ASHP Accreditation Services Division: Pharmacy Residency Programs

ASHP Accreditation Services Division: Pharmacy Residency Programs

Lead Surveyor Procedures

CONFIDENTIAL PAGES AND CRITICAL FACTORS DOCUMENTATION

During deliberations with the guest surveyor at the time of the survey, observations or impressions to the level of compliance with a standard identifiedas a critical factor will be determined.

Critical factors determined to be “low” L-PC, (1-33%), “medium” M-PC, (34-65%), or “high” partial compliance H-PC, (66%-99%) will be documented within a surveyor’s notes, or on the site’s pre-survey questionnaire, or on a critical factors summary worksheet at the discretion of the lead surveyor for the specific type of residency program reviewed.

Upon receipt of the site’s response and confidential pages template from the ASD office,the lead surveyor will review the response provided by the site and send a draft of the confidential page for review by the guest surveyor.

The lead surveyor shall use status abbreviations (e.g. RES, GP, LP, NP, etc.--see assessment definitions below) on the confidential pages to score the resulting overall status of the entire PC statement (not for each individual factor within the PC). The PC status abbreviation will be typed within the dated COC column associated with the citation by the lead surveyor.

The lead and guest surveyor will arrive at consensus via email exchanges or through telephone conversations as needed. Both the lead surveyor and the guest surveyor shall review the response and their notes or worksheets to determine progress on each area of NC or PC.

The citation containing one or more critical factors within the confidential pages and the item number(s) shall be tagged with the letters -CF. (See examples PC3, PC5, PC6, PC7, and PC9 on sample attached)

The lead surveyor shall tag the status abbreviations within the dated COC column as to level of progress made/or not made(if it has not been resolved) with the critical factor(s) within the citation.This effort will provide information to the COC as to level of progress by the site for subsequent reports.

-L for low partial compliance
-M for medium partial compliance
-H for high partial compliance

(See examples PC3, PC5, PC6, and PC9 on sample attached)

For citations with multiple standard items associated with the area of noncompliance or partial compliance (see example PC7) which also contain critical factors, the level of progress on the critical factors shall be documented in the following manner. Within the dated COC column, the CF number(s) will be retyped and tagged with the letters -L, -M, -H (definitions above).

Surveyors should document key evidence used for progress ratings and any suggestions for the site to improve to more fully meet requirements within the citation area containing critical factors that remains in partial compliance or noncompliance whenever possible to assist the Commission members in reviewing the responses and for the review of subsequent progress reports or the next survey of the program.

ONLY a tally of standards identified as critical factors within each Principle that remain in low partial compliance (-L) or remain as noncompliant (NC) after the response shall be documented on the first page of the confidential pages sheets. Critical factors identified as medium partial compliance (-M) or high partial compliance (-H) after the response do not factor into the tally. Ranking of progress as medium or high is useful in cases where the length of accreditation recommended is different than the number of years recommended using critical factors alone. Use of medium and high rankings would also be helpful with subsequent program reaccreditation surveys.

Lead surveyors will use the appropriate residency type (i.e., PGY1, PGY1 community, PGY1 managed care, or PGY2 specialty)critical factors worksheet definitions to determine the recommended length of accreditation based on metrics provided within the worksheet. (see attached Grid).

When length of recommended accreditation does not match the metrics on the critical factors worksheet, discrepancy reporting is required on the first page of the confidential pages under number 5.

Any additional comments about the program for information to the COC can be written under number 8, “general comments.”

Completed confidential pages are to be returned to the ASD mailbox for processing and posting to TeamSpace. ()

Status Assessment Definitions for Confidential Pages

Use the following status definitions to indicate your evaluation of a program's progress in addressing areas of partial compliance or noncompliance identified during the survey. Write the abbreviation of the status definition onyour confidential page assessment grid in the dated COC column for any report submitted to the Commission on Credentialing, including programs’ survey report responses, midterm reports, special case reports, and interim progress reports.

If a program has:

RESOLVED (RES)its issues,the program/department has addressed the issue such that, if resurveyed, the survey team would find that element to be in full compliance. This indicates that a plan has been implemented and the desired outcome achieved. Documentation must be provided to substantiate such progress has been achieved.

Examples:

new facilities have been constructed and they meet the intent of the standard and are in operation;
new evaluations have been implemented and are used appropriately, actual examples , not just forms are included;
a customized plan has been implemented, original plan and at least one update for a resident has been included (not just a form);
new preceptors or pharmacists (FTEs) are fully oriented and are practicing in their areas;
all improvements MUST have been implemented.

GOOD PROGRESS (GP) the program/department has developed a plan of action, has established timelines to address the issues, and work is in progress. Documentation must be provided to substantiate progress, and based upon review of the documentation, it is clear that progress has been made but the intent of the accreditation standard has not been achieved.

Examples:

capital improvements have been approved, budgeted, and a timeline has been established.May be ongoing;
improved evaluation instruments are in use (however need to see more actual examples to insure they are implemented);
new FTEs or vacant FTEs have been filled, but staff is not yet there or fully oriented;
a plan has been developed and started, however it has not been fully initiated.

LIMITED PROGRESS (LP)the program/department has acknowledged that an improvement should occur and has established an action plan, with a reasonable timeline, to address the issue;however, there has been limited or no progress in implementation of the plan. Any documentation of progress should be provided.

Examples:

facilities -funds for capital improvements have been requested and planning is underway;
evaluations – developed but have not yet been implemented;
personnel - FTEs have been identified/approved, but personnel have not been hired and trained.

