Accreditation Quality Assurance and Monitoring Policy

T-300.1 Accreditation Quality Assurance and Monitoring Policy 27 February 2015 Version 2.1 T-300.1

Table of Contents Glossary of Terms... 3 List of Abbreviations... 4 1. Purpose... 5 2. Scope... 5 3. Overview... 5 4. Policy Statement... 5 4.1. Notification of Change... 6 4.2. Reporting... 6 4.2.1. Accredited education program providers... 6 4.2.2. CPD accrediting organisations 2... 6 4.3. Site Evaluation Team visits... 7 4.4. ITP Provider site audits... 7 4.5. CPD site audits... 7 4.6. CPD desktop audits... 8 4.7. Intern Written Examination data collection... 8 4.8. Department of Education and Training data... 8 4.9. Surveys... 9 4.10. ITP Provider Liaison Group... 9 4.11. Website and publication monitoring... 9 4.12. Networking... 9 4.13. CPD activity monitoring... 10 4.13.1. Attendance at conferences or accredited CPD activities... 10 4.13.2. Paper based audits of accredited CPD activities... 10 5. Roles and Responsibilities... 10 6. Supporting Procedures... 11 7. Related documents/ Links... 11 8. References... 11 2

Glossary of Terms Term Accreditation Accreditation Committee Accredited pharmacy education program Accredited pharmacy education program provider CPD accrediting organisation Continuing Professional Development CPD activities CPD activity provider Meaning Accreditation of a degree program, intern training program (ITP) and continuing professional development (CPD) activity against defined standards to ensure that the education and training leading to registration as a health practitioner (i.e. pharmacist) is rigorous and prepares individuals to practise a health profession safely. Is a standing Committee of the APC Council which is structured to draw upon the relevant expertise across the pharmacy profession, academia and the community to undertake accreditation decision making on behalf of APC. Collective term used to refer to pharmacy Intern Training Programs (ITPs), degree programs and other pharmacy related education programs (ie. prescribing programs, vaccination courses) accredited by APC. NB: Please note that the ITPs accredited on behalf of the Pharmacy Council of New Zealand (PCNZ) is not included in the definition for this policy. Refers to an organisation (ie. universities, ITP providers) that is responsible for delivering the pharmacy ITPs and/or degree programs and other education programs accredited by APC. Please note that some pharmacy education programs (ie. prescribing programs, vaccination courses) accredited by APC may also be considered as a CPD activity for pharmacists. Refers to an organisation accredited by APC to accredit pharmacy CPD activities on its behalf. The means by which members of the profession continue to maintain, improve and broaden their knowledge, expertise and competence, and develop the personal and professional qualities required throughout their professional lives (Pharmacy Board of Australia 2010, p.1). The activities undertaken by the members of the profession which enable them to continue to maintain, improve and broaden their knowledge, expertise and competence, and develop the personal and professional qualities required throughout their professional lives (Pharmacy Board of Australia 2010, p.1). Refers to providers of CPD education activities within the pharmacy profession. NB: Please note that in some instances the CPD accrediting organisation and the CPD activity provider is the same. 3

List of Tables Table 1: Quality assurance and monitoring activities undertaken by APC... 5 List of Abbreviations Abbreviation APC CPD ITP NRAS PBA PCNZ SET Term Australian Pharmacy Council Continuing Professional Development Intern Training Program National Registration and Accreditation Scheme Pharmacy Board of Australia Pharmacy Council of New Zealand Site Evaluation Team 4

Accreditation Quality Assurance and Monitoring Policy 1. Purpose To allow for the ongoing quality assurance monitoring of all accredited pharmacy education programs, accredited pharmacy education program providers and Continuing Professional Development (CPD) accrediting organisations. Accredited CPD activities delivered by CPD activity providers will be monitored through the CPD accrediting organisations. 2. Scope This policy applies to all APC accredited pharmacy education program providers 1 and CPD accrediting organisations. 3. Overview The Pharmacy Board of Australia (PBA) has authorised the APC to accredit pharmacy education program providers in Australia. The PBA has further authorised the APC to accredit organisations (ie. CPD accrediting organisations) to accredit CPD activities for pharmacists in Australia. 4. Policy Statement To allow for the ongoing quality assurance monitoring of accredited pharmacy education programs, accredited pharmacy education program providers and CPD accrediting organisations, APC undertakes the following quality assurance and monitoring activities: Table 1: Quality assurance and monitoring activities undertaken by APC Universities and other pharmacy education program providers ITP Providers CPD Accrediting Organisations Notification of change Notification of change Notification of change Reporting Reporting Reporting SET visits ITP provider audits CPD site audits Intern Written Examination data Intern Written Examination data CPD desktop audit Department of Education and Training data Surveys Networking Surveys ITP Provider Liaison Group CPD activity monitoring Website and publication monitoring Networking Website and publication monitoring Networking Notification of change 1 ITPs accredited on behalf of the Pharmacy Council of New Zealand (PCNZ) do not fall within the scope of this policy. 5

