ASHP/ACPE Regulations on Accreditation of Pharmacy Technician Education and Training Programs
Pharmacists have long recognized the need for a corps of technically trained personnel in the profession of pharmacy. This need arises from the fact that the practice of pharmacy encompasses a complex set of tasks in a wide array of environments, some of which require the knowledge and judgment of a pharmacist but many others that do not. Increased utilization of well-trained and appropriately supervised technicians is a key component of pharmacy&rquo;s strategy for moving beyond its traditional functions. By delegating routine tasks to adequately trained technicians, pharmacists have more time to help patients solve medication-related problems. The long-term development of a well-defined group of technical personnel in pharmacy depends on appropriate training for technicians, which in turn requires an ample number of training programs with clear training goals, along with efficient and effective teaching methods. ASHP supports the use of qualified technicians in all pharmacy settings; further, ASHP recognizes an obligation to develop and endorse standards for the training of such personnel. To facilitate a continuing supply of well-qualified technicians for pharmacy practice, an accreditation program is conducted by ASHP.
Accreditation: the act of granting approval to a program conducting pharmacy technician training after the program has met requirements and has been reviewed and evaluated through an official process (document review, site survey, and review and evaluation by the Commission on Credentialing).
Candidate: the status granted to a program that has applied to ASHP for accreditation and is awaiting the official site survey, and review and evaluation by the Commission on Credentialing.
Commission: The accreditation review body (referred to as “The Commission” in the rest of this document).
Objectives of the accreditation program include the following:
- to upgrade and standardize the formal training that pharmacy technicians receive;
- to guide, assist, and recognize those health systems and academic institutions that operate such programs;
- to provide criteria for the prospective technician trainee in the selection of a program by
identifying accredited pharmacy technician training programs;
- to provide pharmacies a basis for determining the level of competency of pharmacy technicians by identifying those technicians who have completed accredited pharmacy technician training programs; and,
- to assist in the advancement and professional development of pharmacy technicians.
The program for accreditation of pharmacy technician training programs is established by the authority of the Board of Directors of ASHP and is implemented by the Commission. All matters of policy relating to the accreditation of programs will be submitted for approval to the ASHP Board of Directors. The Commission shall review and evaluate applications and survey reports submitted and shall be authorized to take action on all applications for accreditation, in accordance with the policies and procedures set forth herein. The minutes of the Commission shall be submitted to the Board of Directors for review and action as appropriate.
V. Initial Accreditation Procedures
The accreditation program shall be conducted as a service of ASHP to any organization voluntarily requesting evaluation of its pharmacy technician training program.
- Application forms are available on the ASHP Website (www.ashp.org) or may be requested from: American Society of Health-System Pharmacists, Director, Accreditation Services Division, 7272 Wisconsin Avenue, Bethesda, MD 20814. The application must be signed by the pharmacy technician training program director, the senior administrator or manager to whom the technician training program director reports, and the organization’s chief executive officer. Applications should be submitted, along with the supporting documents specified in the application instructions, to ASHP’s Director, Accreditation Services Division. A duplicate copy should be retained for the applicant’s files.
- The Director, Accreditation Services Division, or designee of ASD, will acknowledge receipt of the application, and may review it for completeness and to make a preliminary judgment about conformance to the basic requirements of the accreditation standard. If the Director or designee thinks that the program fails to meet the criteria of the accreditation standard in some fundamental way, he/she will notify the signatories of the application accordingly and advise against scheduling a site visit until the fundamental deficiencies have been corrected. The applicant is not bound, however, to accept the Director’s advice to delay the site survey.
- From the point a program has submitted an application, the program will be in a candidate status.
- To apply for candidate status, a student must be in training, but not sooner.
- Site Survey
- A survey will not be done until at least one student has completed all requirements for graduation. The survey team shall consist of at least two individuals, one of whom shall be ASHP’s Director, Accreditation Services Division, or his/her designee. The second surveyor may be a member of the Commission on Credentialing or an individual designated by the Director, Accreditation Services Division.
- Upon the selection of the survey team, surveyors and programs must disclose potential conflict(s) of interest to ASHP’s Director, Accreditation Services Division, who shall take appropriate actions to manage any conflicts(s).
- At an agreed upon time ASHP will send the survey team to review the technician training program. Instructions for preparation for the site survey (e.g., list of documents to be made available to the survey team and suggested itinerary for the surveyors) will be sent to the technician training program director well in advance of the site survey. The site survey is typically conducted in the equivalent of one working day. Programs that cancel the survey may be billed for the survey.
- At least one current student and at least one graduate must be available on-site during the accreditation survey. Others that must be available include the Advisory Committee (e.g., pharmacy and pharmacy technician stakeholders not employed by the organization), a representative from program administration, program faculty, and the program director.
- All records (e.g., copies of the evaluations, learning materials, student files, tests) for students trained by a program undergoing an accreditation survey must be maintained and available to the survey team for review.
