Accreditation – Should All Pharmacy Programs Be Alike?

by Caitlin Frese, Pharm.D., PGY1 Pharmacy Practice Resident, Johns Hopkins Bayview Medical Center

The Accreditation Council for Pharmacy Education (ACPE) is the national agency responsible for accrediting professional pharmacy degree programs since 1932.¹  According to ACPE’s 2013 annual report, there were 109 fully accredited programs, 16 schools in candidate status, and 4 with pre-candidate status.²  Accreditation in healthcare is commonplace – schools/colleges, continuing education providers, and residency training programs are all accredited. Why is accreditation important?  And should all programs be the same?

Accreditation is intended to ensure that high standards are met – not only in terms of the instructional design of the learning program but also its execution. For colleges/schools that offer the Doctor of Pharmacy degree, standards relate to the curriculum, experiential education program, strategic plan, faculty qualifications, and organizational support.  Although accreditation is intended to ensure that every school/college meets and maintains high standards, there is wide variability in skills and competencies obtained by students.  For example, schools of pharmacy located on a academic health sciences campus provide the opportunity for interdisciplinary interactions earlier in their curricula.  Programs located in states with progressive pharmacy practice acts may offer students a greater breadth of practice experiences relative to other programs that are limited by legal constraints.  Differences in curricular design, assessment strategies, experiential education opportunities, and interprofessional interaction often sets one accredited school apart from another.

National pharmaceutical organizations have advocated for revisions in the ACPE accreditation standards to ensure that future graduates are ready for practice and can meet employer expectations.  At a 2012 conference, stakeholders provided recommendations including:

• Greater emphasis on developing skills for literature evaluation and data interpretation.
• Identifying and cultivating behavioral attributes needed by pharmacists in practice including interprofessional collaboration, clinical reasoning, and motivation.
• Ensuring assessment data is utilized for program improvement.
• Using standard assessment questions at the conclusion of advanced practice experiences such as “Would you hire this student?” and “Are the student’s skills at a level ready to enter practice?”³

Many of the recommendations focus on ensuring the pharmacy program adequately trains student pharmacists to enter the workforce as healthcare providers capable of providing direct-patient care.

Reviewing future employer expectations highlights gaps in the current ACPE standards.  Some expectations relate to managerial and business aspects of pharmacy (e.g. delegating tasks, measure/report performance, pharmaceutical supply chains); others place emphasis on health care delivery systems.⁴  Some employers expressed expectations that students should be competent in everyday activities such as documenting in electronic records, respecting patient confidentiality, managing drug waste, and administering common dosage forms.⁴   

After reflecting on my education and listening to the experiences of other recent graduates from different schools of pharmacy, many (but not all) of these expectations are already included in the curriculum.  However, the depth to which they are taught (if they are taught at all) varies greatly.  This likely explains the variability in competencies seen among graduating students today.

ACPE has released a draft version of the 2016 accreditation standards for comment.  These draft standards incorporate many of the recommendations from the stakeholders conference.⁵ These new standards would force schools/colleges of pharmacy to critically review their current curriculum and find opportunities for enhancement. Terminology within the proposed standards better delineates which items are necessary (i.e. “must” statements listed in the standard document) versus items recommended to enhance the quality of the program (i.e. “should” and “could” statements listed in the guidance document).⁵ Twenty-six standards are organized into three major themes: Educational Outcomes, Structure and Process to Promote Achievement of Education Outcomes, and Assessment.⁵ This change in organization of the standards document mirrors the change pharmacy. As health care delivery changes, the pharmacist’s role has shifted from the traditional dispensing/drug distribution functions to a focus on patient care functions, health outcomes, and cost-effective use of drugs.  This shift is evident within the proposed draft of Educational Outcomes as there is greater emphasis on patient care functions and practicing in interprofessional healthcare teams.⁵

One key change between the current and proposed standards is the separation of standards and guidance statements.^5,6 This separation is where pharmacy schools/colleges can customize their program and truly shine.  ACPE acknowledges that pharmacy programs differ and the guidance document is intended to elevate a program from meeting the bare minimum to producing outstanding graduates with unique skills that are highly sought by employers.

