ASHP identified the need for recognition of innovative, high quality, safe and effective hospital and health system pharmacy services throughout the world, and designed an accreditation standard that embodies the processes of continuous quality improvement to elevate pharmacy and patient care services. Accreditation is a process used by health care organizations worldwide to accurately assess their level of performance in relation to established standards and to implement ways to continuously improve. Accreditation specific to pharmacy can foster further development of pharmacy-delivered patient care services and advance practice. This voluntary accreditation process is offered to those international hospital and health-system pharmacies and their associated ambulatory care services with an interest in improving patient care.
ASHP Accreditation Standard for International Hospital and Health-System Pharmacy Services
The ASHP Accreditation Standard for International Hospital and Health-System Pharmacy Services address these primary areas for high quality pharmacy practice.
- Leadership and Management
- Quality
- Medication Policy and Drug Information
- Medication Safety
- Information Management
- Supply Chain
- Medication Use Process
- Clinical Pharmacy Services
- Facilities
- Education and Training
Although not part of the core accreditation standards, hospital pharmacies demonstrating excellence in any of the following areas may be eligible for special recognition (accreditation with commendation).
- Automation
- Collaborative Medication Management
- Research
- Residency Education and Training
The Standard serves as the basis for evaluating international pharmacy services in hospitals and health-systems for accreditation. Within each standard are key areas of focus describing the competencies the pharmacy must demonstrate. Evaluation of the practice is conducted through review of documents and an on-site survey. Achievement of accreditation provides evidence of the safety, effectiveness, and quality of care delivered by the pharmacy.
Pharmacy Services Accreditation Documents
- ASHP Accreditation Standard for International Hospital and Health-System Pharmacy Services
- Description of the Accreditation Standard for International Hospital and Health-System Pharmacy Services
- Administrative Procedures on Accreditation of International Hospital and Health-System Pharmacy Services
Applying for Accreditation
- Application for Accreditation of International Hospital and Health-System Pharmacy Services (.docx)
- Accreditation Process and Instructions
- Required Documents
- Standards Assessed Only During Survey
Accreditation Process
Accreditation is the process by which ASHP will assess your pharmacy department’s level of performance in relation to the established accreditation standard and will create guidance onto implementing ways to continuously improve.
Step 1
Review the accreditation standards and other materials on the ASHP website (www.ashp.org). For programs interested in accreditation for International Hospital and Health-System Pharmacy Services, contact ASHP by email at [email protected] with questions or to express interest. A conference call will be scheduled to review the standards and discuss the accreditation process.
Step 2
Prospective pharmacy departments may choose to seek consultation to assess pharmacy department 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.
Step 3
If the pharmacy department is ready for accreditation, ASHP will send a proposal for international hospital and health-system pharmacy services accreditation. The proposal includes a description of the accreditation process, responsibilities of the applicant and ASHP, and fees.* ASHP will also send an invoice for the fees according to the following schedule:
- A one-time application fee
- An annual accreditation fee (pro-rated from the date received until December 31 of that year. Annual accreditation fees correspond to the calendar year.)
Step 4
Complete the application, with required signatures, and email to [email protected]. You will receive e-mail confirmation when your application is received. ASHP will review the application and verify receipt of the signed proposal and payment of invoices. The application and related documents can be found on ashp.org.
Step 5
A surveyor(s) 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 demonstrating compliance with the standards, and 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 a secure electronic location, specific to your pharmacy within 120 days of receiving the assessment checklist.
- The checklist, your policies, procedures, and other supporting documentation will be reviewed by the survey team within 45 days, and you will receive a written report noting if any policies, procedures, or other supporting 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.
The specified documentation must be complete prior to the on-site survey as verified by your surveyor(s).
Step 6
The on-site survey will be scheduled as early in the accreditation process as possible in order to accommodate the timeline of the pharmacy department and surveyor availability. You will receive a survey plan. 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 hospital management and other hospital staff members
- 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 survey, provide a verbal report of your best practices, consultative suggestions, and any areas of partial and/or non-compliance with the standards.
Step 7
A written survey report will be sent to the Director of Pharmacy within 30 days following the on-site survey. The report will reiterate your best practices, consultative suggestions, and state either your survey is complete or 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 department is eligible for accreditation decision.
Step 8
The program’s survey findings, final action plan with responses, and timeline will be reviewed by the survey team and the ASHP International 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 pharmacy department. The accreditation term is three years.
Ongoing Accreditation Requirements
Annual reports are required for every accredited pharmacy department and reviewed by the ASHP International Accreditation Commission and Practice Advancement Office; more frequent reports may be requested in the judgement of the Commission.
Reaccreditation
Reaccreditation occurs every three years, repeating the accreditation process as described.
*For those pharmacy services with currently accredited ASHP residencies, a partial evaluation of hospital pharmacy services occurred via document review and on-site survey. This previous evaluation will result in a modified accreditation schedule and fee structure.