RACGP · 6th editionStandards for general practices, in plain English
43 criteria sets · 110 criteria

Practice accreditation reference

Every criterion, explained simply, and searchable.

This guide breaks the RACGP Standards for general practices (6th edition) into its five standards, 43 sets of criteria and 110 individual criteria. For each one you get the official wording (what the surveyor will assess), a plain-English summary, why it matters, and practical ways to meet it.

Type in the search box to filter everything on the page — criteria codes, topics, phrases from the guidance. Use the chips to narrow by standard or to see only aspirational criteria.

5 standards43 criteria sets110 criteria4 aspirationalPoCT standard is optional
Foundations of general practiceF1–F11Clinical governanceCG1–CG13Patient participationPP1–PP10Continuous quality improvementCQI1Point-of-care testing (optional)PoCT1–PoCT8

What the Standards are

The RACGP Standards for general practices (6th edition) set out what a safe, high-quality general practice looks like. They are the benchmark used for practice accreditation under the National General Practice Accreditation (NGPA) Scheme.

They are written to focus on outcomes, not processes: each criterion says what must be achieved; the guidance shows ways you could meet it. The word 'could' means the examples are optional — pick, adapt or invent approaches that suit your practice's size and model of care.

Every criterion must be met for accreditation, except those marked Aspirational, which are encouraged but optional.

The quintuple aim

The Standards are built on five goals for healthcare improvement:

  • Patient experience — person-centred care, access, communication and feedback.
  • Population health — preventive care, evidence-based services and good data.
  • Reducing costs — continuous improvement, less waste, better allocation.
  • Practice team wellbeing — collaboration, training, safety and a positive culture.
  • Health equity — culturally appropriate, accessible care.

Environmental sustainability and climate resilience are woven through the Standards, and point-of-care testing has its own optional standard.

How the Standards are organised

There are five standards. Each contains named sets of criteria, and each criterion has a code: the standard prefix, the set number and a letter — for example CG6.B is Clinical governance, set 6, criterion B.

PrefixStandardSets
FFoundations of general practiceF1–F11
CGClinical governanceCG1–CG13
PPPatient participationPP1–PP10
CQIContinuous quality improvementCQI1
PoCTPoint-of-care testing (optional)PoCT1–PoCT8

Each set of criteria comes with a consumer expectation statement (what patients expect), why this is important, and meeting these criteria guidance. This site condenses all of that into plain English and keeps the official wording of each criterion so you can check exactly what will be assessed.

Who can be accredited

To be assessed against the Standards a practice must provide comprehensive, person-centred, whole-person, continuous care, and be predominantly general practice: more than 50% of GPs' clinical time and more than 50% of Medicare-claimable services are general practice.

The practice must be GP-led: clinically governed by one or more GPs who are physically present and consult in person on a regular, ongoing basis (with sensible allowances for remote and multi-site services).

To be accredited against the optional PoCT standard, a practice must meet every required PoCT criterion as well as all other mandatory criteria. The PoCT visit can happen with the main accreditation visit or later.

Who's who — key terms

  • Practice team — everyone who works for or provides care from the practice, including independent doctors.
  • Clinical team — team members with health qualifications (GPs, nurses, Aboriginal and Torres Strait Islander Health Workers/Practitioners, allied health).
  • Employed members — people working under a formal employment agreement. Some criteria (e.g. signed position descriptions, documented PD discussions) apply only to employees.
  • Independent doctors in practice — doctors running their own business from the practice rather than being employed. The practice must still make sure they know its mission, governance, plans and ethics process, and obtain reasonable assurance of certain training (e.g. FDSV).
  • Patient — a person seeking or receiving healthcare. Consumer — a person using a health service or someone supporting them. Consumer representative — a consumer advising on behalf of others.
  • Active patient — attended three or more times in the past two years.

The Standards only cite legislation where it is particularly relevant. Meeting the Standards helps with legal compliance but does not guarantee it — the practice must identify and comply with all applicable laws.

Nothing matches that search. Try a shorter word, a criterion code like CG6, or clear the search.

Standard

Foundations of general practice

The basics of running a well-managed practice: purpose and planning, emergency response, sustainability, induction and training, qualified and autonomous practitioners, team culture, information security, privacy, digital health and AI.

11 criteria sets · 32 criteria

F1

Defining and planning for the practice

What patients expectI expect that this practice has defined mission and values and monitors its progress towards achieving them supported by appropriate and current policies and procedures.

In plain English

Know what your practice stands for, write it down, and run the practice against it. You need a mission/vision/values statement, a strategic plan (big picture, reviewed every 2 years), an operational plan (day-to-day objectives), someone in charge of each, a way of keeping policies current, a way of handling ethical dilemmas within 3 months, a governance process, and a risk register for business risks.

The criteria

F1.AThe practice has a strategic approach to the provision of healthcare that reflects its mission, vision, values, and commitment to safety and quality.

What the standard says

The practice:

  • defines and documents its mission, vision and values
  • incorporates a strategic approach to the provision of healthcare for patients that continuously meets these safety and quality standards
  • communicates its mission, vision and values to the practice team and consumers
  • monitors how its mission, vision and values are reflected in the practice’s operations, safety culture, and quality improvement activities
  • assesses the practice’s safety culture using feedback from team members or other appropriate methods.
F1.BThe practice maintains a strategic plan and measures progress toward achieving its goals.

What the standard says

The practice:

  • documents a strategic plan that includes defined goals and reviews the plan every two years
  • has at least one member of the practice team who has primary responsibility for the practice’s strategic plan and financial management
  • measures its progress toward achieving the defined goals in the practice’s strategic plan.
F1.CThe practice maintains an operational plan and measures progress toward delivering its objectives.

What the standard says

The practice:

  • has a documented operational plan that includes defined objectives
  • has at least one member of the practice team who has primary responsibility for the practice’s operational plan
  • measures its progress toward achieving the defined objectives and how its mission and values are being addressed in the operational plan.
F1.DThe practice’s policies, procedures, and operational documents are current, accurate, and accessible.

What the standard says

The practice:

  • maintains currency, accuracy and accessibility of policies, procedures, and operational documents
  • reviews all policies, procedures and operational documents for currency at least every two years, or as circumstances require
  • has a document version control process that assigns responsibility for sign-off and review of documents.
F1.EThe practice has processes to review, manage and resolve ethical issues.

What the standard says

The practice:

  • facilitates a process for the practice team to review, manage and resolve ethical issues within a defined timeframe of three months.
F1.FThe practice applies a governance process to support safe, high-quality care and accountable decision-making.

What the standard says

The practice:

  • applies a governance process that supports oversight of quality, safety, and performance
  • designates governance roles and accountability to defined individuals within the practice
  • ensures that the governance process informs practice-wide decision-making and continuous improvement
  • aligns the governance process with the practice’s size, structure, and scope of services
  • regularly reviews the effectiveness of its governance process to support safe and sustainable service delivery.
F1.GThe practice identifies and manages governance risks.

What the standard says

The practice:

  • maintains documented processes for identifying, assessing, and responding to strategic, operational, and service-related risks
  • implements, monitors and reports risk management and mitigation actions
  • uses a risk register (or equivalent) to document and prioritise identified risks
  • regularly reviews and reports risks, including their management and mitigation, to practice leadership.
Why it matters

A written purpose and plan keeps decisions consistent, gives the team a shared direction, and turns 'safety and quality' from a slogan into something you actually measure.

How to meet it — practical ideas
  • Write a one-page mission, vision and values statement and put it in the induction pack, on the wall and on the website.
  • Keep a simple strategic plan with SMART goals and a couple of KPIs; diary a review every 2 years.
  • Keep an operational plan with objectives and milestones; talk about it at team meetings.
  • Name one person responsible for the strategic plan and finances, and one for the operational plan (can be the same person).
  • Store all policies in one place (e.g. SharePoint/Google Drive) with a naming convention: name, version, last updated, reviewer, next review date. Review every 2 years or sooner.
  • Assess safety culture — a short staff survey or focus group on infection control, privacy, IT, incident reporting.
  • Keep an ethical issues register (e.g. gifts from patients, staff as patients, waiting-room confidentiality) and resolve each within 3 months; use your MDO for hard cases.
  • Keep a business risk register (IT single points of failure, staff shortages, floods) separate from the clinical risk register in CG7. Report to the owners regularly.
  • Make sure independent (contractor) doctors know the mission, governance, plans and ethics process via their agreement or induction.
F2

Response planning

What patients expectI expect that this practice has appropriate response planning in place to coordinate ongoing high-quality and safe care during emergencies and unexpected events.

In plain English

Have one tested plan for what happens when things go wrong — IT outage, power failure, cyber attack, fire, flood, pandemic, staff shortage, losing access to the building. Name a person responsible, make sure the team knows the plan, include how clinicians keep seeing patients if the computers are down, and test it.

The criteria

F2.AThe practice has a tested response plan for disruption to the continuity of its services, including from unexpected events, emergencies, and interruptions to business- as-usual.

What the standard says

The practice:

  • documents its processes for how it prepares for, responds to and recovers from unexpected events
  • has at least one member of the practice team who has primary responsibility for its response and emergency processes
  • makes the practice team aware of plans for preparedness and response to unexpected events
  • has a process for the clinical team to continue delivering care where feasible, in the event of an emergency that causes information and communication technology (ICT) to stop functioning
  • tests its response plan.
Why it matters

If the practice can't operate, patients can't be cared for. Testing is what turns a document into readiness.

How to meet it — practical ideas
  • Take an 'all-hazards' approach: build core capabilities (comms tree, paper backup, offsite data) rather than a separate plan for every scenario.
  • Write down how clinicians keep consulting during an ICT outage (paper notes, paper scripts, phone triage, later entry into the record).
  • Name a response/emergency lead and put it in their role description.
  • Test at least some of it: a fire drill, a mock IT outage, a cyber tabletop exercise, or a written review of a real disruption (that counts).
  • Use the RACGP Emergency Response Planning Tool (ERPT) or the RACGP Managing emergencies in general practice guide as a template.
F3

Environmental sustainability and responsibility

What patients expectI expect that this practice is aware of its environmental impact and is focused on minimising this.

In plain English

Be aware of climate risks to your practice and have strategies to cope (climate resilience), document what you are doing to shrink your environmental footprint and emissions, and appoint one person as sustainability lead.

The criteria

F3.AThe practice is aware of and takes steps to address/improve its climate resilience.

What the standard says

The practice:

  • identifies climate-related risks to its operations
  • implements strategies to improve climate resilience.
F3.BThe practice is aware of and takes steps to minimise its environmental impact.

What the standard says

The practice:

  • documents strategies aimed at improving its environmental impact and to reduce direct and indirect carbon greenhouse gas emissions.
F3.CThe practice has at least one member of the practice team who has primary responsibility for environmental sustainability in the practice.

What the standard says

The practice:

  • has at least one member of the practice team who has primary responsibility for engaging in and promoting the environmental sustainability of the practice.
Why it matters

Heatwaves, floods, bushfires and storms disrupt services and hit vulnerable patients hardest. Cutting energy and waste also cuts costs and protects the practice's long-term viability.

