Preparing for Specialty Pharmacy Reaccreditation with ACHC

The ACHC accreditation process is not a single, “one and done” activity, but rather an ongoing process spanning three years. The survey that validates continued compliance takes only one to three days of that period to complete, depending on the number of accredited services and the complexity of the individual pharmacy location.

This chart shows the relative amount of time each health system should spend on the application process, the survey itself, and on maintaining compliance during the three-year accreditation cycle.

• Before survey: Apply with ACHC and prepare for survey.
• Survey: The surveyor visits your organization (1-3 days).
• After survey: Submit corrections (when applicable) and receive accreditation documentation. Maintain ongoing compliance for the rest of the cycle.

Preparing for reaccreditation

When is the best time for health systems to start preparing for reaccreditation? The ideal answer: the day after your survey! The more realistic answer: six to nine months before the expiration date. Maintaining continuous compliance ensures survey readiness, but six to nine months prior to expiration is a great time to focus your efforts.

Don’t forget to apply!

Accreditation doesn’t renew automatically. As your expiration date approaches, ACHC will send reminders to submit a renewal application. However, proactively logging in to your customer portal prevents any potential for missed deadlines.

Expect the unexpected

Change is inevitable, and pharmacy operations are no exception. Patients’ needs evolve, payors reframe requirements, regulations (including accreditation standards) shift and business models adjust. The months leading up to reaccreditation are the right time to ensure compliance.

• Review any changes to ACHC standards since your last survey and make sure you’re up to date.
• Confirm that your pharmacy license is active (in every state where you do business).
• Verify whether your state Board of Pharmacy (BOP) regulations have changed; your ACHC surveyor will reference state requirements.
• Don’t forget to review your own policies. The surveyor will hold you responsible for compliance with whatever is more stringent: ACHC standards or your own policy.  

Tip: Monitor new employee onboarding. ACHC pharmacy surveyors frequently cite deficiencies resulting from personnel changes that fail to ensure continuity of knowledge and compliance. If your organization has restructured since the last survey, or if you’ve reassigned or promoted staff, examine staffing transitions for missing documentation or gaps in training.

Example: The pharmacist responsible for developing and implementing clinical assessments leaves, and a new pharmacist is promoted to the role. The new pharmacist decides to help streamline operations by removing parts of the assessment. A year later, during the reaccreditation survey, the pharmacy is cited for inadequate clinical assessments.

The why: During the transition period, the new pharmacist was not educated on the accreditation standards related to assessment requirements or policies were not updated to reflect a change in practice.

Normalize the process of preparation

One of the most effective ways to prepare for reaccreditation is to conduct mock surveys. Whether you bring in an outside party or lead the mock survey yourself, walking through various scenarios can identify areas of noncompliance, instill confidence and ease apprehension.

Revisit the summary of findings from your last survey. Ask veteran employees to share their insights and recollections of past site visits. Scheduling an entire day for a mock survey isn’t always practical for a busy pharmacy, so think in terms of monthly or weekly spot-checks on specific categories of standards. Conduct sample interviews, review records and files, verify shipping test documentation or inspect labels. Plan and customize a mock survey schedule that works for your organization.

Tip: Centralize your documentation, preferably in one location. ACHC surveyors often note that staff cannot find or access requested documentation. Avoid housing documents on a personal computer or using personal electronic files. Instead, store documents on a shared company drive and educate staff on how to access the files. Confirm that team members know how to print or download historical data from continuous monitoring devices or platforms.

During a mock survey, have the mock survey or arrive and ask to see this documentation right away:

• Policies and procedures
• Environmental monitoring, such as temperature and humidity logs
• Cleaning and disinfecting logs
• Incident/adverse event reports
• Grievances and complaint reports/logs

If it isn’t documented, it didn’t happen

The ability to locate and access documentation is one thing. Having the correct documentation in the first place is another. Insufficient record keeping practices dominate survey deficiencies, particularly client/patient records and personnel files.

