Residency Accreditation Survey Response

Residency Accreditation Survey Response

XYZ General Hospital (#12345)

Residency Accreditation Survey Response

Areas of Noncompliance

Finding # / Statement of Non Compliance / Action(s) & Timeline / Appendices
NC-1 / Preceptors do not have descriptions of their learning experiences, including a list of activities to be performed by residents to facilitate achievement of educational goals and objectives. Further, educational goals documented in learning experience descriptions should be consistent with the educational goals assigned to each learning experience in the design of the residency program. [Item 4.1d] / COMPLETED (March 2011)
Item 4.1d of the accreditation standard was shared with preceptors at the monthly Residency Advisory Committee (RAC) meeting.
The example of the learning experience description included in the Residency Learning Workshop materials at the ASHP Midyear Clinical Meeting was reviewed at the RAC meeting, as well.
Learning experience descriptions were drafted by each preceptor, in accordance with the RLS example, and reviewed and edited by the residency program director (RPD), as well as other clinical preceptors via a peer review process.
Finalized learning experience descriptions to be included in the residency manual distributed to each resident at the beginning of the residency. / Appendix A
Example of the Internal Medicine learning experience description

Areas of Partial Compliance

Finding # / Statement of Partial Compliance / Action(s) & Timeline / Appendices
PC-1 / The program director does not have an established preceptor development plan for improving the quality of preceptors’ instruction based on an assessment of residents’ written evaluations of preceptors’ performance and other sources. [Item 4.3c] / March 2011
Ideas discussed for a preceptor development plan at the RAC meeting. Ideas being considered for inclusion in the preceptor development plan include, but are not limited to:
  • 15 minute topics on preceptor development to be presented at each RAC meeting (e.g. ‘criteria-based feedback)
  • Preceptor mentoring program for new preceptors
  • Subscription to ‘Pharmacist’s Letter’ via Higher Learning College of Pharmacy
  • Participation in webinars offered by ASHP, Pharmacist’s Letter, etc., as a group, followed by a 30 minute follow-up discussion
  • Attendance at professional meetings (e.g. ASHP RLS workshop, Residency Preceptors Conference, etc.)
  • Preceptor retreat / ‘boot camp’
  • Peer review of resident evaluations completed by preceptors
  • Surveys developed and distributed to preceptors to determine most challenging issues
  • Survey results will be compiled for discussion at the next RAC meeting
April 2011
Participation in an ASHP live webinar entitled, “Strategies for Creating a Preceptor Development Plan”
Identification of available resources for preceptor development (e.g. webinars, newsletters, on-line CE, etc.)
Development/revision of draft of preceptor development plan
Official preceptor development plan completed and implemented / Appendix B
Copy of the Preceptor Development Survey that was conducted (results pending)
Finding # / Statement of Partial Compliance / Action(s) & Timeline / Appendices
PC-2 / Some preceptors do not have a record of contribution and commitment to pharmacy practice characterized by a minimum of four of the seven criteria outlined in the accreditation standard. [Item 5.9] / Two preceptors identified as noncompliant with Principle 5 (item 5.9) of the PGY-1 accreditation standard
March 2011
  • Principle 5 (item 5.9) of the PGY-1 accreditation standard was distributed and reviewed at the RAC meeting
  • Preceptors informed that item 5.9 will be reviewed annually by the program director, director of pharmacy, and clinical coordinator for compliance
  • Jack Teacher, PharmD, BCPS (preceptor for Infectious Diseases)
  • At the time of the survey, only met 3 of 7 criteria for preceptors
  • Development of treatment guidelines/protocols
  • Formal recognition by peers as a model practitioner
  • Demonstrated effectiveness in teaching
  • Now meets 4 of 7 criteria for preceptors
  • March 2011: Recently appointed to the Antibiotic Sub-Committee of the Pharmacy & Therapeutics Committee
  • Lauren Instructor, PharmD (preceptor for Internal Medicine)
  • At the time of the survey, only met 3 of 7 criteria for preceptors
  • Implementation of a new service
  • Appointment to appropriate drug policy and other committees of the department/organization
  • Demonstrated effectiveness in teaching
  • March 2011: Registered for the BPS Board Certification Exam
  • October 2011: Sit for BPS Board Certification Exam
  • Pending 4 of 7 criteria upon successful passing of the exam

