Getting ready for a practice accreditation site visit: a 90-day plan

Ninety days out from your accreditation site visit is the moment when everything starts to feel real. The date is booked. The assessor is coming. Whatever gaps you have been meaning to close for the last two and a half years are still there.

This is a week-by-week plan for practice managers preparing for a RACGP 5th Edition site visit. It assumes you have the basics in place but need a structured run-in to be genuinely ready.

Before we start, one important note. Your practice is still assessed against the RACGP Standards for general practices, 5th Edition. The 6th Edition was released in August 2026, but transition arrangements have not yet been published. If your survey is in the next 90 days, ignore the 6th Edition for now and focus on the 5th. There is a separate guide on the 6th Edition if you want to look ahead.

This plan is built around 12 weeks, roughly grouped into four phases:

• Weeks 12 to 9: Foundation and gap analysis
• Weeks 8 to 6: Deep work on gaps and evidence
• Weeks 5 to 3: Team readiness, physical environment, dry runs
• Weeks 2 to 1: Final polish and site visit prep

Let's walk through it.

Weeks 12 to 9: Foundation and gap analysis

The first four weeks are about knowing exactly where you stand. Do not skip this and dive straight into fixing things. Practices that start with action instead of analysis end up fixing the wrong things.

Week 12: Confirm the basics

Before anything else, lock down the essentials:

• Confirm your site visit date in writing from your accreditation agency (AGPAL, GPA or QPA)
• Confirm which surveyor is attending and how many days the survey covers
• Book the day out in every clinician's calendar and every reception shift
• Nominate your primary contact for the surveyor (usually the practice manager)
• Nominate a backup in case you are off sick
• Notify your team the survey date is locked in, so nobody is surprised

Week 11: The gap analysis

Print or open a copy of the RACGP 5th Edition Standards. Work through every criterion and mark it against your practice:

• Green: We meet this and we have evidence
• Amber: We meet this but our evidence is thin
• Red: We do not meet this, or we are not sure

Do this properly. Do not rush. Three focused sessions of two hours each is better than one long marathon. Involve your senior GP or clinical governance lead for the clinical criteria.

At the end of week 11 you will have a spreadsheet or list of every amber and red criterion. This is your work list for the next 11 weeks.

Week 10: Prioritise and assign

Take your amber and red list and rank each item by two dimensions:

• Effort: quick fix (under a day), medium (up to a week), or big (multi-week project)
• Assessor visibility: how likely is this to actually come up during the site visit?

Focus first on high-visibility items regardless of effort, then on quick wins across the rest. Big low-visibility items can wait for the next cycle.

Assign an owner to each item. Not "the team" or "we". A named person. Set a due date.

Week 9: Set the rhythm

Book a weekly 30-minute accreditation stand-up in the same slot every week for the next 12 weeks. Standing agenda:

• What did we close last week?
• What is due this week?
• What is stuck and needs a decision?

This becomes the backbone of the whole run-in. If you skip these meetings, things slip.

Weeks 8 to 6: Deep work on gaps and evidence

The middle third is where most of the actual fixing happens. This is head-down work.

Week 8: Policies and procedures audit

Every policy and procedure the RACGP Standards refers to needs to be:

• Current (reviewed within the timeframe stated on the policy)
• Version-controlled (with a clear version number and date)
• Accessible to staff who need it
• Actually followed in practice

Print or list every policy you have. For each, check:

• When was it last reviewed?
• Does it match what the team actually does?
• Can a reception staff member find it in under a minute?

Common gaps to look for:

• Infection control policies that predate the last COVID update
• Cold chain management policies that do not match your fridge log procedure
• Complaints policies that reference a Complaints Officer role nobody currently holds
• Emergency response plans that were never actually practised

Refresh the ones that need refreshing. Get the practice principal to sign off major updates.

Week 7: Patient records and clinical governance

This is one of the most heavily assessed areas. Focus on:

• Health summaries: are they current and complete for active patients?
• Allergy status: is it recorded for every active patient (including "no known allergies")?
• Coding: are diagnoses being coded, not just written as free text?
• Recalls and reminders: is your system working? Is it monitored?
• Results follow-up: do you have a documented process, and is it followed?
• Clinician credentialing: are all GPs current on AHPRA registration, medical indemnity, and CPR?

For each, pull a random sample of five patient records and audit them. The gaps you find are the gaps the surveyor will find. Better you find them now.

Week 6: Registers and evidence trails

Assessors love registers. They are hard evidence, easy to review, and reveal a lot about how the practice operates. Make sure yours are current:

• Incident register: entries from the last 12 months, with actions and outcomes
• Complaints register: entries, resolution, learnings applied
• Cold chain register: temperature logs, breach reports, corrective actions
• Sterilisation register: load numbers, biological indicator results
• Equipment servicing register: dates, service providers, next-due dates
• Emergency drug register: expiry checks, replacements
• Immunisation status register: for all clinical and reception staff

If any of these are missing or incomplete, this is the week to fix them. A blank register looks worse than none at all.

Weeks 5 to 3: Team readiness, physical environment, dry runs

The last third shifts from paperwork to people and place.

Week 5: Team training and briefings

Every team member should know:

• The site visit date and what to expect
• What the assessor is likely to ask them
• Where key documents live
• Who to escalate questions to

Run a 30-minute all-hands briefing. Cover:

• What accreditation is and why it matters
• What happens on the day
• Sample questions the assessor might ask ("Where would you find the infection control policy?", "Show me how you record a temperature breach.")
• Confidence, not memorisation. If someone does not know an answer, the correct response is "I'd check the practice manager" or "I'd look in the policy folder", not fabrication.

