigations, and results are documented and operational

### Criterion C3.4 — Comprehensive Care

- [ ] Preventive health care activities are systematically offered (immunisation, screening, health assessments) - [ ] Chronic disease management systems are in place (care plans, reviews, recall) - [ ] Mental health care pathways are documented - [ ] Medication management processes include medication reconciliation and review - [ ] Systems support care coordination with other providers

### Criterion C3.5 — Prescribing and Medicines Management

- [ ] Medicines management policy is documented - [ ] Antimicrobial stewardship principles are applied - [ ] High-risk medications are managed according to documented protocols - [ ] Repeat prescribing is monitored with regular clinical review - [ ] Drug interaction checking is enabled in the clinical software

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Standard 4: Practice Environment and Safety

### Criterion C4.1 — Practice Facilities

- [ ] Practice premises meet applicable building and safety codes - [ ] Adequate consulting rooms, treatment areas, and waiting areas - [ ] Disability access is provided in accordance with relevant standards - [ ] Emergency exits are clearly marked and unobstructed - [ ] Patient and staff amenities are adequate and maintained

### Criterion C4.2 — Infection Prevention and Control

- [ ] Infection prevention and control policy is documented and current - [ ] Hand hygiene resources are available at point of care - [ ] Hand hygiene audits are conducted and documented - [ ] Standard precautions are applied for all patient contact - [ ] Sharps management procedures are documented and followed - [ ] Waste management follows relevant guidelines (clinical waste segregation, disposal) - [ ] Cleaning schedules are documented and followed - [ ] Sterilisation and reprocessing procedures are documented, validated, and audited - [ ] Staff immunisation records are maintained - [ ] Outbreak management plan is in place

### Criterion C4.3 — Equipment and Medicines

- [ ] Equipment maintenance schedule is documented and followed - [ ] Emergency equipment is available, maintained, and checked regularly (with documented checks) - [ ] Vaccine cold chain management is documented and monitored - [ ] Medication storage is secure and monitored (including temperature-sensitive medicines) - [ ] Drug of dependence storage and recording meets jurisdictional requirements

### Criterion C4.4 — Managing Health and Safety Risks

- [ ] Risk management framework is in place with a documented risk register - [ ] Workplace health and safety policies are current - [ ] Fire safety plan and evacuation procedures are documented and practised - [ ] Staff are trained in emergency procedures - [ ] Hazard reporting system is operational - [ ] Business continuity plan is documented (including data backup and recovery)

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Standard 5: Organisational and Governance Requirements

### Criterion C5.1 — Governance and Management

- [ ] Practice governance structure is documented (ownership, management, clinical leadership) - [ ] Practice policies and procedures manual is maintained and accessible to staff - [ ] Insurance coverage is adequate and current (professional indemnity, public liability, workers' compensation) - [ ] Financial management processes are in place - [ ] Contracts and agreements with third parties are current and documented

### Criterion C5.2 — Human Resources

- [ ] Staff position descriptions are documented and current - [ ] Recruitment and selection processes are documented - [ ] Staff credentialing and registration verification is current for all clinical staff - [ ] Staff orientation and induction program is documented - [ ] Performance review processes are in place and conducted regularly - [ ] Staff training records are maintained - [ ] CPD records are current for all clinical staff - [ ] Adequate staffing levels are maintained and reviewed

### Criterion C5.3 — Information Management and Technology

- [ ] Information management and technology policy is documented - [ ] Clinical software is current and supported - [ ] Data backup procedures are documented and tested regularly - [ ] Business continuity and disaster recovery plan includes IT systems - [ ] My Health Record connectivity is operational and staff are trained - [ ] Secure electronic communication systems are in place for inter-provider communication - [ ] Cybersecurity measures are documented and implemented

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Pre-Assessment Final Checks

- [ ] All policies and procedures have been reviewed within the past 12 months - [ ] Meeting minutes from the past 12 months are compiled and accessible - [ ] Training records for all staff are current and filed - [ ] Audit results and quality improvement evidence are compiled - [ ] Patient feedback data and actions are documented - [ ] Incident register is current and demonstrates review and follow-up - [ ] All clinical staff registrations and insurance documents are verified and filed - [ ] Practice accreditation team has been briefed on assessment process and roles

How to Use This Checklist

1. Assign a lead person for each standard to coordinate the review 2. Work through each item systematically, documenting evidence for each 3. Flag items requiring action and assign responsibility and deadlines 4. Conduct a final review at least four weeks before your assessment date 5. Consider engaging external support for a mock assessment if significant gaps are identified

Need Help Preparing?

Complete Health Partners provides accreditation readiness assessments, gap analysis, mock assessments, and remediation support for practices preparing for RACGP 5th edition accreditation. Contact us to discuss your practice's needs.

Download Full Checklist

Register below to download the printable PDF version of this checklist, including additional guidance notes and evidence templates for each criterion.

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*This checklist is based on the RACGP Standards for General Practices (5th edition). Practices should consult the RACGP for the most current standard documentation and assessment guidance.*