4.1. Notification of Change Frequency: As reported Target: Accredited education program providers and CPD accrediting organisations An accredited education program provider must notify APC in writing of change(s) to any part of the program, including curriculum or resources, immediately following a change decision. It is the responsibility of APC Accreditation Committee to determine if it is a major change and if it warrants a re-assessment of the accreditation status. Re-assessment of the accreditation status can take the form of an Expert Academic Review or a visit from a Site Evaluation Team (SET) or audit team. A CPD accrediting organisation must notify APC in writing of change(s) to any part of accreditation process, including resources, immediately following a change decision. It is the responsibility of APC Accreditation Committee to determine if this warrants a re-assessment of the accreditation status. Re-assessment of the accreditation status can take the form of a desk top audit or a visit from an audit team. 4.2. Reporting Frequency: Annually per calendar year Target: Accredited education program providers and CPD accrediting organisations Accredited education program providers and CPD accrediting organisations are required to complete an annual report per calendar year. The annual report covers the following: 4.2.1. Accredited education program providers 2 Staff list: including changes to employment, changes to qualifications or teaching responsibilities Curriculum changes Enrolled student or intern numbers (including breakdown of international and domestic students) Anticipated changes in the next twelve months, i.e. new buildings, curriculum changes, staff changes) Clinical placement hours delivered per year (pharmacy degree program only) 4.2.2. CPD accrediting organisations 2 Total number of applications for accreditation received Number of applications for accreditation which was rejected and de-identified information regarding the reason(s) for rejection Number of applications for accreditation which was approved Name of accredited CPD activities including the type of activity (ie. journal article, conference presentation etc). Annual reports are reviewed internally by APC staff and any issues arising which require further investigation, or consideration, are reported to the Accreditation Committee for discussion and decision. 2 Please note that this information is used only for APC quality assurance and monitoring purposes and it will not be published on APC website. 6

4.3. Site Evaluation Team visits Frequency: Once per accreditation cycle or as required Target: Universities APC establishes a Site Evaluation Team (SET) to conduct a site visit to ascertain the strengths and weaknesses of a pharmacy school, as well as identify any areas where a program may not adequately to meet the Accreditation Standards for Pharmacy Programs in Australia and New Zealand. A SET normally consists of three to four suitably qualified people with experience in the organisation and structure of undergraduate pharmacy courses and with an understanding of the current professional requirements for practice. The SET include, at a minimum, one pharmacy academic, one community pharmacist, one hospital pharmacist and two members of the APC Accreditation section of the Accreditation and Credentialing Unit. Conducted over several days, the SET visit allows APC to discuss the program with all stakeholders involved in the delivery of the program, from academics to students and preceptors. It further allows to assess the teaching resources and infrastructure of the pharmacy school, e.g. labs, libraries. Draft SET report is provided to the university, inviting any correction of errors, before being submitted to the Accreditation Committee along with an accreditation recommendation. Accreditation recommendations are considered and approved and/or amended by the Committee as appropriate. 4.4. ITP Provider site audits Frequency: Once per accreditation cycle or as required Target: ITP providers Within twelve months of commencement of the first intern cohort, accredited ITP providers are required to participate in a site audit conducted by two members of the Accreditation section of the APC Accreditation and Credentialing Unit. Site audits are conducted over one day and focus on information regarding identified needs for improvements revealed in the accreditation or re-accreditation application assessment and verification of resources and processes as stated in the application. Consequently, ITP provider site audits are conducted once per accreditation cycle (ie. every 3 years for ITP providers). Draft audit report is provided to the ITP provider, inviting any correction of errors, before being submitted to the Accreditation Committee along with an accreditation recommendation. Accreditation recommendations are considered and approved and/or amended by the Committee as appropriate. 4.5. CPD site audits Frequency: Once per accreditation cycle or as required Target: CPD accrediting organisations Within the first 6 months of an organisation being accredited to accredit CPD activities on behalf of APC, a site audit is conducted at the main premises where CPD accrediting activity takes place. The audit is conducted by two members of the Accreditation section of the APC Accreditation and Credentialing Unit. The purpose is to identify any inconsistencies in the process of accreditation and any areas where improvement may be required. Consequently, CPD site audits are conducted once per accreditation cycle (ie. every 3 years for CPD accrediting organisations). Draft audit report is provided to the CPD accrediting organisation, inviting any correction of errors, before being submitted to the Accreditation Committee along with an accreditation recommendation. Accreditation recommendations are considered and approved and/or amended by the Committee as appropriate. 7

