How to Run a RACGP Self-Assessment (Traffic-Light Method)

A self-assessment is how you find your accreditation gaps before a surveyor does. This guide walks the traffic-light method step by step. For the bigger picture of how accreditation works, see the RACGP accreditation pillar; this is the procedure for doing the assessment itself.

Before you begin

Set aside a focused half-day to start, and expect the work to continue over the following weeks as you gather evidence. Involve the people who own the systems being assessed (clinical lead, nurse, reception lead), not just the practice manager. If you want a fast read on where you stand first, the RACGP accreditation readiness quiz gives you a quick baseline before you go indicator by indicator.

Step 1: Get the current Standards and your indicator list

Download the current edition of the RACGP Standards for general practices and list every indicator that applies to your practice. Note which are mandatory indicators, because a failed mandatory indicator stops accreditation, so these get the closest attention.

Working from the actual indicator list, rather than memory or last cycle's notes, is what stops you from missing a requirement that has changed.

Step 2: Assemble your evidence as you go

For each indicator, find the evidence that shows you meet it: the policy that proves a system exists, and the records that prove it runs (training logs, fridge temperature logs, audit results, complaint records). Keep the evidence together as you assess, because the self-assessment and the evidence pack are really the same job.

Where evidence has to build up over time, note it now. That kind of evidence cannot be created retrospectively, so spotting it early is what gives it time to accumulate before the survey.

Step 3: Rate each indicator with the traffic-light method

Go through the indicators and rate each one: green where you have the system and the evidence, amber where it is partial or the evidence is thin, and red where it is missing. Be honest rather than optimistic; an amber you talk up to green is a gap you will meet again on survey day.

Rating every indicator on the same simple scale is what turns a vague sense of readiness into a concrete, prioritised list.

Step 4: Prioritise the gaps, mandatory indicators first

Sort your amber and red ratings into an order of attack. Put every red mandatory indicator at the top, because those are pass/fail, then the rest of the reds, then the ambers. This is also where the common accreditation failures are worth checking against your list, since the same gaps recur across thousands of practices.

Prioritising by mandatory-then-severity is what stops you from polishing low-risk items while a pass/fail gap sits open.

Step 5: Build an action plan and re-rate before the survey

Turn the prioritised gaps into an action plan: for each one, what will change, who owns it, and by when. As actions complete and evidence accumulates, re-rate the indicator. The aim is to reach the survey with every mandatory indicator green and the rest as close as you can get.

Treating the self-assessment as a living document you re-rate, rather than a one-off form, is what links it to continuous quality improvement and keeps you ready between cycles.

What good looks like

• You assessed against the current indicator list, not last cycle's.
• Ratings are honest, with amber and red called as they are.
• Every red mandatory indicator has an owner and a due date.
• Evidence is gathered alongside the ratings, not scrambled for later.
• You re-rate as you close gaps, so readiness is always visible.

Common mistakes: rating from memory instead of the Standards, marking ambers as greens, leaving evidence-over-time items until they cannot be built in time, and treating the self-assessment as a one-off rather than an ongoing system.

Frequently asked questions

What is the traffic-light method for a RACGP self-assessment?

The traffic-light method rates each indicator green (system and evidence in place), amber (partial or thin evidence), or red (missing). It turns the Standards into a simple, prioritised gap analysis that shows exactly where to focus before an accreditation survey.

How long does a self-assessment take?

Plan a focused half-day to work through the indicator list and rate everything, then expect ongoing work over the following weeks to close gaps and gather evidence. The rating is quick; building the missing evidence is what takes time.

What is a mandatory indicator?

A mandatory indicator is an item in the RACGP Standards that a practice must meet to be accredited. A failed mandatory indicator stops accreditation until it is resolved, so red mandatory indicators are always the top priority in your action plan.

When should we run a self-assessment?

Well before your accreditation survey, ideally as a continuous habit rather than a pre-survey scramble. Because some evidence has to build up over time, starting roughly 12 months out gives slow-building items the runway they need.

Do we need evidence for every indicator?

Yes. Each indicator is demonstrated with evidence: a policy that shows the system exists and records that show it runs. Assessors look for both, so gathering evidence as you rate each indicator is the efficient way to work.

Last reviewed 20 June 2026