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Interpretive guide to the RACGP Standards

for Aboriginal community controlled health services

Appendix A

Applicability of the RACGP Standards for general practices

The RACGP Standards for general practices (4th edition) have been written by the general practice profession for general practices in Australia. One of the great strengths of general practice is its diversity. If your practice is a general practice – even if it seems to have an unusual or unconventional structure – then these Standards are applicable.

General practice

The RACGP defines general practice as the provision of patient centred continuing comprehensive, coordinated primary care to individuals, families and communities. The Standards are wholly relevant to general practices which meet this definition.

Special interest practices

The Standards might also be relevant for health services that do not necessarily see themselves as ‘general practices’ but as ‘special interest practices’ in primary care. Special interest practices may focus on a single clinical area (eg. mental health or skin cancer) or a single treatment modality (eg. acupuncture).

Services providing care to specific populations

The Standards may apply to primary healthcare services that are not organised like an office based private general practice, but which nevertheless provide general practice care to a distinct community (eg. Aboriginal medical services, community health services, or mobile clinics caring for homeless people).

The RACGP has worked extensively with the Aboriginal Community Controlled Health Organisation sector to develop an interpretive guide on the RACGP Standards.17

Services providing care outside normal opening hours

There are several options for the provision of care outside normal opening hours, or the advertised opening hours of the practice. Some practices use their own GPs to provide care or alternatively use a local cooperative of GPs or a medical deputising service. Where a deputising service is not available practices may have an agreement with a local hospital. Some practices use a combination of all these arrangements.

Except where specifically indicated, all standards, criteria and related indicators are applicable to services providing care outside normal opening hours.

Self assessment against the Standards

The RACGP encourages all services that provide primary healthcare to consider the Standards as a template for quality improvement and risk management. Most standards and related criteria will be relevant and will enable practices to build the fundamentals of quality and safety into their systems.

Primary health services which do not meet the RACGP definition of general practice and are therefore unable to be formally accredited against the Standards are nevertheless able to conduct a self assessment.

If a practice is undertaking a self assessment against the Standards, it may be helpful to discuss the assessment informally with trusted colleagues. A ‘fresh set of eyes’ over practice systems can assist in identifying areas where the practice does really well and areas where the practice needs to improve. Most importantly, peers can provide feedback on quality improvement activities – they can help the practice verify if changes based on practice data have brought about intended outcomes.

Independent accreditation against the Standards

When the RACGP Standards are used as the basis of an accreditation process, practices are expected to meet the Standards at all times, not just on the day of the accreditation survey. This is important for the safe and effective care of patients.

Any formal assessment process against the RACGP Standards needs to be based on common sense and should not seek to penalise or exclude practices on the basis of technicalities.

The only model of third party review supported by the RACGP for the Standards is by two or more surveyors who meet defined selection criteria and where at least one surveyor is a GP.


  1. The Royal Australian College of General Practitioners. Interpretive guide of the RACGP Standards for general practices (3rd edition) for Aboriginal and Torres Strait Islander health services. South Melbourne: The RACGP, 2010.

Appendix A

Tips to help you prepare for accreditation

This section is a compilation of some tips and hints that may assist you, both in preparing for accreditation and on the day the surveyors visit your service. Note that it is not a definitive summary.

On the day of the visit

Remember that your surveyors also go through the process of accreditation in their own health services and know how stressful and anxious staff can be.

Make sure that the surveyors know where they can park to avoid getting a parking ticket.

Put a notice up letting patients know that there are visitors to the service and that you are having your survey visit today.

Have the surveyors sign a confidentiality agreement after arrival if this is your service’s policy.

A rough guide for the survey visit (which will usually take a minimum of four hours) could include:

  • entry meeting
  • guided tour of the health service
  • formal interviews, as scheduled in advance
  • informal interviews, as requested
  • review of relevant documents and records
  • observation/inspection
  • exit meeting and summation.

Some tips for interviewees to remember about interviews:

  • be well prepared
  • relax, be honest and provide as much relevant information as possible
  • if you do not understand the question, ask the surveyor to rephrase and/or explain further
  • if asked a question that is outside the scope of your role, advise the surveyor
  • remember, it’s the system being assessed – not you personally!


