Preparing for accreditation, counted back from the date.

What to have done at 12, 8 and 4 weeks, and what the surveyor opens.

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Compliance Readiness Report

Northbank Family Practice · General Practice · Newcastle, NSW

Prepared 23 September 2026

AGPAL accreditation is scheduled for 14 May 2027 (233 days away).

Section 01

Executive summary

As at 23 September 2026, Northbank Family Practice is tracking at 85% readiness across 2 compliance frameworks, with 51 of 60 requirements met. 2 critical requirements remain outstanding.

85%

Readiness

51 of 60

Requirements met

2

Critical outstanding

Section 02

Framework performance

RACGP Standards 5th Edition

89%

39 of 44 requirements met · 2 critical outstanding

Privacy Act 1988 (APPs)

75%

12 of 16 requirements met · 0 critical outstanding

Key dates

AGPAL visit233days
CPR (HLTAID009)14days
Count back from your visit date. Each mark is what you have in hand by then.
Count back from your accreditation visitA calendar of four unlabelled months counting back to your accreditation visit. Marks sit at 12 weeks out, 8 weeks out, 4 weeks out and the day of the visit, joined by a line.12 wks8 wks4 wksDayVisit

What to have done, and when

RACGP 5th Edition has 44 criteria across 17 standards in three modules, and each criterion is assessed through its own indicators. Without a system that maps your evidence against every criterion, you go into the assessment knowing some things are missing but not exactly which.

  1. 12 weeks out: know what you have

    Set every item in the RACGP checklist to Not Started, In Progress or Complete, and link the documents you already hold to the item each one evidences.

    • Critical items still open, listed on their own
    • Existing policies uploaded to the evidence library
    • A framework score that moves as each item closes

    RACGP Standards for general practices, 5th edition

    RACGP 5th Edition

    AllCritical 2In Progress 3Complete 39
    QI3Clinical risk management2/3 complete
    QI3.1bNear miss analysisDone
    QI3.2aOpen disclosure policyDone
    QI3.1aIncident reporting systemOpen

    Framework score

    89%
    39 of 44 items complete2 critical open
    The RACGP checklist, open at QI3 Clinical risk management
  2. 8 weeks out: close the gaps

    Start each missing policy from a template, file it in the evidence library against its checklist item, and give it a review date.

    • 82 templates as Word documents, 44 of them free
    • A review date on each policy, with a reminder before it falls due
    • New versions that keep their links to the checklist

    Privacy Act 1988 (Cth), APP 1.3; RACGP Standards 5th edition, C6.3

    Template

    Privacy PolicyFree.docx

    This policy sets out howPractice namecollects, uses, stores and discloses your personal and health information.

    Privacy questions and complaints go to our privacy officer,Privacy officer namewho will respond within 30 days.

    AnswersAPP 1.3andRACGP C6.3

    Template library

    82 templates44 free

    Cited to the current instruments

    The Privacy Policy template, one of 82 (44 free)
  3. 4 weeks out: a live evidence trail

    The surveyor looks for the Standards in operation, so incidents, complaints and vendor documents go on the record as they happen.

    • Incidents and complaints in the registers, with their actions
    • NDIS reportable incidents against the Commission's 24-hour clock
    • IT vendors asked for security documents through the vendor portal

    RACGP Standards 5th edition, QI3.1; NDIS (Incident Management and Reportable Incidents) Rules 2018

    Incident register

    All statusesNDISReportable
    INC-2026-0005Treatment room 2NDIS reportable
    Notify the Commission23h 58m
    INC-2026-0004Under investigationModerate
    NDIS reportable incidentINC-2026-0005
    Immediate notification23h 58m remaining
    5 Day Form6d 23h remaining

    A more detailed 5 Day Form must also be submitted within 5 business days for every reportable incident.

    The incident register, with the Commission's 24-hour clock running
  4. The day: the assessment

    The assessor works from the evidence you submit and, where they visit, from what they open at the practice. The readiness report and the evidence pack are that record.

    • The readiness report, as a PDF: where the practice stands, section by section
    • The evidence pack, as a ZIP: the documents filed against each checklist item
    • The registers, staff credentials and policies behind both, current on the day

    Compliance Readiness Report

    Northbank Family Practice · Prepared 23 September 2026

    Section 03

    Governance registers

    The practice maintains incident, complaint and conflict of interest registers. Activity over the last 12 months:

    RegisterLodgedClosedOpen
    Incidents651
    Complaints330
    Conflicts of interest211

    Section 04

    Training and workforce

    12 active staff members. 47 of 48 credentials current (98%). 1 credential falls due for renewal in the next 60 days.

    Section 05

    Evidence library

    64 documents on file. 52 of 60 requirements carry linked documentary evidence (87%). 1 IT vendor under security document requests; 0 fully verified.

    Sections 03 to 05 of the readiness report: registers, training, evidence

Left it to four weeks?

The visit feels far away until it does not. With four weeks on the calendar, run the same marks one a week, in this order.

  1. Week 1

    Gap analysis

    Walk the RACGP 5th edition checklist and set a status on every item, so the criteria with nothing behind them show up as open.

  2. Week 2

    Close the gaps

    Start the missing policies from the templates, file each against its checklist item and give it a review date.