How to meet it — practical ideas
  • List your local climate risks (heat, flood, cyclone, bushfire smoke) and fold them into the F2 response plan.
  • Write a short environmental sustainability policy: energy, travel, procurement, e-waste, paper, water, recycling, waste.
  • Follow the energy hierarchy: reduce unnecessary use → improve efficiency → switch to renewables. Set the thermostat 20–22°C winter, 24–26°C summer; LED lighting; turn off standby power.
  • Move to e-prescribing and digital documents; reduce single-use items where safe; keep recyclables out of clinical waste bins.
  • If you own the building: solar, insulation, heat pumps, GreenPower.
  • Appoint a 'green champion' or green team and make sustainability a standing agenda item.
  • Consider a free online carbon calculator for a baseline — professional audits are rarely worth it for small practices.
F4

Induction, training and supporting performance

What patients expectI expect that the team at this practice has a clear understanding of their roles and are appropriately managed and trained.

In plain English

Everyone gets an induction. Employees are trained for their role (including person-centred care and Medicare billing resources), have documented professional development chats, and the practice has a framework, training and referral pathways for recognising and responding to family, domestic and sexual violence (FDSV). All staff hold current CPR certification (renewed at least every 3 years).

The criteria

F4.AThe practice inducts members of the practice team.

What the standard says

The practice:

  • has a system to induct members of the practice team
  • has at least one member of the practice team who has primary responsibility for inducting members of the practice team.
F4.BEmployed members of the practice team are trained to perform their role in the practice.

What the standard says

The practice:

  • trains employed members of the practice team about their role when they start working at the practice and provides ongoing training to address continued competency and adaptation to changes
  • trains employed members of the practice team so that they work within the scope of their role
  • makes members of the practice team aware of Medicare billing education resources
  • confirms that employed members of the practice team have completed training appropriate to their role and the practice’s patient population
  • trains employed members of the practice team on the delivery of person-centred care.
F4.CThe practice provides role‑appropriate training and has supporting processes for recognising and responding to abuse and violence, including family, domestic and sexual violence.

What the standard says

The practice:

  • adopts recognised guidelines and a practice framework for recognising and responding to abuse and violence
  • makes local referral pathways available to the practice team to support safe, trauma‑informed practice
  • confirms that employed members of the practice team have completed role‑appropriate training in recognising and responding to family, domestic and sexual violence
  • obtains reasonable assurance that independent doctors in practice have completed role‑appropriate training in recognising and responding to family, domestic and sexual violence
  • promotes a consistent team approach through team discussions/briefings and access to current resources.
F4.DThe practice discusses professional development with each employed member of the practice team.

What the standard says

The practice:

  • supports employed members of the practice team via discussions about professional development
  • documents discussions held with employed members of the practice team about professional development, agreed actions and ongoing development needs.
F4.EMembers of the practice team are certified at least once every three years to perform cardiopulmonary resuscitation (CPR).

What the standard says

The practice:

  • has evidence that members of the practice team complete CPR training at least once every three years.
Why it matters

A trained, well-inducted team delivers safer care. GPs see about five women a week who have experienced intimate partner violence in the past year — the team needs to know how to respond. Professional development conversations improve performance and communication.

How to meet it — practical ideas
  • Write a position description for every role and have employees sign it (independent doctors don't need to sign).
  • Induction covers: mission and values, plans, day-to-day systems and policies, WHS, privacy, ICT security, recall/reminder system, public health rules and local services.
  • Keep a training register showing role-appropriate training completed, including FDSV training (the RACGP White Book and trauma-informed modules, 1800RESPECT, DV-alert etc.). Accept external certificates; you don't have to run training yourself.
  • Keep a short internal FDSV framework: where resources are, safe-contact prompts, who to ask, a local referral list including after-hours/crisis numbers.
  • For independent doctors, obtain 'reasonable assurance' (e.g. a CPD certificate) that they've done FDSV training.
  • Point staff to MBS Online, AskMBS and RACGP Medicare resources at induction.
  • Document PD discussions (goals, agreed actions, development needs) — keep them separate from salary reviews.
  • CPR training must be face-to-face practical assessment with AED use, by an ASQA-approved provider, every 3 years. Online-only does not count.
  • If you use AI tools, include training on their purpose, limits and the need for clinical oversight (see F11).
F5

Registration and qualifications of practitioners

What patients expectI expect the care I receive is always provided by, or supervised by, suitably qualified practitioners.

In plain English

Every clinician has current AHPRA/professional registration and, where relevant, certification. Every GP is a specialist GP (FRACGP/FACRRM or vocationally registered), on a Fellowship pathway, a supervised registrar, or on an approved workforce program. If you genuinely can't recruit those, engage doctors who are properly trained and supported.

The criteria

F5.AMembers of the clinical team have, where applicable, current national registration and accreditation/certification with their relevant professional association.

What the standard says

The practice:

  • ensures that each practitioner has, where applicable, current national registration and accreditation/certification.
F5.BEvery GP who provides general practice services in the practice is one or more of the following:

What the standard says

  • a specialist GP
  • a medical practitioner on a pathway to general practice Fellowship
  • a GP registrar under appropriate supervision from a qualified specialist GP
  • working under an approved workforce program.

If engagement of recognised specialist GPs or doctors on a pathway to Fellowship has been unsuccessful, the practice needs to ensure doctors who it engages have the qualifications and training necessary to meet the needs of patients.

Why it matters

Patients are entitled to care from suitably qualified, registered practitioners.

How to meet it — practical ideas
  • Check AHPRA registration for each clinician at engagement and at renewal; keep copies or a register.
  • Record how each GP qualifies (Fellowship, VR, pathway, registrar with supervisor, workforce program).
  • Where non-specialist doctors are engaged (e.g. remote areas), document their supervision, CPD and support.
F6

Clinical autonomy of practitioners

What patients expectI expect practitioners at this practice to make clinically independent recommendations to me about my care, based on their expertise and knowledge.

In plain English

Clinicians decide the clinical care, who to refer to, what tests to order and from whom, and how long and when appointments are — within their scope and professional obligations.

The criteria

F6.AMembers of the clinical team can exercise autonomy, to the full scope of their practice, skills and knowledge, when making decisions that affect clinical care.

What the standard says

The practice:

  • provides practitioners autonomy in relation to:
    • overall clinical care of their patients
    • referrals to other health professionals
    • requesting investigations
  • duration and scheduling of appointments.
Why it matters

Professional autonomy and clinical independence are essential to high-quality care.

How to meet it — practical ideas
  • Make sure practice policies and contracts don't direct referrals, pathology/imaging providers, or appointment lengths.
  • Allow telehealth versus in-person to be a clinical decision.
  • Note registrars may have training-imposed limits — that's fine.
F7

Practice team culture, safety and involvement

What patients expectI expect that this practice fosters a culture that supports the health, safety and wellbeing of the practice team and consumers, and enables open communication for the team to work together effectively.

In plain English

Look after the team's safety, health and wellbeing (WHS policy, occupational exposure management, protection from aggression, support after traumatic events and incidents, workload monitoring, analysing sick leave and exit reasons), and make sure leadership actively seeks and acts on team input, with a way to escalate and resolve issues.

The criteria

F7.AThe practice fosters a positive culture by supporting the safety, health, and wellbeing of the practice team.

What the standard says

The practice:

  • has a work health and safety policy
  • manages and reduces the risk of occupational exposures
  • supports the practice team during emergencies or other traumatic events
  • supports staff involved in significant clinical incidents, including patient safety incidents
  • educates the practice team in its work safety, health and wellbeing requirements
  • has systems in place to protect members of the practice team from violence and aggression
  • monitors and adjusts the workload of members of the practice team to support their wellbeing
  • collects and analyses workforce data on staff sick leave and reasons for staff departures to inform improvements that support team wellbeing and retention.
F7.BThe practice leadership group actively seeks the involvement and input from all members of the practice team.

What the standard says

The practice leadership group:

  • has a systematic approach to obtaining feedback from the practice team on their experience of working for or engaging with the organisation to implement improvements based on this feedback
  • actively seeks input from all members of the practice team
  • maintains a process for members of the practice team to escalate and resolve issues
  • has processes for the practice team to discuss administrative matters.
Why it matters

A safe, supported team provides safer care and stays longer. Supporting staff after incidents builds trust; seeking input embeds improvement in daily work.

How to meet it — practical ideas
  • Have a WHS policy and a documented exposure management protocol (sharps, body fluids, manual handling, PPE).
  • Zero-tolerance signage for aggression, de-escalation training, duress alarms/cameras, incident recording, and a policy on when to discontinue care.
  • Debrief as a team after traumatic events; point people to EAP, the GP Support Program, DRS4DRS, Nurse & Midwife Support.
  • Review incidents with a 'just culture' — fix the system, not blame the person; involve those affected in the fix.
  • Track workload, sick leave and reasons for leaving (look at raw numbers, not just percentages) and act on trends.
  • Run a staff survey (anonymous helps), hold regular team meetings with minutes, offer exit interviews, and keep a clear process for raising and escalating issues.
F8

Information security

What patients expectI expect that my information is securely managed to protect my privacy.

In plain English

Have a documented and tested ICT continuity, protection and recovery plan (including a cyber incident response plan), backups with a log and proven restores, current antivirus and firewalls, a named person responsible for ICT security (plus a staff member for digital governance if IT is outsourced), a privacy policy that covers storage/access/remote access, safe use of digital comms and social media, and documented procedures for storing, retaining and destroying records. Aspirational: tell patients which communication tools you use.

The criteria

F8.AThe practice has an information and communication technology (ICT) continuity, protection, and recovery plan.

What the standard says

The practice:

  • maintains, documents, and regularly tests an ICT continuity, protection, and recovery plan that includes a cyber security incident response plan
  • has a backup log operated by the practice or contracted provider
  • maintains up-to-date antivirus protection and hardware/software firewalls
  • has secure retention and backup of information in offsite or cloud storage locations and the ability to restore information from chosen backup locations
  • has procedures to inform patients of any instance where there has been a data breach affecting their personal information.
F8.BThe practice has secure electronic systems and ICT.

What the standard says

The practice:

  • has at least one person (a member of the practice team or contracted provider) with primary responsibility for the security of the practice’s electronic systems and ICT
    • if the above person is an external contracted provider, the practice has at least one member of the practice team who has primary responsibility for digital governance
  • documents its policies for the storage of, and access to, health information in the practice’s privacy policy, including remote access if applicable.
F8.CThe practice uses digital communications in a way that protects the privacy of patients and the practice team.

What the standard says

No further indicators — the criterion statement is the requirement.

F8.DThe practice uses social media in a way that protects the privacy of patients and the practice team.

What the standard says

No further indicators — the criterion statement is the requirement.

F8.EThe practice has procedures for the storage, retention, and destruction of records.

What the standard says

The practice:

  • documents procedures for the storage, retention, and destruction of records, both digital and hard copy (physical).
F8.FThe practice informs patients about the digital communication tools it uses to support their care. Aspirational

What the standard says

The practice:

  • informs patients about any communication products or platforms used for communication between the practice and patients to support the delivery of care.
Why it matters

Cyber attacks, hardware failure and disasters can stop care and expose patient data. Clear procedures protect privacy, meet legal obligations and keep patient trust.

How to meet it — practical ideas
  • Your ICT plan should cover: cyber incident response (detect, contain, recover, notify patients/authorities, review), daily automated backups, a backup test schedule, secure offsite/cloud backup, signed agreements with IT providers, antivirus/email scanning, automatic updates, staff cyber training, maintenance outside hours, and remote access rules.
  • Keep a backup log (yours or your IT provider's) and periodically prove you can restore.
  • Know who to call: Australian Signals Directorate (ACSC), police, Home Affairs; know your Notifiable Data Breach obligations.
  • If IT is outsourced, a staff member still owns digital governance: escalation, contacts, staff education, compliance monitoring, procurement.
  • Store data (and backups) in Australia where possible; if overseas, say so in the privacy policy.
  • Retention: keep records for the legally required minimum; destroy or de-identify securely, wipe drives, printers and copiers before disposal.
  • Use the RACGP Information security in general practice, email guiding principles and social media policy template.
F9

Confidentiality and privacy of health and other information

What patients expectinformation I expect that my health information held by this practice is secure and confidential, and I am promptly notified if a data breach occurs.

