Hospital Standards for Accreditation for Afghanistan

Section 4: Ancillary and Support Services

Hospital Pharmacy Management

Hospital Standards for Accreditation for Afghanistan: Assessment of Progress in Achieving the Standards Hospital Department or Area:
Hospital Facility: Assessor:

Hospital Pharmacy Management

__________________________________________ __________________________________________ Date of assessment: ____________________

Standard Number

Standard

Hospital Pharmacy Management Compliance in Criteria for Verification of Meeting Meeting Standard (Score) Standard
Full Partial None 2 1 0 (Circle appropriate score)

Basis for Evaluation Grade/ Comments

Pharmacy Environment: The space and storage areas of the pharmacy are adequate, clean and maintained properly.

Verify the existence of: Adequate and proper space and storage area for pharmacy (infrastructure of the Hospital pharmacy should be taken in consideration like doors, windows, ceiling, walls, ground) Area is clean and well organized Medical refrigerator in working condition Refrigerator is clean and properly organized Temperature controlled room for drugs thermometer is present and temperature record available and up-to-date (daily temperature record for refrigerator and room temperature record is recorded, is

. 2 1 0

2 2 2

1 1 1

0 0 0

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Standard Number

Standard

Hospital Pharmacy Management Compliance in Criteria for Verification of Meeting Meeting Standard (Score) Standard
Full Partial None 2 1 0 (Circle appropriate score)

Basis for Evaluation Grade/ Comments

important to keep room temperature between 1525 C) No non-medical items found in refrigerator (e.g. no staff food) Stock is properly stored (stock is on pallets and shelves where the distance between shelves is at least 30cm, the height of cartons should not be more than 2.5 meters, pallets height is at least 10cm off the floor or ground, the distance between shelves and walls is at least 30 cm) Stock containers have correct and adequate labeling Prepackaged medicines clearly labeled (Manufactured date Expire date information for patients, patients instruction for use space, etc.) Availability of sufficient counting aids and surfaces No Smoking signs are prominently displayed Room has adequate light and ventilation Proper water supply is in or near the pharmacy

2 2 2 2

1 1 1 1

0 0 0 0

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Standard Number

Standard

Hospital Pharmacy Management Compliance in Criteria for Verification of Meeting Meeting Standard (Score) Standard
Full Partial None 2 1 0 (Circle appropriate score)

Basis for Evaluation Grade/ Comments

Pharmacy Store and Storage Conditions: The pharmacy has a separate store area that is adequate and properly maintained

Verify the existence of: Separate room for drug stores Drugs not dispensed to patients from store Room large enough to keep all supplies Door to store room has two lockseach lock has a different and separate key Store kept locked at all times when not in use Facility is well maintainedno cracks, holes or sign of water damage in store Store ceiling in good condition Proper fire prevention and extinguishing equipment is presentuse sand to extinguish fires where there are no fire extinguishers. Place buckets of sand near the door. Drugs with shorter expiry date are exchanged and documented Air moves freely in store; fans and screens in good condition Windows have curtains and are secured with grills Store is free of pests (i.e. cockroaches, rats, mice): no sign of infestations

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1 1 1 1 1 1 1

0 0 0 0 0 0 0

2 2 2 2

1 1 1 1

0 0 0 0

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Standard Number

Standard

Hospital Pharmacy Management Compliance in Criteria for Verification of Meeting Meeting Standard (Score) Standard
Full Partial None 2 1 0 (Circle appropriate score)

Basis for Evaluation Grade/ Comments

3 Storage Procedures: The storage procedures for the pharmacy are adequate and properly followed

Store is tidy: shelves are dusted, floor is swept, and walls are clean Supplies are stored neatly on shelves or in boxes Shelves and boxes are raised off the floor on pallets or on boards and bricks. Narcotics and psychotropic drugs in a separate double-locked storage space. Supplies arranged on shelves by therapeutic class Tablets and other dry medicines (e.g., ORS) stored in airtight containers Liquids, ointments and injectables stored on middle shelves Supplies, such as surgical items, condoms and bandages stored on bottom shelves Temperature-sensitive items stored in refrigerator Supplies arranged on shelves in alphabetical order by generic name Items grouped in amounts that are easy to count No expired drugs in the store Drugs with shorter expiry dates placed in

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1 1 1 1 1 1 1 1 1 1 1 1 1

0 0 0 0 0 0 0 0 0 0 0 0 0

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Standard Number

Standard

Hospital Pharmacy Management Compliance in Criteria for Verification of Meeting Meeting Standard (Score) Standard
Full Partial None 2 1 0 (Circle appropriate score)