It would be helpful to have your relevant key policies on hand, such as:

  • after-hours visits
  • pathology results
  • vaccine potency
  • infection control
  • communication
  • incident management
  • patient identification
  • privacy.

Care outside normal opening hours (Criterion 1.1.4)

Make sure your service has in place a formal agreement for the provision of care outside normal opening hours and that a copy of that agreement is available for the surveyors on the day, if applicable.

If your service has an agreement to participate in an after-hours roster with other health services, have the agreement and a copy of the roster ready for the surveyors.

Check that your answering machine is working and that the message is clear and current – the surveyors will be phoning after hours to check on this.

Check that you have a means of knowing that the other health services with which you share afterhours care, or the medical deputising service you use, have appropriately qualified doctors on staff.

Qualifications of staff (Criterion 3.2.1, 3.2.2, 3.2.3)

Check that your service has current professional registration details for general practitioners, practice nurses, dentists, dietitians, physiotherapists and other allied health professionals.

Check that you have in place a system for making sure you update the professional registration of staff members in their employee records.

Staff training (Standard 3.2)

Ensure that your service has in place documented training records/logs for staff members.

Make sure you have available for the surveyors copies of the GPs’ continuing medical education  triennial points.

Ensure you have evidence that all staff have had CPR training in the previous 3 years.

Job descriptions and staff issues (Criterion 4.1.1)

Check that all staff members have documented, current job descriptions.

Verify that the job descriptions include who is responsible for cold chain management, information technology, cleaning, vaccine management, sterilisation, quality improvements, risk-management systems, infection control, privacy and complaints handling. This could also be shown on a list in staff common areas.

Check that your staff members know what their roles are.

Check that your records show that staff have been offered immunisation, and the outcome.

If you have documented minutes of staff and clinical meetings, make them available for surveyors to look at.

If you use a communication book or equivalent, have this available for the surveyors as well.

Vaccines (Criterion 5.3.2)

The National vaccine storage guidelines: Strive for 5 is now the benchmark reference and a copy should be available in your service.

A ‘don’t switch off’ sign on the power point is a good idea.

Do not overcrowd the fridge.

Have a protocol for when the temperature range is NOT between 2–8°C: who is to be notified and what action is to be taken.

Ensure a copy of data logging is available for surveyors.

Ensure that there is no food or drink in the refrigerator.

S8 drugs summary of requirements (Criterion 5.3.1)

If your service does not stock S8 drugs your GPs need to be able to explain to the surveyor the alternatives to injectable S8 drugs that are used to provide analgesia (pain relief) to patients.

Have your S8 drug register available for the surveyor to look at.

Check the relevant state or territory website (or other publication) to ensure your service’s requirements are current:

ACT: Drugs of Dependence Act 1989:

NSW: Poisons and Therapeutic Goods Regulations:

Queensland: Health (Drugs and Poisons) Regulation 1996, appendix 6:

See, also, appendix C of What doctors need to know, published by Queensland Government
Environmental Health Branch:

South Australia: Code of Practice for the Storage and Transport of Drugs of Dependence:

Tasmania: Schedule 8 Medicine Summary by GPA Assist plus:

Victoria: Drugs, Poisons and Controlled Substances Regulations 2006:

WA: Requirements for the prescribing of Schedule 4 and Schedule 8 medicines in Western

Sterilisation (Criterion 5.3.3)

Ensure that the person who is responsible for sterilisation has had appropriate training and that they are well prepared to explain your service’s processes to the surveyor.          

Check whether your clinical staff know how to ensure the equipment and consumables they are using are sterile.

If your service sterilises its own instruments, check whether you have a steriliser validation certificate that has been done in the last 12 months. This needs to be available for the surveyors.

Make sure your staff are aware of the maximum load that can be processed and ensure sterilisation of instruments is the ‘challenge pack’ load that was used and documented by the technician when they performed the validation. Any load exceeding this ‘challenge pack’ load is not considered to be sterile.

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