In plain English

Handle health information securely and confidentially: tell patients how their information is managed, name a privacy officer, keep a plain-English privacy policy aligned with the Australian Privacy Principles and communicate it, make sure the team follows it, encrypt or use secure messaging unless the patient consents otherwise, and tell patients about your data breach protocol. Only authorised staff can access the clinical system (individual logins, role-based access) and prescription forms, letterhead and official documents are stored securely.

The criteria

F9.AThe practice manages health information securely and confidentially.

What the standard says

The practice:

  • informs patients how their personal health information is managed, including security, confidentiality and access
  • has at least one member of the practice team who has primary responsibility for privacy related matters
  • maintains a privacy policy consistent with the Australian Privacy Principles and communicate it to patients
  • confirms that the practice team understands and implements its privacy policy
  • protects patient privacy when communicating electronically with or about patients by using a secure message system or other method of encryption, unless the patient has provided informed consent to their information being sent without such protection
  • informs patients of its data breach protocols.
F9.BThe practice has a policy and procedure so that only authorised members of the practice team can access its clinical information system, prescription forms, and other official documents.

What the standard says

The practice:

  • only allows authorised members of the practice team to access its clinical information system via unique individual identification and according to the person’s level of authorisation
  • describes in its privacy policy how members of the practice team access patient information, including how access levels are determined and allocated
  • securely stores all official documents, including prescription forms, administrative records, templates and letterhead.
Why it matters

Health information is 'sensitive information' under the Privacy Act and needs the strongest protection. Even de-named details (like an appointment) can identify someone.

How to meet it — practical ideas
  • Use the RACGP privacy policy template; include what you collect, why, how it's stored and shared, remote access, overseas disclosure, how patients access/correct records, how to complain, how document automation is used in referrals, and a review date.
  • Make the policy easy to find: website, QR code at reception, printed copy on request.
  • Give every staff member their own login and only the access their role needs (clinical system, PRODA/Medicare, My Health Record, correspondence).
  • Screens angled away from the public, screensavers/lock on unattended devices, mobile devices secured to the same standard as desktops.
  • Lock away prescription pads, letterhead and templates.
  • Get MDO advice before releasing information to carers or third parties in uncertain situations.
  • Refresh privacy training regularly and record it.
F10

Digital health technologies

What patients expectI expect that digital health technologies provided by this practice are easy to access and use; secure and regularly assessed; and my consent is obtained prior to use.

In plain English

Use telehealth, apps, portals, remote monitoring and secure messaging safely: have a process for clinicians to get informed consent before using them, a documented process for assessing, costing, implementing and managing new digital technologies (including impact on staff and patients), and give the team access to technical experts.

The criteria

F10.AThe practice uses digital health technologies safely and securely.

What the standard says

The practice:

  • facilitates processes for members of the clinical team to obtain informed consent from patients when using digital health technologies
  • has a documented process for assessing, costing, implementing and managing digital health technologies, including consideration of their potential impacts on the practice, members of the practice team and patients
  • provides members of the practice team with access to and opportunities for collaboration with technical experts for the digital health technologies it uses in the provision of high-quality patient care.
Why it matters

Digital tools improve access and continuity, but only if they are reliable, secure and understood by patients and staff.

How to meet it — practical ideas
  • Before adopting a tool, assess purpose, safety, usability, workflow changes, team readiness, costs (licences, upgrades, support) and how it will be reviewed.
  • Test hardware/software regularly and after updates; ensure internet and video/audio quality suit clinical use.
  • Help clinicians explain how the tool works, its limits, and how data is stored and shared; tailor to the patient's digital literacy; revisit consent when tools change.
  • If staff work offsite: secure remote access with read/write to the clinical system, secure messaging, My Health Record if applicable.
  • Involve IT/vendor experts in workflow design, training and periodic performance reviews, not just support tickets.
  • Follow the RACGP Guide to providing telephone and video consultations and Medical Board telehealth guidelines.
F11

Artificial intelligence (AI)

What patients expectI expect that this practice asks for my consent to use artificial intelligence, explains how it will be used to provide me with care, and ensures my safety and privacy.

In plain English

If you use AI (scribes, decision support, chatbots, admin automation): get and document informed consent, de-identify data where possible, only feed identified data into AI when clinically necessary and governed, involve the team, have governance with clear accountability and legal compliance, and document clinical oversight of outputs — clinicians remain accountable. Assess and mitigate risks before implementation, and keep monitoring and improving afterwards.

The criteria

F11.AWhere the practice uses artificial intelligence, it does so safely and securely and consistent with existing standards.

What the standard says

The practice:

  • facilitates processes for members of the clinical team to obtain and document informed consent from patients when aspects of care will be delivered using AI
  • facilitates data deidentification/anonymisation when using AI tools that process patient data
  • ensures that identified patient data is not used by AI tools unless its use is clinically necessary, explicitly authorised, and supported by documented governance and consent processes
  • discusses the implementation and use of AI with members of the practice team to identify practical implications and training needs
  • establishes governance processes for AI use, including accountability and compliance with legislation
  • documents processes that support clinical oversight of AI outputs.

Members of the clinical team:

  • are accountable for care decisions supported by AI tools.
F11.BThe practice assesses and evaluates its use of artificial intelligence.

What the standard says

The practice:

  • has a process to assess and evaluate the use of AI, including risk mitigation, prior to implementation
  • has processes for monitoring, review, and quality improvement to ensure AI tools deliver safe, high-quality care, with mitigation of any unintended consequences.
Why it matters

AI can speed workflows and improve care, but poorly governed AI can misdiagnose, breach privacy and create legal problems. Consent keeps patients informed and in control; evaluation catches problems early.

How to meet it — practical ideas
  • Ask each AI vendor: Do you comply with the Privacy Act/APPs? Can data be used or sold for other purposes? How is data encrypted, stored, destroyed? Can clinicians review outputs before use? Is the tool an ARTG-registered medical device if it needs to be?
  • Tell patients what the tool does, what it collects, where data goes and who can see it; record consent; let patients opt out at any time and document the withdrawal and the alternative pathway.
  • Write an AI governance section: who is accountable, risk assessment before go-live, how clinicians review/override outputs, how patients and staff can challenge an AI output.
  • Include AI in the incident register (CG7): wrong outputs, outages, privacy breaches, behaviour changes after updates.
  • Monitor after go-live: staff feedback, audits of AI-generated notes or recommendations, complaints, support tickets, usage rates, review of vendor updates.
  • Check the tool works fairly for your population (bias, cultural safety, low health literacy, disability, language). Respect Indigenous data sovereignty.
  • Contracts with vendors must cover data handling, consent and accountability. The practice stays responsible even when a third party runs the tool.
  • Useful reading: RACGP AI scribes and conversational AI resources, AHPRA AI obligations, ACSQHC pragmatic AI guidance, TGA guidance on AI as a medical device.

Standard

Clinical governance

Systems that keep patients and staff safe: records, patient identification, guidelines, handovers, results follow-up, risk and incident management, immunisation, infection control, environment, equipment, cold chain and research.

13 criteria sets · 40 criteria

CG1

Clinical information systems

What patients expectI expect my digital health information is managed, kept up-to-date and available when my care provider needs it, or I request it.

In plain English

Use a digital clinical information system. If you use more than one (a hybrid system), keep the health summary up to date in each and make sure each record shows that a consultation happened and where the full notes are.

The criteria

CG1.AThe practice uses a digital clinical information system to manage its patient health information.

What the standard says

The practice:

  • has a digital clinical information system to manage patient health information
  • maintains, if more than one digital clinical information system is used:
    • up-to-date patient health summaries in the patient health records of each system
    • records of each consultation or interaction in each patient health record, which includes where the clinical notes are recorded.
Why it matters

Digital records support communication, decision-making and quality improvement.

How to meet it — practical ideas
  • If hybrid: put a visible note in each system saying the practice uses multiple systems and where to look; keep allergies, medications and problems identical in both.
  • A brief note or billing record in the main system pointing to the other system is enough — full duplication is not required.
  • Tell all clinicians, including locums, about the hybrid arrangement at induction.
CG2

Patient identification

What patients expectI expect I am correctly identified by this practice.

In plain English

Confirm three approved identifiers every time a patient engages with the practice: name (given + family = one), date of birth, address, Medicare/DVA number, individual phone number.

The criteria

CG2.AThe practice uses a minimum of three approved patient identifiers to correctly match each patient to their patient health record.

What the standard says

The practice:

  • uses a minimum of three of the following approved patient identifiers to confirm a patient’s identity each time they engage with the practice:
    • name (family and given names together are one identifier)
    • date of birth
    • address
    • Medicare or DVA number
    • individual phone number.
Why it matters

Wrong-patient errors can be life-threatening. Three identifiers separates, for example, a parent and child with the same name and address.

How to meet it — practical ideas
  • Ask the patient to state identifiers rather than reading them out for confirmation.
  • Check at booking, arrival, phone/electronic contact, script requests, when a second clinician sees the patient, and when filing documents — and at every telehealth consult (document it).
  • Use private areas, written prompts or discreet check-in for at-risk patients; use multi-factor authentication on kiosks/online check-in.
  • Photo ID can be sighted but must not be copied into the record. A Medicare card alone is not sufficient.
  • Support anonymity/pseudonyms where lawful (e.g. FDSV situations) and consider restricting record access to the usual GP.
  • Be mindful of cultural protocols around naming deceased Aboriginal and Torres Strait Islander people.
CG3

Facilitating complete patient health records

What patients expectI expect my digital health information is managed, kept up-to-date and available when my care provider needs it, or I request it.

In plain English

Records for active patients (3+ visits in 2 years) must hold coded identification, contact, next-of-kin and emergency contact details, and Aboriginal and Torres Strait Islander status. Clinicians document an initial assessment, enough detail for each consult and communication, follow-ups, and relevant safeguarding information. The health summary is coded (reactions, problems, family history, risk factors, immunisations, allergies, past and social history) and 100% of active records have allergy status recorded. Medicines lists are accurate and included in referrals. Shared decision-making and refusal of advice are documented, as are all contacts and interpreter use. Aspirational: coded ethnicity, birth sex, gender and pronouns.

The criteria

CG3.AThe active patient health records contain all required demographic and identification details for each active patient in codable fields.

What the standard says

The practice:

  • Codes, for each active patient:
    • identification details
    • contact details
    • next of kin
    • emergency contact information.
CG3.BThe practice routinely records the Aboriginal and Torres Strait Islander status of patients in a codable field.

What the standard says

No further indicators — the criterion statement is the requirement.

CG3.CThe practice has a patient health records system that allows clinicians to record their patient consultations and clinical-related communications.

What the standard says

No further indicators — the criterion statement is the requirement.

CG3.DThe patient health records contain sufficient information that documents consultations and clinical-related communications.

What the standard says

Members of the clinical team:

  • document the assessment of the patient in the initial consultation
  • document sufficient information for consultations and clinical related communications
  • document matters that have been followed up from previous consultations
  • document relevant safeguarding information when provided by the patient or a lawful authority and where it is necessary for safe communication or continuity of care.
CG3.EThe practice’s clinical information system facilitates the recording of details of each patient’s current health summary in codable fields.

