Pharmacy Practice and Operations Assessment Guide

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IntroductionThe Alberta College of Pharmacists governs pharmacists, pharmacy technicians, and pharmacies in Alberta to support and protect the public’s health and well-being. We take responsibility for pharmacy practice by setting and enforcing high standards of competence and ethical conduct.

The primary role of the Professional Practice department is to promote quality patient care and ensure patient safety. We achieve this through pharmacy practice and operations assessments conducted with pharmacy teams by Pharmacy Practice Consultants (PPCs). Trends and performance indicator results gleaned from the assessments inform our department about educational interventions that may be needed to address key practice issues. They also assist us in identifying best practices that we can share with all pharmacy teams.

Assessments help elevate pharmacist practice in order to meet and/or exceed the minimum standards to improve patient care and ensure patient safety. During an assessment, the PPC will evaluate your pharmacy’s practice and operations to ensure the requirements of all federal and provincial legislation, the Standards of Practice for Pharmacists and Pharmacy Technicians, and the Standards for the Operation of Licensed Pharmacies are adhered to, while providing recommendations for implementing best practices.

This guide will provide details about the overall pharmacy assessment process and help you navigate through the online pharmacy assessment system. This system streamlines the pharmacy assessment process by providing an efficient method of communicating, completing and sharing assessment information.

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Overview of the pharmacy assessment process

Licensee and pharmacy team education

Continue making improvements to operations and practice

Pharmacy team feedback to ACP

Follow up by practice consultants

Correct deficiencies, implement practice changes

On-site assessment

Self-assessment

Assessment notification

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Symbolizes a routine assessment. Though the first three steps containing this symbol occur for this type of assessment only, the college strongly encourages ongoing team education for the advancement and continuous quality improvement of pharmacy practice in Alberta.

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Types of assessments There are four types of assessments that a pharmacy may receive.

Routine ACP aims to conduct routine assessments of each Alberta pharmacy about once every three years. A routine assessment is a thorough review of the pharmacists’ practice and pharmacy environment. A routine assessment is initiated if a pharmacy has not been assessed within the three year time frame, if a pharmacy opens, or changes owners.

A routine assessment will be conducted in two steps: an electronic self-assessment completed in advance by the licensee, followed by an on-site assessment conducted by the PPC. The on-site portion of the assessment can be performed with any pharmacist and may include other members of the pharmacy team.

The licensee is responsible for ensuring that all pharmacy staff, including relief staff, are aware of the policies and procedures specific to their pharmacy’s practice and operations so that they are capable of reviewing the components of the self-assessment with the PPC during the on-site assessment.

Renovation and RelocationThe college also assesses a pharmacy if a renovation or relocation occurs. The PPC will assess the pharmacy to ensure the renovation or relocation has been completed according to the information provided to the college and that the change(s) meet all federal and provincial legislation and Standards. This type of assessment does not require the licensee to complete a self-assessment.

ConsultationThe Professional Practice department also assists pharmacy teams in elevating pharmacy practice by reviewing the corrected deficiencies from a routine assessment and providing educational tools and resources to support teams in implementing recommendations. This type of educational visit is deemed a consultation and there is no requirement for the licensee to complete a self-assessment.

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Pharmacy assessment instructions

Within the email are instructions on how to access ACP’s website, where the online assessment system resides.

Please note that ACP emails and newsletters are official methods of notification to pharmacists licensed by the college. In addition to providing timely information, college emails serve in administrative hearings as proof of notification. Ensure ACP emails are not blocked by the pharmacy’s network and accurate licensee contact information is provided to the college.

Step 1: Assessment notification

Licensee receives assessment notification email which provides instructions and a link to ACP’s website.

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Step 2: Licensee and pharmacy team education R

• Standards of Practice for Pharmacists and Pharmacy Technicians• Standards for the Operation of Licensed Pharmacies• Section 21(2) of the Pharmacy and Drug Act• Any other relevant provincial and federal legislation• The pharmacy’s policies and procedures for operations and practice• The Systems Approach to Quality Assurance• Chat, Check and Chart

Licensees: Review the following materials before completing the self-assessment.

Pharmacy teams: Review the following materials with your licensee before your on-site assessment with the PPC.

You can find these items under Practice Resources on ACP’s website (pharmacists.ab.ca).