For faculty (or those seeking faculty positions), knowledge of the proposed standards and guidance documents should inform course development. The new standards allow for flexibility in terms of innovative course design and delivery methods.⁶  This could include adopting the “flipped classroom” method when redesigning a course or creating a new interdisciplinary elective.  The guidance document includes examples of co-curricular experiences that can be built into courses including student participation in activities such as Legislative Day, brown bag and medication review events, and serving as an institutional ambassador.⁶  It is unlikely that a school/college of pharmacy will be able to successfully implement and master all recommendations included in the guidance document.  Being selective about what can be optimally incorporated into the pharmacy program will maximize student learning and help set the school/college apart.

Ultimately the guidance document encourages schools to strive for excellence.  Accreditation ensures that students gain foundational knowledge and attain a reasonably similar level of competency to perform core professional functions regardless of what school/college they attend.  However, not all schools / colleges are alike.  Utilizing the guidance recommendations and capitalizing on local or state resources will help good programs become great programs.

References

1. Accreditation Council for Pharmacy Education. Accreditation standards and guidelines for the professional program in pharmacy leading to the doctor of pharmacy degree (Guidelines Version 2.0, Adopted: January 23, 2011, Effective: February 14, 2011). Accessed March 14, 2014.
2. Vlasses PH, Wadelin JW, Boyer JG, et al. Annual Report of the Accreditation Council for Pharmacy Education. Am J Pharm Educ 2013; 77(4):Article 83.
3. Zellmer WA, Beardsley RS, Vlasses PH. Recommendations for the Next Generation of Accreditation Standards for Doctor of Pharmacy Education. Am J Pharm Educ 2013; 77(3):Article 45.
4. Vlasses PH, Patel N, Rouse MJ, et al. Employer Expectations of New Pharmacy Graduates: Implications for the Pharmacy Degree Accreditation Standards. Am J Pharm Educ 2013; 77(3):Article 47.
5. Accreditation Council for Pharmacy Education. Accreditation standards and key elements for the professional program in pharmacy leading to the doctor of pharmacy degree (Draft Standards 2016, Released: February 3, 2014).  Accessed March 14, 2014
6. Accreditation Council for Pharmacy Education. Guidance for the accreditation standards and key elements for the professional program in pharmacy leading to the doctor of pharmacy degree (Draft guidance for standards 2016, Released: February 3, 2014).  Accessed March 14, 2014.

Providing Effective Feedback

by Monique L. Mounce, Pharm.D., PGY1 Pharmacy Resident, Johns Hopkins Bayview Medical Center

One of the toughest yet crucial aspects of being an instructor is providing effective and constructive feedback.  Whether you are inside or outside the classroom teaching, you will have the responsibility of providing feedback both praise and constructive at some point in your career.   Although it may be uncomfortable for some, there are many techniques to assist you with providing verbal and written feedback to a learner.  Personally, as a Doctor of Pharmacy student and now a resident, providing written and verbal feedback to preceptors or pharmacy students has been a struggle.   Like others, I am always afraid of hurting someone’s feelings. I believe the key to effective feedback is the timing and the environment in which the feedback is delivered.

Feedback is defined as information provided by an agent (teacher, peer, parent, self, or experience) regarding aspects of one’s performance, thus it is a consequence of performance.¹ Feedback should be structured to fill the gap between what is understood and what is expected of the learner.  Structured methods for providing feedback date back to the early 1900s when behaviorism was developed.  In behaviorist terms, “positive feedback” is positive reinforcement and “negative feedback” is punishment.  Although feedback is powerful, it is not always accepted.  Feedback can be accepted, modified, or rejected by the learner thus it does not necessarily reinforce actions despite behaviorist’s initial theories on how feedback shaped behavior.  Feedback methods vary based on timing, amount, mode, audience, and its content.  Furthermore, the content varies based on focus, comparison, function, valence, clarity, specificity, and tone (Table 1).¹