4.6. CPD desktop audits Frequency: Once per accreditation cycle or as required Target: Organisations Authorised to Accredit CPD 12 months following a CPD site audit, CPD accrediting organisations are required to complete a paper based audit which provides evidence of a quality improvement process. Authorised organisations are required to submit the following information: Significant changes that have occurred regarding the accreditation process Evidence that feedback has been sought from CPD participants and accredited organisations and any actions that have arisen Evidence of customer satisfaction with CPD programs Evidence of independent verification of CPD outcomes Paper based audit materials are reviewed internally by APC and a report is provided to the Accreditation Committee for noting and, where required, decision regarding any additional improvements or modification to the authorisation required. 4.7. Intern Written Examination data collection Frequency: Annually Target: Universities, ITP Providers With the implementation of the National Registration and Accreditation Scheme (NRAS) all Australian interns are required to sit a written examination delivered by APC. As the Australian interns register for their Intern Written Examination with APC, information regarding their degree program and ITP provider are collected. Results of the written examination are then collated according to university and ITP provider and that data is considered annually by the Accreditation Committee. Results of each university s graduates and ITP provider s interns are benchmarked against the national mean and any outliers are discussed by the Accreditation Committee. Where required, the university or ITP provider identified as an outlier will receive a request from the Committee for an explanation of the results. De-identified results of each accredited program s interns or graduates compared to the national mean are provided annually, to each university and ITP provider for internal quality improvement purposes only. 4.8. Department of Education and Training data Frequency: Annual Target: Universities APC requests data on an annual basis from the Department of Education and Training (the Department) regarding the following information related to Australian pharmacy degree programs accredited by APC: Approved degree Programs and structures Actual student load Data collected from the Department is cross checked against annual reports to verify information received from accredited degree programs and to look for any variations which may prompt further investigation. 8

4.9. Surveys Frequency: Annual in March Target: Universities, ITP Providers APC will survey newly registered pharmacists to obtain subjective feedback regarding the quality of their education, preceptor experience and other at both at the degree and internship level. Survey results will be monitored by the APC for any trends, or any complaints requiring further investigation and any trends or complaints will be raised with the Accreditation Committee and/or the PBA where appropriate. 4.10. ITP Provider Liaison Group Frequency: Annual Target: ITP Providers The ITP Provider Liaison Group (the Liaison Group) is a quality improvement and communication mechanism to allow APC to distribute, collect and discuss information related to ITPs with accredited ITP providers. The Liaison Group is intended to provide APC with a mechanism for seeking feedback from the ITP Providers, as well as discussing best practice amongst all accredited ITPs. 4.11. Website and publication monitoring Frequency: Twice annually and as required Target: Universities, ITP Providers Using a publication and website scan, all accredited education program providers are monitored twice annually and as required to ensure that advertising of programs complies with the requirements of APC Accreditation Marketing Policy and that any programs offered which are not accredited are not improperly advertised as leading to registration. Any accredited education program provider found in breach of APC requirements is formally requested to provide an explanation and all information is then submitted to the Accreditation Committee for discussion and further action. 4.12. Networking Frequency: Ongoing Target: Universities, ITP Providers and CPD accrediting organisations APC liaises with a wide range of stakeholders including the universities, professional bodies and other health professions. Through relationships with these individuals and organisations APC is able to monitor changes in accredited programs, such as staffing changes, or levels of satisfaction with service provision such as CPD accreditation. Should the information obtained warrant further investigation, APC will contact the accredited education program provider or CPD accrediting organisation involved formally. 9