- After concluding its site survey, the survey team will present a verbal report of its findings to the pharmacy technician training program director, the senior administrator or manager to whom the technician training program director reports, the organization’s president and anyone else selected by the technician training program director.
- The Survey Report and Follow-Up
- Following the site survey, the survey team will prepare a written report, citing areas of noncompliance, partial compliance, and consultative recommendations. The report will be sent to the pharmacy technician training program director, the senior administrator or manager to whom the technician training program director reports, and the organization’s chief executive officer. This report will be sent to the site electronically within 30 days of the onsite survey.
- The pharmacy technician training program director must respond to ASHP with an action plan outlining how the program will address areas of noncompliance and partial compliance. This must be submitted within 45 days of receiving the electronic copy from ASHP. This action plan will be signed by the pharmacy technician training program director, the senior administrator or manager to whom the technician training program director reports, and the organization’s chief executive officer.
- Any comments that individuals from the program wish to make regarding the accuracy of the survey report must be submitted to the Director, Accreditation Services Division, within 45 days of receiving the report. Comments regarding the report must set forth the specific reasons for the disagreement with the survey report.
- The program’s accreditation application file, the surveyors’ report and comments received from the program in response to the surveyors’ findings will be reviewed by the Commission.
- Notice of action taken regarding accreditation status will be sent to the pharmacy technician training program director, the chief executive officer after the Board of Directors has reviewed and accepted the Commission voted actions in the meeting minutes. The report will indicate that the ASHP has acted either (1) to accredit the program for a period not to exceed 6 years or (2) to withhold accreditation. Additional reports to monitor compliance with the accreditation standard may be requested at this time.
- A decision on accreditation status may be deferred if insufficient information is provided in the survey response.
- To be eligible for accreditation, a program must have graduated its first class.
- If accreditation is granted, it shall be retroactive to the date on which ASHP’s Director, Accreditation Services Division, received a valid and complete application for accreditation in candidate status.
- Failure of the program to submit reports and/or submit appropriate annual fees as requested may result in accreditation being withheld.
- A program granted accreditation will continue in an accredited status until the Commission recommends further action.
- A certificate of accreditation will be issued to a program that has become accredited. The certificate cannot be used after accreditation has been discontinued.
- Once the program is accredited, any reference by the program to accreditation by ASHP in technician training program promotional materials (e.g., catalogs, bulletins, web sites, or other form of publicity) may include the ASHP-accredited logo (available on the ASHP website) in conjunction with the following statement: The pharmacy technician training program conducted by (name of the organization, city, state) is accredited by the American Society of Health-System Pharmacists.
- Formal program documents, including the certificate issued to graduates, must make reference to the fact that the program is accredited by ASHP. The program category must be stated as specified in the program’s certificate of accreditation. The use of the ASHP-accredited logo on certificates is encouraged.
VI. Continuing Accreditation
- ASHP regards evaluation of accredited pharmacy technician training programs as a continuous process; accordingly, the Commission shall request that directors of accredited programs submit periodic status reports to assist the Commission in evaluating the continued conformance of individual programs to the accreditation standard. Reports shall be required from program directors at least every 3 years. To maintain accreditation, programs must comply with all requests from ASHP for reports.
- Organizations must notify ASHP’s Director, Accreditation Services Division, of changes to leadership in the pharmacy technician training program (i.e., changes in pharmacy technician training program director or administrator, name of organization, and change in accreditation status with another organization), content and construct of the program, and organizational ownership and accreditation within 30 days of the change. Any substantial change in the organization of a program or lack of timely notification may be considered justification for re-evaluation of the program and/or a site survey.
- The Commission will evaluate the credentials of each new pharmacy technician training program director using the requirements outlined in the accreditation standard, and ASHP will notify the site regarding the results of the evaluation.
- When requested, the pharmacy technician training program director must provide ASHP’s Director, Accreditation Services Division, a list of names of graduates who have completed the program’s requirements that year.
- Accredited programs will be re-examined by site survey every 6 years.
- At least one current student, graduate, the advisory committee, program instructors, a representative from program administration, program faculty and the program director must be available on-site during the reaccreditation survey.
- All records (e.g., copies of evaluations, student files, teaching materials) for students trained by an ASHP-accredited program must be maintained for three years and available to the survey team for review.
- The length of time that accreditation may be granted to a program is 6 years (full-cycle) or a fraction thereof (e.g., 1 year, 3 year).
- The Commission, on behalf of ASHP, may request reports at any time between the 6-year site survey intervals. Failure of the program to submit reports as requested may result in reaccreditation being withheld or accreditation withdrawn.
- In the event that the accreditation standard is revised, all accredited programs will be expected to be compliant within one year of approval or as determined by the Commission.
VIII. Quality Improvement
Following a site survey, ASHP’s Director, Accreditation Services Division, will send the program director a thank-you letter and a site survey evaluation form. This is an opportunity for the program director and administrator to provide feedback on the survey process and information for quality improvement. Programs may submit constructive verbal or written comments to ASHP at any time.
