Presentation at the CSHP Harrison conference by College of Pharmacists of BC, Bob Nakagawa, on February 24, 2017.

1. Hospital Practice Reviews:
What Managers and Practitioners Need to Know
Bob Nakagawa, Registrar, College of Pharmacists of BC
February 24, 2017
#CPBC

2. Presenter Disclosure
Presenter’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

3. Commercial Support Disclosure
• This program has received no financial or
in-kind support from any commercial or other organization

4. 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

5. 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?

6. Hospital Pharmacy Demographics
• Over 70 Hospital Pharmacies

7. 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

8. Hospital Pharmacy Demographics
• Over 1600 Hospital Pharmacy
Professionals

9. Community Pharmacy Demographics
• Over 1200 Community Pharmacies
• Over 4200 Community Pharmacy
Professionals

10. All Community & Hospital Pharmacy Professionals, and
Pharmacies in BC included in Practice Review Program
• Over 1270 Pharmacies
• Over 5,800 Pharmacy
Professionals

11. Why Practice Reviews?

12. 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

13. Hospital Practice Reviews
(Beginning April 2017)

14. Practice Reviews
• Pharmacy Review
(review of pharmacy and pharmacy manager’s responsibilities)
• Pharmacy Professionals Review
(individual reviews of pharmacists and pharmacy technicians)

15. 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

16. Pharmacy Review

17. 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

18. 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

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

20. Pharmacy Professionals Review

21. 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

22. 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

24. Methods of Assessment
Observe (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?”

25. Practice Review Scheduling

26. 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)

27. 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

28. What Challenges Did We Face?

29. Practice Review Program Challenges
Assessing 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)

30. PRP Resources
BCPharmacists.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).

31. Tweet your questions to us
with #CPBC