Community Pharmacy Assessments

The College is currently piloting a new model for community pharmacy assessments. The new assessment model includes two parts:

1. Operational Assessment

  • An assessment of the pharmacy’s operations and processes
  • Designed to ensure adherence to operational standards and ensure proper processes and procedures are in place in the pharmacy
  • For detailed operational assessment criteria: Operational Assessment Criteria for Community Pharmacies.

2. Practitioner (Practice) Assessment

  • An evaluation of the pharmacy professionals working in the pharmacy was added as a pilot in late 2014
  • Designed to increase adherence to practice standards and ensure pharmacy professionals are delivering positive health outcomes for patients
  • For detailed practitioner assessment criteria: Pharmacist Practice Assessment Criteria (criteria for pharmacy technicians is currently under development)
  • Visit the Key Initiative — New Practice Assessments to learn more about the pilot and this piece of the assessment process

The previous model for pharmacy assessments was focused solely on the pharmacy’s operations


Types of Community Pharmacy Operational Assessments:

New opening assessments
All community pharmacies are assessed and given authorization to operate (accredited) prior to opening day. Read more about opening a pharmacy.

Routine assessments
All community pharmacies undergo routine assessments every one to four years, depending 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.

Change in ownership 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.

Change in location 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 as a result of a significant renovation.

Re-assessments
Re-assessments may be ordered by a College practice advisor (previously called inspectors), or may be escalated and ordered by the Accreditation Committee. Re-assessments are scheduled depending on the severity of the deficiencies 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 Operational Assessment Outcomes

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

The status and/or outcome of all pharmacy assessments that occurred after July 1, 2013 are posted on Find a Pharmacy or Pharmacy Professional.

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

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

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

Issues that have the potential to affect public safety — If issues that have the potential to affect public safety are identified at the time of the assessment, the practice advisor has two options available to them:

  1. The practice advisor may choose to order a re-assessment and re-visit the pharmacy to ensure that all issues are rectified. When a reassessment is ordered, the pharmacy will have a status of pending on Find a Pharmacy or Pharmacy Professional. When the practice 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 practice advisor will refer the pharmacy to the Accreditation Committee for further consideration (see below). Pharmacies that are awaiting review by the Accreditation Committee have a status of pending (AC) on Find a Pharmacy or Pharmacy Professional
  2. For more serious issues, the practice advisor may choose to refer the pharmacy to the Accreditation Committee without conducting a re-assessment first. Pharmacies that are awaiting review by the Accreditation Committee have a status of pending (AC) on Find a Pharmacy or Pharmacy Professional



Referral to the Accreditation Committee

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 issues with the potential to affect public safety.

Community pharmacies that are awaiting review by the Accreditation Committee have a status of pending AC on Find a Pharmacy or Pharmacy Professional.

The Accreditation Committee will review the pharmacy’s file and may do one or more of the following:

  1. Consider the pharmacy’s operations to be satisfactory and issue a pass, and the assessment is complete.
  2. Impose conditions on the pharmacy’s right to operate. For example, the Committee may restrict the pharmacy from dispensing methadone. If the Committee imposes conditions, the pharmacy will have a status of pass with conditions on Find a Pharmacy or Pharmacy Professional, a list of conditions will be included.
  3. Order a practice advisor to re-assess the pharmacy. If the Committee chooses this option, the practice 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 a status of pending AC on Find a Pharmacy or Pharmacy Professional, while awaiting the re-assessment and Committee decision.

The Accreditation Committee may also refer the pharmacy’s owner 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.