Considering PCAB Accreditation? Here's a few tips!

In July 2014, the Pharmacy Compounding Accreditation Board (PCAB) became a service of the Accreditation Commission for Health Care (ACHC). ACHC is a large, nationally recognized agency that accredits health care practices spanning the industry. With this new change also came new standards for pharmacy compounding. Those familiar with the PCAB accreditation manual will no longer see this set of standards as their reference for practice. 

In recent news, PCAB made headlines after the Professional Compounding Centers of America (PCCA) announced the establishment of a preferred provider network of compounding pharmacies that are PCAB accredited. This network, called PersonalMed, will be the middleman between PCCA's member pharmacies and the PBMs handling claims for their compounded drugs. Like other preferred networks, pharmacies will pay a pre-negotiated fee to participate be included in the network and will be subject to the terms set forth by PersonalMed including reimbursable formulary, audits, credentials, and more. 

The popularity and number of PCAB accredited pharmacies has been steadily growing since the group's inception in 2007. The revised standards recently set forth by ACHC set the industry benchmark for quality in pharmacy compounding. Pharmacies striving to achieve this distinguished status invest significantly in time, energy and money. The ability to market and demonstrate a commitment to quality makes this investment worthwhile. 

ITL Consulting's pharmacists began consulting for PCAB accreditation in 2011. Since then, PCAB accreditation has become an integral part of our core services. Under ACHC, the accreditation process has undergone some key changes. In order to accelerate the process for our clients, we have developed a unique approach to the process in order to achieve accreditation goals in a minimal amount of time. Provided here are some key considerations for determining the readiness for your practice and some tips for facilitating the process. 


To begin the process, you will need to logon to and register your practice. Along with creating a pharmacy profile an accreditation application must be completed along with detailed information about the business. An application fee will also need to be submitted along with agreements of terms. 


The ACHC standards for pharmacy compounding must be downloaded through the website. For pharmacies that are currently accredited through the PCAB standards, there is a cross-walk available to reference the new standards according to your own policy manual. 


The new ACHC standards should be reviewed by the party responsible for leading the accreditation process and examined to determine any financial requirements, staff changes, or other major operational considerations. Major changes will need to be considered in the overall project budget and often times become the deciding factor. 

GAP Analysis 

The policies and procedures manual is often the most time consuming part of the process. Each pharmacy is responsible for submitting a manual that it is in compliance for the accreditation applied for. The completion of this step is not required to be completed prior to the application process, but will allow for a head start on planning to meet the standards. To begin this process, a GAP analysis referencing the current policy manual should be performed. This analysis should be used to make a project timeline which will be the guiding tool for the project. 

A Preliminary Evidence Report that must also be submitted along with the initial application information. This is a checklist signifying to ACHC that the applicant meets the initial requirement of baseline policies and procedures prior to scheduling a survey. The list of these policies and procedures is including in the application info. 


Once the required application info and agreements have been submitted and approved, the applicant will be able to choose days which an ACHC representative will not show up for the initial survey. Each practice should consider which days are best in order to have the project leader available to answer questions and guide the representative during the visit. Consider blacking out days where high-volume is expected, key staff may be away, or other projects may interfere with practice workflow. 

These initial few steps should provide a solid foundation for efficiently launching the accreditation process. In small businesses, efficiency is as critical as ever, and misallocating human capital to nonessential tasks may pose a serious financial threat. A cost analysis of how great a financial burden an accreditation project may be using only internal staff  may be greater than expected due to the large time commitment and unknown logistical challenges. ITL Consulting works with pharmacies where this financial burden is simply too great to consider accreditation. Our pharmacists provide all the resources needed for the accreditation process in a single program. By allowing each organization to design their consulting program according to their needs, we take pride in making accreditation a reality for our colleagues. Contact a pharmacist consultant today to learn more about how you can benefit from PCAB accreditation.