What the standard says

The practice:

  • uses a clinical information system that facilitates coding of patient health information
  • ensures the clinical information system facilitates active patient health records in which clinicians can code in the patient’s health summary:
    • adverse drug reactions
    • current health problems
    • family history
    • health/lifestyle risk factors, such as smoking, nutrition, alcohol, physical activity
    • immunisations
    • known allergies
    • past health history
    • social history
    • ensures that all (100%) of the active patient health records document known allergies or indicate that the patient has no known allergies in a codable field.
CG3.FMembers of the clinical team keep an accurate and current medicines list in each patient health record.

What the standard says

Members of the clinical team:

  • keep an accurate and current medicines list in each patient’s health record
  • include the accurate and current medicines list in patient referral letters.
CG3.GThe practice supports members of the clinical team to involve patients in shared decisions about their care.

What the standard says

The practice:

  • provides members of the clinical team with shared decision-making information and resources to use when discussing treatment and care options and individual treatment plans with patients.

Members of the clinical team:

  • identify and respect patients’ preferences or choices
  • document shared decision making in the patient’s health record
  • document that individual treatment plans have been developed, are monitored, reassessed and modified in coordination with the patient and/or care giver.
CG3.HMembers of the clinical team discuss, document and provide information to patients regarding the purpose, importance, benefits, risks and side effects of:

What the standard says

  • proposed investigations
  • referrals
  • diagnosis
  • treatment options
  • management of their conditions
  • a patient's refusal to follow significant clinician advice
  • the process implemented when a patient has refused treatment, advice or a procedure.
CG3.IMembers of the practice team record all communications with patients.

What the standard says

Members of the practice team:

  • record attempts to contact, or successful contact with, a patient
  • record patient‑initiated contact, including the reason for contact and any advice and/or information provided
  • record when a translation service was used for a patient, including relevant contact details of the service.
CG3.JThe active patient health record facilitates the collection, where relevant, of the following demographic details in codable fields: Aspirational

What the standard says

  • ethnicity
  • birth sex
  • gender
  • preferred pronouns.
Why it matters

Complete, coded records support continuity, safe prescribing, quality improvement and benchmarking. Factual records matter when FDSV or child safety information may end up in legal proceedings.

How to meet it — practical ideas
  • Run regular data-quality reports (e.g. missing allergy status, missing ATSI status, empty health summaries) and fix them — this doubles as a CQI activity.
  • Ask 'Are you of Aboriginal or Torres Strait Islander origin?' of every patient, explain why, record the answer without comment; use 'Not stated' if declined.
  • Prompt patients to update details at each booking; record all names a patient uses plus the official name.
  • Reconcile medicines at new prescriptions, ceases, post-discharge and specialist reviews; include the list in every referral.
  • Document shared decisions, refusals (with risks discussed and alternatives), information given (paste the URL), and every contact attempt.
  • Record safeguarding facts objectively: DVOs/AVOs, safe contact method, who may/may not receive information, custody arrangements and how verified. No opinions or emotive language.
  • Provide clinicians with decision aids and consumer factsheets to support shared decision-making.
CG4

Provision of clinical and medicines guidelines

What patients expectI expect this practice provides and ensures access to current information and evidence-based guidelines to the clinical team to facilitate best practice healthcare.

In plain English

Give the clinical team access to current, evidence-based medicines information and clinical/emergency guidelines, have a process for suspected medicines-related problems, support environmentally sustainable and climate-resilient clinical practice, and give clinicians and patients resources to reduce inappropriate antibiotic use.

The criteria

CG4.AThe practice ensures the clinical team has access to current, evidence-based medicines information.

What the standard says

The practice:

  • ensures members of the clinical team have access to current evidence-based information relating to medicines, including information about the purpose, importance, benefits and risks of medicines.
  • has processes for responding when a healthcare provider or patient identifies a suspected medicines-related issue.
CG4.BThe practice ensures the clinical team has access to current, evidence-based clinical and emergency guidelines that help diagnose and manage patients.

What the standard says

No further indicators — the criterion statement is the requirement.

CG4.CThe practice supports members of the clinical team to adopt environmentally sustainable and climate resilient clinical practices.

What the standard says

The practice:

  • provides members of the practice team with access to information, resources and/or strategies for the implementation of environmentally sustainable clinical practices.
CG4.DThe practice supports members of the clinical team and patients to reduce inappropriate antibiotic prescribing.

What the standard says

The practice:

  • provides members of the clinical team with access to information and resources to reduce inappropriate antibiotic prescribing
  • provides patients with access to information and resources to reduce inappropriate antibiotic use.
Why it matters

Best-practice prescribing and diagnosis rely on current guidelines. Healthcare is a major emitter, and antimicrobial resistance is a growing global threat.

How to meet it — practical ideas
  • Subscribe to Therapeutic Guidelines/AMH or equivalents, keep clinical software drug databases and CMI current, and link to HealthPathways.
  • Have a simple process for reporting and acting on suspected medicine-related issues (including to the TGA).
  • Share resources on low-value care, deprescribing, lower-carbon inhalers, e-scripts, reusable vs single-use PPE; add sustainability to CPD and team discussions.
  • Share climate-health guidance: heatwave management, thunderstorm asthma, smoke, emerging infections; use telehealth during climate emergencies.
  • Antibiotics: give GPs prescribing guidelines and let them compare their own prescribing; put patient information on the website, waiting-room screens and via QR codes.
CG5

Transitions of care

What patients expectI expect that this practice communicates with other healthcare services and that my health information is securely transferred in a timely way when requested or authorised by me.

In plain English

Have processes for smooth handovers and referrals: support patients when care is coordinated with other services, communicate with other clinicians, share information in line with the Privacy Principles, use referral templates that contain all required content, keep legible copies of referrals, and have a handover process for planned and unplanned clinician leave. Transfer records securely and promptly on valid request, with patient consent, under a privacy policy that covers it.

The criteria

CG5.AThe practice has processes that facilitate timely transitions of care.

What the standard says

The practice:

  • supports consumers when coordinating care to be provided by other health services
  • collaborates and communicates with internal and external practitioners and services throughout transitions of care
  • documents and shares patient health information to allow continuity of care in accordance with the Australian Privacy Principles (APPs)
  • provides templates that allow the clinical team to write referral letters containing all required information outlined in the RACGP’s guidance document
  • has a process for handover of care in the event of expected or unexpected leave by a member of the clinical team.

Members of the clinical team:

  • keep copies of referrals to other services that are legible and contain all required information.
CG5.BIn response to authorised, valid requests, the practice transfers relevant patient health information in a timely and secure manner.

What the standard says

The practice:

  • facilitates the transfer of care when requested by the patient, authorised caregiver or a general practitioner in the practice
  • obtains patient consent for the health information being transferred to another practitioner or service
  • has a privacy policy that addresses the timely, authorised, and secure transferral of patient health information.
Why it matters

Poor handover causes delayed treatment, missed results, repeated tests, medication errors, adverse events and legal action.

How to meet it — practical ideas
  • Document a handover policy: internal and external handovers, locums, buddy system for results when a GP is away, how handovers are recorded, how near misses are reported.
  • Use ISBAR for emergency handovers (e.g. to ambulance/ED) and have a process to review discharge summaries.
  • Pass on risks, goals, preferences, relevant beliefs, carer contacts and safeguarding flags (privacy flags, court orders, safe contact method).
  • Mental health crises: know your state's mental health legislation, CATT and ED contacts, and document the crisis, actions, referrals and legal steps.
  • Send information by secure messaging or encryption unless the patient has consented otherwise.
  • Have a template/process for record transfer requests; tell patients about any cost; ask the MDO if a third-party request seems doubtful.
  • Upload shared health summaries/event summaries to My Health Record where the patient wants it.
CG6

Follow-up systems

What patients expectI expect that this practice has systems in place to notify me of results. This includes quick and effective communication of high-risk results, so I know what action is recommended.

In plain English

Every result and piece of correspondence is reviewed, notated (electronically or by signature), acted on and filed. Clinically significant results are recalled with every contact attempt documented. There is a process for results that never arrive, a reminder system for preventive care, and staff can explain the results process to patients. A written policy covers high-risk results arriving after hours, and your main pathology/imaging providers hold the after-hours contact details of the responsible clinician or deputising service.

The criteria

CG6.AThe practice acts on all clinical information received regarding its patients in a timely manner.

What the standard says

The practice:

  • has a system for GPs to review, notate, act upon and incorporate clinical information which is received by the practice into the patient health record
  • has follow-up systems for recalling and documenting interactions with patients who have clinically significant results, which include documenting in the patient’s health record each attempt to contact and recall patients with clinically significant results
  • has a process to follow-up results and investigations when they have not been provided to the GP
  • has a process for the initiation, management and documentation of patient reminders
  • educates members of the practice team so they can inform patients about the practice’s processes for receiving and advising results.

Members of the clinical team:

  • ensure that pathology results, imaging reports, investigation reports and clinical correspondence received are:
    • reviewed
    • electronically notated, or, if on paper, signed or initialled
    • acted on where required
    • incorporated into the patient health record.
CG6.BThe practice has a system to manage high-risk (seriously abnormal and life- threatening) results identified outside normal opening hours.

What the standard says

The practice:

  • has a policy that outlines the process for the practice’s management for high-risk results identified outside of normal opening hours
  • provides its main diagnostic services with the contact details of the practitioner responsible for results outside normal opening hours, such as the practitioner who ordered the investigation or delegated practitioner or after-hours service.
Why it matters

Missed results cause harm and are a leading source of medico-legal claims. Reminders improve preventive care uptake, such as cancer screening.

How to meet it — practical ideas
  • Allocate clear responsibility for the inbox and cover when the requesting GP is away (buddy system, remote access).
  • Write a recall policy: who does what, how patients are contacted, how many attempts (e.g. three calls at different times then a letter/SMS), what language reception may use, what happens if the patient doesn't respond or attends for something unrelated.
  • For at-risk patients, verify the safest contact channel and keep messages non-specific if others may see them.
  • Automate reminders from the clinical software with templates; publish the reminder process on the website.
  • Give pathology and imaging providers an after-hours number that will actually be answered (the GP, a delegate or the deputising service) and brief deputising doctors on what to do and to inform the practice next day.
CG7

Managing clinical risks and incidents

What patients expectI expect that clinical risks are properly reported, investigated and documented, and that improvements are made to reduce risk.

In plain English

Maintain a documented clinical risk management process and a clinical risk register, report risks and lessons to leadership, and distribute public health alerts to the right people promptly. Keep an incident/near-miss register, tell staff how and to whom to report without fear of blame, investigate causes, and implement and share improvements.

The criteria

CG7.AThe practice has a clinical risk management system that identifies, monitors, mitigates and evaluates clinical risks in the practice.

What the standard says

The practice:

  • has a documented process for clinical risk management
  • develops procedures to mitigate clinical risks
  • maintains a clinical risk register
  • reports results of risk identification, management and mitigation, including lessons learnt, to the practice’s leadership
  • has appropriate systems in place to receive and share relevant public health notifications to relevant members of the practice team in a timely manner.
CG7.BThe practice monitors, identifies, responds to, reports on, and improves its processes related to significant clinical incidents and near misses, including patient safety incidents.

What the standard says

The practice:

  • maintains a clinical incident or event register
  • informs members of the practice team how and to whom to report a near miss or significant clinical incident, and that they can do so without fear of recrimination
  • investigates and analyses the causes of near misses and significant clinical incidents to reduce the likelihood of recurrence
  • implements improvements when learning from significant clinical incidents and near misses including recording, reporting and sharing actions and learnings.
Why it matters

A risk register lets you act before harm occurs; analysing incidents and near misses stops them recurring. A 'just culture' encourages people to speak up.

