Approved: September 15, 2024
Effective Date: October 1, 2024
Version #: 1.00
Purpose
The purpose of this policy is to articulate the Ontario College of Pharmacists’ (the College; OCP) expectations of registrants related to supervising registered pharmacy professionals, non-registered pharmacy personnel and other regulated (non-pharmacy) health professionals.
The information within this policy brings together the provisions and requirements related to supervision of pharmacy personnel found in the Pharmacy Act, 1991, and its regulations, the Drug and Pharmacies Act, 1990, and the Regulated Health Professions Act, 1991, to which all pharmacy professionals are accountable.
Scope
This policy applies to all practice settings[1] and to:
- Pharmacy professionals supervising pharmacy personnel
- Those who require supervision[2]
The scope of this policy does not include:
- Supervision related to the operation of a pharmacy
- Workplace-specific supervision arrangements or reporting relationships that are not based on legislation relevant to this policy
- Supervision of activities outside the scope of the profession
Definitions
Designated Manager (DM): A Part A pharmacist designated by the owner of the community pharmacy, in information provided to the College, as the pharmacist responsible for managing the pharmacy.[3] The DM is responsible for the human resources management in a pharmacy, including the supervision of pharmacy personnel (Drug and Pharmacies Regulation Act, 1990).
Direct supervision: Supervision that is provided by a person who is physically present on the pharmacy premises where the practice that is being supervised is carried out (Ontario Regulation 256/24),[4] and in a manner that allows for observation and prompt intervention by the person supervising.
Emergency assignment (EA) pharmacy professional: A pharmacist (EA) or pharmacy technician (EA) who has been issued an emergency assignment certificate of registration, during a time when the emergency assignment registration is active.
Hospital pharmacy administrator (HPA): The person with oversight of the hospital’s pharmacy operations who is accountable for ensuring that all systems required to provide safe and effective pharmacy services are in place. The HPA is not required to be a registrant of the College (Standards of Operation).
Incapacitated: A person who is suffering from a physical or mental condition or disorder that makes it desirable in the interest of the public that the registrant’s certificate of registration be subject to terms, conditions or limitations, or that the registrant no longer be permitted to practice (Regulated Health Professions Act, 1991).
Incompetence: When the care being provided to patients by a pharmacy professional or other regulated health professional displays a lack of knowledge, skill or judgment of a nature or to an extent that demonstrates that the registrant is unfit to continue to practice or that the registrant’s practice should be restricted (Schedule 2 s.52(1) under the Regulated Health Professions Act, 1991).
Intern: A person who is registered as an intern (pharmacist) under the Pharmacy Act, 1991 (Drug and Pharmacies Regulation Act, 1991).
Intern technician: A person who is registered as an intern technician (pharmacy technician) under the Pharmacy Act, 1991.
Part A: A registrant who provides patient care and holds a certificate of registration as a Part A pharmacist or Part A pharmacy technician (Ontario Regulation 256/24 under the Pharmacy Act, 1991).
Part B: A registrant who does not provide patient care and holds a certificate of registration as a Part B pharmacist or Part B pharmacy technician (Ontario Regulation 256/24 under the Pharmacy Act, 1991).
Pharmacy personnel: Includes both regulated pharmacy professionals (see definition below) and unregulated pharmacy staff, including pharmacy assistants, pharmacy students, pharmacy technician students, as well as other regulated health professionals (e.g., nurses).
Pharmacy professional: Regulated professionals registered with the Ontario College of Pharmacists, including pharmacists, pharmacy technicians, interns, intern technicians, pharmacists (EA) and pharmacy technicians (EA).
Pharmacy student[5]: A person enrolled in an educational program for the purposes of fulfilling the requirements to become a pharmacist.
Pharmacy technician student: A person enrolled in an educational program for the purposes of fulfilling the requirements to become a pharmacy technician.