  3. Week 3

    Build the evidence trail

    Log incidents and complaints in the registers, and ask your IT vendors for their security documents through the vendor portal.

  4. Week 4

    Mock audit and export

    Walk the criteria with your clinical governance lead, then export the readiness report as a PDF and the evidence pack as a ZIP.

Which standards the visit uses

  • The 5th edition, for now. The RACGP published the 6th edition of its Standards for general practices on 26 August 2026. Practices are assessed against the RACGP 5th Edition Standards (general practice) until the Australian Commission on Safety and Quality in Health Care publishes transition arrangements. What the 6th edition changes.
  • Any of the four agencies. ACHS, AGPAL, Global-Mark and QPA are the agencies approved to accredit general practices, and all four assess against the same RACGP Standards, so one file serves whichever you booked.
  • The rest of the file. The same evidence library holds the NDIS Practice Standards (Core Module), the Privacy Act 1988 and Australian Privacy Principles, the Notifiable Data Breaches scheme (OAIC) and the RACGP Computer and Information Security Standards.

Accreditation prep, answered

Need a hand mapping your evidence? Talk to the team.

How long does it take to prepare a practice for accreditation?

If your practice has been operating for at least 12 months and most policies exist in some form, four weeks is realistic with a structured prep plan. If foundational documents are missing, plan for six to eight weeks. The bottleneck is rarely writing policies (templates handle most of that). It is collecting the live evidence: incident logs, meeting minutes, audit cycles, vendor documentation, and staff acknowledgement records.

What evidence does an RACGP accreditation surveyor actually want to see?

RACGP 5th Edition surveyors look for evidence of the Standards in live operation. That means policies that exist AND are followed: signed-off privacy policy, infection control logs with sterilisation validation, NDB breach response plan with rehearsed scenarios, incident and near-miss register with documented outcomes, clinical audit cycle with at least one completed iteration, staff CPD records, patient feedback with documented responses, and vendor documentation for every external system that touches health information.

What is the difference between AGPAL, QPA, ACHS and Global-Mark accreditation?

The Australian Commission on Safety and Quality in Health Care approves four accrediting agencies under the National General Practice Accreditation Scheme: the Australian Council on Healthcare Standards (ACHS), the AGPAL Group of Companies, Global-Mark and Quality Practice Accreditation (QPA). All four assess against the same RACGP Standards for general practices. The differences are in agency fees, surveyor style, online portal experience and turnaround times. The evidence required is identical, so a practice that is ready for one is ready for all four.

Do I need a consultant to prepare for accreditation?

Most practices do not. Consultants charge for an accreditation prep engagement, and they spend the bulk of that time on tasks that are template-driven: writing policies, building registers, structuring the evidence pack. ClinicComply replaces the structural work. You keep the consultant for strategic advice and clinical governance review if you want a second pair of eyes.

How does ClinicComply help in the final 4 weeks before an audit?

Three things, in order. First, the RACGP 5th Edition checklist shows the status of every item, so you can see exactly what is missing. Second, a template library that closes documentation gaps, with a review date and a reminder on each policy. Third, the readiness report, exported as a PDF, states where the practice stands, and the evidence pack exports as a ZIP of the documents filed against each checklist item.

Can I get an accreditation extension if I am not ready?

The four approved accrediting agencies (ACHS, AGPAL, Global-Mark and QPA) generally allow practices to request a short extension before the visit if there is a defensible reason (staff illness, IT system change, recent practice transition). Extensions are not guaranteed and the agency will usually expect a written plan showing how the additional time will be used. Do not rely on them. Plan to be ready four weeks before the visit, not on the day.

Does ClinicComply work for NDIS accreditation as well as RACGP?

Yes. The platform covers RACGP 5th Edition for general practice, NDIS Practice Standards (Core Module) for registered NDIS providers, Privacy Act and NDB obligations, and IT vendor documentation. All frameworks live in a single evidence library so practices that span both general practice and NDIS supports do not have to duplicate work.

12 Australian healthcare frameworks in one platform.

Not a generic compliance tool adapted for healthcare. Every framework is mapped to the actual criteria your accreditation assessor checks, with guided checklists your team can act on today.

New frameworks are added as Australian standards evolve.

See every criterion we cover
R5
RACGP 5th Edition
GP practices
Full standards mapped criterion-by-criterion
PCH
PCH Standards
Allied health & dental
Primary and Community Healthcare Standards, all 65 actions
PA
Privacy Act 1988
Australian Privacy Principles
All 13 APPs, Health Records provisions
NDB
NDB Scheme
Data breaches
Guided breach response wizard
MHR
My Health Record
Federal
Security and access duties under the 2026 Rules
VIC
Vic Health Records Act
Victoria
Health Records Act 2001
NSW
NSW HRIP Act
New South Wales
Health Records and Information Privacy
DE
Dental Essentials
Dental practices
Dental-specific items alongside the PCH Standards
CS
RACGP CompSec
IT security
Computer and Information Security Standards
AQ
AGPAL / QIP Readiness
Accreditation
The accreditation cycle, from registration to survey
ND
NDIS Standards
Disability services
The full Core Module, all 24 outcomes
AH
Allied Health Essentials
Allied health
Registration, CPD, insurance and billing obligations
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Choose your frameworks and work through the checklist. Walk into your next visit with your evidence linked and current, and nothing left to chase.

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