Community Pharmacy Assessments

During a community pharmacy assessment, a College practice advisor reviews the pharmacy’s operations. The assessment is designed to ensure the pharmacy is adhering to operational standards and has the proper processes and procedures in place. All 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.

Access detailed assessment criteria in the Operational Assessment Criteria for Community Pharmacies.

The College also evaluates pharmacy professionals working in the pharmacy. For details on this program, visit Practice Assessments or view the Pharmacist Practice Assessment Criteria or the Pharmacy Technician Practice Assessment Criteria.

Types of Community Pharmacy Operational Assessments:

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.

New opening and new opening follow up assessments
All community pharmacies are assessed and given authorization to operate (accredited) prior to opening day. Additionally, a practice advisor will conduct a follow up assessment within three to 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 as a result of a significant renovation.

Re-assessments and Re-assessments ordered by the Accreditation Committee
Re-assessments may be ordered by a College practice advisor or may be escalated and ordered by the Accreditation Committee. Re-assessments are scheduled depending on 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 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 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/Professional. Please note that due to a technical issue, community pharmacy assessments that occurred between July 1, 2013 and December 31, 2015 are not currently displaying. We anticipate that this issue will be resolved soon.

There are several potential outcomes, depending on what the practice 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 practice 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 practice advisor may choose to order a re-assessment and another practice advisor will re-visit the pharmacy to ensure that all issues are rectified.
When a 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 an outcome of Referred to Accreditation Committee on Find a Pharmacy/Professional.

Referred to Accreditation Committee
If there are potential public safety issues, the practice advisor may refer the pharmacy to the Accreditation Committee. Pharmacies that are awaiting review by the Accreditation Committee have a 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. Issue an outcome of Pass with Conditions. The pharmacy will have a list of identified issues where the Committee expects full compliance with the standards at the next assessment, which will be conducted within 60 days. This list is available on Find a Pharmacy/Professional next to the assessment outcome.
  3. Order a practice advisor to re-assess the pharmacy. If the Committee chooses this option, a 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 an outcome of Pending Committee Report on Find a Pharmacy/Professional while awaiting the committee’s consideration of the re-assessment report from the practice 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.