The American Society of Health-System Pharmacists (ASHP) 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 a resident or pharmacy technician education and training student 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, program directors, faculty members, students or residents regarding human resource issues (e.g., retention, appointment, promotion or dismissal).
ASHP accredited residency or pharmacy education and 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, students, and preceptors) 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 solely by email 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:
Steps on Submitting a Formal Complaint
- 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.
- 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).
- 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).
- The name of the complainant shall remain confidential, until the point that a formal complaint has been received by ASHP.
- 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.
- 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.
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:
Content of the Formal Complaint
- 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)
- Related circumstances that are the reason for the unresolved complaint that relate directly to the violation of the ASHP-accreditation standard or regulation.
- Include related dates and timelines, names of individuals, and programs involved.
- Specify steps that were taken to try to resolve the issues within the program or organization.
- Copies of any documents that support your complaint.
- A statement of the action you are looking for from ASHP.
- The name of the program, organization, and address with alleged violation.
- Your name, relationship to the program in question, and contact information (phone, email, and address)
- Signature and Date of your letter.
Complaints should be addressed to:
Janet Silvester, Pharm.D., MBA, FASHP
Vice President, Accreditation Services Office
American Society of Health-System Pharmacists
4500 East West Highway, Suite 900
Bethesda, MD 20814
3. ASHP Procedures for Processing a Formal Complaint
Upon receipt of a formal complaint:
ASHP Procedures for Processing a Formal Complaint
- 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.
- The Vice President of Accreditation Services Office shall determine if additional information from the complainant is required.
- 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.
- If the complaint 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.
- If the complaint is related to a specific ASHP standard(s) or regulation(s), ASHP will contact the program director and the organization’s administrator of the accredited or accreditation-pending training program in question, requesting a written response to the allegation(s) within 30 days. The response must be signed by the program director and the organization’s administrator.
- 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.
- Information from the complainant and the program's response will be provided to the Commission on Credentialing or Pharmacy Technician Accreditation Commission 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* or Pharmacy Technician Accreditation Commission* will review both the complaint and the program's response to the complaint, and may determine that:
Complaint Review Committee Action
- The response satisfactorily addressed the allegations and no further action is required;
- There is validity to the complaint and a subsequent report on correction beyond what the program has provided, is still needed;
- There is validity to the complaint and the onsite-surveyors shall be directed to investigate the matter at the time of the next (regularly scheduled) site-visit;
- The matter is sufficiently serious to warrant a site-visit before the next scheduled visit and will be at the program’s expense;
- The matter is sufficiently serious to take action at the next ASHP Commission on Credentialing (COC) or Pharmacy Technician Accreditation Commission (PTAC) meeting that can change the program's accreditation status.
- The matter is sufficiently serious to take action to revoke and reject the application for accreditation any program in pre-candidate and candidate phase of accreditation. Reapplication for accreditation will be determined by the COC or PTAC.
Following consideration by a complaint review committee, the program director and complainant shall be informed in writing of the COC or PTAC complaint review committee's decision on the complaint. The COC or PTAC complaint review committee’s decision on the complaint is final and may not be appealed by either the complainant or the program director.
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. A copy of the site’s response will be provided to the complainant unless the site provides compelling reasons for maintaining the confidentiality of its response. In such case, the site shall provide two versions of the response to ASHP. The second version shall be the response with any confidential information redacted. The site shall additionally indicate the reasons for any proposed redaction. The final decision as to whether and to what extent the proposed redacted version is provided to the complainant shall be solely that of ASHP.
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.*The complaint review committee of the ASHP Commission on Credentialing or Pharmacy Technician Accreditation Committee will consist of a minimum of (but not limited to) three individuals, the Chair of the COC or PTAC, the Past Chair, or Vice Chair: the respective accreditation services director (or designee); and a lead surveyor. Reviews may occur through conference calls to expedite decisions.