Table 1 - Feedback Strategies and Content

Feedback Strategy	Aspects	Recommendations
Timing	-When -How often -Where	Provide immediate feedback for incorrect facts Reserve criticism for appropriate timing and when there is privacy Suggest a different location other than your office to make learner more comfortable.
Amount	-Number of points to make -Elaboration	Prioritize: No more than 2 “lessons” in one session The smaller and more frequent, the better
Mode	-Verbal -Written -Electronic	In-person discussions are best to allow a conversation and to ensure understanding Electronic can be interpreted differently than intended. Use this with short remarks only
Audience	-Individual -Group/Class	Focused attention is best- avoids embarrassment Share the feedback if common among learners but be careful about “picking on” one person
Feedback Content	Aspects	Recommendations
Focus	-Process used for task -Work/actions itself -Student’s self-regulation -Student personally	Most effective- focus on the process used for task completion and observed behavior Avoid personal comments because it makes learner get defensive and reject feedback
Comparison	-To standard of work (criteria-specific) -To other students (norm-specific) -To learner’s own past performance (self-specific)	Criteria-specific feedback for work itself Norm-specific feedback for student’s process or effort Self-specific feedback for illustrating growth and progress towards task
Valence	-Positive -Negative	Use positive comments that describe what actions were well done Give examples for improvement with negative comments
Specificity	-Excessive -Balanced -Vague	Be specific as possible, yet avoid nitpicking Provide specific feedback but do not complete the task for them Be direct: do not beat around the bush
Tone	-Implications -What students “hear”	Brainstorm what you will say and how you want the feedback to be received Choose words that communicate respect for the student and their work

Adapted from:   Brookhart SM. How to Give Effective Feedback to Your Students.  Alexandra, VA: Association for Supervision and Curriculum Development (ASCD); 2008.

How effective is feedback?

A comprehensive meta-analysis by Hattie in 2007 evaluated the effect of providing feedback in the classroom.²  This analysis examined factors that influence educational achievement such as schooling, homes, students, teachers, and curricula.  A subgroup analysis of studies evaluating feedback observed an average effect 50% greater than the effect than schooling itself.  Other influences on achievement in decreasing order of their magnitude of effect include direct instruction, reciprocal teaching, homework, the use of calculators, and reducing class size.  Most teachers are comfortable with providing homework and calculators, yet feedback is at least 50% more powerful at influencing the learners’ achievement.   Not all modes of providing feedback are effective.  Praise, punishment, and rewards contributed to the smallest effect on achievement.

A study evaluating survey responses of over 340 pharmacy students in the United Kingdom on their perceptions of feedback from faculty showed that 98% of students agreed that receiving feedback was an important part of their degree program and 80% of students agreed that feedback from faculty improved their performance.³  Not surprisingly, less than 33% of the students agreed that they were satisfied with the feedback they received.  Inconsistencies in providing feedback, the quantity, quality, and timing were common reasons cited by students.  Feedback given at the end of a module was viewed as the least useful.

Balance between positive and negative feedback

“Negative feedback isn’t always bad and positive feedback isn’t always good.  Too often, they say, we forget the purpose of feedback.  It’s not to make people feel better, it’s to help them do better”

- A. Tugent, New York Times

Studies have shown that learners that truly desire to improve their skills want constructive feedback and view the comments as opportunities for improvement and growth.  People learning a new task prefer positive reinforcement to boost their confidence.⁴   Yet some instructors struggle to give what some would perceive as “negative” feedback.  The term “constructive feedback” is perhaps better nomenclature.  Constructive feedback includes remarks that are productive, useful, redirecting, and motivational, not destructive.  This does not mean the learner should only receive praise.

Example of feedback techniques & Strategies ^(4-6)

One common method of providing feedback is the Feedback Sandwich.⁴  This technique provides the so-called negative feedback between two positive comments.  This strategy has received much criticism for being ineffective because many learners will only hear the praise, thus undermining the intent.  Authors of The Power of Feedback argue that focusing the feedback on the task and self-regulation are the most powerful modes of feedback, whereas feedback about the self as a person is the least effective. ²    In the One Minute Preceptor technique, the preceptor probes the learner for supporting evidence after the learner has articulated a recommendation.  The preceptor then reinforces actions done well and lastly makes recommendations for improvement.⁵   Another common way of providing feedback is the W3 in which the preceptor allows the learner to self-reflect utilizing three questions:  what worked well, what did not work well, what we can do differently next time.  There are other strategies such as 360 degrees that attempts to elicit feedback from various sources such as other learners, colleagues, as well as supervisors.

I like the W3 method but sometimes learners are their own worst critic; therefore, I like utilizing the W3 informally. I like constructive feedback from the instructor about a specific task in real time (e.g. while I’m performing the task or immediately afterward).  As a learner, the worst experience is not receiving any feedback until the end of the learning experience and realizing you weren’t meeting expectations.  It is human nature to assume if there is no feedback that everything must be fine.  At the very least, feedback sessions should be held formally at the middle and end … but informal feedback should be given as much as possible.

