Accreditation management can be simple.
We developed the tools and systems we wish we'd had access to when we were PIC's.
ACHC
ACHC focuses on organizational structure, patient care outcomes, risk management (infection and safety control), quality management, and fiscal and human resources management.
Here are the most common accreditation deficiencies identified by ACHC:
- Welcome Packet Documentation: Many organizations fail to document that patients received their welcome packets. This is critical for compliance and patient education.
- State Regulatory Agency Information: URAC found that some organizations neglected to include state regulatory agency information in the grievance and complaint packets provided to patients, creating gaps in patient rights awareness.
- HR Competency Assessments: HR management of staff competency assessments is frequently incomplete or inconsistent.
- Provision of Care and Record Management: URAC stated that some pharmacies will not perform complete patient evaluations and assessments, completing some of each of the 5 elements but not all required elements. They also have found that many care plans are identical - not individualized for the specialty disease or drug that the patient is taking.
URAC
URAC emphasizes patient assessments, clinical interactions, quality management, cold chain and room temperature shipping compliance, distribution accuracy, and prescription turnaround time.
Here are the most common accreditation deficiencies identified by URAC:
- Primary Source Verifications: URAC was quick to mention issues with primary source verifications, an issue I see frequently. These are often missing completely, missing specific dates, or and are not done specific to the frequency in the standard or the organizational policy.
- Clinical Assessments: Like ACHC, URAC also finds missing documentation of patient management clinical assessments is a recurring issue.
- Temperature Management: URAC discussed specific issues with distribution and temperature qualification testing and auditing. This testing is often not completed or does not match the criteria (e.g., 36 hours).
Read more » Managing & Maintaining Your URAC Accreditation
NABP
NABP focuses on compliance with state and federal regulations, auditing dispensing processes, and ensuring prescription accuracy.
Here are the most common accreditation deficiencies identified by NABP:
- Incomplete Patient Profiles: NABP often finds deficiencies specific to missing information in patient profiles specific to critical information for patient care. These are things like allergies, goals of therapy, and safety measures.
- Patient Education Documentation: Unlike other accrediting bodies, NABP requires proof of patient education on safe medication handling and vaccine recommendations, which is often overlooked.
- Welcome Kit Documentation: Like ACHC, NABP often sees missing documentations that welcome kits were sent or received by patients.
- Narrow Drug Utilization Reviews (DURs): NABP stated that, sometimes, DURs are too narrow. This is a deficiency that can be easily corrected by including OTC and herbal supplements as part of the med rec process and documenting diagnosis codes.
NCODA
NCODA provides accreditation and resources tailored to oncology practices and pharmacies, focusing on improving patient outcomes in cancer care.
Here are the most common accreditation deficiencies identified by NCODA:
- Baseline Adherence Assessments: NCODA presented their top deficiencies as missing baseline adherence assessments for risk of non-adherence. I see this as especially important due to the challenges and delays in getting oncology products for start of therapy is critical to improving outcomes for cancer patients.
- Initial Patient Assessments: Inconsistent documentation or unclear location of these assessments is a recurring problem.
- Competency Assessments: Similar to other accrediting bodies, staff competency documentation continues to be a challenge.
Read more » Why Specialty Pharmacies Fail Accreditations and How to Prevent It
Overcoming Accreditation Challenges and Enhancing Compliance
Though each accrediting body highlighted unique challenges, they shared a common emphasis on the importance of detailed documentation, tailored processes, and adherence to standards. Addressing these deficiencies not only ensures compliance but also enhances patient care and operational efficiency.
Managing accreditation and compliance doesn’t have to be an overwhelming task for your pharmacy. By consolidating all your accreditation and compliance needs into one streamlined system, you can simplify the process, reduce errors, and gain peace of mind knowing that nothing is overlooked. D2’s AccredComply, paired with our expert pharmacist consultants, offers a seamless solution to manage documentation, competency assessments, patient education, and regulatory requirements. This streamlined approach keeps your pharmacy audit-ready and compliant while freeing your team to focus on what truly matters—patient care.
If you’re interested in connecting to chat more about your accreditation journey, reach out to me at quintin.jessee@d2rx.com or through our website.