Remote dispensing location (RDL): A place where drugs are dispensed or sold by retail to the public under the supervision of a pharmacist who is not physically present.
Supervision: If not preceded by the word “direct,” supervision means supervision that is provided by a person who may not be physically present on the premises but is available to the person being supervised for consultation or assistance, as needed.
Policy
The specialized knowledge and skills required to manage the risks inherent to the practice of pharmacy requires that the College develop and enforce practice standards and policies to protect the public from risks of harm. Pharmacy personnel require some degree of supervision to ensure that patients are receiving safe, effective and ethical care.
The following pharmacy personnel require supervision and/or direct supervision:
a) Pharmacy professionals with a certificate of registration
- Pharmacists (EA)
- Part B pharmacists (when transitioning to Part A, and providing patient care)
- Part A pharmacy technicians
- Pharmacy technicians (EA)
- Part B pharmacy technicians (when transitioning to Part A, and providing patient care)
- Interns
- Intern technicians
b) Pharmacy personnel without a certificate of registration from OCP
- Pharmacy students[5]
- Pharmacy technician students
- Pharmacy assistants
- Non-pharmacy regulated health professionals
Determining the Nature and Extent of Supervision
The nature of each supervisory relationship varies depending on the pharmacy setting, the person being supervised, the terms, conditions and limitations on the certificates of registration of those involved, and the purpose of the supervisory relationship.
It is imperative for supervisors to know the scope of practice of the pharmacy professionals they are supervising to determine what activities they can and cannot perform independently. Refer to the Legal Authority for Scope of Practice/Authorized Acts for a summary. The terms, conditions and limitations of each registrant class, within Ontario Regulation 256/24 (General) under the Pharmacy Act (1991),4 detail all legislated requirements and limitations around the performance of controlled acts. Any other tasks or duties assigned in the course of supervising, if not clearly detailed in legislation, should be assigned in a manner that considers public safety, the Code of Ethics and the Standards of Practice.
A supervisor determines the extent of supervision required based on:
- The registrant class of the person to be supervised and their authorized scope of practice
- Assessment of the person’s competence through initial observation of their performance in practice and considering their experience to date
- Discussion and agreement with the person to be supervised regarding the types of practice activities that may be performed independently and how the supervisor would be consulted
The supervisor must document the nature of the supervisory relationship and their rationale when determining what a person being supervised can and cannot do.
Accountability
In a supervisory arrangement, accountability exists for both the pharmacy professional providing supervision and the person being supervised.
Responsibilities of the Supervisor
- Registrants acting as supervisors must assess their own competence, skills and training needs to ensure they can safely provide supervision. There must not be any terms, conditions or limitations on their own certificate of registration that would prevent them from supervising another pharmacy professional.
- Supervisors must ensure that all pharmacy personnel clearly identify their registrant class or role to patients, by actively communicating this information (e.g., verbally or in writing) and/or passively (e.g., with signage or worn identification). The name of the supervising pharmacist must be available to the public at any point in time.
- Supervisors must determine and provide the appropriate level of supervision. This will vary depending on the individual they are supervising and/or the specific act(s) to be performed.
- Failing to provide the appropriate level of supervision to those they are obligated to supervise is considered an act of professional misconduct.[6]
- Registrants providing supervision can be liable for the actions of those under their supervision.
- While supervising pharmacy personnel, registrants who are also the Designated Manager (DM)/hospital pharmacy administrator (HPA) must:
- Consult the Public Register to confirm the current registration status of any pharmacy professional they employ
- Ensure the pharmacy has an adequate number of qualified and trained staff to maintain the accepted standards of professional practice and to deliver safe and effective patient care
- Report to the College if they revoke privileges, terminate, or suspend a regulated health professional for reasons of professional misconduct, incompetence or incapacity[7]
- If the regulated health professional is not a pharmacy professional, the DM/HPA must make the report to the appropriate health regulatory college.
