(Management Case Study) All Hands on Deck: Application and Survey for the Center of Excellence in Medication-Use Safety and Pharmacy Practice Certification

This activity qualifies for live CPEL℠ recertification credit.

Purpose: Our health system submitted our application and underwent the survey for the ASHP Center of Excellence (COE) in Medication-Use Safety and Pharmacy Practice Certification. The pursuit of the ASHP COE certification allows our health system to differentiate itself from other systems, indicating the high quality, credibility, and value of pharmacy services to our health system community. Although still in a pending status as of this submission, we are expecting certification in the next few months. The purpose of this presentation is to enhance awareness and provide advice to other health systems about the ASHP COE application and survey process.

Methods: The application process required a comprehensive and dedicated team approach with the frontline pharmacy members led by pharmacy administrative and clinical leadership. Prior to submission, twelve teams were created to explore each of the twelve domains of the certificate and compare those individual standards with the current practice of our health system. After a thorough exploration of our current practices, we identified areas where our pharmacy teams could perform at a higher level, deliver more quality outcomes, and advance services to patients. This was an important part of the introspective process of the application in refining services prior to the on-site survey. This process allowed the opportunity to evaluate current policies and procedures for their alignment with the standards, as well as create action plans to further the advancement of pharmacy within our health system.

Results: As we progressed to the survey, our team prepared to address the 112 elements of the ASHP COE and respond to the survey findings with an effective plan. Areas for improvement were identified during ASHP COE application and on-site survey process. Upon survey, twelve elements were identified of the 112 essential elements requiring action plans to achieve the certification standard. In addition there were ten consultative recommendations for continued development of service excellence. Our dedicated teams worked to address the twelve elements requiring additional detailed plans, along with the ten consultative recommendations. From that response, ASHP deferred action and required additional information on four of our areas of improvement.

Conclusion: Our health system was the first to undergo the ASHP COE certifcation as an entire health system, and thus can offer a unique perspective in leading other health systems through this process. Health system strategic planning can be accelerated and advanced through the expert professional consultation of the survey team findings and recommendations.