2 August 2022

Want to ace accreditation? Follow these top 3 tips

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We asked practice manager, Carmel Brown, for her top tips to prepare and stay calm when undergoing assessment.


Many medical practices dread preparing for accreditation and undergoing assessment day, every three years. 


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But when you think of accreditation as being about improving the quality of your patient care, it becomes more meaningful. And with a bit of forward planning and good systems in place, you can make the experience less stressful for you and your team.

We asked practice manager, Carmel Brown, leading figure in practice management and a fellow of the Australian Association of Practice Management (AAPM), for her top tips to help you prepare with ease and stay calm on the day.

1. Prepare your documentation early

Gather the documentary evidence of your compliance points as set out in the RACGP Standard’s 5th edition. Pay attention to showing your practice adheres to these requirements:

Provide evidence of vaccination status for all practice team members

You need to show that your practice team (including allied health and specialists) are fully vaccinated against influenza, hepatitis B, measles, mumps, rubella, pertussis, varicella, and especially now, COVID-19.Verbal confirmation of immunisation status will not satisfy the requirement, you need the documentation – whether that’s proof of which vaccines a person has had, or a signed statement from a team member who refuses vaccination. In this case, you have to balance up the risk to the person refusing vaccination and the risk they pose to the rest of your team and your patients. Setting expectations around practice vaccination policy when recruiting staff can help here.

Provide evidence of clinical staff’s qualifications, registrations and education

Ensure you keep thorough records of all your doctors’ CPD points for the time period being assessed. And remember that your nurses need to update their CPR training every 12 months as part of their Ahpra registration – not every three years for accreditation, as with your GPs and non-clinical staff.

Document your business risk management processes

Can you demonstrate the systems your practice has in place to manage and mitigate business risk?

Carmel recommends you focus on areas such as:

  • reputational risk – Ensure your practice has firm policies around social media use that could potentially damage the practice reputation or breach Ahpra advertising guidelines.
  • financial risk – Is your practice compliant with Medicare billing, and payroll and ATO obligations?
  • equipment maintenance – you need to provide a history showing your equipment calibration and other maintenance is done in accordance with manufacturers’ requirements and timeframes.
  • cyber security – computer viruses and data breaches are a major risk to practices, so ensure your IT services provider is on top of your digital security processes.

2. Involve all your team in accreditation preparation and participation

When you get the whole team to help with accreditation, it not only alleviates your workload stress, but encourages greater accountability and collaboration among your team in creating a safer, quality practice. 

Nominate in advance which GPs and nurses will be interviewed by the surveyor on the day. Sometimes the surveyors might ask your reception staff questions unexpectedly, but if your whole team is involved in the preparation, and aware of what questions may be asked, this shouldn’t be an issue.

3. Use PracticeHub to simplify your accreditation experience

Carmel recommends PracticeHub’s online practice management software, which she has used in many accreditation assessments, as well as to improve her practice’s daily operations.

Its policy and procedure templates are aligned with the RACGP’s 5th edition standards, and you can centrally store all your practice documents online so all staff can access them. An equipment register keeps you on top of your equipment maintenance, and the Ahpra Alerts and Certificate of Insurance apps automate the collection, validation and storage of your clinical team’s registration and indemnity insurance documents. It includes learning modules, so you can train staff in-house, and keep detailed records of courses completed, to demonstrate your commitment to ongoing quality improvement.

On assessment day, you can also give your surveyor access to your PracticeHub site, to streamline their review and to demonstrate the solid foundation your practice processes give to the quality of your patient experience.

Discover how PracticeHub can streamline your accreditation preparation, and make your daily business operations safer, for better patient care. To find out more, book a demo or call 1300 96 86 36.

Persons implementing any recommendations contained in this publication must exercise their own independent skill or judgment or seek appropriate professional advice relevant to their own particular practice. Compliance with any recommendations will not in any way guarantee discharge of the duty of care owed to patients and others coming into contact with the health professional or practice. Avant and PracticeHub are not responsible to you or anyone else for any loss suffered in connection with the use of this information. Information is only current at the date initially published. © Avant Mutual Group Limited 2021.