Lead Surveyor Training

Module 1: Introduction

Welcome to ASHP as a Lead Surveyor for the Accreditation Services Division (ASD)! As a lead surveyor, you're joining a team helping organizations improve residency training, and the practice of pharmacy, throughout the nation. Thanks for joining this gratifying and worthwhile mission!

This series of online modules is designed to help you get the basics under your belt. You will also have the opportunity to meet with other lead surveyors to learn from their experiences. Most importantly, you'll observe on surveys, gradually taking increased responsiblity for whole surveys and survey teams.

This is the introductory module. Here are the objectives:

Module One: Introduction

1. Define accreditation and the accreditation process.
2. Describe the role of the lead surveyor and the members of the survey team in the accreditation process.
3. Describe materials with which the lead surveyor must be thoroughly familiar in preparation for the survey process.  
4. Define and identify "critical factors" and "consistency criteria" and their importance and role in the survey process.
5. Identify parts of the standards that are "frequent findings."
6. Explain ASHP policies on disclosure and conflict of interest.

Accreditation 101

The formal definition of accreditation, from the "ASHP Regulations on Accreditation of Pharmacy Residencies," is: "the act of granting approval to a postgraduate residency program after the program has met set requirements and has been reviewed and evaluated through an official process (document review, site survey, review and evaluation by the Commission on Credentialing). An approved program is in an "ASHP-accredited" status."

Accreditation protects the public by setting standards. Being accredited lets the public know that a program meets professional standards, thereby assuring quality. Accreditation allows a profession to engage in self-regulation. While it is a voluntary process, many organizations consider it essential to the integrity of their reputation. The accreditation process upholds standards and quality and may also encourage progressive practice when standards address such practices. In pharmacy, accreditation standards have been shown to have a positive impact on the practice of pharmacy as a whole. In addition, residency programs that are eligible for CMS medicare pass-through dollars must be ASHP-accredited.

The Surveyor's Role

As the lead surveyor, you are the leader of the survey team. Your primary task is to determine whether or not a residency program meets ASHP accreditation standards and whether or not, and for how long, the program should be recommended for accreditation. Lead surveyors are either ASHP full time staff members or on contract with ASHP to conduct surveys. The survey team also includes practitioner (guest) surveyors, who you will work with on surveys.

In addition to making the judgements discussed, your responsibilities include logistics of leading the survey team, including:

- Determining at what day and time the survey team should meet in the survey city prior to beginning the survey in order to discuss survey strategy

- Arranging for hotel accommodations for the survey team

- Making contact with the practitioner surveyor(s) to provide guidance for travel arrangements including when to arrive, anticipated departure time, hotel information, guidance on expenses.

- Paying expenses incurred when the survey team is together (e.g., hotel bill, meals, car rental)

You are the final decision maker on recommendation for accreditation for voting by the ASHP Commission on Credentialing (COC). Lead surveyors are also responsible for providing the element of consistency on the survey team, including consistency in the process, conduct of the review, knowledge of the standards and regulations and keeping the review in order.

Survey teams may be as small as two individuals or may have many surveyors if a site has multiple PGY1 and PGY2 programs. A guest surveyor for each PGY2 area usually is involved with the surveys with multiple guest surveyors.

Practitioner (Guest) Surveyor Role

The practitioner surveyor is invited by the individual on staff in the Accreditation Services Division (ASD) who does the scheduling for surveys. The practitioner surveyor is usually someone who is serving or has served on the COC, has completed a practitioner surveyor workshop, or has been a program director for a residency program for an extended period of time. The practitioner surveyor for post graduate year two (PGY2) residency program surveys generally fulfills the criteria listed for PGY1 reviewers but are specific to the type of program that they lead. Practitioner surveyors must be familiar with the standards and regulations and are often called upon to conduct sessions independently in multiprogram or multisite reviews.

Each surveyor makes their own travel arrangements. ASHP will be responsible financially for surveyor's airfare, ground transportation, lodging and food expenses during the time on survey. You will generally pay for team meals on your charge card. Per diem rate for food is $75 per day. Mileage, if a car is used, is 0.555 cents per mile and is adjusted as customary rates change by the ASHP Finance Division. ASHP will not pay for movies, phone or internet use. You will be provided with a travel expense form to complete and must provide receipts for expenses.

What You Need to Know

Here are the references that you need to be thoroughly familiar with in your role as lead surveyor, reviewing the relevant ones before surveys as needed, depending on the survey type.

Standards

All of the four standards, accessible by clicking the links below or at this link: http://www.ashp.org/menu/Accreditation/ResidencyAccreditation.aspx

(You may need to copy and paste this link into your brower. Click on "Regulations and Standards").

· ASHP Accreditation Standard for Postgraduate Year One (PGY1) Pharmacy Residency Programs

· ASHP Accreditation Standard for Postgraduate Year Two (PGY2) Pharmacy Residency Programs

· Accreditation Standard for Postgraduate Year One (PGY1) Community Pharmacy Residency Programs

· ASHP Accreditation Standard for Postgraduate Year One (PGY1) Managed Care Pharmacy Programs.

Note that a rewrite of residency standards is in progress. The last revision was done in 2005 and went into effect in 2007.

