Responding to an ASHP Residency Accreditation Survey Report:

Program Improvement Opportunity

 

Introduction

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If you've had a residency accreditation survey and the survey team left you with a list of findings, don't be discouraged! Not only does your response to the survey report give you an opportunity to help your accreditation status, the process of responding to the report is an opportunity for improvement of the pharmacy and/or residency program, depending on the findings.

 

Accreditation decisions aren't made until your response to the report is received and reviewed. Improvements that you put in place in your pharmacy and residency program, and how you communicate them in your response to the survey report, have a powerful positive influence on your accreditation status. This program will tell you what to do (and NOT do) to ensure program improvement and a positive accreditation status outcome!

 

Objectives

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By the end of this program you will be able to:

1. Explain how your survey report response impacts on pharmacy and program improvement and accreditation status decisions.

2. Identify the types of problems the Commission on Credentialing (COC) commonly sees in responses to survey reports.

3. Explain the processes that occur at the end of a survey and after, including the surveyors report, site response and COC review and accreditation decisions.

4. Describe the importance of, and guidelines for, responding to the survey report, developing an effective response document, including types of appendices and other information to include to address areas of partial and noncompliance.

5. Explain frequent survey findings and how to respond to each, including pharmacy services findings and program findings.

 

 

 

 

 

Why is there a program on how to respond to the survey report?

The Commission on Credentialing Perspective

Program responses to reports sometimes leave the Commission with questions. There is often a large variability in the quality of responses received.

 

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For example, the Commission may find:

- Lack of an action plan to address deficiencies

- Programs sometimes send the same materials - but they don't address the standards of concern.

 

 

 

 

The Program Perspective 

Programs express frustration with understanding how to respond, including continually having to write reports addressing changes.

 

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Programs request more direction about what is wanted by surveyors and the Commission: "Tell us what you want!"

 

This program will address these concerns. We'll start by reviewing what happens at the end of a survey and after. Then we'll cover how your response fits into the process and how to ensure it has a positive impact - and limits future paperwork!

 

 

 

 

What happens at the end of the survey?

 

At the end of the survey, the survey team will present a preliminary review of their survey findings and conduct an exit interview. This is your opportunity for clarification of the surveyors' findings. If you are not sure of the surveyors' intent, feel free to ask for clarification. Ask surveyors to explain how changes could be made in the program for it to fully comply with the standard.

 

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Written Surveyor Report

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You will receive the formal, written survey report within about 30 days of the survey. This report details the areas of partial or non-compliance. The issues identified in the written report should match the information given verbally in the exit interview. The information in the presurvey checklist is utilized in the report. In addition to items describing requirements for compliance with the standards, consultative recommendations are included. While these are not required, they are offered for your consideration based on the surveyors' experience, both as a practitioner and a surveyor, who has had the opportunity to see practices in many sites.

 

 

 

Implementing Improvements: The Key to Your Response

 

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The main point of your response is to make changes to improve areas of partial and non-compliance that were noted during the survey and to describe these improvements in your written response, including evidence to demonstrate the changes you are making. Completed forms, such as resident evaluations, are the best evidence you can include and greatly increase the power of your written response.

 

 

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As you review the survey report and prepare to respond, pay special attention to items identified as "Critical Factors." These are factors that have been determined to be most important and have greater weight in accreditation decisions. It is most important that you address these issues as quickly and effectively as possible.

 

Be sure that your written response is signed by: the RPD, the Pharmacy Director and the CEO.

 

 

 

 

Survey Response Timing

 

Programs surveyed between June 1st and November 30th are reviewed at the March Commission on Credentialing (COC) meeting.  Programs surveyed between December 1st and May 31st are reviewed at the August COC meeting. The COC decision is forwarded to the site within 45 days (after ASHP Board approval).

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How the Commission on Credentialing Makes Accreditation Decisions

What happens at COC meetings and how are accreditation decisions made? The Commission ensures that the survey report and the program's written response for each program is reviewed in detail by multiple Commission members. The surveyors who conducted the site visit are available to answer questions.

