(Management Case Study) A Multi-Hospital System Pharmacy Quality Management and Regulatory System

Purpose: Advocate Aurora Health (AAH) System Pharmacy Department chartered a Quality Management and Regulatory Committee (QMRC) which ensured continuous accreditation readiness at 27 hospitals and compliance with NIAHO medication management and ISO standards in DNV accredited areas of AAH. This new system pharmacy department committee was charged with ensuring policy oversight and establishing processes for accreditation preparedness.

Methods: The system pharmacy quality management committee charter included committee scope, membership, and responsibilities. The committee membership includes pharmacy leaders representing different states, differing facility sizes, and one senior pharmacy leader. The committee is responsible for training select pharmacy leaders who complete onsite accreditation readiness audits which are completed annually at each site, preparing system pharmacy department policies and accreditation readiness education, acting as a liaison with system regulatory and quality teams, establishes system standards of site quality management reporting, providing accreditation survey consultation and support, communicating updates on compliance, regulatory, and accreditation issues. The committee monitors action plans, establishes system standards of site quality management reporting. Pharmacy residency learning experiences were established to drive continuous compliance and improvement. A department auditing tool was developed to assess alignment and compliance on various topics (practice advancement, financial management, regulatory compliance, etc.).

Results: Annually each hospital is audited onsite by a trained pharmacy leader.
Annually deparment leaders are evaluate department complaince on select accreditation standards and policy expectations
All system pharmacy authored policies are reviewed annually.
All accreditation survey findings are collated, evaluated, and monitored by the system committee.

Conclusion: A system pharmacy quality management committee and systems support high quality consistent care is provided at 27 inpatient pharmacies within a health-system.