MEMORANDUM
DATE:
TO:
FROM:
SUBJECT:
xxxxxxxxxxxxxxxxxx
ASHP Accreditation Services Lead Surveyor
Residency Accreditation Survey Visit and Preparation Memo
Site:
Type:
Dates:
CC:
Greetings from ASHP! I will be the lead surveyor of the Accreditation Services team
visiting your site and our guest practitioner surveyor will be
My contact information:
Cell: (xxx) xxx-xxxx
Email: xxxxxxxxxx@ashp.org
In addition to the correspondence you have received directly from ASHP, I have noted
below the link to materials that are found on the ASHP website to help you when
preparing for the survey.
http://www.ashp.org/Import/ACCREDITATION/ResidencyAccreditation.aspx#Preparing
forResidencyAccreditationSurvey
When completing the Pre-survey Questionnaire, the choice of FC (fully compliant)
indicates the standard is met in the residency program and the site and there is
documentation available; NC (noncompliance) indicates that the standard is not currently
met in the residency program or the site; PC (partial compliance) indicates that there is
some evidence that the standard is met partially in the program or the site; and NA (not
applicable) indicates that this standard does not apply to the program or the site. In
instances where NC or PC is marked on the pre-survey questionnaire, please provide
information in the comments section on the Pre-survey Questionnaire and tag the
appropriate standard numbering identifier it is associated with (e.g. 4.1d, etc) for easy
reference. The surveyors will assist in the determination of level of compliance onsite of
these elements of the standard with you.
ASHP Accreditation Services has worked with the McCreadie Group to provide all lead
and guest surveyors with read-only access to ResiTrak™ records of your program (if you
use ResiTrak™). I will be requesting access for a window of time prior to the survey for
the surveyors to be able to review your ResiTrak™ documents. You will receive an email
confirmation from ResiTrak® when this has been set up. However, copies of ResiTrak™
documents requested in the pre-survey material as attachments must still be printed out
and provided.
[PLEASE NOTE: DO NOT print out ResiTrak™ learning experience descriptions, if
sent in as examples, to the level of objective (OBJ), instructional objective (IO) or criteria
(C) as this wastes too much paper. The level of taught and evaluated goals is all that is
needed. My preference is to review copies of written learning experience descriptions in
your pre-survey material that you have developed for your program that show correlation
of activities with the goals and objectives chosen.]
We suggest that when duplicating, use double sided copying to reduce paper and weight
whenever possible. Your pre-survey materials (in triplicate) need to arrive in
Accreditation Services 45 days in advance of the survey. If you need any additional time,
or if the materials will be arriving late, please email me. Overnight or next day delivery
is not required. The three pre-survey packets may be bundled and mailed without the use
of binders if you prefer to reduce bulk and to decrease shipping weight. You may choose
to purchase delivery confirmation from your carrier.
Mailing Address:
American Society of Health-System Pharmacists
c/o Janet Teeters, Director
Accreditation Services Division
7272 Wisconsin Ave.
Bethesda, Maryland 20814
On-site Survey
Please provide a large enough conference room for the survey team and the participants
to meet. It is helpful to not have to switch to other conference rooms whenever possible.
All interviews except the entry and exit sessions with hospital and/or system
administration should be conducted in that conference room.
Materials for on-site review should be in the conference room for both days of the
survey. The room should also be set up with access available to computer/online material
if applicable to the site. Please insert written material into binders that are tabbed for
reference as applicable. Only one set is required on-site. My list of requested items for
on-site review is expanded from the list on the website and includes:
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Scope/Description of Pharmacy Services document
Pharmacy Department Mission Statement
Residency Program Manual (print out or online if applicable)
Application packet of current residents and criteria used during interview and
ranking process
Copies of current resident offer and acceptance letters which include information
on the terms and conditions of the appointment
A sample copy of the certificate awarded to residents upon the completion of the
residency program
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Manuscripts of residents’ completed projects for the last two years, where
applicable
A list of residents and corresponding projects for each of the last five years, where
applicable.
Documentation of each current resident’s project
A list of current job positions of past residents, where applicable
Records of current and immediate past previous residents’ training progress
(each resident’s manual/notebook/binder/or portfolio preferred) to include:
o Initial program customized plan with schedule and quarterly updates
o Any documented formative evaluations of resident performance (presentation
critiques/feedback on projects/snapshots/activities or work, etc.) by
preceptors
o Preceptor summative evaluations of resident progress if not using ResiTrak
o Resident formative (see above) and summative self-evaluations if not using
ResiTrak
o Documentation of various projects/activities accomplished during the year
Policy and Procedure Manual-do not print out if online, but must be available if
surveyors ask for specific policies
Policy and Procedure related to Drug Overrides if automatic dispensing devices
(Pyxis®, Accumed®, Omnicell ®, etc.) are used in the organization (print out)
List of medications available on override in the institution
Policy and Procedure related to preparation and checking of antineoplastic agents
(if applicable to the organization—print out)
One example of a pre-meeting packet for the Pharmacy and Therapeutics
Committee
Minutes of the Pharmacy and Therapeutics Committee and other drug policy
committee meetings for the last 12 months (separate binder-or online access)
List of organization’s committees and identification of pharmacy specific member
involvement (i.e., name of individual(s))
Examples of pharmacy workload documentation
Examples of pharmacy financial performance documentation
Reports that show improvement in patient care outcomes accomplished by the
pharmacy department (e.g., medication utilization review or quality improvement
projects that show improvement in patient outcomes: decreased side effects,
decreased readmission rates, faster resolution of diseases, benchmarking or
dashboard results for the organization, etc.)