 

Based on this review and discussion, the accreditation status and length are determined. For accreditation status, a program can be accredited or not accredited. The length of accreditation can be a maximum of six years. The Commission may also decide to grant accreditation for two years, three years or one year, and occasionally another length of accreditation.

 

Your responses to each of the surveyor findings are important in the Commission's decisions. Based on your response to a finding, it may be considered resolved. You can demonstrate that a finding is resolved if you have implemented and documented changes that demonstrate that 100% compliance is now in place. The Commission will notify you of findings considered "resolved" and there is no need to respond to resolved findings in subsequent reports!

 

 

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Check Up!

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Before we go on, take this opportunity to check your understanding so far. Try these questions:

 

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Guidelines for Preparing Your Written Response

Here is an excerpt from a sample response report:

 

XYZ General Hospital (#12345)

Residency Accreditation Survey Response

 Areas of Noncompliance

 

Finding

#

Statement of Partial or Non Compliance

Action Plan or Description of Resolution

(include date of plan or resolution)

Appendices

 

NC-1

 

Preceptors do not have descriptions of their learning experiences, including a list of activities to be performed by residents to facilitate achievement of educational goals and objectives.  Further, educational goals documented in learning experience descriptions should be consistent with the educational goals assigned to each learning experience in the design of the residency program.  [Item 4.1d]

 

 

COMPLETED (March 2011)

Item 4.1d of the accreditation standard was shared with preceptors at the monthly Residency Advisory Committee (RAC) meeting.

 

The example of the learning experience description included in the Residency Learning Workshop materials at the ASHP Midyear Clinical Meeting was reviewed at the RAC meeting, as well.

 

Learning experience descriptions were drafted by each preceptor, in accordance with the RLS example, and reviewed and edited by the residency program director (RPD), as well as other clinical preceptors via a peer review process.

 

Finalized learning experience descriptions to be included in the residency manual distributed to each resident at the beginning of the residency.

 

 

 

Appendix A:  Example of the Internal Medicine learning experience description

 

 Although this report format is not required, the elements included in this sample are needed for the survey team and the COC to review the progress of your program. Of particular importance:

 

Timing: You have 75 days from the end of the survey to respond to the report.

 

Key Points:

- Describe progress made in implementing remedies since the survey

- Describe specific changes

- Include time of implementation

- For changes that have not yet occurred, but are planned, include timeline and responsible individual.

 

Last, although it is not required, you are encouraged to respond to the consultative recommendations.

 

 

 

 

 

 

Why is it important to write a good survey response?

 

Writing a good survey response affects your accreditation status. In addition, it can reduce the number of findings that need a response. As described in the previous section, resolving as many findings as possible in your response will save you paperwork later in the process since you will no longer need to respond to them later.

 

 

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Most Frequent Findings, How to Respond - And NOT Respond!

Review some of the most frequent findings listed below. As you review the frequent findings, reflect on how your program is doing in these areas.

Most Frequent Pharmacy Service Findings

- Sterile Product preparation area(s)

- Safe, effective drug distribution system

- Written responses, retrieval & QA of drug information requests

- Facilities (space, workflow)

- Computerized systems support of a safe-medication use system

- Direct patient care services

 

Most Frequent PGY1 Residency Program Findings

- Documentation of prolonged leave of the resident

- Preceptor contribution to the total body of pharmacy knowledge

- Resident customized plan

- Preceptorship

- Written assessment / evaluation strategy

- Resident self-evaluations

- Practice Management experience

 

Most Frequent PGY2 Residency Program Findings

- Individual resident plan

- Completion of PGY1 residency or equivalent experience

- Individualized goals and objectives

- Resident self-evaluation

- Routine evaluation of resident

 

 

 

How to Respond

In addressing how to respond, first review the list of words and phrases to use and avoid below. Then you'll see excerpts demonstrating how to respond (and not respond) to parts of a survey report. Finally, you'll be able to click on a link showing an of example of an entire response report, as well as a follow-up response report.