Finding # / Statement of Partial Compliance / Action(s) & Timeline / Appendices
PC-3 / Some preceptors do not demonstrate an aptitude for teaching that includes mastery of the four preceptor roles of instructing, modeling, coaching, and facilitating. Further, preceptors do not provide residents sufficient, criteria-based written feedback that is objective and actionable. [Item 5.10] / March 2011
  • Principle 5 (item 5.10) of the PGY-1 accreditation standard was distributed and reviewed at the RAC meeting
  • The four preceptor roles were addressed
  • The program director provided an in-depth explanation of the four preceptor roles and how to integrate them into learning experiences
  • The program director and preceptors engaged in a discussion on the four preceptor roles and everyone shared ideas of how to incorporate each role into the learning experience, while achieving a balance between the roles and considering individual resident factors
  • The program director informed the preceptors that their ability to incorporate the four preceptor roles into their learning experiences would be assessed by the program director via resident evaluations of preceptors and during the formal evaluation of the preceptor by the program director
  • Criteria-based written feedback was addressed
  • An example of a quality, criteria-based evaluation was shared
May 2011
  • With the implementation of the preceptor development plan, criteria-based written feedback will be addressed in several ways:
  • 15 minute topic on ‘Criteria-based written feedback’, followed by discussion and question & answer session
  • Peer review of resident evaluations by preceptors
  • Review of each preceptor’s evaluation of the residents by program director
  • Program director will give preceptors feedback during one-on-one formal evaluation session
  • Attendance by preceptors at one of the ASHP RLS workshops and/or the national residency preceptors conference
/ Appendix C Example of a resident evaluation since review and discussion of criteria-based written feedback
Finding # / Statement of Partial Compliance / Action(s) & Timeline / Appendices
PC-4 / Pharmacists do not participate prospectively in the development of individualized treatment plans. (Attention should be directed towards expanding clinical services in internal medicine and cardiology.) [Item 7.6a(4)] / Currently, there is a shortage of two staff pharmacists in the central inpatient pharmacy due to one pharmacist being on maternity leave and the other pharmacist resigning to relocate out of state with his family. As a result, the internal medicine clinical pharmacist and the cardiology clinical pharmacist have been assisting with order entry each morning for two hours (8am – 10am) to prevent delays in medication processing and delivery.
Unfortunately, the internal medicine and cardiology teams round during the hours of 8am – 10am, causing the clinical pharmacists in those areas to miss rounds as a result of assisting with order entry. Consequently, those pharmacists have not been able to be active participants on rounds to contribute to clinical decisions; many of the recent interventions have occurred after the order has already been written
January & February 2011
  • Recruiting efforts began to fill the two vacant pharmacist positions in the central inpatient pharmacy
March 2011
  • Conducted interviews for candidates for vacant pharmacist positions
April 2011
  • Completed interviews for vacant pharmacist positions
  • Extend an offer to the top two qualified candidates to fill the positions
  • Due to the timing of graduation and licensure, hired individuals likely unable to begin working prior to July 2011
July 2011
  • Two new pharmacists anticipated to begin working in the inpatient central pharmacy
  • Internal medicine and cardiology clinical pharmacists will return to full-time clinical duties and rounding with medical teams in their respective areas

Finding # / Statement of Partial Compliance / Action(s) & Timeline / Appendices
PC-5 / Automated medication systems and software do not support a safe medication-use system. Not all of the automated dispensing cabinets in the emergency department are interfaced with the pharmacy information system; this precludes pharmacists’ review of orders prior to administration of medications. [Item 7.8c] / Computerized physician order entry (CPOE) officially launched hospital-wide in October 2008. At that time, there was not a pharmacy presence in the emergency department (ED). Therefore, it was the decision of the hospital’s executive leadership to allow overriding capabilities in the ED, in terms of not requiring pharmacist review of orders prior to dispensing, to prevent delays in the delivery and administration of medications to patients.
In regards to the Joint Commission, this practice is acceptable as long as the order is generated and entered into the computer by a physician or licensed independent practitioner (LIP) (i.e. nurse practitioner).
The pharmacy department recognizes that best practice requires that all orders be reviewed by a pharmacist prior to dispensing to ensure a safe and accurate medication use process. In August 2009, the pharmacy department hired a clinical pharmacist full-time in the ED to assist with various clinical functions, but specifically to ensure safe medication practices and involvement in clinical decisions prior to order entry and dispensing.
February 2011
  • The director of pharmacy presents cost-savings and adverse drug event data from the ED, since the hiring of the clinical pharmacist, to the hospital’s executive leadership
  • The director of pharmacy proposed integration ofcomputer databases in the ED and the pharmacy to ensure profiling and review of medication orders by pharmacists prior to dispensing
March 2011
  • The executive leadership approves the update and integration of the pharmacy and ED computer databases
  • April 2011
Anticipated completion/implementation of systems integration