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Clinical Governance in Community Pharmacy


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Title: Clinical Governance in Community Pharmacy

Clinical Governance in Community Pharmacy
  • Kent and Medway Pharmaceutical Collaborative Team

What is Clinical Governance?
  •  .. a framework through which NHS organisations
    are accountable for continuously improving the
    quality of their services and safeguarding high
    standards of care by creating an environment in
    which excellence in clinical care will develop

Clinical Governance for Community Pharmacy The
K M Model
  • Key Area One pharmacy premises
  • Key Area Two training of pharmacy staff
  • Key Area Three CPD for pharmacists
  • Key Area Four communication complaints
  • Key Area Five health promotion

Accreditation Process
  • Pharmacies apply for an accreditation visit
  • undertaken at an agreed time
  • voluntary
  • Two accreditors
  • One pharmacist through the Collaborative
  • One PCT non-pharmacist
  • Visits take approx. one hour
  • Accreditation valid for two years

Accreditation Process
  • Checklist made available in advance
  • expected standards and methods for checking are
  • Format of visit communicated at start of visit
  • Visit is completely non confrontational
  • Both professional and member of the public
  • Written evidence of compliance with the framework

Key Area 1 Pharmacy Premises
  • Standard 1 the dispensary, shop floor and all
    staff have a professional appearance
  • Standard 2 the property should be kept in good
    order both externally and internally
  • Standard 3 displays in both the shop interior
    and the windows should reflect a professional
  • Standard 4 There should be good access for
    customers (incl. disabled) and floor areas within
    shop should be kept free of stock to allow access

Premises cont.
  • Standard 5 A suitably private area for
    consultations should be identified
  • Standard 6 A notice board or similar must
    include info about complaints procedure, identify
    the full range of services provided by the
    contractor and the out of hours access to
  • Standard 7 Date checking procedures for all
    medicines and foods should be in operation
  • Standard 8 An up to date procedure manual should
    be readily available on the premises.

Key Area 2 Training of Pharmacy Staff
  • All members of staff whose work regularly
    includes sale of pharmacy medicines should have
    completed, or be working towards completion of a
    course covering the knowledge syllabus of the
    chemist counter assistant unit of the NVQ level 2
    in retail operations or equivalent
  • All members of staff who have completed course
    should participate in relevant continuing

Key Area 3 CPD
  • All pharmacists will complete a minimum of 30
    hours of accredited CPD each year

Key Area 4 Communications Complaints Procedures
  • Standard 1 Documentary evidence of compliance
    with the NHS complaints procedures must be
  • Standard 2 A notice on how complaints will be
    handled should be displayed in the pharmacy
  • Standard 3Confidential records of complaints
    should be kept and reviewed regularly in order to
    ensure continuing improvement of services

Key Area 5 Health Promotion
  • Standard 1 each pharmacist must complete the
    CPPE distance learning course health promotion
    and health screening
  • Standard 2 contractors to participate when
    appropriate in HA or PCT wide health promotion

Health Promotion cont.
  • Standard 3 pharmacists will hold in house
    training sessions for their medicine counter
    staff on health promotion campaigns being run by
    the contractor
  • Standard 4 health promotion leaflets will be
    displayed in a suitable manner
  • Standard 5 the pharmacist manager will meet with
    local surgery staff at least once a year to
    discuss issues of mutual interest

Accreditation Process
  • Successful visit
  • Report prepared post
  • Congratulatory letter confirming compliance with
    the standards
  • Certificate prepared and signed on behalf of the
    Strategic HA and relevant PCT
  • Certificate sent to pharmacy to display

Accreditation Process
  • Unsuccessful visit
  • Report prepared post visit
  • Sympathetic letter sent to Clinical Governance
    lead at the pharmacy, highlighting the shortfalls
    and presenting two options

Accreditation Process
  • Option 1
  • Up to three months to rectify shortfall
  • written or photographic evidence to be submitted
    to show evidence of compliance
  • support offered
  • Repeat visit made to pharmacy, if necessary

Accreditation Process
  • Option 2
  • Request that case is referred to the Steering
    Group for arbitration
  • Written submissions to the Steering Group within
    28 days to challenge any decision made
  • Steering Group
  • Will send decision to the pharmacy within 28 days
    of the decision being made

Accreditation Process
  • Steering Group comprises
  • 2 PCT Clinical Governance facilitators
  • 2 PCT Pharmaceutical Advisers
  • 2 LPC representatives
  • Patient forum representative
  • 1 PCT Clinical Governance lead
  • 1 PCT Prescribing Adviser
  • voting members

Accreditation Process
  • Accreditation withdrawn if
  • Clinical Governance pharmacist leaves or reduces
    their hours to less than three days/week
  • Premises are relocated
  • A serious complaint is upheld against the

Accredited Pharmacies to End January 2005
Clinical Governance the New Pharmacy Contract
  • Three stages of accreditation
  • National standards
  • Seven key components that contractors must
    achieve as part of Essential Services. Will be a
    baseline across Kent Medway
  • Kent Medway standards
  • Additional level that contractors must achieve
    to be eligible for PCT commissioned Enhanced
  • Advisory standards
  • Additional level of good practice

The New Contract National Standards
  • Resources and processes
  • Processes for quality improvement
  • Patient public involvement
  • Clinical audit
  • Risk management
  • Clinical effectiveness programmes
  • Staff focus
  • Staffing and staff management
  • Education, training and continuing professional
    and personal development
  • Use of information
  • Use of information to support clinical governance
    and health care delivery