Effective feedback is essential for the learner’s growth and professional develop.  With practice, the instructor will develop his/her own strategy to effectively deliver motivational and useful feedback to learners of all levels.  Effective feedback is FAST:  frequent, accurate, specific, and timely.   If you are going to make a feedback sandwich, make it a “meaty” one.

References:

1. Brookhart SM. How to Give Effective Feedback to Your Students.  Alexandra, VA: Association for Supervision and Curriculum Development (ASCD); 2008. [cited March 5 20014]
2. Hattie J, Timperley H. The power of feedback.  Review of Educational Research. 2007:77-81.
3. Hall M, Hanna L, Quinn S. Pharmacy students’ views of faculty feedback on academic performance.  Am J Pharm Educ. 2012; 76: Article 5.
4. Tugend A. You’ve been doing a fantastic job. Just one thing... New York Times [online]. April 2013.
5. Hohrenwend, A.  Serving up the feedback sandwich.  Fam Pract Manag. 2002;9:43-6.
6. Furney SL, Orsini AN, Oretti KE, et. al.  Teaching the one-minute preceptor.  J Gen Inten Med. 2001;16:620-4.

Interprofessional Education: Just Another Catch Phrase?

by Allison Butts, Pharm.D., PGY1 Pharmacy Practice Resident, The Johns Hopkins Hospital

Only nine months into my pharmacy career and I’m tested every day to effectively use my clinical knowledge, rational decision-making skills, adaptability, and confidence to deliver optimal patient care working alongside health professional colleagues.  I found the transition from student pharmacist to licensed pharmacist to be fairly smooth, which I attribute to the interprofessional education I received in pharmacy school.  If healthcare practitioners are expected to work together, communicate, and use their skills in an integrated manner, it seems clear that it is best to train students in an interprofessional environment.  In writing this essay I reflected on my educational experiences and how best to prepare students for practice in healthcare today.

In 2003, the Institute of Medicine (IOM) issued a report entitled, “Health Professions Education:  A Bridge to Quality.”  This report highlighted a number of necessary changes to professional health care education to improve the quality of care provided in the United States.  The report emphasized five core competencies that should be addressed through professional education:  patient-centered care, evidence-based practice, quality improvement, informatics, and interprofessional teams.¹   The Accreditation Council for Pharmacy Education (ACPE) addressed the 2003 IOM reports and adopted the core competencies into their 2007 Guidelines for ACPE Accreditation Standards, with a special focus on interprofessional education.²  In 2011, a joint effort between the American Association of Colleges of Nursing, American Association of Colleges of Osteopathic Medicine, American Association of Colleges of Pharmacy, American Dental Education Association, Association of American Medical Colleges, and the Association of Schools of Public Health further refined the core competencies.³  A 2012 survey found that only 34% of the participating colleges of pharmacy provided instruction regarding interprofessional teaming.  Most of these colleges / schools of pharmacy has some interprofessional teaching in their curriculum (53%), while others offered it as topic within a course (24%) or as a standalone course (17%) format.  While only a third were actively teaching interprofessional teaming, an impressive 83% of respondents indicated a desire to include this core competency into their curriculum.⁴

Colleges of pharmacy from across the country continue to look for new ways to teach the principles of interprofessional teaming in their curriculum.  Faculty from the South Carolina College of Pharmacy, MUSC Campus, recently published data on pharmacy students’ perceptions regarding interprofessional collaboration after completing a required longitudinal clinical assessment course.  The course addressed several domains of interprofessional education in nine separate learning activities.  The activities involved students from pharmacy, physician assistant studies, medicine, and nursing.  The Interprofessional Education Perception Scale (IEPS) was used to assess the perceptions of pharmacy students prior to and at the completion of the course.  In 16 of the 18 questions surveyed, perceptions of interprofessional collaboration improved after completing the course.  The items that had the most improvement were:  “individuals in other professions respect pharmacists” and “individuals in my profession are positive about their goals and objectives.”⁵

Other published examples of interprofessional teaching models include a required introductory pharmacy practice experience (IPPE) course in which pharmacy students visit practice sites of local physicians and nurse practitioners who serve as primary preceptors, participation in a service-learning advanced pharmacy practice experience (APPE), medical missions trips, patient simulation activities, and interprofessional didactic coursework.^6-12