How to meet it — practical ideas
  • A spreadsheet risk register with a simple likelihood × severity matrix (low/moderate/high/extreme) is enough.
  • Make risk a standing agenda item at clinical meetings; use PDSA cycles and audits to address register items.
  • Have your MDO check the incident recording/response process.
  • Include AI-related incidents (wrong outputs, outages, privacy breaches, changed behaviour after updates) and coordinate with vendors.
  • Share learnings — including 'good catches' where a system prevented harm.
CG8

Immunisations

What patients expectI expect members of this practice team to be immunised according to guidelines to reduce risk to the health of the team and consumers.

In plain English

Encourage staff to be immunised as recommended in the Australian Immunisation Handbook for their duties; record their immunity/immunisation status (with consent) and offer the vaccines.

The criteria

CG8.AOur practice team is encouraged to obtain immunisations recommended by the current edition of the Australian immunisation handbook based on their duties and immunisation status.

What the standard says

The practice:

  • records the natural immunity to vaccine-preventable diseases or immunisation status of practice team members if known (with their consent)
  • offers staff members immunisations recommended in the Australian immunisation handbook, as appropriate to their duties.
Why it matters

Protects staff and patients from vaccine-preventable disease and helps meet state/territory requirements.

How to meet it — practical ideas
  • Do a role-based risk assessment of which vaccines each team member needs.
  • Offer serology or vaccination at the practice or via their own GP, ideally before or soon after starting.
  • Document staff who can't be vaccinated so they can be reassigned in an outbreak; seek legal advice if someone declines mandated vaccines.
CG9

Infection prevention and control, including reprocessing

What patients expectreprocessing I expect that this practice uses current evidence-based Australian systems to protect me from infections.

In plain English

Have a written, practice-specific infection prevention and control (IPC) policy based on current Australian guidelines (the RACGP IPC Guidelines are recommended), communicated to patients and followed by all staff. Appoint a clinical team member as IPC coordinator with the role in their job description. Everyone applies standard and transmission-based precautions, has PPE, and manages sharps and clinical waste safely. Patients are told about respiratory hygiene and have hand sanitiser, tissues, masks (if symptomatic) and soap and water. If you reprocess reusable devices, follow the RACGP guidelines (or equivalent Australian standard) with a documented risk assessment, and trace sterilisation load numbers to patients.

The criteria

CG9.AThe practice has a written, practice-specific policy that outlines its infection control processes.

What the standard says

The practice:

  • maintains an up-to-date practice-specific infection control policy that is based on current, evidence-based Australian guidelines and standards (specific requirements are outlined in the criteria guidance )
  • communicates the policy with patients
  • ensures all members of the practice team are aware of and implement the policy.
CG9.BThe practice has at least one member of the clinical team with the roles and responsibilities of infection prevention and control coordinator.

What the standard says

The practice:

  • has at least one member of the clinical team who has primary responsibility for infection control and the use of sterile equipment (their responsibilities are outlined in the Infection prevention and control guidelines )
  • documents the responsibilities of the practice’s infection prevention and control coordinator in their job description
  • ensures all members of the practice team are aware of who is the practice’s infection prevention and control coordinator and their responsibilities.
CG9.CAll members of the practice team manage risks of cross-infection in the practice in line with current, evidence-based Australian guidelines and standards.

What the standard says

The practice:

  • manages risk of cross-infection in the practice team, in line with current, evidence- based Australian guidelines and standards (the practice team’s responsibilities are outlined in the criteria guidance )
  • ensures the practice team understands all aspects of standard and transmission- based precautions, in line with current, evidence-based Australian guidelines and standards
  • ensures the practice team has access to personal protective equipment (PPE)
  • safely stores and disposes of sharps and clinical waste.
CG9.DThe practice’s patients are informed about appropriate precautionary techniques to prevent the transmission of communicable diseases.

What the standard says

The practice:

  • informs patients about appropriate techniques to prevent the transmission of communicable diseases, including respiratory hygiene
  • provides patients with access to alcohol-based hand sanitiser and tissues
  • provides patients who have respiratory symptoms with access to masks
  • provides patients with access to soap and water after using the toilet.
CG9.EIf the practice reprocesses reusable medical devices, it does so in accordance with the RACGP’s Infection prevention and control guidelines or another model that meets the current Australian standard.

What the standard says

The practice:

  • includes in the practice-specific infection control policy details of risk assessment for reprocessing reusable medical devices
  • reprocesses reusable medical devices in accordance with the RACGP’s Infection prevention and control guidelines or another model that meets the current Australian standard.
CG9.FThe practice ensures that the record of sterilisation load numbers from the sterile barrier system can be traced to relevant patients.

What the standard says

The practice:

  • has a process to record sterilisation load numbers for each patient when sterile items have been used.
Why it matters

Reduces infection transmission between patients and staff; Australian evidence-based guidelines keep practice current.

How to meet it — practical ideas
  • Policy must cover: IPC coordinator role, standard and transmission-based precautions, sharps injuries, blood/body fluid spills, hand hygiene, environmental cleaning, aseptic technique, reprocessing (on- or off-site, with monitoring/validation evidence), occupational exposure, waste, PPE access, PPE education, managing potentially infectious patients. Review every 2 years.
  • Audit IPC practice (observation, cleaning, equipment), seek feedback, add an 'IPC moment' to meetings.
  • Educate staff at induction and ongoing; record competency.
  • Use triage, spacing, isolation rooms, telehealth for respiratory illness, home visits for the vulnerable.
  • Communicate to patients via signage, website, booking alerts, voicemail and social media.
  • Outreach/no-premises practices remain responsible for IPC at the sites they visit.
CG10

Practice environment

What patients expectI expect that this practice provides my care in an environment that is clean, hygienic and ensures privacy.

In plain English

The environment supports safe care: visual and auditory privacy in consults, solid consulting-room doors and privacy screening around couches, a policy on privacy if you have no physical premises, space for distressed patients/carers, a waiting area sized for usual demand, a cleaning policy aligned with RACGP IPC guidelines, and timely access to toilets with sink, liquid soap, hand drying, bins, sanitary disposal, a change table or private changing spot, and ventilation.

The criteria

CG10.AThe practice environment accommodates the provision of safe, quality care.

What the standard says

The practice:

  • ensures the practice environment maintains auditory and visual privacy during patient consultations
  • ensures that consultation rooms have solid doors and provides adequate privacy screening around the examination couch/bed
  • has a policy that describes the process for optimising patient privacy during consultations, if the practice does not have a physical practice environment
  • has space that accommodates patients and caregivers in distress
  • has a waiting area that accommodates the usual number of patients and other people who would be waiting at any given time, if the practice has a physical practice environment
  • has a cleaning policy aligned with the RACGP’s Infection prevention and control guidelines or another relevant Australian standard
  • ensures the practice team and patients have timely access to toilets, that have:
    • hand washing and drying facilities, including a sink and liquid hand soap
    • rubbish bins
    • sanitary bins or hygienic means to dispose of sanitary items
    • a change table or private changing location
    • exhaust fan/s or natural ventilation.
Why it matters

A clean, private environment protects dignity, confidentiality and safety for patients and staff.

How to meet it — practical ideas
  • Gowns/sheets and curtains in every consulting space; door seals and background music to mask conversations; a private room available for confidential talks if treatment bays aren't private.
  • Screens hidden from public view; reception layout with clear sight of waiting area.
  • Cleaning policy covers responsibilities, WHS, scheduled and unscheduled cleaning and how effectiveness is monitored.
  • Consider ventilation: natural airflow, HEPA filtration, professional advice on building design.
  • Telehealth also needs physical, audio and visual privacy.
  • No physical premises? Show how privacy is protected (screens, in-home protocols) and how hand hygiene and toilet-dependent tests are handled.
CG11

Practice equipment

What patients expectI expect this practice has and maintains the equipment and medicines to provide the care I need, and the clinical team can use them safely.

In plain English

Have all required equipment for comprehensive primary care, emergency care and resuscitation (including a stocked doctor's bag), maintained, calibrated annually, stored per manufacturer instructions, accessible and working. Document equipment training for clinicians. Have timely access to a spirometer. Acquire, store, administer, supply and dispose of medicines, samples and consumables according to manufacturer directions and the law.

The criteria

CG11.AThe practice has equipment that enables the provision of comprehensive primary care, emergency care and resuscitation.

What the standard says

The practice:

  • has all required equipment (see the RACGP’s required practice equipment list and doctor’s bag list on the CG11 web page), ensuring each item is maintained, calibrated annually, and stored according to manufacturer’s instructions, easily accessible and in working order at all times.
CG11.BMembers of the clinical team can use the practice’s clinical equipment safely and effectively.

What the standard says

The practice:

  • documents that members of the clinical team have been provided with education on the safe use of the practice’s clinical equipment that is relevant to their role.
CG11.CThe practice has timely access to a spirometer.

What the standard says

No further indicators — the criterion statement is the requirement.

CG11.DThe practice ensures that medicines, samples and medical consumables are acquired, stored, administered, supplied and disposed of in accordance with manufacturers’ directions and relevant laws.

What the standard says

The practice:

  • acquires, stores, administers, supplies and disposes of medicines, samples and medical consumables according to manufacturers’ directions and relevant laws.
Why it matters

Working, well-maintained equipment enables safe comprehensive and emergency care; the doctor's bag lets GPs respond off-site.

How to meet it — practical ideas
  • Keep an equipment register and room checklists with cleaning, servicing and calibration dates; keep external calibration certificates.
  • Annual service for anything electrical, battery-powered, calibrated or with expiring consumables: ECG, spirometer, autoclave, vaccine fridge, scales, defibrillator.
  • Height-adjustable bed in every practice with premises: ideally 45–95 cm range, 175 kg capacity, 71 cm wide, 193 cm long, two sections.
  • Audit the doctor's bag regularly; use the PBS emergency drug list and store it per S4/S8 law.
  • Consider bariatric equipment and mobility aids for your population.
  • Record equipment training at induction and when new equipment arrives; keep a refresher calendar.
  • Spirometer: on-site strongly encouraged; otherwise a local provider offering timely testing.
  • Rotate consumables by expiry, audit expiry dates, appoint someone responsible; return unwanted medicines via a pharmacy.
  • The full required equipment and doctor's bag lists are on the RACGP CG11 web page (expandable lists that were not included in the PDF export).
CG12

Maintaining vaccine potency

What patients expectI expect that this practice stores and delivers vaccines safely and effectively in line with current guidelines.

In plain English

Have a written cold chain policy based on the current 'Strive for 5' guidelines, communicated to patients and staff and followed by everyone, with records of all fridge temperature monitoring. Appoint a trained cold chain lead, tell the team who it is, and have a delegate when they're away.

The criteria

CG12.AThe practice has a written, practice-specific policy that outlines its cold chain processes.

What the standard says

The practice:

  • maintains a cold chain management policy and procedure that is:
    • based on the current edition of the National vaccine storage guidelines: Strive for 5
    • communicated to patients and members of the practice team
    • implemented by all members of the practice team
  • has a record of all monitoring of vaccine refrigerators, including the temperature.
CG12.BThe practice has at least one member of the practice team who has primary responsibility for cold chain management in the practice.

What the standard says

The practice:

  • has a member of the practice with primary responsibility for cold chain management, which includes ensuring the practice complies with the current edition of the National vaccine storage guidelines: Strive for 5
  • ensures the responsible member of the practice team has had appropriate training in cold chain management and understands their role
  • informs members of the practice team who is responsible for cold chain management
  • has a process to delegate cold chain management when the member of the practice team with primary responsibility is unavailable.
Why it matters

Vaccines only work if kept within the recommended temperature range from delivery to administration.