You also need to be familiar with the supplemental goals and objectives, if applicable, for the specific program you will be surveying. They are also available at this link: http://www.ashp.org/menu/Accreditation/ResidencyAccreditation.aspx

In addition, you should compare the site's completed "Pre-Survey Questionnaire" and "Self-Assessment Checklist" to the corresponding "ASHP Accreditation Standard" for either PGY1 (pharmacy, community, managed care pharmacy) or PGY2 programs.

Guidelines

For all programs, you should compare their materials to the appropriate guidelines that can all be found on the ASHP website, including the following guidelines, which are often referred to during the survey process. Click on the name of the guideline to access it.

• ASHP Guidelines on Quality Assurance for Pharmacy-Prepared Sterile Products
• ASHP Guidelines on the Safe Use of Automated Medication Storage and Distribution Devices
• ASHP Guidelines: Minimum Standard for Pharmacies in Hospitals
• ASHP Guidelines on a Standardized Method for Pharmaceutical Care
• ASHP Guidelines: Minimum Standard for Pharmaceutical Services in Ambulatory Care
• ASHP Guidelines on Preventing Medication Errors with Antineoplastic Agents

In addition to the ASHP guidelines listed above, these guidelines from the United States Pharmacopeia (USP) may be helpful:

USP 797 Guideline

Best Practices

You should also be familiar with the Best Practices for Hospital and Health-System Pharmacy book published by ASHP, which you can access via this link: http://www.ashp.org/bestpractices. The accreditation process is looking to see if "Best Practices" are followed at a training site.

Critical Factors

It is also important to be familiar with the "Critical Factors" for PGY1, PGY1 Community and PGY2 programs you will be surveying. These factors are considered critical and are weighted more heavily in determining the length of accreditation for a program. You will determine, when the site's report comes back to review, if areas of PC/NC (partial compliance/non compliance) have been resolved.

Consistency Criteria

As already mentioned, consistency among surveyors is important. To aid in achieving as much consistency as possible, the consistency criteria were developed. You can review them by clicking here.

Here is a summary of resources on the web for presurvey preparation:

Frequent Findings

It is useful to pay special attention to parts of the standard that are frequently cited. Recent frequent findings for PGY1 and PGY2 programs are listed below.

March 2013 Top Areas of Partial Compliance with PGY1 Pharmacy Residencies (n=53)

Residency Program Issues:

83%   Preceptors have not adequately developed & documented descriptions of learning experiences - CF

79%    Preceptors do not adequately apply clinical teaching roles or provide effective criteria based feedback - CF

79%    Not all preceptors have made adequate contributions to the total body of pharmacy knowledge & meet 4/7 preceptor criteria- CF

70%    Preceptors do not complete all aspects of the assessment plan (e.g self-evaluation) - CF

58%    Customized plans for residents are not documented/implemented/updated adequately - CF

49%    Preceptors development is inadequate / RPD does not have a plan for improving the quality of preceptors' instruction

Service Issues at the site:

72%    Services are not of a scope and quality commensurate with identified patient needs. - CF

50%    Professional and technical staff is insufficient to provide level of services required of all patients - CF

45%   Pharmacists do not prospectively help develop individualized patient treatment plans - CF

43%    Unit dose system is inadequately developed to provide a safe drug distribution system - CF

34%    Pharmacists do not adequately design and implement medication therapy monitoring plans for patients - CF

34% Floor stock system is inadequately controlled to provide a safe drug distribution system - CF

March 2013 Top Areas of Partial Compliance with PGY2 Pharmacy Residencies (n=53)

Residency Program Issues:

96%   Preceptors do not ensure all aspects of the assessment plan are completed (e.g. self-evaluation) - CF

92%   Preceptors have not adequately developed and documented descriptions of learning experiences - CF

62%   Summative evaluations are not timely or do not provide criteria based feedback - CF

60%   Not all preceptors have made adequate contributions to the total body of pharmacy knowledge & meet 4/7 preceptor criteria- CF

51%   Program design does not facilitate completion of all required goals and objectives - CF

Service Issues at the site:

60%   Pharmacists do not prospectively develop individualized patient treatment plans - CF

60%   Services are not of a scope and quality commensurate with indentified patient needs - CF

47%   Pharmacists do not adequately design and implement medication therapy monitoring plans for patients - CF

36%   Pharmacists do not adequately identify medication related problems - CF

Disclosures and Conflicts of Interest

As a surveyor, you need to be aware of the ASHP Commission on Credentialing Conflict of Interest Policy: External Professional Business Activities and the ASHP Commission on Credentialing Policy on Disclosure of Outside Interests.

As examples of conflicts of interest, you should not review a program if you recently worked there, did your residency there, the RPD is a former resident, etc. You may be a colleague, especially in the PGY2 areas that are "small world" but you must still maintain objectivity.

 Summary

This module has reviewed:

• Accreditation and the accreditation process
• The role of the lead surveyor and the members of the survey team in the accreditation process
• Materials with which the lead surveyor must be thoroughly familiar in preparation for the survey process
• Critical factors and consistency criteria
• Frequent findings
• ASHP policies on disclosure and conflict of interest.

Congratulations! You have completed Module 1. Module 2 will cover the Pre-Survey process.