Looking back on my pharmacy education, I recognize how fortunate I was to have trained at an institution located within a large academic medical center, especially one in which clinical pharmacy services are full integrated in the delivery of care.  When considering my personal experiences and reconciling them with examples from the literature, there is a combination of approaches that I believe will create the optimal environment for students to learn about the principles of interprofessional teaming and become skillful team members:

• Provide interprofessional experiences early and often.  It is never too early in the curriculum to introduce students to their health care colleagues.  Students across disciplines take many of the same basic science classes early in their respective programs, so should be feasible to have students from different professional programs in the classroom together.  Activities should evolve as students move through their curricula, allowing for the development of solid relationships prior to clinical rotations.
• Engage students in the development of interprofessional initiatives.  Students themselves can be the best gauges of a program’s success.  By understanding their needs, goals, and perceptions, educators can tweak the curriculum to best prepare students for clinical practice.
• Develop unique methods of student assessment.  Students are often graded at the completion of a interprofessional patient care activity (real or simulated) based on a SOAP note or patient presentation.  Educators should also measure the success of the team by how well they utilize their colleagues.  Students should be asked what each team member contributed as well as how they utilized their teammates to accomplish their tasks.
• Provide variety.  Ideally, health care students should interact with students from several different professional programs.  There are admittedly resource limitations and logistical barriers, but colleges/schools of pharmacy should strive to work with at least two other professional degree programs.  Create a variety of learning activities and consider nontraditional experiences to achieve the competency standards. 

The concept of interprofessional education is more than a catch phrase in today’s professional education landscape.  It is a true necessity in preparing pharmacy and other health professional students to become successful practitioners.  Primary professional education organizations have formed a united voice in favor of this practice model and interprofessional training should be a priority at schools/colleges across the country.

References

1. Greiner AC, Knebel E, eds.  Institute of Medicine.  Health Professions Education:  A Bridge to Quality.  Washington, DC:  National Academies Press; 2003. Accessed 10 March 2014. 
2. Accreditation Council for Pharmacy Education.  Accreditation Standards and Guidelines for the Professional Program in Pharmacy Leading to the Doctor of Pharmacy Degree.  Guidelines Version 2.0 for Standards 2007.  Effective February 14, 2011.  Accessed 10 March 2014. 
3. Interprofessional Education Collaborative Expert Panel.  Core Competencies for Interprofessional Collaborative Practice:  Report of an Expert Panel.  Washington, DC: Interprofessional Education Collaborative; 2011.
4. Zeind CS, Blagg JD, Amato MG, and Jacobson S.  Incorporation of Institute of Medicine Competency Recommendations within Doctor of Pharmacy Curricula.  Am J Pharm Educ.  2012; 76: Article 83.
5. Shrader S, Griggs C.  Multiple Interprofessional Education Activities Delivered Longitudinally Within a Required Clinical Assessment Course.  Am J Pharm Educ.  2014; 78: Article 14.
6. Turner CJ, Altiere R, Clark L, Dwinnell B, and Barton A.  An Interprofessional Introductory Pharmacy Practice Experience Course.  Am J Pharm Educ. 2004; 68: Article 10.
7. Jones KM, Blumenthal DK, Burke JM, et al.  Interprofessional Education in Introductory Pharmacy Practice Experiences at US Colleges and Schools of Pharmacy.  Am J Pharm Educ.  2012; 76: Article 80.
8. Johnson JF.  A Diabetes Camp as the Service-Learning Capstone Experience in a Diabetes Concentration.  Am J Pharm Educ.  2007; 71: Article 119.
9. Werremeyer AB, Skoy ET.  A Medical Mission to Guatemala as an Advanced Pharmacy Practice Experience.  Am J Pharm Educ.  2012; 76:  Article 156.
10. Fernandez R, Parker D, Kalus JS, Miller D, Compton S.  Using a Human Patient Simulation Mannequin to Teach Interprofessional Team Skills to Pharmacy Students.  Am J Pharm Educ.  2007; 71: Article 51.
11. Van Winkle LJ, Cornell S, Fjortoft N, et al.  Critical Thinking and Reflection Exercises in a Biochemistry Course to Improve Prospective Health Professions Students’ Attitudes toward Physician-Pharmacist Collaboration.  Am J Pharm Educ.  2013; 77: Article 169.
12. Westberg SM, Adams J, Thiede K, Stratton TP, Bumgardner MA.  An Interprofessional Activity Using Standardized Patients.  Am J Pharm Educ.  2006; 70: Article 34.