Pharmacy department newsletter (recent edition if applicable)
Please note, I would like you to follow my recommendations for setting up the itinerary
over 1 ½ days. In some instances, we may have to alter the end time due to travel
arrangements and distances to airports. It is best to set up appointments early with
administrators, physicians, nurses, etc. who we are to meet and who are part of the survey
process. Use this template as a guide to customize the itinerary to your organization.
Include names and position titles whenever possible. If time switches are necessary to
accommodate individuals, please discuss with me first.
The beginning and ending times of the site survey depend on the size of the institution,
the number of preceptors, the amount of touring of the facility or facilities (if multi-site)
that is needed, the city and location of the airport in relation to the institution, and the
surveyors’ travel arrangements.
Multi-site Programs: if any of your learning experiences are conducted off-site in
another location, facility, or different hospital within your health-system and totals more
than 25% of your program at this/these locations, you are considered a multi-site
program. Please read the Multi-site policy:
http://www.ashp.org/DocLibrary/Accreditation/ASD-Policy-Multiple-Sites-COC.aspx
The appropriate paperwork should have been submitted to ASHP Accreditation Services
Division if you have not already done so:
http://www.ashp.org/DocLibrary/Accreditation/ASD-Form-to-Add-a-Site101310.aspx
Pharmacy services (Principles 6 and 7, where applicable) will also be a focus of
discussion at this/these sites. Please notify me as soon as possible as we will need to
adjust the itinerary template to accommodate travel to this/these sites and may make the
survey longer.
The length of some of the meetings will depend on the size of the program; we can
discuss that when I contact you regarding the itinerary. Therefore, the suggestions below
are merely a guide. Please contact me if you have questions or concerns, and before the
itinerary is finalized. Residents are welcome to participate in the survey process, with the
exceptions noted. Beverages such as water and coffee in the room are always
appreciated.
Please provide me with information as to where I should park. An email link or printed
copy of a map of your site is helpful if you have one.
**Finally, I appreciate assistance with travel information and if you can send me a brief
email (within the next 2 weeks) with answers to these questions, it helps me to plan the
trip appropriately:
Closest airport and driving distance/time to site? Need for a rental car?
Closest couple of hotel chains, such as a Marriott Courtyard, Hampton, Hilton Garden
Inn, or Holiday Express Inn, Drury Inn, or similar? Do they offer reduced rates to
visitors to your institution?
2-3 Restaurant suggestions with addresses
Should you have any questions related to this preparation memo or the survey process,
please do not hesitate to contact me. We look forward to working with you and to a
productive survey!
ASHP PGY1 Residency Program Accreditation Visit
Itinerary Template
Site Name:
Address:
Residency Program Director:
RPD Cell Phone Number:
Survey Dates:
Day One: Date
Time
Location
Purpose
8:00 am
Suggest where
surveyors are to
park and meet
RPD
Arrival/meet and greet
8:15
Attendees
(Names and Titles)
RPD and surveyors
Meet with CEO
8:30-11:30
Conference room
location?
11:30-12:30
Lunch/Paperwork
Review
12:30-2:00
Pharmacy &
Institution Tour
DOP, RPD and
Resident(s) if desired
Program Discussion/Onsite
RPD
Paperwork Review
DOP
RPC(s) if applicable to
program
Resident(s)
If lunch can be provided and
Surveyors
delivered to the room, saves us RPD
time. If I need to reimburse
DOP if available
you for the expense, please let Resident(s)
me know. If this is the only
RPC(s)
time that we can meet with
as applicable to the
your physicians, it may be used program if desired.
for that purpose, please let me
know.
As applicable to the site: Inpatient As determined by DOP
and outpatient pharmacy,
and RPD
IV/chemo room(s), compounding Resident(s)
area, investigational drug area,
Please plan out the route
emergency department, critical
in advance to maximize
care unit: med storage and floortime and travel
stock, internal medicine unit,
pediatrics, outpatient/ ambulatory
care clinics, resident office area
2:15-2:45
Conference
Room
2:45-4:00
Conference
Room
Meet with Pharmacy
Managers, 1-2 pharmacists,
Tech Managers/or 1-2 techs
where applicable
Meet with Preceptors
Inpatient/Outpatient
where applicable
RPD, DOP and residents
excused
Available preceptors (list
if possible)
DOP and resident(s)
4:00-5:00
Conference
Room
Meet with Residents
5:00-6:00
Conference
Room
Surveyor private
conference/departure
excused
RPD may be asked to
stay prn
Current (and most recent
past if still on staff or if
survey is done early in
the residency year (JulSept)
RPD, DOP excused
RPD (Residency Program Director)
DOP (Director of Pharmacy, or if unavailable, Pharmacy Operations Manager)
RPC (Residency Program Coordinator- and if Multi-Site)
Day Two: Date
Time
Location
8:00 am*
Conference Room
8:30*
Conference Room
*times can be
interchanged
with these
folks prn
9:00*
Conference Room
Purpose
Arrival and Surveyor set up
Attendees
Surveyors
*Meet with 2-3 Nurses:
an administrator (CNO or
designee),
unit based/clinic nurse,
nursing unit manager
*Meet with P&T Chair(s)and
1-2 other physicians (MDs
who have worked with or have
exposure to the residents)
Final Questions with RPD and
DOP
RPD, DOP and
resident(s) excused
9:30-10:00*
Conference Room
10:00-10:30*
Conference Room
Surveyor Conference Time
10:30-11:30*
Conference Room
Exit Report to Staff
11:30/11:45*
12:00/12:30*
Exit Report to CEO
*times subject to alteration
due to travel departure
times of the surveyors
Departure
I will work with you on time adjustments as
needed
RPD, DOP and
resident(s) excused
Resident(s) excused
RPD, DOP, residents,
and preceptors; others as
determined by the DOP
or RPD
As determined by DOP