IX. Accreditation Fees
- An application fee shall be established by ASHP and shall be assessed to the program at the time of initial application for accreditation.
- An annual accreditation fee, established by ASHP, shall be assessed for accredited and application-submitted pharmacy technician training programs. The annual fee is based on a calendar year. This fee begins as soon as a program has filed an application for accreditation (it will be prorated for the first year, based on the number of months remaining in the year, from point of application).
X. Withdrawal of Accreditation
- Accreditation of a program may be withdrawn by ASHP for any of the reasons stated below:
- Accredited programs that no longer meet the requirements of the applicable accreditation standard(s) shall have accreditation withdrawn;
- Accredited programs without a student in training for a period of 3 consecutive years shall have accreditation withdrawn at the beginning of the fourth year without a student;
- A program makes false or misleading statements about the status, condition, or category of its accreditation;
- An accredited program that fails to submit periodic written status reports as requested;
- A program that fails to submit appropriate annual accreditation fees as invoiced.
- ASHP shall not withdraw accreditation without first notifying the pharmacy technician training program director of the specific reasons. The program shall be granted an appropriate period of time to correct the deficiencies.
- Withdrawal of program accreditation may occur at any point during a training session.
- The program shall have the right to appeal the decision of the Commission.
- If accreditation is withdrawn, to regain accreditation the program may submit a new application and must undergo re-evaluation.
- Programs may voluntarily withdraw from the accreditation process and/or forfeit accreditation at any time by notifying the Director, Accreditation Services Division, in writing. When notified, the Director, Accreditation Services Division, will report these programs to the Commission and the ASHP Board.
XI. Appeal of Decision
- Notification of Intent to Appeal. In the event that a program is not accredited or reaccredited, or if accreditation is withdrawn, the pharmacy technician training program director, the senior administrator or manager to whom the technician training program director reports, or the organization’s chief executive officer (hereafter referred to as the appellants) may appeal the decision to an appeal board on the grounds that the accreditation decision was arbitrary, prejudiced, biased, capricious, or based on incorrect application of the standard to the program. An appellant must notify the Director, Accreditation Services Division, of the program’s intent to appeal, by registered or certified mail, within 10 business days after receipt of the notice. The appellant must state clearly the grounds upon which the appeal is being made. The appellant shall then have an additional 30 days to prepare for its presentation to an appeal board.
- Appeal Board. On receipt of an appeal notice, the Director, Accreditation Services Division, shall contact the ASHP General Counsel. The office of the ASHP General Counsel will proceed to constitute an ad hoc appeal board. The appeal board shall consist of one member of ASHP’s Board of Directors, to be appointed by the President of ASHP, who shall serve as Chair, and two program directors of accredited pharmacy technician training programs, neither of whom is a member of the Commission, one to be recommended by the appellant and one by the Chair of the Commission. The President of ASHP will appoint a school or health care administrator in an ex officio, nonvoting capacity. The General Counsel of ASHP shall serve as Secretary of the appeal board. The Director, Accreditation Services Division, shall represent the Commission at the hearing in an ex officio, non-voting capacity. As soon as recommendations for appointments to the appeal board have been made, ASHP General Counsel will contact all parties to confirm their appointment and a hearing date. The ASHP General Counsel will immediately forward copies of all of the written documentation considered by the Commission in rendering its decision to the ASHP Board of Directors. ASHP General Counsel will send the documentation to the appeal board members.
- Potential Conflict of Interest. All members of the appeal board will complete an ASHP
“Disclosure Report” form regarding professional and business interests prior to formal appointment to the appeal board. The appeal board Chair will take appropriate action to manage potential conflicts.
- The Hearing. The appeal board shall be convened in no less than 30 days and no more than 60 days from the date of receipt of an appeal notice by the Director, Accreditation Services Division. ASHP General Counsel shall notify appellants and appeal board members, at least 30 days in advance, of the date, time, and place of the hearing. The program filing the appeal may be represented at the hearing by one or more appropriate officials and shall be given the opportunity at such hearing to present written, or written and oral, evidence and arguments intended to refute or overcome the findings and decision of the Commission. The appeal board shall advise the appellant organization of the appeal boardâ€™s decision, by registered or certified mail, within 10 business days of the date of the hearing. The decision of the appeal board shall be final and binding on both the appellant and ASHP.
- Appeal Board Expenses. The appellant shall be responsible for all expenses incurred by its own representatives at the appeal board hearing and shall pay all reasonable travel, living, and incidental expenses incurred by its appointee to the appeal board. Expenses incurred by the board member, the Commission-selected program director, and school or healthcare administrator shall be borne by ASHP.
Approved by the ASHP Board of Directors on September 20, 2013. Approved by the ASHP Commission on Credentialing on August 18, 2013. Supersedes the previous regulations on accreditation approved on September 26, 2003.
Copyright 2013, American Society of Health-System Pharmacists, Inc. All rights reserved.