Pharmacists can help meet Joint Commission standards

August 10, 2009

For hospitals and health systems, Joint Commission accreditation is an ongoing issue of vital importance. With their specialized knowledge and skills, pharmacists can contribute greatly to the continuous process of refining goals and meeting standards.

Key Points

Health-system pharmacists have many responsibilities. One of the most important is staying up-to-date and informed about Joint Commission standards and National Patient Safety Goals, which often require special attention from pharmacy employees.

Whatever role a pharmacist chooses, it can help protect the hospital and help to ensure continued accreditation, Kienle said. "It can mean some serious issues for a hospital or organization if a pharmacist is not complying or playing his or her role in accreditation," she added. "It could really put the hospital at risk of not being compliant."

Pharmacists who have less time to offer have found other ways to become involved, such as suggesting ways to improve medication storage or dispensing that will make these processes safer, more effective, or more secure, said Louise Kuhny, RN, MPH, MBA, senior associate director, standards interpretation, Joint Commission. Pharmacists can also see to it that hospital pharmacy employees are following compliance programs. "Pharmacists should be consistently performing self-evaluations to ensure compliance," she said.

There are several places pharmacists can go if they have questions about other ways to get involved in accreditation. Bona Benjamin, BS Pharm, director of medication use and quality improvement, American Society of Health-System Pharmacists, said there are usually two hospital departments - risk management and hospital quality - that can help pharmacists learn more about how to become involved with committees or boards responsible for implementing programs to meet Joint Commission standards. "Bringing any concerns, questions, or suggestions to staff meetings is another way to get involved and have your voice heard," Benjamin said.

It's important to find out what other pharmacists think about patient safety goals within the hospital, but it's also important to find out what physicians, dieticians, and members of other departments are doing to cooperate, Benjamin said. When pharmacists collaborate with other departments, program development is often more successful, more well-rounded, and more likely to address all elements of the standards.

"One great way of making sure pharmacists get involved is to make Joint Commission a standing agenda item during regular staff meetings," Benjamin said. "There's usually a lot of discussion that comes from these issues. So it's better to get input regularly than have one particular meeting to discuss them right before the implementation deadline."

Other than getting involved with implementation, pharmacists also have a say in how the Joint Commission phases in a requirement or a standard.

The Commission can provide a communications opening for the pharmacist who wants to have a voice in the requirements for accreditation, said Rita Shane, PharmD, FASHP, director of pharmacy services, Cedars-Sinai Medical Center, and assistant dean, University of California, San Francisco School of Pharmacy. "There are a lot of pharmacists out there who are bilingual, but if they can also learn to understand and translate the Joint Commission's language, then they can be multilingual," Shane said.

Some of that interpretive skill can be useful during the comment period when the Joint Commission requests feedback or suggestions about proposed changes, additions, or new standards. Such feedback helps sculpt the final standards and patient safety goals, and can also help ensure that any confusing language is clarified. "It's a pharmacist's responsibility to stay abreast of all this," she said.

Shane said Cedars-Sinai recently created a new position at the medical center for a compliance pharmacist who will be responsible for staying up-to-date on the Commission's accreditation requirements. To maintain compliance, the pharmacist will use tracer methodology to ensure that procedures are followed. The same individual also will be responsible for educating staff about standards and patient safety goals, and for completing periodic audits of paperwork processes and medication management protocols.

Another way pharmacists can help their hospital pharmacies stay in tune with the Joint Commission is by attending meetings such as those of the American Society of Health System Pharmacies or of state groups offering update sessions. Also, list serves have helped pharmacists to involve themselves in accreditation issues and to become familiar with common or best practices used by hospital pharmacists to meet various objectives, such as the 2009 Patient Safety Goal on improved safety of medication use.

"List serves can be a great networking tool to help gauge what some other trends are for accomplishing these goals," Shane said. "You can read all about what challenges other people are having and use them to communicate with and learn from other people in the profession."