Community Pharmacy Assessments

During a community pharmacy assessment, a College operations advisor reviews the pharmacy’s operations. The assessment is designed to ensure the pharmacy is adhering to operations standards and has the proper processes and procedures in place. The frequency of routine pharmacy assessments is dependent on the activities performed at the pharmacy and the risk of harm those activities pose to the public.

The College operations advisor uses the Operations Assessment Criteria for Community Pharmacies to assess the pharmacy.

The reason for and outcome of every community pharmacy assessment is published on the pharmacy’s profile on the Find a Pharmacy/Professional tool.

Evaluations of pharmacy professionals working in a pharmacy occur via a separate and distinct process. For details on this program, visit Practice Assessments page on the College website or view the Pharmacist Practice Assessment Criteria or the Pharmacy Technician Practice Assessment Criteria.

Types of Community Pharmacy Operations Assessments

Routine assessments

All community pharmacies undergo routine assessments on a cycle dependent on the activities performed at the pharmacy and the risk of harm those activities pose to the public. For example, a pharmacy dispensing methadone or doing sterile compounding will be assessed more often than a pharmacy where those activities aren’t occurring.

New opening and new opening follow up assessments

All community pharmacies are assessed and given authorization to operate (accredited) prior to opening day. Additionally, an operations advisor will conduct a follow up assessment within six months after opening. Read more about opening a pharmacy.

Acquisition assessments

A change in ownership (if an existing pharmacy is purchased by a new owner) is equivalent to opening a new pharmacy and requires an assessment before opening day. Learn more about changes in ownership/purchasing a pharmacy. This is similar to assessments that occur at the time of a merger or amalgamation.

Relocation assessments

A change in location (if an existing pharmacy moves to a new address) also requires an assessment before opening day. Learn more about changes in location/relocating a pharmacy. Pharmacies may also require an assessment because of a significant renovation.

Re-assessments and Re-assessments ordered by the Accreditation Committee

Re-assessments may be ordered by a College operations advisor or may be escalated and ordered by the Accreditation Committee. The timing of a re-assessment is determined by the severity of the issues identified during the previous assessment, the potential time required to fix any deficiencies, and the risk of harm to the public. See below for more information about assessment outcomes and details regarding the re-assessment process.

Community Pharmacy Operations Assessment Outcomes

When community operations advisors visit a pharmacy, they assess its operations and processes to determine if it is operating safely. The operations advisor uses the operational assessment criteria to determine if the pharmacy is safe, or if further action is required.

There are several potential outcomes, depending on what the operations advisor observes at the time of the assessment.

Pass

If no notable issues are identified at the time of the assessment, the pharmacy receives a Pass and the assessment is complete.

If only minor issues are identified at the time of the assessment, the pharmacy is granted the opportunity to rectify the issues. The operations advisor will follow up to ensure they are satisfied that the issues have been addressed. The pharmacy then receives a Pass and the assessment is completed. Usually, the time frame to rectify the issues is 30 days but could be longer depending on the issue.

Re-assessment required

If issues that have the potential to affect public safety are identified at the time of the assessment, the operations advisor may choose to order a re-assessment and a re-visit of the pharmacy will occur to ensure that all issues are rectified.

When an operations advisor re-visits the pharmacy:

• If no notable issues are identified at the time of the re-assessment, the pharmacy receives a Pass and the assessment is complete.
• If only minor issues are identified at the time of the re-assessment, the pharmacy is granted the opportunity to rectify the issues (as above under “minor issues”). Assuming all issues are rectified, the pharmacy will receive a Pass and the assessment is complete.
• If issues that have the potential to affect public safety are identified at the time of the re-assessment, the operations advisor will refer the pharmacy to the Accreditation Committee for further consideration (see below). Pharmacies that are awaiting review by the Accreditation Committee have an outcome of Referred to Accreditation Committee on Find a Pharmacy/Professional.

Referred to Accreditation Committee

If there are potential public safety issues, the operations advisor may refer the pharmacy to the Accreditation Committee. Pharmacies that are awaiting review by the Accreditation Committee have an outcome of Referred to Accreditation Committee on Find a Pharmacy/Professional.

Only a small number of community pharmacies are referred to the Accreditation Committee each year. Most of these have already undergone a routine assessment and a re-assessment, and continue to have challenges satisfying the assessment criteria which then has the potential to affect public safety.

The Accreditation Committee will review the pharmacy’s file, including information provided by the pharmacy as to how they may have resolved or addressed the issues of concern, and may do one or more of the following:

1. Determine the pharmacy’s operations to be satisfactory and issue a Pass if they feel that the pharmacy has appropriately addressed the issues identified. The assessment is then complete.
2. Following a referral to the Accreditation Committee, the committee may issue an outcome of Pass with Conditions if they are not assured that operational issues have been addressed. An operations advisor will conduct a re-assessment and the results will be returned to the committee for further review.
3. Order an operations advisor to re-assess the pharmacy. If the Committee chooses this option, an operations advisor will return to the Committee with a report, and the Committee will decide whether the pharmacy’s operations are now satisfactory (as above in #1) or whether the pharmacy should have conditions on its right to operate (as above in #2), or if further action should be taken. The pharmacy will have an outcome of Pending Committee Report on Find a Pharmacy/Professional while awaiting the committee’s consideration of the re-assessment report from the operations advisor.

The Accreditation Committee may also refer the pharmacy’s owner and Designated Manager to the Discipline Committee. A referral to the Discipline Committee is not an outcome of an assessment, and usually coincides with either a re-assessment or conditions on the pharmacy’s right to operate. A referral to the Discipline Committee will require the pharmacy’s Designated Manager or Director Liaison to appear before the Committee, usually on allegations of proprietary misconduct. The pharmacy itself will stay under the review of the Accreditation Committee.