Basis for Evaluation Grade/ Comments

Ordering of drugs and supplies: The drugs and supplies needed are ordered in a timely manner and are based on usage and expected needs of patients. Note: For more complete explanation on good practices for ordering of drugs, see Managing Drug Supply

front of those with later expiry dates (FEFO) Supplies with no expiry or manufacture date stored in order received (FIFOfirst in, first out) No damaged containers or packages are stored on shelves No overstocked or obsolete items on shelves. Disposal of drugs is recorded and includes amount value ,date, time witness and reason's). Orders consumption based and respond to expected needs of patients Appropriate frequency in distributing drug orders Calculation and use of lead time in ordering and receipt of drug shipments to determine when drugs are to be ordered Calculation of Average Monthly Consumption (AMC) Stock out periods taken into consideration when calculating AMC Maximum Stock calculated by multiplying AMC by Maximum Stock

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0 0 0 0 0 0 0 0 0 0
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Section 4: Ancillary and Support Services. Hospital Pharmacy Management Hospital Standards ManualAfghanistan

Standard Number

Standard

Hospital Pharmacy Management Compliance in Criteria for Verification of Meeting Meeting Standard (Score) Standard
Full Partial None 2 1 0 (Circle appropriate score)

Basis for Evaluation Grade/ Comments

Receiving supplies: Proper procedures are followed for receiving supplies.

Factor Maximum Stock calculated for each item Maximum Stock recorded on each item's stock card Order placed when stock balance is less than Maximum Stock Quantity to Order formula used when ordering All orders placed in writing using prescribed forms All information on requisition complete, accurate, and written clearly Verify whether: Deliveries are received by a health worker overseeing the delivery Condition of boxes at time of delivery checked by a health worker Deliveries acknowledged and dated on standard forms Delivery person signs form before leaving the facility or warehouse Supplies received match items listed on delivery form Expiry dates of all items checked before

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0 0 0 0 0 0 0 0 0 0 0 0

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Standard Number

Standard

Hospital Pharmacy Management Compliance in Criteria for Verification of Meeting Meeting Standard (Score) Standard
Full Partial None 2 1 0 (Circle appropriate score)

Basis for Evaluation Grade/ Comments

Receiving supplies: Prompt and proper action taken if deterioration of drugs received is suspected.

Stock cards are used for proper inventory control: Stock cards are used to control inventory and are used continually

final acceptance of delivery Verify whether: There are regular inspections to determine if there is any deterioration of drugs (e.g. unusual odors of tablets and capsules, damaged tablets or capsules, injectables with small particles that reflect light) All discrepancies are documented and reported: unacceptable expired drugs or drugs of poor quality identified As soon as supplies are stored, all receipts recorded on stock cards Verify the existence of stock cards and their proper usage by ensuring: Stock card exists for each item in store All information on stock card up-to date and accurate (verify calculations) Stock card kept on same shelf as item Information recorded on stock card at time of movement of drug or item Accurate running tally kept in balance column Physical count made at regular intervals (at least once a month) and regular verification and cross-check by hospital

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0 0 0 0 0 0 0 0

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Standard Number

Standard

Hospital Pharmacy Management Compliance in Criteria for Verification of Meeting Meeting Standard (Score) Standard
Full Partial None 2 1 0 (Circle appropriate score)

Basis for Evaluation Grade/ Comments

Drugs are dispensed properly to patients: There is an appropriate system for dispensing drugs to patients--inpatients and outpatients

director or inspection team at least twice a year. Verify that: Patients are greeted and treated with respect Pharmacy staff are appropriately dressed and have a clean appearance while on duty All medicines dispensed are checked by a second staff member before issuing the prescription to a patient A proportion of prescriptions are crosschecked for accuracy in listing of the patients name at point of receipt Dispensing containers are cleaned before use Records of delivery of drugs to patient maintained Records of unsatisfied demands maintained Pharmacist explains to patients the dosage, side effects, and possible adverse reactions in use of their medication Dosage of the prescribed drug written on medicine envelopes

2 2 2

1 1 1

0 0 0

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Standard Number

Standard

Hospital Pharmacy Management Compliance in Criteria for Verification of Meeting Meeting Standard (Score) Standard
Full Partial None 2 1 0 (Circle appropriate score)

Basis for Evaluation Grade/ Comments

Pharmacist or dispenser has confirmed that patient knows how and when to take the drug properly Patients are able to repeat and remember the instructions for taking their medication

2 2

1 1

0 0

Row A B C D E F

Scoring compliance with the standards

Total Score (sum total checks for full, partial and no compliance) Score for each category (Full compliance =2, Partial compliance =1 and Non-compliance =0) Score of Full, Partial and Non-compliance (Multiply Row A times Row B) TOTAL: Sum of scores for Full, Partial and Non-compliance(Add all three columns in Row C) Score possible (Total criteria times 2less any N/A) Percentage Compliance with these standards (Divide Row D by Row E) 2 1 0

158 %

Total criteria 79 x 2 pts = maximum 158 point s possible (less any N/A)

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