- When supervising students during experiential learning placements, the supervisor must prioritize the experiential learning and skill development of the student. Performing administrative tasks and meeting pharmacy-specific metrics must not be the primary focus of the student’s experience.
- When supervising EA pharmacy professionals, a supervisor must:
- Be a Part A pharmacist, if supervising a pharmacist (EA)
- Be a Part A pharmacist or pharmacist (EA), if supervising a pharmacy technician (EA)
- Have agreed to supervise the EA pharmacy professional
- Have a current and legitimate association with the EA pharmacy professional’s practice site (e.g., reported workplace, shareholder stake, ownership) and have reported to the College which practice site supervision of the EA pharmacy professional shall occur
- Be available to consult in real-time with the EA pharmacy professional. If this communication is virtual (e.g., phone or video consultation), both parties must ensure they protect personal health information from unauthorized disclosure in accordance with privacy legislation.
- While supervisors are accountable for the regulated or unregulated pharmacy personnel under their supervision, ultimate accountability in a community pharmacy lies with the pharmacy owner and/or Designated Manager, as detailed in s.166(1) of the Drug and Pharmacies Regulation Act, 19903
- Temporary transfers of supervisory responsibility:
- There may be instances in which a registrant must supervise pharmacy personnel they do not normally supervise (e.g., if the usual supervisor is away from the pharmacy). In these situations, the supervisory authority and responsibility shifts to the interim supervisor, who assumes temporary responsibility for the person being supervised. The interim supervisor is responsible for assessing the individual they are to supervise and for reaching an agreement with that individual about what they can or cannot do under their supervision. A temporary, new supervisory relationship may result in different expectations than what was previously established.
Responsibilities of Pharmacy Technicians
Pharmacy technicians have a responsibility to practice according to the terms, conditions and limitations of their certificate of registration, including any requirements for supervision.
- When practicing in an accredited community pharmacy, pharmacy technicians must work under the direct supervision of a Part A pharmacist or pharmacist (EA).
- When practicing at a remote dispensing location (RDL), a pharmacy technician must be under the supervision of a Part A pharmacist or pharmacist (EA)3,[8] who is physically present at the accredited pharmacy that operates the RDL.
- A pharmacist provides remote supervision via a live, two-way audio-visual link that permits dialogue between the pharmacist who is physically present in the accredited pharmacy and RDL staff.
- In all other practice settings, including hospital pharmacies, pharmacy technicians must only practice their profession under the supervision of a Part A pharmacist or pharmacist (EA).
Responsibilities of Interns and Intern Technicians
Interns and intern technicians have a responsibility to practice according to the terms, conditions and limitations of their certificate of registration, including any requirements for supervision.
- When practicing in an accredited community pharmacy, interns must work under the direct supervision of a Part A pharmacist or pharmacist (EA).
- In all other practice settings, including hospital pharmacies, interns must only practice the profession under the supervision of a Part A pharmacist or pharmacist (EA).
- Intern technicians must only practice their profession under direct supervision of a Part A pharmacy technician, a pharmacy technician (EA), a Part A pharmacist or a pharmacist (EA).
- Interns and intern technicians must never supervise others in the practice of the profession.
Responsibilities of Emergency Assignment Pharmacy Professionals
Emergency assignment pharmacy professionals have a responsibility to practice according to the terms, conditions and limitations of their certificate of registration, including any requirements for supervision.
- Emergency assignment (EA) pharmacy professionals have not completed all requirements for registration as a pharmacist or pharmacy technician and therefore require supervision.
- Pharmacists (EA) require supervision (not direct supervision)
- Pharmacy Technicians (EA) must have direct supervision while practicing in an accredited community pharmacy, and require supervision when practicing in all other settings, such as hospital pharmacies or RDLs.
- In the course of providing patient care, a record of any consultation between the pharmacist (EA) and their supervising pharmacist must be documented in the relevant patient’s file by the pharmacist (EA) in a manner that is timely and readily retrievable.
