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Christopher Thomas, PharmD, BCPP, BCPS

I have been the Residency Program Director (RPD) at the Chillicothe VAMC since 2006 which has allowed for the fortunate opportunity to serve as an ASHP practitioner surveyor for both PGY-1 and PGY-2 psychiatry programs across the country in the last three years. I truly view the accreditation process as a quality improvement opportunity to strengthen each program to maximize the resident’s training experience.  


Presurvey Preparation

Once a program applies for accreditation or reaccreditation, a site survey is scheduled and conducted by a lead surveyor from ASHP and one volunteer practitioner with specialization in the program area. A site survey is usually conducted over one to three days depending on the complexity of the hospital and the number of programs involved. Prior to arrival at any program site, several hours are spent by the surveyors reviewing pre-meeting materials. This is essential in order to have a basic understanding of the program design, structure and policies as well as the strengths and weaknesses of the program. In addition, it is imperative to review these materials so the program is compared to the accreditation standard rather than another program recently surveyed. My own approach to the survey process also involves thorough review of the program structure and resident evaluations to determine the quality of feedback the resident receives. A good predictor of a great residency program is easily detected in good, quantitative feedback provided to the resident.

During the Survey

During the first morning, onsite documents are reviewed and key personnel (RPD, preceptors, and pharmacy leadership) are interviewed. The afternoon consists of touring the facility and specifically the pharmacy. To end the first day, current residents meet with the survey team. The second day consists of more interviews (Physicians, Nursing Staff, and other healthcare employees interacting with current pharmacy residents). The survey concludes with presentation of the surveyor findings to key pharmacy personal and hospital leadership.

Responding to the Survey

Once a survey is complete, a findings report is sent to the RPD within 30 days of the conclusion of the survey. The RPD must respond to the report within 45 days and it is then presented to the Commission of Credentialing (COC). The COC determines the accreditation status and the length of accreditation based on the programs response to the survey findings. It is imperative that the program respond very thoroughly with documented action plans related to areas of noncompliance or partial compliance since this will be a major factor in length of accreditation. Once the COC votes on length of accreditation, the accreditation status only becomes official after the ASHP Board of Directors sign minutes of the COC meeting. In general, a program can expect to have an onsite accreditation site visit every 6 years.

After each survey, I am reminded that our members are doing incredible work and developing creative practice sites to expand our reach in treating the neuropsychiatric patient. In addition, I enjoy meeting current residents who are the future leaders of CPNP; it is invigorating to observe their eagerness to learn and involve themselves in their residency program. Finally, I also enjoy giving suggestions/recommendations in making good residency programs even better through the accreditation process and standards. The ASHP site surveys also provide invaluable insight and improvement for my own PGY-1 and 2 programs from colleagues I know and respect. I cannot count how many times I have changed or implemented a new rotation, process, or policy based on observations from a site survey. I would encourage all RPD’s to contact ASHP’s Accreditation Services Division to take the training to become a surveyor.

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