Can a self-inspection programme improve compliance with professional standards in a hospital pharmacy?
Authors: Bryars N , McLeod K 
Published: November 2023

Abstract

Introduction
Pharmacies must comply with professional standards to provide high-quality services. However, gaining assurance of compliance can be challenging and self-inspection was investigated as a means of consistently achieving this.

Aim
This project aimed to develop and implement a self-inspection programme to assess compliance with professional standards in a hospital pharmacy. Through the self-inspections, we aimed to identify required improvements and maintain achieved compliance through effective reporting, evaluation, and communication of results.

Methods
Standards from Royal Pharmaceutical Society professional guidance1, standards2 and General Pharmaceutical Council standards3 were used to create 41 self-inspection questions. These assessed different aspects of medicines management, including the receipt, storage, dispensing, delivery, disposal, and security of medicines. They also assessed compliance with health and safety measures and service quality indicators taken from the monthly quality report, health and safety report, cleaning logs, expiry date checks and stock checks in the department.
Self-inspections were conducted monthly over a 12-month period by members of the Pharmacy Senior Leadership Team. Self-inspections were recorded using the Tendable accreditation application. Training in using the application and a standard operating procedure was in place to support this. Questions in the self-inspection were only answered as “Yes” or “No”. Additional information, images or actions taken were required for any question that was negatively scored.
Following self-inspections, results were calculated by the application and a summary generated. A full report was also produced by the application. These were analysed by the Pharmacy Quality Assurance Team and included in the monthly departmental quality report for review by the Pharmacy Senior Leadership Team. Any identified actions were communicated by e-mail to the relevant team leader and an inspection summary later displayed in the department.
This study did not require ethics approval.

Results
Compliance with standards increased steadily from 75% on the first self-inspection to 95%, with an average of 89% over the 12 months.
During the self-inspections, non-compliance with 14 different standards was identified. 3 concerned non-compliance of staff with processes, which was addressed and not repeated. 11 concerned non-compliance that was repeated, including delays in updating essential documents, delays in completing essential tasks, medicines storage not complying with requirements, a correct responsible pharmacist notice not displayed and building work disrupting services. All of these have now been resolved, except deficiencies in the storage of bulk fluids, where risks have been mitigated and a long-term plan is in place.

Discussion/Conclusion
Compliance with professional standards in the pharmacy has been improved through the implementation of a self-inspection programme. Questions in the self-inspection defined the required standards and guidance on conducting self-inspections ensured consistent assessment, enabling both compliance and non-compliance to be identified. Processes for reporting, evaluating and communicating results from the self-inspections directed how non-compliance was resolved. This promoted awareness of required standards and helped maintain achieved compliance.
Limitations of the study included failing to assess compliance with standards not covered in the self-inspection questions. A regular review of self-inspection questions, standards and results is therefore required to maintain reliability and continued improvement.

References
1. Royal Pharmaceutical Society (2018) Professional guidance on the safe and secure handling of medicines https://www.rpharms.com/recognition/setting-professional-standards/safe-and-secure-handling-of-medicines
2. Royal Pharmaceutical Society (2022) Professional standards for hospital pharmacy services https://www.rpharms.com/recognition/setting-professional-standards/hospital-pharmacy-professional-standards
3. General Pharmaceutical Council (2018) Standards for registered pharmacies https://www.pharmacyregulation.org/standards/standards-registered-pharmacies