Top five RACGP accreditation pitfalls and how to avoid them

Preparing for RACGP accreditation doesn’t need to be stressful, but many practices fall into the same avoidable traps. At QIP Consulting, we’ve supported healthcare organisations across Australia with accreditation support, clinical governance advice, and quality improvement strategies. Through this work, we’ve identified five common areas where practices frequently lose receive non-compliances due to simple oversights, and how to proactively address them.

1. Clinician qualifications and equipment training

One of the most consistent non-compliances relates to clinician qualifications – especially expired CPR certificates and undocumented CPD. Many practices or rely on clinicians to self-manage this evidence, or realise too late that a CPR certificate is expired and don’t have time to arrange training before their accreditation survey. Similarly, some practices assume GPs are confident in common equipment they use and don’t think to check this competency when the GP starts in their clinic.

Solution: Create and maintain central registers that tracks registration, CPR, CPD, and equipment training. Incorporate key requirements into onboarding and induction processes. Remember, even if a GP has used an ECG before, they still need to understand your model. Simple checklists and signed induction records go a long way to evidencing relevant training.

2. Incomplete health summaries

A patient’s health summary must include a number of items such as current medicines, allergies, health risk factors, social and cultural history. Due to the number of items needed to create a complete health summary, it’s not surprising one or two factors sometimes fall through the cracks.

Solution: Use your clinical software to identify gaps and encourage self-audits among GPs. Train nurses to assist with collecting social history during new patient registration. Where possible, standardise data entry with drop-down lists and minimise free text. Practices that integrate this into routine care avoid last-minute data sprints.

3. Workplace immunisation records

Many practices lack clear records of staff immunisation status or fail to document refusals. This can be particularly risky when staff are exposed to blood or bodily fluids.

Solution: Develop an immunisation register for all team members and keep it updated. You don’t need to mandate immunisation – but you do need to document status and refusals, and ensure risk is managed appropriately. For example, a staff member without Hepatitis B immunity should not be cleaning blood spills.

4. Cold chain and vaccine management

Non-compliances within the cold chain management criterion are a regular occurrence. However, this is rarely due to cold chain breaches or mismanagement of temperature recording – it’s the lack of documentation and completion of annual storage audits that let practices down.

Solution: Conduct and document annual audits of vaccine storage practices in line with the Strive for 5 Guidelines. Assign responsibility for cold chain oversight in a formal position description or within the cold chain manual, and encourage this person to feel ownership over management, implementation and update of the manual.

5. Patient feedback

Practices often underestimate the time and strategy required to meet patient feedback indicators. Too many rely solely on the Practice Accreditation Survey (PAIS) or forget to record informal feedback entirely.

Solution: Start feedback activities early in your cycle and use every opportunity – formal or informal – to record, analyse, and respond to patient input. Keep a feedback register, minute discussions (or keep records of internal emails), and show evidence of improvement. Only one of the three indicators within the QI1.2 criterion actually requires the PAIS survey to be complete to meet it – the other two indicators can still be met in other ways even if your survey results aren’t back yet.

At QIP Consulting, we specialise in healthcare accreditation support, quality improvement services, and strategic planning for general practice teams. We’re here to help you not only meet the RACGP Standards, but embed sustainable systems that support excellence in care.

Need expert support with your accreditation journey? Reach out to our team today.