Supervising Students
In the process of becoming a regulated health professional (i.e., during experiential learning placements), pharmacy students and pharmacy technician students are authorized, under section 29(b) of the Regulated Health Professions Act (1991) to perform the controlled acts of their respective professions. Although students are no longer registered with the College under a separate registration class, supervision of students in placements remains a requirement. Both pharmacy and pharmacy technician students must be supervised by a registered pharmacy professional when practicing the profession of pharmacy and performing controlled acts.
- Pharmacy students must be supervised by a Part A pharmacist or pharmacist (EA).
- Pharmacy technician students must be supervised by a Part A pharmacist, pharmacist (EA), Part A pharmacy technician or pharmacy technician (EA).
Further, the section 149(1)(c) of the Drug and Pharmacies Regulation Act (1990) specifies that when performing the acts of compounding, dispensing, and/or selling any drug in a community pharmacy, direct supervision of students is required.
Supervising Pharmacy Assistants or Other Unregulated Personnel
Pharmacy assistants may be assigned tasks (e.g., counting, measuring, labelling, packaging, managing inventory) that are part of controlled acts such as dispensing or compounding medications. The supervising pharmacy professional remains responsible and accountable for the controlled act, including implementing whatever safeguards are necessary to ensure the tasks performed by pharmacy assistants are done correctly.
Pharmacy assistants and other personnel working in pharmacies (e.g., cashiers, clerks, volunteers) are unregulated staff who are not accountable to the College. The College has no authority over their actions, and therefore does not have a policy regulating who must supervise their work. It is at the discretion of the pharmacy owner, the DM or HPA to determine who supervises pharmacy assistants and other unregulated personnel, and how. Ultimately, DMs or pharmacy owners are responsible and liable for the actions of unregulated personnel.
Supervising Registrants and Students from Other Regulated Health Professions
In situations where a registrant is supervising another regulated health professional (e.g., nurses, dietitians) in a pharmacy practice setting, the DM or pharmacy owner is responsible and liable for the actions of the regulated health professionals under their supervision. However, the regulated health professional is also accountable to their own regulatory authority.
Pharmacy professionals may, on occasion, be asked to supervise non-pharmacy students (e.g., medical students, nursing students). In these cases,
- supervisors must be aware of their own professional scope and not supervise students in the performance of controlled acts that are outside of the scope of pharmacy
- supervisors must assess their own knowledge and skills, and not supervise students in the practice of another health profession that is beyond their knowledge and skills as a pharmacy professional
Pharmacy professionals are reminded that there may be legislation that limits who can provide supervision to a student of another regulated health profession in the practice of that profession.
Tables A and B below summarize the supervision authority of pharmacy personnel – who can supervise them, and who they can supervise – in a community pharmacy environment. Direct supervision is always implied, unless indicated otherwise.
1. Pharmacy professionals with a certificate of registration from OCP
| OCP registrant class | Who supervises them? | Who can they supervise? |
|---|---|---|
| Part A pharmacist |
|
|
| Pharmacist (emergency assignment) |
Supervision does not need to be direct (i.e., supervisor does not need to be physically present). |
|
| Part B pharmacist – when in the process of moving to Part A
(requires approval by Registrar to perform controlled acts or provide patient care) |
|
|
| Part A pharmacy technician |
|
|
| Pharmacy technician (emergency assignment) |
|
|
| Part B pharmacy technician – when in the process of moving to Part A
(requires approval by Registrar to perform controlled acts or provide patient care) |
|
|
| Intern pharmacist |
|
|
| Intern technician |
|
|
2. Pharmacy personnel without a certificate of registration from OCP
| Non-registered pharmacy personnel | Who supervises them? | Who can they supervise? |
|---|---|---|
| Pharmacy student |
|
|
| Pharmacy technician student |
|
|
| Pharmacy assistant |
|
|