How to meet it — practical ideas
  • Use a monitoring template and a roster; keep data-logger/min-max records.
  • Cover cold chain in induction and ongoing training; audit vaccine storage against Strive for 5.
  • Subscribe to state/territory cold chain alerts; review the policy every 2 years.
  • Tell patients in plain, reassuring language (waiting room sign, website, consent forms) that vaccines are stored to national guidelines.
CG13

Research

What patients expectI expect that this practice asks for my consent for research, gives me the choice to opt out, and ensures all ethics and approvals are in place.

In plain English

Any research involving your patients has Human Research Ethics Committee approval, records, protocol compliance and an agreement with the research institution. Confirm indemnity that matches the risk level. Share identifiable information for research only with patient consent (documented) or when the law requires; tell patients declining won't affect their care; cover research in the privacy policy. Share de-identified data only under a formal data-sharing agreement, with best-practice data management, patient information and an opt-out.

The criteria

CG13.AAny research the practice and/or practice team participates in has been approved by an appropriate Human Research Ethics Committee.

What the standard says

For any research that involves patients of the practice, the practice:

  • keeps evidence of ethics approval for research activities
  • maintains records of any research activity conducted at the practice
  • complies with the research protocol
  • provides evidence of an agreement between the practice and the research institution.
CG13.BIf the practice conducts research, it confirms that the appropriate indemnity is in place for research, based on the level of risk.

What the standard says

The practice:

  • maintains records of appropriate indemnity for the practice and GPs based on research activity level of risk.
CG13.CThe practice only shares identifiable patient health information for research purposes to a third party with patient consent or if required by legislation.

What the standard says

The practice:

  • documents in the patient’s health record the patient’s consent for the practice to transfer their health information to a third party to conduct research
  • informs patients that declining to participate in research will not affect the care they receive at the practice
  • allows patients to refuse consent for identifiable data provision to a third-party
  • specifies in the privacy policy how patient health information is used in research.
CG13.DThe practice only shares deidentified patient health information for research purposes to a third party in accordance with its legal obligations and ethical responsibilities.

What the standard says

The practice:

  • enters into a formal data sharing agreement or contract with external parties who intend to use its deidentified general practice data for research or other secondary purposes
  • ensures all parties demonstrate compliance with data management best practice
  • provides information on secondary use to patients
  • provides patients an opportunity to opt out of providing data for secondary uses.
Why it matters

General practice research builds the evidence base, but it must be ethical, lawful and properly insured.

How to meet it — practical ideas
  • Follow the NHMRC Australian Code for the Responsible Conduct of Research and the AIATSIS Code where relevant.
  • Check that your and each GP's indemnity covers the research; for clinical trials confirm the sponsor's indemnity covers the practice.
  • Use the RACGP 'Three key principles for secondary use of general practice data' when drafting data-sharing agreements.
  • Explain data use and opt-out on registration forms, the website and posters; separate identifiers from clinical data before any linkage.

Standard

Patient participation

Putting patients at the centre: practice information, communication, cultural safety, consent, accessibility, prevention, complaints, feedback, triage and after-hours care.

10 criteria sets · 17 criteria

PP1

Information about the practice

What patients expectI expect that practice information is easy for me to access and understand and provided at the time I need it.

In plain English

Patients can easily find current information about the practice: address and phone, hours and after-hours arrangements, appointment types, billing principles, the clinical team, communication policy (how calls/emails are handled), privacy policy, recall/reminder policy, how to give feedback or complain, and services offered. Provide it promptly, accessibly, in simple language, keep it updated, and tell patients about out-of-pocket costs.

The criteria

PP1.AConsumers can access up-to-date information they need about the practice.

What the standard says

The practice:

  • makes practice information available to consumers. This includes, at a minimum, the following information:
    • the practice’s address and telephone numbers
    • consulting hours and details of arrangements for care outside normal opening hours
    • appointment types
    • the practice’s billing principles
    • a list of the clinical team
    • the practice’s communication policy, including when and how it receives and returns telephone calls and electronic communications
    • the practice’s policy for managing patient health information (or its principles and how full details can be obtained from the practice)
    • the practice’s policy for recalls and reminders
    • how to provide feedback or make a complaint to the practice
    • details on the range of services the practice provides
  • provides practice information:
    • in a timely manner
    • in formats that are accessible to consumers
    • in simple language that consumers understand
  • updates practice information when there are any changes
  • informs patients about out-of-pocket costs for healthcare they receive from the practice.
Why it matters

Patients need accurate, current, understandable information — including costs — to use the practice safely.

How to meet it — practical ideas
  • Website, QR codes, social media, printed sheets, translated versions for your community, pictures/Easy Read versions.
  • Explain in-person vs telehealth availability and appointment lengths before booking.
  • Display billing information in the waiting room and on the website, and explain it in person.
  • Ask patients what information they need through feedback and social media.
PP2

Communications

What patients expectI expect that this practice coordinates its communication with me so that I can access and understand the information I receive to support and enhance my care.

In plain English

Communicate with patients in ways that support timely, effective care: interpreters when needed, information in a format and language patients understand, clear guidance on which phone numbers/emails to use, how long a response takes and that email is not for emergencies, and internal procedures for how messages are passed on, recorded, delivered when someone is absent and answered promptly. Every communication system tells people to call 000 in an emergency. Digital communications and social media are used in ways that enhance care.

The criteria

PP2.AMembers of the practice team communicate with consumers in a manner that supports timely and effective care/partnerships.

What the standard says

The practice:

  • facilitates communication between the practice team and consumers that supports timely and effective care/partnerships
  • facilitates the use of interpreters when consumers do not speak the primary language of the practice team
  • provides information in a format and language that is understood by the consumer
  • informs the consumer about the forms of communication it allows such as telephone and electronic communication including email, and advises the consumer:
    • of specific phone numbers and email address(es) they can use
    • of how long they can expect to wait for a response
    • that they should not use email to contact the practice in an emergency
  • has procedures to manage:
    • how messages are communicated by the practice team – internal electronic messaging systems are preferable
    • how communication with the patient is recorded in the clinical information system
    • how a message is given to the intended person and what to do if the intended recipient is absent
    • how the practice team can respond to messages in a timely manner.
PP2.BThe practice communication systems advise consumers to call 000 in case of an emergency.

What the standard says

The practice:

  • has all practice communication systems inform consumers to call 000 if they have an emergency
  • directs consumers who have called the practice to call 000 in the event of an emergency.
PP2.CThe practice uses digital communication systems to enhance patient care.

What the standard says

No further indicators — the criterion statement is the requirement.

PP2.DIf the practice uses social media, it does so in a way that enhances patient care.

What the standard says

No further indicators — the criterion statement is the requirement.

Why it matters

Good communication underpins safe care and patient partnership; patients must know what to do in an emergency.

How to meet it — practical ideas
  • Reception asks 'Is this an emergency?' before putting anyone on hold; on-hold messages, voicemail, website and email auto-replies all say 'call 000'.
  • Use TIS National (free for Medicare-eligible services) and the National Relay Service; offer interpreters to Aboriginal and Torres Strait Islander patients; record if an interpreter is declined.
  • Speak directly to the patient even with a support person; use AAC-friendly approaches, apps, audio and Easy Read.
  • Avoid personal questions at the front desk; move sensitive conversations to a private space.
  • Publish digital communications and social media policies; set auto-responses stating expected reply times.
PP3

Respectful, culturally appropriate and culturally safe care

What patients expectsafe care I expect to be treated in a respectful way that considers my cultural background and individual choices.

In plain English

Respect every patient's rights, diversity and individuality, tell patients their rights and responsibilities, provide culturally safe care for Aboriginal and Torres Strait Islander patients, and provide respectful, person-centred care for all.

The criteria

PP3.AThe practice recognises and respects the rights, diversity and individuality of all patients.

What the standard says

The practice:

  • considers and respects patients’ rights
  • informs patients of their rights and responsibilities
  • facilitates culturally safe care for Aboriginal and Torres Strait Islander patients
  • recognises diversity within the patient population and provides respectful and person-centred care.
Why it matters

Care must be free of bias and racism. For Aboriginal and Torres Strait Islander peoples, cultural safety is judged by the patient and is inseparable from clinical safety.

How to meet it — practical ideas
  • Cultural safety training (recorded in the training register), a cultural safety policy, feedback from Aboriginal and Torres Strait Islander patients and Elders, Acknowledgement of Country signage, flags/art, culturally appropriate resources, participation in significant dates.
  • Anti-discrimination policy; patient rights and responsibilities policy (RACGP General Practice Patient Charter / Australian Charter of Healthcare Rights posters).
  • Ask respectfully about cultural identity and beliefs and record them; consider clinician gender preference, role of family, trauma history.
  • LGBTQIA+ inclusive practice: team discussion of needs, visible symbols, gender-neutral toilets.
  • Trauma-informed, non-judgemental communication; respect a patient's choice not to proceed.
PP4

Informed consent

What patients expectI expect that the risks, benefits and alternatives of treatment are explained to me in a way I can understand and then choose to consent to or reject. I expect that this practice asks for my consent when an additional person is introduced into a consultation.

In plain English

Have processes for clinicians to obtain and document informed consent for procedures and treatments, and to document consent to any third party the practice arranges (students, registrars, chaperones, interpreters) — asked before the consultation, not in the room.

The criteria

PP4.AThe practice has processes to obtain and document informed consent for clinical procedures and treatments.

What the standard says

The practice:

  • provides processes for clinicians to obtain informed consent for clinical procedures and treatments.
PP4.BThe practice has processes to obtain and document informed consent for when a third-party is present.

What the standard says

The practice:

  • facilitates the documentation of the patient’s consent to the presence of a third party arranged by the practice.
Why it matters

Patients can only decide with enough information; consent to a third party protects confidentiality and prevents pressure.

How to meet it — practical ideas
  • Valid consent is free, from someone with capacity, and specific to the procedure. Seek express consent for anything with significant risk and document the information given, the discussion (risks, harms, side effects) and the response.
  • Identify substitute decision-makers in the record where a patient lacks capacity.
  • Waiting-room signs when students are present; re-check earlier consent at each visit; record the third party's role or initials.
  • Put third-party consent in the policy manual and induction.
PP5

Accessibility of services

What patients expectI expect that I can access services that meet my needs, regardless of my abilities.

In plain English

All patients, including those with disability or impairment, can access the practice and its services with dignity.

The criteria

PP5.AAll of the practice’s patients, including those with disability, can access services from the practice.

What the standard says

The practice:

  • has infrastructure and processes that enable patients with disabilities or impairment to access its services.
Why it matters

Required under the Disability Discrimination Act, and it's the right thing to do.

How to meet it — practical ideas
  • Wheelchair-friendly paths, hallways, rooms and toilets; ramps and rails; a wheelchair available; clear signage and pictures.
  • Telehealth, home visits, transport options, flexible or quieter appointment times, alternative entry for patients with safety concerns.
  • Don't disadvantage patients who don't use digital technology.
  • Tell patients where the nearest accessible parking is.
PP6

Health promotion and preventive care

What patients expectI expect that this practice provides me with preventive health information and information on all issues relevant to my healthcare. I expect that this practice provides me with information about my health, treatment and care choices in a way l can understand to make decisions that are right for me.

In plain English

Provide information on preventive care, illness prevention and health promotion, and document preventive discussions in the record. Share information with patients about environmental issues relevant to their care.