NO PROGRESS (NP)the program/department has acknowledged that an improvement should occur in the survey response, but has not developed a plan of action or timelines to address the issues.

The following identifiers will not be published, but will remain for confidential use by the Commission on Credentialing:

NO PROGRESS (NPD) the program/department disagrees with the findings of the survey team in the survey response.

UNCHANGED (UNC)this would be used only on follow up reports. Description and documentation does not substantiate that improvements in the residency program or the pharmacy services have been made since the last report was submitted.

REGRESSED (REG)this would be used only on follow up reports. The program’s report shows it has lost ground since the previous report. Example:

program had a plan or an approved FTE, but new management has come in and changed the plan or taken away the FTE.

Last Update: February 2, 2012/ksf

FOR ACCREDITATION SERVICES DIVISION INTERNAL USE ONLY

Critical Factors Summary Worksheet

PGY1 / PGY1 Community / PGY1 Managed Care / PGY2
Principle 1 -0- / Principle 1 -1- / Principle 1 -0- / Principle 1 -2-
1.3 / 1.1 1.2
Principle 2 -3- / Principle 2 -3- / Principle 2 -4- / Principle 2 -3-
2.5 2.8 2.9 / 2.5 2.8 2.9 / 2.5 2.8 2.9 2.10 / 2.5 2.8 2.9
If > 1/4 [2 or more] are L-PC or NC = 1 year
Principle 3 -0- / Principle 3 -0- / Principle 3 -0- / Principle 3 -0-
Principle 4 -16- / Principle 4 -11- / Principle 4 -18- / Principle 4 -10-
4.1 b (1), (2), (3), (4), (5), (6)
4.1 c (1), (2)
4.1 d
4.2 b (1)
4.2 c
4.2 d (1), (2), (3)
4.2 e (1), (2) / 4.1 b
4.1 c (1), (2)
4.1 d
4.2 b (1)
4.2 c
4.2 d (1), (2), (3)
4.2 e (1), (2) / 4.1 b (1), (2), (3), (4), (5), (6), (7)
4.1 c (1), (2), (3)
4.1 d
4.2 b (1)
4.2 c
4.2 d (1), (2), (3)
4.2 e (1), (2) / 4.1 b
4.1 c (1)
4.1 d
4.2 b (1)
4.2 c
4.2 d (1), (2), (3)
4.2 e (1), (2)
If > 5/16 [6 or more] are L-PC or NC = 1 year / If > 5/16 [6 or more] are L-PC or NC = 1 year / If > 5/17 [6 or more] are L-PC or NC = 1 year / If >3/10 [4 or more] are L-PC or NC = 1 year
Principle 5 -6- / Principle 5 -6- / Principle 5 -7- / Principle 5 -8-
5.1 5.6 5.7 5.8 5.9 5.10 / 5.1 5.6 5.7 5.8 5.9 5.10 / 5.1 5.6 5.7 5.8 5.9 5.10 5.11 / 5.1 a, b, c
5.6 5.7 5.8 5.9 5.10
If > 2/6 [3 or more] are L-PC or NC = 1 year / If > 2/6 [3 or more] are L-PC or NC = 1 year / If > 2/7 [3 or more] are L-PC or NC = 1 year / If > 3/8 [4 or more] are L-PC or NC = 1 year
Principle 6 -1- / Principle 6 -6- / Principle 6 -1- / Principle 6 -1-
6.1 / 6.1
6.3 a, b, c, d, e (individual tally) / 6.1 / 6.1
If > 3/6 [4 or more] are L-PC or NC = 1 year
Principle 7 -20- / Principle 7 -15- / Principle 7 -16-/-4- / Principle 7 -20-/-3-
7.3 e
7.4 a
7.5 a, b, h
7.6 a (1), (2), (4), (5), (6), (7), (8)
7.7 a, b, c, d
7.8 a, c, d, e / 7.3 d
7.3 g (1), (2), (3)
7.3h
7.4 a
7.6 (a,b,c,d,e) (count as one CF)
7.7 a (1), (2), (4)
7.8
7.9 a, c, d, g / 7.3 e
7.4 a
7.5 a, b, h (eachas applicable to practice site)*
7.6 a (1), (2), (4), (5), (6), (7), (8)
7.7 a, b, c, d
7.8 a, c, d
7.8 b (as applicable to practice site)* / 7.3 e
7.4 a
7.5 a, b, h
7.6 a (1), (2), (4), (5), (6), (7), (8)
7.7 a, b, c, d
7.8 a, c, d, e
7.9 a, b, c*
If > 7/20 [8 or more] are L-PC or NC = 1 year / If > 5/15 [6 or more] are L-PC or NC = 1 year / If > 5/16 [6 or more] are L-PC or NC = 1 year
*If > 6/20 [7 or more] are L-PC or NC = 1 year as applicable* / If > 9/20 [50% in this principle only-10 or more] are L-PC or NC = 1 year
*7.9 If ANY are L-PC or NC = 1 year*

Six Years of Accreditation

No areas are documented as “no progress” on any PC or NC on the confidential page (There is at least a documented plan in the response)
No areas of NC (they must have moved at least to partially resolved on confidential page)
No areas of L-PC on any of the critical factors

Three Years of Accreditation

≤ 33% of critical factors occur in any of the specified Principles after response
If Low PC or NC, progress must be documented on the confidential page

One Year of Accreditation

>33% of critical factors occur in any one or more of the specified Principles at NC or L-PC
If NO PROGRESS on any L-PC or NC (critical factors)

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Revised February 2012