person using laptop with graphics in front

The top 5 accreditation areas of non-compliance – and how to meet them

Undergoing accreditation every three years is one way a healthcare practice demonstrates its commitment to continually improving the safety and quality of their patient care. And successful practices look at their quality improvement as a daily process, not just at accreditation time. This approach not only makes preparation and assessment day less stressful, it leads to increased practice efficiencies, a more engaged team, and better patient outcomes. However, there are five assessment criteria from the RACGP Standards for general practices that accreditation body, AGPAL has identified as the most common areas of non-compliance from surveying 3,000 practices. Ensuring your practice meets these criteria will help improve your accreditation performance.

Number 5: Criterion QI2.2E: Safe and quality use of medicines

Some reasons that practices didn’t meet this criterion include:

  • expired medical consumables,
  • incorrect storage of S4 and S8 medications and
  • inaccurate labelling or patient details missing for S8 records.

These pose an increased risk of patient harm, so make sure your stock rotation and documentation processes are methodical. Online practice management platform, PracticeHub, is ideal for documenting and recording your processes for safe use of medicines. The software includes customisable policy and procedure templates aligned with the RACGP Standards, and you can link directly to your state’s legislation on medicines management to ensure your processes are always up to date, compliant and safe.

Number 4: Criterion C3.1C: Business operations systems / Business risk management system

Risk management in practices is not only about clinical risk. While documenting adverse events and near misses is important, so is having business risk management systems in place to mitigate risks around compliance (ATO, Medicare, Ahpra, payroll), security and financial, practice reputation and operations.

A risk matrix is an effective tool to gauge the severity of risks to your business – from low to medium and high. Knowing these, you can then concentrate most of your efforts on mitigating the high-risk areas.

Because risk management is an ongoing process, by storing your risk strategy and documents in PracticeHub, they are easy for staff to access and update. PracticeHub’s integrated registers are another useful risk management tool, to document practice risks and your control measures. You can also set an automatic reminder to review these registers in your staff meetings. By involving staff in your risk management, everyone stays alert to risk prevention, helping create a safer practice for your team and your patients.

Number 3: Criterion C8.1 B: CPR Training (non-clinical)

All non-clinical practice staff must complete CPR training every three years. Training must be conducted by an accredited training organisation, or a clinical team member with a current instructor certificate. It must include a physical demonstration – online training only does not meet this indicator requirement. Meeting this criterion is also about having the documentary evidence of completed training readily available for accreditation. You can record this in PracticeHub, by creating a personnel file for each team member, linking relevant training, such as CPR, and certificates of completion, in their profile. You can also include a training and development plan and record whether training is done in-house or externally.

Number 2: Criterion GP3.1A: Qualifications, education and training (clinical)

This criterion is focused on Ahpra registration, CPD documents and training, and CPR for your entire clinical team. Detailed and current record keeping is also important to meet this requirement. Your GPs or clinical staff may well be Ahpra registered and actively participating in CPD, but you need to keep records as evidence for accreditation. In PracticeHub, you can record CPR and CPD training, again in the personnel section, as for the previous criterion. And with the Ahpra Alerts app, you can manage practitioners’ registrations automatically, ensuring they’re always current.

Number 1: Criterion C3.5B: Practice team immunisations

This is a timely standard criterion to adhere to, during the pandemic. And again, it comes down to having documentary evidence that your staff are up to date with immunisations recommended in the Australian immunisation handbook. Using PracticeHub, you can keep documents of which staff have signed consent forms and received which vaccinations and who has signed refusal forms. This not only covers you for accreditation but also for Work Health and Safety.

Make accreditation preparation easier

The first thing to remember when preparing for accreditation is you’re not alone. Involve your practice team in the process, so everyone’s engaged in a successful outcome and can contribute to making preparing quicker and less stressful. And remember, AGPAL and your practice management colleagues can provide useful support.

Involving your team is easy when you store all your practice documents in one place, using PracticeHub. Everyone can access and update your policies and procedures. You can assign tasks to staff and send them direct messages, such as meeting reminders. And it’s easy to pull up all your documentary evidence, such as your registers for equipment, contracts and insurance, and completed training modules. Regulatory compliance is easier, too, with the Ahpra Alerts and Certificate of Insurance apps, automating the collection and storage of these essential credentialing documents.

You can give your surveyor access to PracticeHub to streamline the process for them and for you.

Working with your practice team on accreditation preparation, and quality improvement in general brings you all a great sense of satisfaction. When everyone can see the changes they’ve made in your practice to strengthen it as a business, you create a better quality practice now and in future.

Our in-depth accreditation workshop has many more tips to help you pass with flying colours.

Find out more about using PracticeHub to improve your processes, for accreditation success, and in your daily business operations. To find out more, book a demo or call 1300 469 866.


This article is not comprehensive and does not constitute legal or medical advice. You should seek legal or other professional advice before relying on its content, and practise proper clinical decision making with regard to the individual circumstances. Persons implementing any recommendations contained in this article must exercise their own independent skill or judgement 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 is 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 2024.

To Top