The criteria

PP6.AThe practice provides patients with relevant information about preventive care, illness prevention and health promotion.

What the standard says

The practice:

  • provides information about preventive care, illness prevention and health promotion.

Members of the clinical team:

  • document in the patient’s health record discussions or activities relating to preventive care, illness prevention and health promotion.
PP6.BThe practice shares information with patients about environmental issues relevant to the healthcare they receive.

What the standard says

No further indicators — the criterion statement is the requirement.

Why it matters

Much illness can be prevented or reduced; health literacy lets patients act on information. Environmental information helps patients protect their health and the planet.

How to meet it — practical ideas
  • Tailor material to your population: screening programs, chronic disease, immunisation, culturally specific resources, discreet FDSV help information (e.g. in toilets).
  • Assume most people find health information hard; use plain words, teach-back, multiple formats, and give links.
  • Environmental: returning unused medicines to pharmacies, heat and smoke advice, RACGP climate-and-health posters.
PP7

Open disclosure and complaints

What patients expectI expect that this practice manages and responds openly to complaints in a timely manner.

In plain English

Apply the Australian Open Disclosure Framework when things go wrong, and manage complaints: acknowledge each complaint promptly, keep a complaints process and register, and tell patients how to escalate to the health complaints commissioner.

The criteria

PP7.AThe practice applies the Australian Open Disclosure Framework.

What the standard says

No further indicators — the criterion statement is the requirement.

PP7.BThe practice uses a complaints management process to respond to complaints in a timely way.

What the standard says

The practice:

  • acknowledges receipt of each complaint to the complainant in a reasonable time
  • maintains:
    • a complaints management process
    • a complaints register
    • practice information for consumers on how to escalate a complaint to the relevant complaints commissioner.
Why it matters

Honest disclosure after adverse events shows compassion and keeps trust; patients must be able to raise concerns.

How to meet it — practical ideas
  • Open disclosure policy: explain what happened, apologise where warranted, explain what's been changed; record it in the patient record; train at induction and team meetings; involve the MDO.
  • Complaints: a named person responsible, acknowledge receipt, keep the complainant informed of progress and outcome, review complaints at meetings, feed learnings into CQI, and publish how to escalate (state complaints commission).
PP8

Engaging consumers

What patients expectI expect that this practice engages consumers in a proactive, ongoing and meaningful way to gain feedback on their experiences, and uses these insights to improve care.

In plain English

Engage patients formally and informally to monitor, review and improve care, and tell them what you changed because of their feedback.

The criteria

PP8.AThe practice engages with consumers to monitor, review and improve care.

What the standard says

The practice:

  • engages with consumers to improve care using formal and informal engagement
  • informs consumers about how it has responded to feedback and used feedback to improve care.
Why it matters

Consumer engagement is linked to better clinical effectiveness, safety, medication adherence and screening uptake.

How to meet it — practical ideas
  • Formal: PREMs/PROMs surveys, focus groups, patient journey mapping, follow-up calls, yarning circles, consumer advisory group, a consumer on the QI committee.
  • Informal: suggestion box, real-time feedback tools, social media, website comments.
  • Analyse feedback, prioritise with the team, build an action plan, and close the loop with posters, website or newsletter — including explaining when a change isn't feasible.
PP9

Responsive system for patient care

What patients expectI expect that this practice provides a variety of appointment types based on my current healthcare need.

In plain English

Triage patients by urgency, with a clinical team member responsible for training staff to spot urgent needs, reprioritise in emergencies, get urgent clinical help, and manage urgent patients when fully booked. Offer a range of consultation types and tell patients how to get care when they can't attend in person.

The criteria

PP9.AThe practice has a triage system for prioritising patient care.

What the standard says

The practice:

  • prioritises patients according to their urgency of need
  • has a member of the clinical team who has primary responsibility for training the practice team in triage, including how to:
    • identify patients with an urgent medical need
    • identify emergency events and reprioritise appointments accordingly
    • seek urgent medical assistance from an appropriate member of the clinical team
    • manage patients with urgent medical needs when the practice is fully booked.
PP9.BPatients can access different consultation types to accommodate their needs.

What the standard says

The practice:

  • provides a variety of consultation types
  • provides information to patients about how they can access care when they are unable to attend in person.
Why it matters

Patients must reach the right clinician at the right level of care in the right time.

How to meet it — practical ideas
  • Triage guidelines/flowchart at reception; waiting-room sign asking patients with worsening symptoms to tell reception; update the waiting list after emergencies and explain delays.
  • Train staff in privacy-aware communication when patients raise safety concerns.
  • Offer short/long consults, walk-in or appointment, telehealth, home visits, after-hours pathways, GP advice lines.
PP10

Care when the practice is not open

What patients expectI expect to find information about alternative ways to access care when this practice is closed.

In plain English

Tell patients how to get real-time (synchronous) care from AHPRA-registered doctors or nurses when the practice is closed — including after hours and temporary closures.

The criteria

PP10.AConsumers are informed how to access synchronous care that is provided by clinicians who meet Australian health professional obligations when the practice is not open.

What the standard says

No further indicators — the criterion statement is the requirement.

Why it matters

Patients need appropriate care when you're closed, and this eases pressure on emergency departments.

How to meet it — practical ideas
  • After-hours phone message, website, email signatures, social media, a visible sign at the door, plus crisis helpline information.
  • If you use a deputising or telehealth provider, have a written agreement covering documentation flow, emergency contact, quality and privacy, triage/escalation, and how patients needing in-person care are seen.
  • Healthdirect and Medicare Urgent Care Clinics are acceptable options to signpost.
  • Consider a separate procedure for holiday closures and staff absences.

Standard

Continuous quality improvement

Measuring, reviewing and improving services and environmental performance in ongoing cycles.

1 criteria sets · 3 criteria

CQI1

Continuous quality improvement activities

What patients expectI expect that this practice continuously monitors the services and care provided and makes improvements to enhance patient care.

In plain English

Train the person(s) responsible for quality improvement, have a system to identify QI activities, complete at least one QI activity every 12 months (one using coded clinical data), record team feedback, document improvements made from feedback, complaints or audits, and report performance and QI to leadership. Assess and act on environmental performance against your sustainability strategies. Aspirational: measure environmental-impact metrics.

The criteria

CQI1.AThe practice team undertakes continuous quality improvement activities.

What the standard says

The practice:

  • trains member/s of the practice team who have the primary responsibility for quality improvement activities in the practice about their role
  • has a system to identify quality improvement activities
  • undertakes at least one quality improvement activity every 12 months, one of which includes the use of coded clinical data
  • keeps a record of feedback from the practice team about quality improvement systems
  • documents quality improvements made to the practice or practice systems in response to feedback, complaints, or audits
  • has processes to report performance data and quality improvement activities to the practice’s leadership.
CQI1.BThe practice assesses and acts on its environmental performance to track progress toward sustainability goals and compliance with its documented strategies to reduce direct and indirect carbon greenhouse gas emissions.

What the standard says

The practice:

  • assesses progress toward sustainability goals and compliance and reports it to the practice’s leadership
  • implements actions based on the practice’s assessment that reduce direct and indirect carbon greenhouse gas emissions.
CQI1.CThe practice measures environmental-impact metrics to assess and manage its overall environmental footprint. Aspirational

What the standard says

The practice:

  • assesses and manages its overall environmental footprint.
Why it matters

Continuous cycles of measurement and change improve safety and care. Environmental improvements reduce pollutant exposure and build resilience.

How to meet it — practical ideas
  • Put QI responsibilities in a position description; make QI a standing agenda item; keep notes.
  • Pick performance indicators (PIP QI measures are a ready-made set) and keep them for a whole accreditation cycle to see trends.
  • Coded-data activities: immunisation rates, chronic disease/preventive care, smoking/alcohol/activity recording, antibiotic use. GPs can claim CPD for these.
  • Report to leadership verbally or with short summaries — formal reports are not required. Publish some results publicly (waiting room, website).
  • Environmental: agree measures (energy, waste, recycling, water), set targets, review actions; use existing building data rather than new meters.

Standard

Point-of-care testing (optional)

An optional standard for practices doing point-of-care pathology testing: purpose, responsibility, training, facilities, performance, data, quality control and external quality assurance.

8 criteria sets · 18 criteria

PoCT1

Clinical purpose

What patients expectI expect that this practice follows evidence-based processes to ensure my safety when suggesting and performing point of care testing.

In plain English

Be able to explain, with evidence, why you use each point-of-care test, set the analytical performance you need for that purpose, verify performance at commissioning and after major repairs, use evidence-based reference intervals/decision limits and review them, record and review adverse and non-conformance events, and be able to keep caring for patients if PoCT is unavailable.

The criteria

PoCT1.AThe practice team can describe the clinical and diagnostic purposes of PoCT based on best practice evidence, and how it can be applied.

What the standard says

The practice:

  • describes the clinical and diagnostic purposes for using PoCT
  • ensures the clinical and diagnostic purposes of PoCT are evidence-based.
PoCT1.BThe practice’s specifications for the analytical performance of PoCT are determined by the relevant clinical and diagnostic purposes.

What the standard says

The practice:

  • provides evidence that the analytical performance specifications of each test method are based on the clinical and diagnostic purposes for which they will be used
  • demonstrates that the analytical performance of each test method has been evaluated upon commissioning and following major repairs.
PoCT1.CThe practice team uses reference data that is based on best practice evidence and is regularly reviewed to interpret test results.

What the standard says

The practice:

  • demonstrates that it uses reference intervals and/or clinical decision limits for interpreting PoCT results
  • demonstrates reference intervals and/or clinical decision limits are evidence- based.
PoCT1.DThe practice team uses processes that minimise the risk to patients and improve the quality of PoCT.

What the standard says

The practice:

  • records and addresses adverse and non-conformance events
  • documents how it is reviewing adverse and non-conformance events, and documents the outcome of the review
  • demonstrates that the practice can maintain continuity of care if PoCT is not available.
Why it matters

PoCT enables immediate decisions, but only if the test is fit for its purpose and interpreted correctly.

How to meet it — practical ideas
  • Evaluate devices on Selection, Verification and Quality (calibration, QC, EQA) before use; use supplier, pathology and professional-body evidence — you don't need to generate your own.
  • Agree reference intervals, including for children and pregnancy, and document them.
  • Log adverse/non-conformance events, review them at meetings, report device issues to the TGA.
  • Write down what you'll do (e.g. send to pathology) if PoCT is down.
PoCT2

Clinical responsibility

What patients expectI expect that this practice takes responsibility for safe and quality delivery of point of care testing.

In plain English

One clinical team member has overall responsibility for PoCT implementation, quality and accreditation; a competent clinician is on duty and responsible whenever PoCT is used.

The criteria

PoCT2.AThe practice has at least one member of the clinical team who has primary responsibility for the quality of PoCT.

What the standard says

The practice:

  • has at least one member of the clinical team who has overall primary responsibility for the implementation, conduct, quality and accreditation of PoCT within the practice
  • has at least one member of the clinical team on duty when PoCT is being used who accepts the responsibility of running PoCT within the practice
  • demonstrates that the responsible member of the clinical team is competent in using PoCT.
Why it matters

PoCT needs skills, knowledge and oversight; clear responsibility keeps results uniformly reliable.

How to meet it — practical ideas
  • The lead understands PoCT applications and limits, these standards and your policies, and can prove competence via training records.
  • Day-to-day duties can be delegated to trained PoCT practitioners; keep a clinical governance policy and standing orders for nurses.
PoCT3

Qualifications, education and training of PoCT practitioners

What patients expectpractitioners I expect that practitioners at this practice understand their role and have up-to-date training to perform point of care testing.

