Certification Process and Instruction

Become an ASHP Certified Center of Excellence™ in Medication-Use Safety and Pharmacy Practice

Certification is the process by which ASHP will assess your pharmacy department’s level of performance in relation to the established certification standard and will create guidance onto implementing ways to continuously improve.  It takes roughly 8 to 10 months, and consists of the following steps: application, document submission, site survey, and determination of certification status.

Readiness Assessment

Prospective pharmacy departments may choose to seek consultation to assess pharmacy department readiness for certification. ASHP Consulting provides on-site and virtual readiness assessments that includes advice on how to improve pharmacy services and prepare for the certification survey; a mock certification survey may also be requested and conducted. Please contact ASHP Consulting by email at [email protected], and view its complement of services.

Step 1

Review the certificate standard and other materials on the ASHP website (www.ashp.org). For programs interested in being recognized as an ASHP Certified Center of Excellence™ in Medication-Use Safety and Pharmacy Practice, contact the Director, Pharmacy Accreditation at ASHP by email at [email protected] with questions or to express interest. A telephone conference call will be scheduled to review the Standard, discuss the certification process, and answer questions of the interested pharmacy department representative. 

Step 2

ASHP will provide you with a fee proposal for ASHP Certified Center of Excellence™ in Medication-Use Safety and Pharmacy Practice.  ASHP will prepare a Letter of Agreement (LOA), including the accepted pricing proposal, and provide a Business Associate Agreement (BAA) for signature by the hospital pharmacy and ASHP.  ASHP will also provide the pharmacy executive with an invoice for the fees according to the following schedule:

• A one-time application fee
• An annual certification fee (pro-rated from the date received until December 31 of that year.  Annual certification fees correspond to the calendar year.)  

Complete the online application, with required signatures, and email to [email protected]. You will receive e-mail confirmation when your application is received. The Director, Pharmacy Accreditation will review the application and verify receipt of the signed Letter of Agreement and Business Associate Agreement and payment of invoices. 

Step 4

• A lead surveyor will be assigned to your pharmacy department to oversee the certification process; all pharmacy surveyors are highly experienced pharmacy leaders who have accreditation and certification survey experience.
• ASHP will send the Document Assessment Checklist, which is a tool used for self-reporting documented evidence demonstrating compliance with the certification Standard.  It will assist you in collecting and organizing documentation for submission to ASHP for review.  The completed Document Assessment Checklist and the referenced, supporting documents are submitted through a secure cloud file specific to your pharmacy department.     
• The completed Document Assessment Checklist and the referenced documentation should be submitted to secured cloud file within 120 days of receipt.
• The Document Assessment Checklist and referenced documentation will be reviewed by the survey team within 45 days of receipt. The lead surveyor will provide a written report noting if any documentation is missing or requires clarification.  
• The lead surveyor will schedule a telephone or video conference call with the pharmacy executive and others selected by the pharmacy executive 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 5

The pharmacy executive or designee will receive a survey plan from the lead surveyor.  During the onsite survey, the survey team will:

• Review and tour all pharmacy operations and patient care areas
• Review health-system, pharmacy department, and select patient records for compliance with policies, procedures, and documentation;
• Observe patient care services being performed (where appropriate)
• Interview senior hospital management representatives, physicians, and other hospital leaders and staff members
• Interview pharmacy department personnel concerning their duties and responsibilities for the delivery of pharmacy services to patients and other health care professionals, their adherence to policies and procedures, and use of recognized best practices

The survey team will communicate with the pharmacy executive and others selected throughout the survey process, and at the close of survey, will provide a verbal report of best practices, consultative recommendations, and any areas of partial and/or non-compliance with the Standard.

Step 6

A written survey report will be sent by electronic mail to the pharmacy executive within 30 days following the conclusion of on-site survey.  The report will reiterate observed use of best practices and consultative recommendations.  It will also state the survey team’s determination of the level of compliance with the Standard; the survey process may be complete or there may be outstanding items to continue to address to reach compliance with the Standard.   

Within 30 days of receipt of the written survey report from ASHP, a written response report with a plan of corrective action and timeline for resolution of any non-compliant standard element is required to be sent to the Director, Pharmacy Accreditation.  The written response report, 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 future required action plan reports must be provided, according to the accepted timeline, until all plans are complete.    

The pharmacy executive will be notified when the pharmacy department is eligible for a certification decision.

Step 7

The pharmacy department’s survey findings, final action plan with responses, and timeline will be reviewed by the survey team, Director, Pharmacy Accreditation, and the ASHP Pharmacy Practice Accreditation Commission (PPAC). If appropriate, the PPAC will recommend certification of the program to the ASHP Board of Directors. The ASHP Board of Directors will consider the recommendation and make their decision regarding certification of the pharmacy department.  The certification term is three years.

Download a PDF version of the Certification Process and Instructions

Download a PDF of the Certification Administrative Procedures

For individual questions about certification, please contact us at [email protected].

*For those pharmacy departments 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 certification schedule and fee structure.