Hospital Practice Reviews:What Managers and Practitioners Need to KnowBob Nakagawa, Registrar, College of Pharmacists of BCFebruary 24, 2017

#CPBC

Presenter DisclosurePresenter’s Name: Bob Nakagawa

• I have no current or past relationships with commercial entities

• I have received no speaker’s fee for this learning activity

Commercial Support Disclosure• This program has received no financial or

in-kind support from any commercial or other organization

Learning Objectives• Understand how the College’s PRP program protects public

safety• Identify the types of practice reviews• Identify practice review focus areas• Identify methods of assessment • Understand the process for resolving areas of non

compliance through action items• Recognize the opportunities to improve your practice prior to

a practice review

Text BCPHARMACY to 37607 to join the session, then… • 50• 70 or• 100

Or respond at PollEv.com/BCPHARMACY

How many Hospital Pharmacies does the College License in BC?

Hospital Pharmacy Demographics

• Over 70 Hospital Pharmacies

How many Hospital Pharmacy Professionals does the College License in BC? Text BCPHARMACY to 37607 to join the session, then… • 1200• 1600 or• 1800

Or respond at PollEv.com/BCPHARMACY

Hospital Pharmacy Demographics

• Over 1600 Hospital Pharmacy Professionals

Community Pharmacy Demographics

• Over 1200 Community Pharmacies

• Over 4200 Community Pharmacy Professionals

All Community & Hospital Pharmacy Professionals, and Pharmacies in BC included in Practice Review Program

• Over 1270 Pharmacies

• Over 5,800 Pharmacy Professionals

Why Practice Reviews?

Practice Review Program – Rationale• Directed by the Board• Directly assesses practice• Focuses on areas that have the most impact on patient safety• Designed based on practice setting

Hospital Practice Reviews

(Beginning April 2017)

Practice Reviews

• Pharmacy Review

(review of pharmacy and pharmacy manager’s responsibilities)

• Pharmacy Professionals Review

(individual reviews of pharmacists and pharmacy technicians)

Pharmacy Manager Responsibilities• Review info on the College website bcpharmacists.org/prp• Confirm availability for Manager, pharmacy and staff • Work with College to confirm number of regulated staff to be reviewed • Update staff roster in College eServices Pharmacy Portal• Print and post “Practice Reviews in Progress” poster • Request staff update College eServices profiles• Complete Pharmacy Pre-Review• Schedule staff for Pharmacy Professionals Reviews • Be on-site at the start and end of the Pharmacy Review

Pharmacy Review

Pharmacy Review• Review of compliance with physical requirements of a pharmacy and

responsibilities of a pharmacy manager • Based on College Pharmacy Operations and Drug Scheduling Act

(PODSA) Bylaws and Policies • Built on former pharmacy inspection• Requires a Pre-Review to be completed by Pharmacy Manager• Results (and action items) delivered to pharmacy manager• 30 calendar days to complete assigned action items• Compliance Officer follows up with Pharmacy Manager on Action Items • Escalation process in place if Action Items are not completed

Pharmacy Pre-Review• First step of the Pharmacy Review, happens prior to on-site review• Pharmacy Manager assesses practice setting against requirements

and identifies any areas of non-compliance• Opportunity to address any areas of non-compliance prior to the

on-site Hospital Pharmacy Review• Compliance Officers use same review questions on-site as the pre-

review, so there are no surprises

Pharmacy Review Categories - Hospital• Security• Equipment• Drug Orders• Confidentiality• Inventory Management

o Pharmacyo Nursing Units

• Narcotics and Controlled Drug Substances

• Dispensed Products• Patient Records/Documentation• After Hours Services• Pharmacy Manager’s

Responsibilities• Sterile Compounding*• Non-Sterile Compounding*• Telepharmacy*• Bulk Repackaging*• Residential Care*

*non-mandatory pharmacy categories

Pharmacy Professionals Review

Pharmacy Professionals Review• In-person individual review of a pharmacy professional's practice • Based on College Health Professions Act (HPA) Bylaws and Policies • Focuses on areas that have the greatest impact on patient safety• Review questions available on college website, so there are no surprises• Results (and action items) are shared with the individual• 30 calendar days to complete assigned action items• Compliance Officer follows up with individual pharmacy on Action Items• Escalation process in place if Action Items are not completed

Can you name one of the PRP Focus Areas?

Text BCPHARMACY to 37607 to join the session, then… • [Focus Area]….

Or respond at PollEv.com/BCPHARMACY

Methods of AssessmentObserve (Action)• Watch work performed• Interact when clarification is needed

Recall (Case)• Ask “How did you?”• Review recent work (recall charts,

orders, computer records, etc.)

Describe (Process) • “How would you?”

Practice Review Scheduling

Hospital Selections• College will review all Hospital Pharmacies in BC on a cyclical basis• Scheduling of Hospital sites will be prioritized based on • oldest “last inspection date” from former pharmacy inspection

(initially)• oldest “practice review period”

(after a first practice review has occurred)

Minimizing Disruption During a Review• 60 calendar days of advance notice• Review period limited to 1 month• Larger hospitals reviewed for a maximum of 1 month on site,

followed by 1 month off, until all Pharmacy Professional Reviews completed

• Only 1 day for Pharmacy Review (additional ½ day for any satellite)• Only ½ day for individual Pharmacy Professionals Review• Additional staff during a practice review not required

What Challenges Did We Face?

Practice Review Program ChallengesAssessing important areas where bylaws or policies may not be clear or may not exist

• Developing PRP identified areas where Bylaws and Policies needed to be developed or improved

• New bylaws and policies developed as a result for Patient ID (without face-to-face interaction), Product Preparation, and Final Check

Minimize disruption, prevent any impact to patient care• 60 days advance notice of a practice review• 1 month on site, 1 month off (at larger hospitals)• Review pharmacy professionals while working through observation – no need to bring in

additional staff to cover

Assessing Pharmacy Professionals when observation is not available• 3 possible methods of assessment - Compliance Officers can still complete assessment

when observation is not possible (observation is always preference)

PRP ResourcesBCPharmacists.org/PRP

All information included in this presentation developed by the College of Pharmacists of BC and available on http://www.bcpharmacists.org/prp (2017).

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