A Pharmacy Quality and Internal Audit Program Promoting Continuous Survey Readiness with Medication Management Standards

Abstract

Background: Showcasing compliance with Joint Commission Medication Management (MM) standards during accreditation visits is important, but it is equally vital to maintain a state of continuous survey readiness. This article describes a Pharmacy Quality and Internal Audit Program to promote continuous survey readiness and sustained compliance with MM standards.

Methods: A comprehensive MM audit was developed to assess for compliance in all inpatient, ambulatory, and procedural areas that use medications, with each area undergoing the internal auditing process at least twice per calendar year. The audit is performed by an MM subject matter expert from the Department of Pharmacy and incorporates electronic chart review, clinical staff interviews, and observations of area-specific medication practices. Notable findings and recommendations are communicated to area-specific leadership. Institutionwide scorecards are compiled to track performance with MM standards, identify opportunities, and determine future focus areas to improve and sustain compliance.

Results: Results revealed consistent compliance (≥ 90%) with a majority of MM standards. These included hazardous medication management, controlled substances compliance, look-alike/sound-alike drugs, medication storage/security, and labeling of medication syringes. Several areas of opportunity were identified: awareness of high-alert medications and risk-reduction safety strategies, compliance with pill cutter standards, and therapeutic duplication of "as needed" medication orders. Subsequent implementation of corrective actions and mitigation strategies resulted in improved compliance rates from < 50% to ≥ 90% for awareness of high-alert medications and risk-reduction strategies, from < 60% to ≥ 80% for compliance with pill cutter standards, and from < 90% to ≥ 90% for therapeutic duplication of "as needed" orders.

Conclusion: Establishment of a Pharmacy Quality and Internal Audit Program allowed for performance tracking, identification of compliance deficiencies, implementation of focused corrective actions, and promotion of continuous survey readiness with MM standards.