Verify documentation required (monthly, quarterly and annually) since your last survey is available, complete and organized. Make sure your templates are thorough and cover all necessary components and information. Do client/patient records document the receipt of new patient packets? Do personnel files contain compliant competency assessments?

Tip: Audit, audit, audit. Your organization is likely well acquainted with internal audits as part of your performance improvement activities. If you’ve missed a few chart audits, six to nine months prior to expiration is the time to focus on preparation. Are you using a checklist to verify that files and records are complete and accurate? A documentation checklist is one of the easiest, most attainable ways to maintain compliance – but it may not be enough. The documentation must not only be present, but complete and accurate.

For example, during an internal audit, the care plan in a patient’s medical record was noted as present. The plan included a medication that was discontinued and replaced two months prior, but the new medication was not addressed in the care plan. However, the patient record was marked as “compliant” in the audit. Why? The internal auditor checked for the presence of a care plan and moved on. The process would have benefitted from deeper investigation into the contents of the care plan and cross referencing to the medication list.

Correct and reflect

The most valuable phase of the reaccreditation process is the time you take to correct and reflect. This stage may take a couple of weeks or months to make informed decisions.

Your path forward can only be determined after you’ve reviewed the standards, conducted mock surveys, audited files and gathered all other necessary data to be analyzed and synthesized into your organization’s corrective action plan. A corrective action plan should be established for any noncompliant item, or any items that don’t meet goals or thresholds established by your organization. Effective corrective action makes one change at a time and remeasures the result. Ask for input, discuss solutions, implement change and communicate results.

Tip: Follow up on a regular basis. Monitor your corrective action to determine if it resolved the issue as intended. Is it consistently hitting the goal or threshold? Do you need to regroup and reframe? Remember that the surveyor could cite failure to follow up as a deficiency.

It takes a team

Accreditation is a team endeavor and a team achievement. Clearway Health and ACHC have embodied this approach through a partnership to enhance the accreditation process for health systems. Together, our focus is on prioritizing the patient, optimizing pharmacy operations and improving patient outcomes.

Within health systems, one of the most powerful ways to maintain compliance is to invest in staff. Provide educational opportunities, introduce project management tools and implement quality management platforms. Schedule specific time for personnel to complete competencies, participate in performance improvement activities and pursue additional training. Foster collaboration by assigning roles and responsibilities based on individual strengths.

Tip: Delegate and cross-train. Empower someone to oversee compliance with accreditation standards and monitor for the release of standard revisions. Cross-train additional team members on all aspects of the accreditation process and be sure to assign a backup who can cover if the assigned coordinator is not available on the day of the survey.

Preparing for reaccreditation uncovers what doesn’t work, but it also illuminates what does. Be proud of how far you’ve come since your last survey and think of the next survey as the opportunity to demonstrate the quality you deliver. ACHC is invested in your success.

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For more information, connect with ACHC’s pharmacy team at customer service@achc.org or (855)937-2242. If your organization is currently accredited with ACHC, reach out to your account advisor for guidance.

‍How Clearway Health Supports ACHC Accreditation:

Clearway Health helps health systems develop their specialty pharmacy programs to be “accreditation ready” shortly after launch – poised to provide the complex and comprehensive care that ACHC demands of accredited pharmacies right out of the gate. We have a team of accreditation experts who work alongside the pharmacy team to prepare their program for initial accreditation, and then our experts provide an ongoing compliance and audit roadmap for reaccreditation readiness.  

We partner with our clients as the subject matter experts for the organization, always available to answer accreditation questions, perform audits, and provide updates on the evolving accreditation landscape and changing accreditation standards. It is the core of our partnership with our pharmacy partners – creating world class health system specialty pharmacy programs that distinguish themselves through achievements like ACHC accreditation. The partnership with ACHC also allows Clearway Health’s health system partners to receive special pricing on ACHC specialty pharmacy accreditation. Discounts on select ACHCU educational resources are also available.