Words for Success
(OR NOT)

Here is what NOT to say!

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"It is anticipated…"

"Will be focus of discussion"

"It is hoped…"

"If…, it may be possible to…"

"Have attempted to address"

"We encourage"

"Soon"

"It's in ResiTrakTM."

Notice that these responses are vague or unsubstantiated.

 

 

 

 

Words for Success

YES! Say this:

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"The plan is…"

"The timeline for implementation is as follows:…"

"We have implemented…"

"We have revised…"

"We are addressing this issue by…"

"The RPD has ensured...."

"We have approved....."

 

 

Notice how much more specific these responses are!

 

 

 

 

Excerpts Demonstrating How to Respond (and Not Respond) to Parts of a Survey Report

 

Pharmacy Service Example 1

Area of Partial Compliance

PC-1: Safeguards that ensure the integrity of all drugs to the point of administration to patients are not maintained consistently (e.g., lack of complete unit dose distribution to the NICU and emergency department).

 

What's wrong with these response comments?

"Minimizing the number of medications mixed on the floors has been a focus of discussion."

 "It is hoped that a new pharmaceutical care liaison will be in place soon to assist in addressing these issues." 

 "If the hospital is able to implement xxx, it will be possible to divert more pharmacy time to mixing specific doses for the pediatric areas."

 

These responses are vague and lack a commitment to action. Decisions made and plans for their implementation are needed, rather than "focus of discussion," descriptions of "hopes" or "if's."

 

Review the response below for an example that follows guidelines:

 

How to Respond

Areas of partial compliance:

1. Safeguards that ensure the integrity of all drugs to the point of administration to patients are not maintained consistently (e.g., lack of complete unit dose distribution to the NICU and emergency department).

a. Action Plan is as follows:

NICU, Emergency Department

Timeline for Implementation: NICU:   October 2011, ED:   November 2011

NICU Action Plan:

Committee comprised of Pharmacy Director, Nurse Manager, Medical Director, staff RPh, staff RN formed May 2011

Plan is for all non-emergency drugs to be dispensed by pharmacy in unit-dose packaging by October 2011.

Progress to date:

- New emergency floor stock list developed

- Policy developed

- Pharmacist, Pharmacy Technician and Nurse training currently under development

- Training planned for September

- Implementation: October 1, 2011

See appendices:

- Revised emergency floor stock list

- New Policy

 

Why is this response more effective? Notice the specificity, complete with examples demonstrating actions taken. Rather than describing hopes, discussions or contingencies, this response describes actions and decisions and provides documentation to demonstrate their implementation.

 

Pharmacy Service Example 2

Area of Partial Compliance

PC -7: Sterile product preparation areas to do not meet USP 797 requirements.  The area is cluttered with numerous cardboard boxes.  There is no IV Room dress code.  There is frequent unnecessary traffic in the sterile preparation areas.

 

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What NOT to say

"Our hospital pharmacy was constructed in 1970.  We hope to get a new pharmacy and IV room in 2012 when a new building is planned.  All issues will hopefully be addressed at that time."

 

What to Say

Area of partial compliance:

 

PC-7: Sterile product preparation areas to do not meet USP 797 requirements.  The area is cluttered with numerous cardboard boxes.  There is no IV Room dress code.  There is frequent unnecessary traffic in the sterile preparation areas.

Actions Taken:

- USP 797 gap analysis completed in November 2010

- Area was fully cleaned in December 2010

- All cardboard was removed from the area in December 2010

- All staff have documented competency in IV Preparation – April 2011

- IV Room dress code implemented in April 2011

- Environmental monitoring implemented – May 2011

Actions Planned:

- Minor renovation is budgeted and scheduled to be completed in July 2011 to minimize traffic in the area

- New IV room meeting all requirements approved for inclusion in 2011 hospital construction

- Cindy Supervisor assigned responsibility for oversight of Sterile Product Prep and USP 797

 

 

 

Residency Program Example 1

Area of Partial Compliance 

PC-3: Written evaluations of resident performance have not been conducted routinely for all learning experiences.

