Procedures for Addressing Complaints Against ASHP Accredited Training Programs

The American Society of Health-System Pharmacists will investigate formal complaints related to noncompliance with accreditation standards if the formal complaint procedures are followed and substantial evidence determines the program/organization is not meeting the accreditation standards.

The process may begin with an anonymous inquiry to the Vice President of Accreditation Services. The name of the complainant remains confidential until the point that a formal complaint has been filed.

ASHP will not intervene on behalf of an individual complainant regarding matters that are not related to ASHP accreditation standards and regulations (e.g. dismissal of residents or technician from a program, or to resolve individual disputes between individuals and accredited training program personnel). ASHP will not intervene on behalf of individuals for preceptors, programs directors, faculty members, students or residents regarding human resource issues (e.g., retention, appointment, promotion or dismissal).

Steps for a Complaint

ASHP-accredited residency or pharmacy technician training program staff (or programs in the process of being accredited) must comply with ASHP accreditation standards and regulations. Program staff must provide an environment in which individuals (e.g., residents, preceptors, and students) may discuss matters in a manner that encourages cooperative resolution of issue(s). Note: anyone having evidence of non-compliance with ASHP accreditation standards may submit a formal complaint to ASHP, provided attempts to resolve the issue have occurred prior to contacting ASHP. Any complaint must be submitted in writing and relate directly to issues of non-compliance with accreditation standards or regulation. Anonymous complaints or complaints submitted solely by e-mail will not be considered as a formal complaint.

1. Submitting a Formal Complaint

If the complainant is a resident, student, preceptor, teacher, or other person affiliated with the program or organization in question, the following steps should be taken before submitting a complaint to ASHP:

View Steps on Submitting a Formal Complaint

  1. Start by addressing your concern with your program director.  Make sure you are aware of the organization's official policies and procedures and process for filing a complaint or grievance. Follow their processes.
  2. If the efforts above do not resolve the issue, follow the organization's formal grievance or complaint process to raise the complaint to the next level at the organization. (e.g. the director of the pharmacy, school administrator, or human resources department).
  3. If the efforts in a and b above do not resolve the issue, you may contact the Vice President of Accreditation Services Office at ASHP to discuss submitting a formal complaint.  The complaint must directly relate to a specific accreditation requirement (please be prepared to explain which part of the accreditation standard or regulation that is relevant to the complaint).
  4. The name of the complainant shall remain confidential, until the point that a formal complaint has been received by ASHP.
  5. If the complainant has threatened or filed legal action against the program involved, ASHP will not investigate complaints until resolution of the legal action has occurred, after that time the complainant can file the formal complaint with ASHP.
  6. If a decision is made to file a formal complaint, review the information for content of the formal complaint letter below.

If the complainant is someone outside of an ASHP-accredited program, they may contact the Vice President of Accreditation Services at ASHP as the first step in the process.
Vice President of Accreditation Services: 301-664-8873

2. Content of the Formal Complaint

When submitting a complaint that alleges non-compliance with ASHP accreditation standards or regulations, the complaint must be in the form of a written letter complete with signature and date (i.e., not an email) and include the following:

View Content of the Formal Complaint

  1. A description of the alleged specific non-compliance with the accreditation requirements (e.g. what part of the ASHP- accreditation standard or regulation is in non-compliance)
  2. Related circumstances that are the reason for the unresolved complaint that relate directly to the violation of the ASHP-accreditation standard or regulation.
  3. Include related dates and timelines, names of individuals, and programs involved.
  4. Specify steps that were taken to try to resolve the issues within the program or organization.
  5. Copies of any documents that support your complaint.
  6. A statement of the action you are looking for from ASHP.
  7. The name of the program, organization, and address with alleged violation.
  8. Your name, relationship to the program in question, and contact information (phone, email, and address)
  9. Signature and Date of your letter.

Complaints should be addressed to:
Vice President, Accreditation Services Office
American  Society of Health-System Pharmacists
7272 Wisconsin Avenue
Bethesda, MD 20814

3. ASHP Procedures for Processing a Formal Complaint

Upon receipt of a formal complaint:

View ASHP Procedures for Processing a Formal Complaint

  1. The individual sending a formal complaint will receive notification of receipt of the complaint from ASHP Accreditation Services Office within 15 business days of receiving the complaint at ASHP.
  2. The Vice President of Accreditation Services Office shall determine if additional information from the complainant is required.
  3. When sufficient information has been provided, the Vice President of Accreditation Services Office or designee shall review the information to determine if the complaint is related to a specific accreditation standard or regulation.
  4. If the request is determined to not be related to specific ASHP-accreditation standard or regulation requirements and therefore outside the authority of the ASHP Commission on Credentialing, the complainant will receive written notification of that decision.
  5. If the request is related to a specific ASHP standard or regulation, ASHP will contact the program director of the accredited training program in question, requesting a written response to the allegation(s) within 30 days.  The response must be signed by the program director.
  6. Failure of the program director to respond within the established timelines will be considered an indication that the complaint has merit, unless the program director has requested an extension on the deadline.
  7. Information from the complainant and the program's response will be provided to the Commission on Credentialing Complaint Review Committee for further action.

Individuals filing official complaints must understand that once the complaint has become formal the information will be shared with the site. Training program staff will then need to respond with any documentation they have related to the situation.

4. Complaint Review Committee Action

A complaint review committee of the ASHP Commission on Credentialing* will review both the complaint and the program's response to the complaint, and may determine that:

View Complaint Review Committee Action

  1. The response satisfactorily addressed the allegations and no further action is required;
  2. There is validity to the complaint and a subsequent report on correction beyond what the program has provided, is still needed;
  3. There is validity to the complaint and the on site-surveyors shall be directed to investigate the matter at the time of the next (regularly scheduled) site-visit;
  4. The matter is sufficiently serious to warrant a site-visit before the next scheduled visit.
  5. The matter is sufficiently serious to take action at the next ASHP Commission on Credentialing meeting that can change the program's accreditation status.

Following consideration by a complaint review committee, the program director and complainant shall be informed in writing of the complain review committee's decision on the complaint.

5. Confidentiality

The name of the complainant will remain confidential, until a formal written report is received in the ASHP office. At this time the information may be provided to the site to gather more information regarding the situation.

6. Complaint File

During the period when the complaint is being processed, the Vice President of Accreditation Services shall maintain the relevant correspondence in a case file that is separate from the official program file. When the case has been closed, the file shall be referred to the on-site surveyors for review at the next scheduled accreditation survey.