Star Shine Pharmacy Page

City/State

Postgraduate Year One Community Pharmacy Residency Program Dates of Survey

Surveyors:

RPD:

C O N F I D E N T I A L

Surveyors' Recommendation to the Commission

(Note: This recommendation is intended for consideration by the ASHP Commission on Credentialing only and is not to be transmitted to the institution.)

  1. Recommendation for the duration of accreditation – initial recommendation: (check appropriate box by double clicking)

1 YR
3 YRS
6 YRS
For COC Review:
Withhold
Conditional
Other
  1. Check the appropriate box for type of program surveyed: Residency ProgramTechnician Training Program

(Items 3-6 below are not applicable to technician training programs)

  1. # of NC or L-PC Critical Factors (based on specific residency program type: PGY1, PGY1 community, PGY1 managed care, or PGY2 specialty)

Principle 1 / Principle 2 / Principle 4 / Principle 5 / Principle 6 / Principle 7 / 1
  1. Is this recommendation consistent with the critical factors guideline for length of accreditation? Yes No
  1. If not, explain discrepancy:
  1. Is the volume or progress on non-critical factors an issue? Yes No
  1. The surveyors conducted a thorough review of the new residency program director’s/technician training program director’s academic and professional record. It was noted that all requirements specified in the Standard that pertain to the program director have been met, or will be met according to the following comments. Therefore, a recommendation for approval is made with this report. (Surveyors: please provide appropriate commentary to indicate full-approval or contingent approval)
  1. General comments on program:

SURVEYOR Recommendations to be included in the COC voted action letter to the site

MARCH OR AUGUST 20XX:

SPA Recommendation to the Commission

March OR AUGUST 20XX:

Actions of the Commission

March OR AUGUST 20XX:

List areas of non-compliance and/or partial-compliance and your assessment:

Key to Status: RES: Resolved; GP: Good Progress; LP: Limited Progress; NP: No Progress; NPD: No Progress, site disagrees

RE: Regressed; UNC: Unchanged (these are used for follow-up reports only)

NC/PC Finding / 03/XXCOC
PC1 / Residents’ evaluations are discussed by preceptors with residents and the residency program director; however, the reviews do not include any documentation signed by the residency program director. [Item 4.1e(1)(c)] / RES
PC2 / Residents do not complete an evaluation of learning experiences at the end of each learning experience (or at least quarterly in longitudinal learning experiences). [Item 4.1e(3)] / GP
PC3 / Written customized plans are not developed adequately at the beginning of the residency to describe how areas of strength and weaknesses, or areas for improvements, that have been identified through assessments of residents’ incoming knowledge, skills, abilities, and interests that are unique to each resident will be addressed. [Item 4.2b(1)]-CF / GP-h
PC4 / A plan for improving the quality of preceptors’ instruction, based on assessments of residents’ written evaluations of preceptors’ performance and other sources, is not developed adequately to personalize training for preceptors. [Item 4.3c] / GP
PC5 / Some preceptors do not have a record of contribution and commitment to pharmacy practice characterized by three of the criteria specified by the accreditation standard. [Item 5.9]-CF / GP-M
PC6 / Role-modeling, coaching, and facilitating residents to provide clinical services for specific patients in the community setting with whom both residents and preceptors are involved is not always sufficient. Further, new preceptors do not effectively use these roles when working with residents, versus pharmacy students, as they have not had previous experience with residents. [Item 5.10]-CF / GP-M
PC7 / The following patient care services or activities, in collaboration with other health care professionals, have not been developed adequately at the Star Shine Pharmacy sites used for the program: medication therapy management, disease state management, and development of treatment guidelines and protocols for patient care. Additional patients should be enrolled into existing programs and new services should be developed to sustain and increase the value of patient care services. The scope of services is not commensurate with patient population needs. [Items 6.3f, 7.2a, 7.2b, 7.7a(1), 7.7a(2), and 7.7a(5)]
7.7a(1) MTM – CF=M, 7.7a(2) Disease State MgmtCF=L
Most of the population is elderly, have some MTM reviews, onlyhave diabetes as disease state management – not many patients. They are attempting new protocols with local MDs, there is a hospital right across the street they are trying to partner with for programs. They do have some other targeted review projects. Looking at Procrit project and getting CLIA waiver to do cholesterol testing. / GP
7.7a1-M
7.7A2-L
PC8 / Patient care outcomes data (quality, safety, and cost) are not collected and documented adequately to evaluate routinely the quality of patient care services provided by pharmacists involved with the program, and to be able to use as a marketing tool. [Items 7.3g(3) and 7.8b] / GP
PC9 / An adequate system is not in place to review adverse drug reaction reports and to implement new policies and procedures to improve medication safety. [Item 7.8a]-CF / GP-M

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