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By preparing, you will benefit from a:

1. More accurate self-assessment Licensees must complete a self-assessment within 15 days of receiving the assessment notification. This is an opportunity for the licensee and their pharmacy teams to reflect on their practice and their pharmacy environment. By reviewing certain topics before completing the self-assessment, licensees can conduct a more accurate self-assessment. This results in fewer “surprises” during the review and helps focus questions and time with the PPC.

2. More efficient, informative, valuable on-site assessment A review of these materials will help pharmacy teams enjoy a more efficient, informative, and valuable on-site assessment with the PPC. They will gain greater insight to successfully correct deficiencies and implement recommendations arising from the on-site assessment, ultimately improving patient care.

You can find all materials for review on ACP’s website (pharmacists.ab.ca) under the left hand menu of the Practice Resources section.

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After reviewing the information highlighted in Step 2, the licensee must complete the electronic self-assessment. To access the self-assessment, click on the link contained in the assessment notification email or go to pharmacists.ab.ca.

1. Click Registrant profile login.

2. Enter your User ID (ACP registration number) and password. (Forgot your password? Look below the login box and click on “Click here if you forgot your password.”)

Step 3: Licensee completes self-assessment

Licensee completes and submits self-assessment online within 15 days of receiving assessment notification.

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Each time you want to access the online pharmacy assessment system, you must login via the Registrant profile login.

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3. The login box will change to confirm that you are logged into the system. Choose the Pharmacy Assessment tab in the top right hand corner.

The pharmacy assessment homepage will be displayed; it is divided into three sections:

1. Review Pharmacy Information: The Pharmacy and Drug Regulation requires that ACP be notified when a regulated member changes employment. This section provides an opportunity for the licensee to review their current staff list and email ACP should the information require updating.

2. Pharmacy Practice and Operations Assessment: This section will be visited most often by the licensee. Assessments are displayed under the Assessment History heading. Click on the row to open the assessment.

3. Implement Recommendations: Practice change recommendations made by the PPC during an assessment appear here and remain available for the licensee to view and share with their pharmacy team.

Please remember that the self-assessment must be completed within 15 days of receiving the assessment notification.

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To open the self-assessment, scroll to the Pharmacy Practice and Operations Assessment section. Under Assessment History, click on the assessment with Awaiting Self-Assessment indicated in the Status column.

The Pharmacy Practice and Operations Assessment welcome page will be displayed. Please read the instructions carefully.

To begin, choose the Next button at the bottom of the welcome page. Remember to choose Save if you are temporarily disrupted or required to leave the self-assessment.

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Please note that all questions must be answered. There may be some services that the pharmacy does not provide (e.g., injections, methadone dispensing, sterile compounding). When asked about these services, please choose No as the appropriate response if the pharmacy does not provide them. The system will then disable all questions related to that topic and display “Question not applicable.” If the question is left blank, the system will not accept the self-assessment. If you require assistance with the questions, please click on the help icon to the right of the question, as shown below.

When all questions have been completed, the page links at the top and bottom of the page will be dark purple. A page link in light purple (see number 9 below) indicates that a question on that page has not been answered. Should there be a light purple page link, please return to that page to review and answer the questions.

Once all of the page links are dark purple, choose the Submit button at the bottom of the page to send ACP the self-assessment.

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All on-site assessments performed by the PPC are unscheduled and completed by drop-in. This authority is granted under Section 21(2) of the Pharmacy and Drug Act.

The unscheduled assessment allows the PPC to interact with as many pharmacists and pharmacy technicians as possible to discuss continuous quality improvement. By not having scheduled visits, consultants can spend the time required to address the concerns of the pharmacy team instead of having to rush off to their next appointment. This helps ensure that quality assurance and quality improvement measures are implemented and sustained to enhance patient safety and your practice.

Although the licensee is ultimately responsible for the practice and operations of the pharmacy, in order to meet and exceed standards, every pharmacy team member’s support is critical. All pharmacy team members have an opportunity to participate in the preparation for the assessment, in the on-site assessment itself, and in assisting the licensee with correcting deficiencies and implementing practice recommendations. The on-site assessment can be performed with any pharmacist and may include other members of the pharmacy team. All staff pharmacists should be aware of the operating procedures of the pharmacy. If staff pharmacists are oriented thoroughly and have access to the current operations manual, they are in a good position to provide feedback concerning any questions or concerns regarding the pharmacy’s practice and operations.