Do a role-specific top-up with reception and clinical teams separately. The questions each will get are different.

Week 4: Physical environment walk-through

Do a full walk of the practice with fresh eyes. Better still, ask a colleague from another practice to walk through, or ask your primary health network representative if they'll do it.

Look for:

• Expired items in every fridge, cupboard and treatment room
• Sharps containers over the fill line
• Clinical waste bins in general waste zones (or vice versa)
• Hand hygiene stations empty or blocked
• Sterilisation dating and packaging integrity
• Cold chain fridge placement (not near heat sources, thermometers correctly placed)
• Emergency exits clear and signage current
• Fire extinguisher tags in date
• Oxygen cylinder secured and in date
• Emergency medications not expired
• Defibrillator battery and pad expiry
• Privacy in reception (screen positioning, phone conversations audible from waiting area?)

Fix everything you can that week. What you cannot fix immediately, add to a punch list.

Week 3: Continuous quality improvement evidence

If you have been running a QI activity, this is when you pull the evidence together. The surveyor wants to see:

• A defined problem or opportunity
• A planned intervention
• Data before and after
• Reflection on what you learned
• What changed as a result

If your CQI activity is thin, be honest about it and start something small now that you can genuinely evidence by week 1. A four-week PDSA cycle on a real problem beats a fabricated six-month one.

Weeks 2 to 1: Final polish and site visit prep

Week 2: The dry run

Book a two-hour block. Walk the practice as if you are the surveyor.

• Ask staff sample questions from your briefing prep
• Check that everything in your evidence folder is current, dated, and correctly filed
• Test that policies open when you click on them (not "file not found")
• Check that the surveyor's workspace (room, table, chair, wifi, water) is ready

Note anything that comes up and fix it in the first half of week 1.

Also, do one final check on:

• Team immunisation records
• CPR certification for all clinical staff
• First aid certification where required
• Working with Children Checks where applicable
• Position descriptions matching what people actually do

Week 1: Ready state

The last week is for polish and calm, not for panic.

Print, tab, and organise the evidence folder in the order the assessor will use. Every policy referenced, every register, every training record, all in one place.

Send the team a final email:

• The day's schedule
• What to wear (business or scrubs as usual)
• Who the surveyor will speak to and when
• Reminder that "I don't know, but I'd check the policy" is a valid answer
• Reminder to be themselves

The day before, do the final walk-through. Fridges, sharps, waste, hand hygiene, waiting area, treatment rooms. Nothing left to chance.

Get some sleep.

On the day

The surveyor will typically want:

• An initial meeting with the practice manager and principal
• Time to review documents and evidence
• Interviews with a mix of staff (GP, nurse, reception)
• A walk through the practice
• A closing meeting to give initial feedback

Have your evidence folder ready, staff briefed on where to be and when, and a private meeting space for the surveyor to work between conversations. Coffee, water, wifi, and the passwords they need are basic hospitality. Do not overdo it.

Answer questions honestly. If something is not perfect, name it and explain how you are addressing it. Assessors are generally more forgiving of a practice that says "we know this is thin and here is our plan" than one that pretends everything is perfect.

After the visit

The assessor will give initial feedback on the day, then submit a formal report. You will typically have an opportunity to close any minor gaps within a defined window.

Do not lose momentum here. The systems you built in the last 90 days are what will make the next accreditation cycle easier. Keep the weekly stand-up going in a lighter form. Keep the registers current. Keep the evidence rolling.

Continuous compliance is the trick. If you build the rhythm now, three years from now the run-up will feel much less like an emergency.

Common mistakes in the final 90 days

Six things I see practices get wrong in the final quarter:

Rewriting policies in the last two weeks. A policy you rewrote yesterday cannot show a review history. If it needs a genuine rewrite, do it early. Otherwise, refresh what you have.

Panicking the team. Anxious staff give bad answers. Calm, briefed staff give clear answers. Your job the last two weeks is to keep the team steady.

Missing evidence for things you actually do well. Undocumented compliance does not count. If your team runs a great morning huddle, does anyone write down what was discussed? If your fridge check happens twice daily, is it logged?

Overcomplicating the CQI activity. A simple, real, well-documented PDSA cycle on one issue beats an ambitious project you cannot evidence.

Ignoring the physical environment until the last week. Expired items and full sharps bins are quick wins that also make an immediate impression. Do the walk in week 4, not week 1.

Treating the survey as adversarial. Assessors are trying to verify quality and safety, not catch you out. Be professional, be honest, be prepared. Most surveys go well.

How Practice Managed helps

Practice Managed was built to make continuous compliance the default, not the exception. Everything in the 90-day plan above is easier when your policies, registers, staff training, and CQI activities all live in one system that keeps itself current.

If you have been managing accreditation across spreadsheets, shared drives, and sticky notes, we can help.

Practice Managed opens for sign-up soon. Join the early access list to be first to start your free 30-day trial. No credit card needed.

Final thought

Ninety days is enough time to prepare well if you use it. Twelve weeks is not enough time to fix everything you should have been maintaining for the last three years, but it is enough to close the important gaps, get your evidence tidy, and walk into the site visit calm.

The practices that do best treat the last quarter as a run-in, not a rescue. Take the week-by-week approach, keep the stand-up going, and lean on your team. You will get through it.

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This guide is general information for Australian practice managers. It is not a substitute for professional advice or the RACGP Standards themselves. For the definitive text, visit the RACGP's 5th Edition hub.