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Five survey tips to prepare for 2006

Pharmacy Regulation Resource, December 14, 2005

With 2006 and the arrival of the unannounced survey process, having a firm grip on the medication management standards and other issues impacting pharmacy will help hospitals ace their next inspection, a preparation expert says.

"There's probably not going to be anything as important as trying to stay compliant with these standards going forward," says John Uselton, BSPharm, vice president of operations improvement for Cardinal Health in Houston.

Uselton offers five survey-preparation tips to help hospital pharmacies ready themselves for unannounced inspections and the numerous issues that can arise:

1. Be knowledgeable. Know all the medication management standards. Understand other issues impacting the pharmacy, including other areas of the JCAHO standards manual and hot topics such as sterile compounding. Develop a compliance plan, and back it up with actions and sound procedures.

Checking those procedures will make sure you stay on top of your compliance, Uselton says. The periodic performance review-now an annual part of accreditation-will help do just that.

2. Clean, organize, and secure the pharmacy. First impressions matter to surveyors, meaning a clean and organized pharmacy is a prepared pharmacy, Uselton says. Organize all medications, records, and documents, and make sure medications that must be secured are done so properly.

3. Concentrate on problematic areas. Identify areas that have posed compliance issues in the past, and make sure they meet the appropriate standards. Focus on high-risk spots, such as controlled substances, automated distribution, respiratory therapy, and anesthesia, Uselton says.

4. Emphasize safe medication use. Concentrate on the National Patient Safety Goals daily, and make sure your actions match what your policies state, Uselton says.

"[Surveyors] look at those probably more than anything else," Uselton says.

5. Demonstrate competence. Assess competency at least annually, and document competencies in personnel files. Make sure surveyors will have access to all appropriate documents, and be able to prove that staff are adequately trained to handle their daily tasks, he says.

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