In plain English

Everyone who performs PoCT is trained, demonstrates competency, receives regular updates, and is retrained when methods change, new tests/instruments arrive or CQI finds problems.

The criteria

PoCT3.AMembers of the practice team who perform PoCT:

What the standard says

  • have successfully undertaken training
  • participate in training and education updates.

The practice:

  • provides evidence that PoCT practitioners can demonstrate competency in PoCT
  • provides evidence that PoCT practitioners receive regular training and education updates
  • provides evidence that all PoCT practitioners receive training updates when:
    • significant changes to method(s) are introduced
    • new tests and/or instruments are introduced
    • CQI mechanisms identify issues.
Why it matters

Untrained operators cause pre-analytical, analytical and post-analytical errors that undermine clinical decisions.

How to meet it — practical ideas
  • Training covers policies, clinical purposes, device principles, malfunction handling, consumable storage, patient preparation, specimen handling and labelling, recognising abnormal/urgent/erroneous results, documentation, QC and EQA.
  • Keep qualifications in staff files, a training calendar, a training-needs record and annual performance reviews; assess competency in all PoCT duties.
PoCT4

Facilities for testing

What patients expectI expect that this practice provides point of care testing in an environment that is clean, private, and uses equipment and consumables in line with manufacturer’s guidelines.

In plain English

Testing happens in a safe area with visual and auditory privacy; the area has suitable space, lighting, power, security and temperature; consumables are logged, in date, stored per manufacturer (with min–max thermometer records if temperature-sensitive) and disposed of lawfully; there is a contingency plan for equipment failure.

The criteria

PoCT4.AThe practice conducts testing in a safe environment that ensures patient privacy.

What the standard says

The practice:

  • demonstrates that specimen collection and testing and result communication is performed in a safe area where patients’ visual and auditory privacy is ensured.
PoCT4.BThe practice ensures that instruments and consumables are located and managed to optimise performance.

What the standard says

The practice:

  • has a testing area that has appropriate space, lighting, power, security and ambient temperature for sample/specimen handling, testing and documenting
  • maintains records of consumables
  • stores the required quantity of within-date consumables as per the manufacturers’ instructions
  • disposes of used and expired consumables in accordance with local, state and federal requirements
  • where temperature-sensitive consumables are stored as per the manufacturers’ instructions, uses a minimum–maximum thermometer to monitor temperature, and keeps records of that monitoring
  • has a documented contingency plan for continued operations in the event of equipment and other failures.
Why it matters

Proper handling of instruments and consumables gives accurate results; a private, safe area protects patients and staff.

How to meet it — practical ideas
  • A consult or nurse's room is fine if privacy is maintained.
  • Keep a log of consumables, lot numbers, expiry dates and temperature monitoring, plus a risk matrix and contingency steps.
PoCT5

Performance of tests

What patients expectI expect that this practice performs point of care testing in line with manufacturer’s guidelines and results are communicated in an understandable and timely manner.

In plain English

Follow manufacturer instructions for every test, check data transfer/transcription accuracy, record and communicate results to the clinician and patient promptly and act on them, record and investigate deviations, keep specimens positively identified throughout (and label any retained), document technical support arrangements, and commission and maintain equipment per the manufacturer with records of installation, repairs, maintenance and failures.

The criteria

PoCT5.AThe practice follows the manufacturers’ instructions for PoCT.

What the standard says

The practice:

  • demonstrates that it follows the manufacturer’s instructions for each test method
  • demonstrates that it checks the accuracy of transfers of data and transcription of results.
PoCT5.BThe practice records and communicates results appropriately. The practice:

What the standard says

  • demonstrates that the practice team records and communicates results to the responsible clinician and the patient in a timely manner
  • demonstrates that results are acted upon appropriately.
PoCT5.CThe practice identifies and reviews errors and deviations.

What the standard says

The practice:

  • demonstrates that it records and investigates deviations appropriately.
PoCT5.DThe practice ensures that specimens remain positively identified with patients throughout the testing process.

What the standard says

The practice:

  • demonstrates that specimens remain positively identified with patients throughout the testing process
  • clearly identifies patient specimens retained for any purpose.
PoCT5.EThe practice has documented its requirements for PoCT technical support services.

What the standard says

The practice:

  • demonstrates that it has ongoing arrangements with providers of technical support services.
PoCT5.FThe practice commissions and maintains PoCT equipment in accordance with each manufacturer’s instructions.

What the standard says

The practice:

  • retains records of installation, major repairs and commissioning
  • ensures that maintenance is undertaken by appropriately trained operators
  • retains records of maintenance in accordance with the manufacturers’ instructions
  • retains a log of failures and investigations performed.
Why it matters

Results must be valid and reliable; standardised procedures and error detection make that possible.

How to meet it — practical ideas
  • Write SOPs/work instructions for each test (including patient interaction and result management, which manufacturers don't cover); keep only current versions; store a copy with the instrument.
  • Transfer results electronically where possible; have manual transcriptions checked by a second person.
  • Agree service response times, maintenance frequency, training and troubleshooting with suppliers; consider written agreements.
PoCT6

Data management

What patients expectI expect that my results from point of care testing are included in my health record.

In plain English

Record PoCT results in the patient record, including who did the test and when. Aspirational: record results in coded fields.

The criteria

PoCT6.AThe practice records PoCT results in the patient’s health records.

What the standard says

The practice:

  • keeps PoCT records, including who performed the tests and the date.
PoCT6.BThe practice facilitates the recording of PoCT results using a nationally recognised coding system. Aspirational

What the standard says

This criterion is aspirational. The practice could:

  • use a clinical information system that facilitates coding of PoCT in patient health information.
Why it matters

Records support clinical decisions and let you investigate a doubtful result (operator, reagent batch, QC status, transcription).

How to meet it — practical ideas
  • Ensure you can retrieve all data for a testing episode; code results rather than free text where possible.
PoCT7

Quality control procedures

What patients expectI expect that this practice has processes in place to ensure the quality of all point of care testing.

In plain English

Run quality control according to manufacturer recommendations and regulations, with SOPs stating acceptable QC limits and actions for unacceptable results, and review QC results regularly.

The criteria

PoCT7.AThe practice uses quality control procedures to ensure the PoCT is functioning optimally.

What the standard says

The practice:

  • demonstrates that all quality control procedures comply with manufacturers' recommendations and applicable regulations
  • has standard operating procedures or work instructions that include the acceptable limits for quality control testing results and record actions taken in the event of an unacceptable result
  • regularly reviews quality control results.
Why it matters

QC confirms the device and the operator are performing correctly and catches sub-optimal performance.

How to meet it — practical ideas
  • Use manufacturer or third-party QC material at appropriate times; record results against the target window; stop patient testing and document corrective action if out of range.
  • The PoCT lead reviews QC regularly; occasionally compare a PoCT result with the lab on the same specimen.
PoCT8

External quality assurance program

What patients expectI expect that this practice participates in an external quality system to monitor point of care testing, detect issues early, and act if needed.

In plain English

Enrol every test method and instrument in an approved external quality assurance (EQA) program from an accredited provider, keep participation records, review reports, and record actions after sub-optimal performance.

The criteria

PoCT8.AThe practice participates in an external quality assurance program.

What the standard says

The practice:

  • enrols all test methods and instruments in an approved external quality assurance program from an accredited provider
  • keeps records of participation
  • reviews reports from external quality assurance programs
  • keeps records of all action taken after investigation of suboptimal performance.
Why it matters

EQA provides peer comparison and early detection of problems.

How to meet it — practical ideas
  • Investigate and document remedial actions whenever EQA shows results differing significantly from peers.

Glossary

Active patient
A patient who has attended the practice three or more times in the past two years. An inactive patient has not.
Adverse event / incident
Any event during care that led, or could have led, to unexpected harm, loss or damage — includes near misses, sentinel events and unsafe acts.
After-hours
Services Australia defines normal hours as 8am–6pm weekdays and 8am–12 noon Saturdays. 'Sociable' after-hours is 6–11pm weekdays; 'unsociable' is 11pm–8am weekdays, Saturday afternoons, and all day Sundays and public holidays.
AI scribe
An AI tool that turns a consultation conversation into a clinical note, summary or letter. Also called digital, virtual or ambient scribes.
Aspirational criterion
A criterion the RACGP encourages practices to meet but which is not required for accreditation (F8.F, CG3.J, CQI1.C, PoCT6.B).
Buddy system
A colleague follows up results and correspondence, or continues care, for an absent colleague.
Clinical decision limits (PoCT)
Cut-off points that trigger a diagnosis or a defined action, based on expert guidelines.
Clinical governance
A framework through which clinicians and managers are jointly accountable for patient safety and quality.
Clinical handover
Transfer of professional responsibility for some or all of a patient's care from one person or group to another.
Clinical information system
Software that manages patient details, histories, recalls and reminders, medications, referrals, results and decision support.
Clinical significance
The probability a patient will be harmed without further advice, treatment or tests, and how serious that harm would be.
Codable field / coding
A structured field that records information using a recognised vocabulary (e.g. SNOMED CT-AU, ICPC-2) rather than free text, so it can be searched and reported.
Cold chain management
Keeping vaccines within the recommended temperature range from manufacture to administration, per 'Strive for 5'.
Consumer expectation statement
A statement, developed with consumers, of what patients value and expect for each set of criteria.
Cultural safety
Care that respects a person's culture and beliefs without discrimination. For Aboriginal and Torres Strait Islander peoples it is defined by the recipient of care and requires ongoing critical reflection by practitioners.
Employed members
People working directly for the practice under a formal employment agreement.
External quality assurance (EQA)
A program in which all participants test identical samples and compare results, revealing whether a practice's method differs from peers.
FDSV
Family, domestic and sexual violence, including child abuse, neglect and coercive control.
GP-led
Primary care clinically governed by GPs who are physically present and consult in person on a regular, ongoing basis.
Health summary
The overview part of a record: current medications, past history, family history, allergies and adverse drug reactions.
High-risk results
Seriously abnormal results indicating a life-threatening condition that must be communicated as soon as practicable.
Independent doctor in practice
A registered medical practitioner who cares for patients while operating their own business from the practice, rather than as an employee or contractor.
Informed consent
Consent given freely, by someone with capacity, specific to the intervention, after receiving sufficient information. Can be express (signed/stated) or inferred (e.g. extending an arm for a blood test).
Just culture
An approach to incidents that seeks to understand causes and improve systems rather than blame individuals.
Near miss
An incident that could have caused harm but did not.
Open disclosure
Openly and honestly communicating with patients after an adverse event, per the Australian Open Disclosure Framework.
Point-of-care testing (PoCT)
Pathology testing done at the time and place of care, enabling immediate decisions.
PREMs / PROMs
Patient-reported experience measures and patient-reported outcome measures — validated tools for collecting patient perspectives.
Quality control (PoCT)
Testing artificial samples with known values to confirm a device and operator are performing within the manufacturer's acceptable range.
Recall
Asking a patient to attend for further advice on a matter of clinical significance.
Reference interval (PoCT)
The average value and normal variation for a test in a 'normal' population.
Reminder
A prompt to a patient to attend for routine or important health tasks, e.g. screening.
Synchronous care
Care delivered in real time — face-to-face, phone or video — as opposed to messages answered later.
Transitions of care
Any transfer of care between providers: covering an absent colleague, locums, referrals, shared care, hospital admission/discharge, record transfers.
Triage
Prioritising patients by urgency of need.