 

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What NOT to say

"…In an effort to improve the use of snap-shot evaluations, pre-printed versions were developed and tested last year, with some success…"

"We've reminded preceptors of their responsibility to complete evaluations."

 

What to Say

"…In an effort to improve the use of snap-shot evaluations, pre-printed versions were developed and tested in the 2004-05 yr. 

They were used routinely by most preceptors; however, there were 2 preceptors (critical care, pediatrics) who did not... 

The RPD has reviewed this issue with the 2 preceptors and is ensuring this issue is addressed on their rotations in the 2005-2006 residency year…

An example of a snap-shot used in the critical care rotation in November 2005 is attached as Appendix…"

"We have incorporated timely and effective completion of evaluations into our performance appraisal process."

 

 

 

 

Residency Program Example 2

Area of Partial Compliance

PC-2: Not all residency preceptors have a record of contributing to the total body of knowledge in pharmacy practice through publication … presentations at professional meetings.  Further, some preceptors have not demonstrated leadership in advancing the profession of pharmacy through active participation…

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What NOT to say

"All preceptors are encouraged to do presentations at national meetings as well as publish their work in journals.  This year we have been short staffed but we hope to do more of this next year.  We also encourage our preceptors to participate in professional organizations."

 

What to Say

"At the time of survey 4 of 6 preceptors had not had any recent presentations or publications.  In addition 3 of 6 preceptors were not members of a professional organization. 

Since the survey, 4 preceptors have had a total 4 posters and 1 podium presentation at National Meetings. 

All of our preceptors are now members in a professional organization. 

Joe Preceptor has been appointed to an ASHP Council.

The list of presentations are attached in Appendix _."

 

 

Entire Response Examples

Review an example of an entire response report that meets guidelines for an effective response by clicking on the link below.

 

Click here for the example.

 

Click on the next link to see the follow-up report given by the same example.

 

Click here for the example.

 

Click on this link to see Appendix A, referenced in the response example(s) in the above link(s).

Appendix A

 

Click on this link to see Appendix B, referenced in the response example(s) in the above link(s).

 

Appendix B

 

Click on this link to see Appendix C, referenced in the response example(s) in the above link(s).

 

Appendix C 

 

The format in the examples is not required. However, you should include the information in the categories named in each column.

 

 

 

What if you don't agree with some part of the standards?

 

Comments and suggestions for the next revision of the standards should be sent to asd@ashp.org with "Comments on Standards" in the subject line of the email.

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Keep in mind that it is not within the power of the survey team to change the standards. The survey team's job is to review programs against the current standards. Only the Commission on Credentialing with the approval of the ASHP Board of Directors can approve changes to the standards. The standards are revised about every six years.

 

With this in mind, making suggestions or voicing concerns about the standards will have the greatest impact if you contact ASHP directly as described above rather than taking time during the survey for this purpose. Your comments will be considered during the next revision to the standards.

 

 

 

Keys to Success

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Here are some extra tips to give your response a boost!

 

- Resolve simple issues immediately

- Address the areas of non or partial compliance – don't talk around the issue

- Get clarification if needed

- Don't make excuses

- Be succinct

- Provide specific action plan

- Share specific timeline

- Assign responsible person

- Provide actual examples

- Provide statistics if appropriate

 

 

 

Try a few more questions:

 

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For future reports...

 

Going beyond the initial response to the survey report, in future reports the important point is to:

 

- Show progress!!!

 

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- Time passes quickly so...

 

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- Follow these tips to stay on track!

 

 

 

 

Good luck with your survey, response and program!

 

 

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Thanks for the content and development of this program go to:

Alison L. Apple, B.S., M.S., Director of Pharmacy, Methodist University Hospital, Memphis, TN,

Commission on Credentialing Chair, 2010