4.13. CPD activity monitoring Frequency: See below Target: CPD accrediting organisations APC will monitor accredited CPD activities to ensure the quality of the activities and their compliance with Accreditation Standards for Continuing Professional Development Activities. 4.13.1. Attendance at conferences or accredited CPD activities Frequency: Once per accreditation cycle or as required The APC will formally conduct an independent review of at least 1 conference or an accredited CPD activity per CPD accrediting organisation at a minimum of once per accreditation cycle or as required. CPD Activity Review Form (found at Appendix A, Accreditation Standards for Continuing Professional Development Activities: Guidelines 2015) is used by APC in its CPD activity reviewing process. CPD accrediting organisations will then receive a formal environmental snapshot report outlining recommendations and continuous quality improvement opportunities from APC. These recommendations will be followed up with the CPD accrediting organisation at their subsequent site audit. 4.13.2. Paper based audits of accredited CPD activities Frequency: Annually or as required The APC will conduct an independent assessment of not less than 3 accredited CPD activities per CPD accrediting organisation per year. The CPD activities will be selected randomly from the annual report submitted by CPD accrediting organisations. APC will formally request each CPD accrediting organisations to provide information relating to the 3 selected accredited CPD activities. Should the assessment indicate that a review of the CPD accrediting organisation s accreditation process and procedures is required, APC will contact the organisation formally. 5. Roles and Responsibilities The Accreditation and Credentialing Unit of APC is responsible for the implementation and compliance monitoring of the policy. Director Accreditation and Credentialing Assistance Director Accreditation and Accreditation and Policy Pharmacist Accredited pharmacy education providers CPD accrediting organisations Recommendation of policy direction Degree program, ITP and CPD matters including implementation of advised changes, compliance monitoring and version control Ensure that the policy is implemented and that all necessary parties are informed and compliant with the policy. Ensure that the policy is implemented and that CPD activity providers and other relevant parties are informed and compliant with the policy. 10

6. Supporting Procedures 1. Australian Pharmacy Council 2014, CPD Activity Review Form, Australian Pharmacy Council, Canberra S:\Accreditation\CPD Accreditation\Discussion Papers\CPD QA and Monitoring Framework\Attachment 3 - CPD Activity Review form.doc 2. Australian Pharmacy Council 2014, CPD Audit Cycle and Monitoring and Quality Assurance Information, Australian Pharmacy Council, Canberra S:\Accreditation\CPD Accreditation\Discussion Papers\CPD QA and Monitoring Framework\Attachment 2 - CPD Audit Cycle and Monitoring and Quality Assurance Information.docx 3. Australian Pharmacy Council 2013, ITP Audit Cycle, Australian Pharmacy Council, Canberra S:\Accreditation\ITP Accreditation\ITP Audit_Documents\ITP Audit Cycle.docx 7. Related documents/ Links 1. Australian Pharmacy Council 2014, Accreditation Marketing Policy, Australian Pharmacy Council, Canberra, http://pharmacycouncil.org.au/content/assets/files/accreditation/policies/accredited- Provider-Marketing-Policy-Website.pdf 2. Australian Pharmacy Council 2013, Accreditation Standards for Continuing Professional Development Activities, Australian Pharmacy Council, Canberra, http://pharmacycouncil.org.au/content/assets/files/publications/standards%20and%20guidelines%2 0for%20the%20Accreditation%20of%20CPD%20Activities%20July%202013_APC%20CPD WEB. pdf 3. Australian Pharmacy Council 2010, Accreditation Standards for Intern Training Programs, Australian Pharmacy Council, Canberra, http://www.pharmacycouncil.org.au/content/assets/files/accreditation/itp%20accreditation%20stds %20NZ%20Final.pdf 4. Australian Pharmacy Council 2014, Accreditation Standards for Pharmacy Programs in Australia and New Zealand, Australian Pharmacy Council, Canberra, http://pharmacycouncil.org.au/content/assets/files/publications/accreditation%20standards%20for% 20Pharmacy%20Degree%20Programs%202014.pdf 8. References 1. Pharmacy Board of Australia 2010, Continuing Professional Development Registration Standard, viewed 29 January 2015, http://www.pharmacyboard.gov.au/registration-standards.aspx 11

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