To prepare them for the on-site assessment, please print a copy of the self-assessment and ensure that all pharmacists know where it is located.

During the on-site assessment the PPC will review the information contained within the self-assessment, identify deficiencies and recommendations, and work on setting SMART goals with the pharmacy team to ensure that improvement goals are Specific, Measurable, Achievable, Relevant, and Time-based and are documented in the Action Report.

Please discuss any questions about deficiencies, recommendations, and other practice topics with the PPC. They are accessible and here to help you.

Step 4: PPC performs on-site assessment

PPC performs on-site assessment with any licensed pharmacist.

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Step 5: Acknowledge Action Report

PPC generates electronic Action Report for documenting deficiencies and recommendations.

At the conclusion of the on-site assessment, the PPC will identify any practice or operational deficiencies and/or practice recommendations on an electronic form called the Action Report.

A deficiency is a practice or operation that the pharmacy is not performing according to all federal and provincial legislation, and Standards. The identified deficiency must be corrected to ensure quality patient care and patient safety is delivered by the pharmacy team. A deficiency must be corrected within 30 days.

A recommendation is a practice or operation that the pharmacy is performing according to all federal and provincial legislation, and Standards, but requires improvement. The identified recommendation should be implemented by the pharmacy team to improve the quality patient care and patient safety that is delivered by the pharmacy team. To access the Action Report, the pharmacist in attendance (which may or may not be the licensee) must:

• login to ACP’s website using their User ID and password, • choose the Pharmacy Assessment tab, • scroll to the Pharmacy Practice and Operations Assessment section, and • click on the assessment with Acknowledge Action Report indicated under the Status

column (the pharmacist in attendance will also receive an automated email containing these directions).

After reviewing the Action Report with the PPC, the pharmacist in attendance (which may or may not be the licensee) must choose the Acknowledge Action Report button at the bottom of the page.

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Step 6: Correct deficiencies

Licensee has 30 days from the date of on-site assessment to correct all deficiencies. The Action Report can be printed for use as a communication tool for the pharmacy team.

The deadline for correcting all deficiencies is 30 days from the date of the on-site assessment. Once the Action Report has been acknowledged, it will become available for the licensee to document which member of the pharmacy team has been assigned to correct the deficiency and to enter the completion date of that correction.

The online system contains detailed instructions on how to edit deficiencies and recommendations. Please see the screen print below:

Please note that Action Reports must be submitted via the online system. Printed copies will not be accepted.

ACP will email the licensee upon acknowledgement of the Action Report, reminding them that all deficiencies must be corrected within 30 days.

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Following the correction of all deficiencies, the Action Report must be updated to reflect the completion date of each deficiency. To access the Action Report, the licensee must: • login to ACP’s website and choose the Pharmacy Assessment tab,• scroll to the Pharmacy Practice and Operations Assessment section, and • click on the assessment with Action Report in Progress indicated under the

Status column.

The Action Report will then be displayed. Refer to the top of the Action Report for instructions on how to close a deficiency.

Licensees may want to assign the correction of a deficiency to a member of their pharmacy team. The Action Report can be printed and used to communicate these assignments. To do this, simply choose the Print the Action Report link.

Licensees may also want to use the printed Action Report as a working document to record the completion dates of deficiencies as they are corrected. Remember that once all deficiencies are corrected, the electronic Action Report must be updated. A time saving tip is to update the electronic Action Report only once versus returning to the online system multiple times.

Step 7: Submit Action Report online

Licensee must submit the Action Report online. Only electronic Action Reports are accepted.

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Once a completion date has been entered for each deficiency, the licensee must complete his/her professional declaration and then choose the Submit Action Report button.

Failure to submit the Action Report or declaring false or inaccurate information will be grounds for referral to the Complaints Director for further investigation

Step 8: Follow up

PPC will return for follow up in 3-6 months.

Submitting the Action Report closes the pharmacy practice and operations assessment. Licensees must share results of the pharmacy assessment and actions taken to correct deficiencies with all pharmacy staff. In three to six months, the PPC will follow up on deficiencies and help implement best practices, through additional unscheduled on-site consultations lasting less than an hour, as required.

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Notes

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Notes

1100 – 8215 112 St. NWEdmonton, AB T6G 2C8

Toll free: 1–877–227–3838Telephone: 780–990–0321Fax: 780–990–0328Email: acpinfo@pharmacists.ab.caWeb: pharmacists.ab.ca