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Four tools for taking the anxiety out of accreditation

By Craig Frost

When people raise the topic of accreditation, the word often causes anxiety. But why? Accreditation is a way to prove a pharmacy meets a baseline of competencies. To become accredited, a pharmacy will have policies and procedures in place, certain equipment, and capabilities in its facility to meet the standards of the accrediting body.

Accreditation Software

Accreditation can also be a prerequisite for payment. For instance, the Centers for Medicare and Medicaid Services turn to the Joint Commission, a deemed status provider for accreditation, to accredit healthcare provider organizations. If a pharmacy fails accreditation by the Joint Commission or other deemed status provider, then CMS must consider whether to exclude the pharmacy. CMS may send a Medicare surveyor to take a closer look. So, in this case, accreditation, or the lack thereof, can get between the pharmacy’s work and payment. Particularly with specialty and infusion pharmacies, commercial payors typically require accreditation by the Accreditation Commission for Health Care (ACHC), the Utilization Review Accreditation Commission (URAC), the National Infusion Center Association (NICA), or the Health Care Accreditation Council (HCAC).

Getting organized for accreditation

In 2022, a pharmacy benefit management company required Indiana’s oldest and largest AIDS service organization Damien Center to be accredited by the HCAC. Damien Center’s Director of Pharmacy Services Brad Plunkett says having SectyrHub LicenseTrak® compliance software in place helped earn HCAC accreditation, in part, because Sectyr loaded the current standards into the accreditation portion of the software. Once added, Damien Center had a comprehensive accreditation task list, including a calendar with action items. By referencing the data in SectyrHub LicenseTrak, Damien Center showed HCAC the clinic had met the requirements and stored all the supporting documents. 

“We even mention LicenseTrak in our policies and procedures, so HCAC knows the system is our way of organizing ourselves and staying updated with licensure and more,” Plunkett says.  

Earning accreditation, staying there

Essentially, the accrediting bodies look to see if a pharmacy has policies and procedures in place and, most importantly, if the organization is following its policies to deliver quality care. There is a heightened level of anxiety when pharmacies must scramble or struggle to prove they are competent for whatever service they provide. The brunt of that often falls on whomever serves as the lead for accreditation. Sometimes, that person is the chief quality officer, chief pharmacy officer, or another person tapped to keep up with quality and operations.  

With compliance management software, pharmacies can produce documentation to show Evidence of Compliance, or EOC. For example, NuCara, an owner and manager of community-based pharmacies and medical equipment locations, credits SectyrHub LicenseTrak with not only helping prove compliance but also preparing for accreditation with ACHC.

“LicenseTrak has a template with all the ACHC accreditation tasks, and we can add to those when there’s something specific to a state board of pharmacy and our SOPs,” says Brett Barker, vice president of Operations at NuCara. “LicenseTrak helps guide us to accreditation and keep us there.”

Four elements to look for in compliance management software

Gaining accreditation, however, requires an extensive–sometimes complicated–list of EOC in the form of licenses, documentation, certificates, and CE. For compliance software to truly handle the task, and eliminate anxiety for a pharmacy or other healthcare provider, the platform should offer:

  1. Task management – a pharmacy may be doing everything right. But if a manager cannot document that, the good work does not count in the eyes of an accrediting body. When a manager wants proof, the task management capability delivers one source of truth.
  2. License management – a pharmacy not only has to prove its staff has valid licenses in place to dispense drugs but also regularly validate this per, for instance, a payor contract.
  3. Incident management – when a patient has a potential clinical event, or a pharmacy has a service issue getting drugs to someone on time, these are variances from expected outcomes. Compliance software must have functionality to help pharmacists and pharmacy owners manage, record, investigate, and resolve issues.
  4. Learning management – this functionality supports all the competencies a pharmacy staff needs to learn and master, from legal to clinical. Delivering and tracking the outcome of learning also fits hand in glove with identifying variances and supporting a patient population. Learning management offers one-off training or support for overall professional development.

In the coming weeks, I will write additional blog posts on each of the four areas mentioned above including examples of how healthcare providers use these capabilities to prove they are doing what they say–delivering quality outcomes, developing their team’s professional skills, and earning accreditation. Accreditation is important. Providing EOC is, too often, a burden. Compliance software lifts the weight from a pharmacy’s shoulders.