Adaptable, Consultative, Respected
ASHP pharmacy services accreditation applies ASHP standards in an accreditation process that brings ASHP’s pharmacy knowledge and accreditation expertise in to your pharmacy organization. These standards reflect national quality initiatives and contemporary and future practices. The process is designed to be easy to understand, flexible, and consultative in nature. The accreditation process can be tailored to different models of care. Accreditation focuses on optimal delivery of pharmacy care.
Successful accreditation signifies to payers, patients, and other healthcare providers that the pharmacy provides an advanced level of high-quality, safe, and efficient patient care in a predictable and measurable way.
The community and outpatient pharmacy practice standards outline specific performance areas for community and outpatient pharmacy practices to achieve accreditation. The standards focus on three domains:
1.0 Practice Management
2.0 Patient Care Services
3.0 Quality Improvement
Within each standard domain are key standards that demonstrate competency in the identified area of community and outpatient pharmacy practice. The accompanying narrative for each standard describes the specific criteria for ASHP evaluation of the community or outpatient pharmacy practice to determine consistency with the standards for accreditation within the overall management of medications and clinical pharmacy management of patients. The document also includes published best practices and related professional standards.
All standards are required for accreditation except those designated as a "goal." Accredited practices will be expected to work toward these goals. As best practices evolve and become more prevalent, standards currently designated as goals will be required for accreditation.
In order to receive accreditation, patient care and dispensing services provided by the pharmacy practice must demonstrate compliance with applicable state and national regulatory requirements and/or standards established by a recognized organization appropriate for the services provided.
Standard Domain 1: Practice Management
The pharmacy practice is appropriately managed to allow for safe and effective delivery of services.
- Organizational structure
- Staffing to deliver quality services
- Environment for service delivery
- Information systems and technology
- Interoperability of health information system
- Integrity and privacy of patient information and data
Standard Domain 2: Patient Care Services
The pharmacy practice provides patient-centered services.
- Criteria for patient care services
- Medication therapy management services
- Other patient care services
- Proactive patient counseling
- Staff training and professional development
- Process for evaluating patient care services (Goal)
Standard Domain 3: Quality Improvement
The pharmacy practice operates a continuous quality improvement (CQI) program to enhance patient safety.
- Operation of a CQI program
- Training and education of staff on CQI initiatives
- Patient feedback to improve patient satisfaction and outcomes of care
The Community and Outpatient Pharmacy Practice Standard Self-Assessment will assist the practice in preparing for accreditation. The practice can rate their status on each standard as "meets the standard" (M), "likely to meet standard with minor changes" (LM), and "requires process or procedure development" (PD). The practice can use this spreadsheet to then determine Detailed Action Plans and track Next Steps towards meeting each of the community and outpatient pharmacy practice standards.
Accreditation is the process by which ASHP will assess your pharmacy’s level of performance in relation to the established accreditation standard and will create ways to continuously improve. It takes roughly 8 to 10 months, and consists of the following steps:
Review the accreditation standards and other materials on the ASHP website. A conference call will be scheduled to review the standards and discuss the accreditation process. ASHP will send a proposed timeline for the accreditation process and a pricing proposal for the community and outpatient pharmacy practice accreditation based on the needs and the structure of the organization.
A self-assessment is provided to interested community and outpatient pharmacy practices. Community and outpatient pharmacy practices may also choose to seek consultation to assess pharmacy practice readiness for accreditation. ASHP Consulting provides an on-site readiness assessment that includes advice on how to improve pharmacy services and prepare for the accreditation survey. Consultation can include a mock accreditation survey. Please contact ASHP Consulting by email at [email protected], and view its complement of services.
- Self-Assessment Document (.docx)
ASHP will prepare a Letter of Agreement (LOA), including the accepted pricing proposal, and provide a Business Associate Agreement (BAA) for signature by the community or outpatient pharmacy and ASHP.
ASHP will also send an invoice for the fees according to the following schedule:
- A one-time application fee
- A one-time accreditation fee
- Year One participation fee(s)
Complete the application and supplemental documentation. Supplemental documentation includes business and ownership information, personnel, and facility licensure. Email your completed application and supplemental documentation to [email protected] ASHP will review the application and verify receipt of signed LOA/BAA, and payment of invoice. After your application and supplemental documentation have been processed, you will receive a welcome letter signifying the commencement of the accreditation process.
A surveyor or surveyor team will be assigned to your pharmacy and you will receive the Document Assessment Checklist. The Document Assessment Checklist is a tool provided for self-reporting policies and procedures and demonstrating compliance with the standards. It will assist you in collecting and organizing policies and procedures for submission.
- The completed Document Assessment Checklist and the referenced policies and procedures should be submitted to our secure electronic location specific to your pharmacy within 90 days of receiving the assessment checklist.
- The checklist, your policies and procedures, and other supporting documentation will be reviewed by the survey team within 4-6 weeks, and you will receive a written report noting whether any policies, procedures, or other documentation are missing or require clarification.
- Your surveyor(s) will schedule a conference call with you and your team to discuss the report and any questions, as well as to plan for the on-site survey.
Your surveyor notifies you of survey readiness. Your survey will occur within six weeks of this notification. The survey is unannounced. You may request dates to be avoided for the site survey. These requests must be submitted as early in the accreditation process as possible to be given consideration. When possible, these requested dates will be avoided; however, this cannot be guaranteed. (For multisite organizations, a headquarters survey is scheduled followed by unannounced surveys at additional sites).
You will receive a general survey plan from your surveyor. The surveyor will be a pharmacist, and will arrive at the pharmacy during normal business hours. Surveyors are sensitive to the business of the pharmacy practice, recognizing your need to take care of patients. Surveyors typically avoid Monday mornings and the day immediately before or after a holiday.
During the on-site survey, the survey team will:
- review and tour all pharmacy operations and patient care areas
- review patient records for compliance with policies, procedures, and documentation
- observe patient care services being performed (where appropriate)
- interview senior management and other staff members (where appropriate)
- ask questions of personnel concerning their duties and responsibilities relating to their roles in the delivery of pharmacy services to patients and other health care professionals, and their adherence to policies and procedures.
The survey team will converse with you throughout the survey and at the close of the survey will provide a verbal report of your best practices, consultative suggestions, and any areas of partial and/or non-compliance with the standards.
A written survey report will be sent to the Pharmacy Manager within 30 days following the on-site survey. The report will reiterate your best practices, consultative suggestions, and state either that your survey is complete or that there are outstanding items to address for compliance with the standards. Within 30 days of receipt of the report, a written response with a plan of corrective action and timeline for any non-compliant standards is required. The action plan and timeline will be reviewed by the survey team and may require additional information, with evidence of completion, as determined by the survey team. Any required action plan reports must be provided, according to the accepted timeline, until all plans are complete. You will be notified when your pharmacy practice is eligible for an accreditation decision.
The programs' survey findings, final action plan with responses, and timeline will be reviewed by the survey team and the ASHP Accreditation Commission. If appropriate, the Commission will recommend accreditation of the program to the ASHP Board of Directors. The ASHP Board of Directors will consider the recommendation and make their decision regarding accreditation of the community pharmacy practice. The accreditation term is three years.
You are notified of the accreditation decision in writing. When you achieve accreditation status, you will receive a formal accreditation letter accreditation certificate, digital files with the accreditation seal, and guidelines for use of the seal.
Ongoing Accreditation Requirements
Annual reports are required for every accredited pharmacy practice and are reviewed by the ASHP Accreditation Commission and Office of Practice Advancement. More frequent reports may be requested in the judgement of the Commission.
Reaccreditation occurs every three years, repeating the accreditation process as described.