Category: Professional Posters
Purpose: Accreditation and regulatory agencies review hospital pharmacies on a routine cycle. Often there is a ramp up of compliance related activities prior to an anticipated accreditation or regulatory visit. Between visits, attention to detail in practice standards may become lax. The system pharmacy leadership team implemented an annual performance audit tool to establish a process for consistent, high level of practice across the health system
Methods: The system pharmacy leadership team prepared a list of key metrics to measure pharmacy practice performance. The categories of focus included the following practice areas: regulatory compliance, controlled substance management, automation management, inventory management, general operations, sterile compounding management, medication safety, human resources, staff development, quality processes, pharmacy and therapeutics functions, clinical processes, and financial standards. Within each area, key metrics were determined and scoring criteria established. Critical metrics were scored as “pass/fail”; others were given a numeric value. An onsite assessment was conducted at each hospital by a third party. Each hospital received a report on their results as well as a system summary of the results. Upon completion of the summary report, the health system pharmacy leadership team reviews the results and determines what actions are required to correct identified gaps.
Results: The survey has been completed for three consecutive years. As anticipated, hospital scores have continued to improve year over year. The average score from 2016 through 2018 increased from 76% to 85%. Annually, assessment elements are reviewed and updated to reflect the most current and critical standards of practice.
Conclusion: The annual survey has provided valuable insights to both system pharmacy leadership as well as local pharmacy leaders. System pharmacy leadership utilizes the information to set initiatives for the next fiscal year as well as to identify areas where additional support may be needed. Local pharmacy leadership has used the results to support initiatives at the site level. In addition, the audit results have provided quick insights for pharmacists stepping into a new hospital pharmacy leadership positions.