PHARMACY CONNECTION ARTICLE

We’re Piloting Changes to Operational Assessments: Look for an Expanded Focus on the Standards of Practice

Published on: October 3, 2025

Standards of Practice Must Be Met for Patient Safety and Quality of Care

Standards of practice outline the minimum standards that all registered pharmacists and pharmacy technicians must meet. Regardless of a professional’s position or practice environment, when a pharmacist or pharmacy technician performs a specific task or activity, they must perform it to the level specified in the Standards of Practice and meet all of the standards associated with that role.

The NAPRA Model Standards of Practice for Pharmacists require patient assessment for all patients, those with new prescriptions and refills, and require decision making, documentation and communication when required based on the patient assessment.  Pharmacists should be ensuring that this is occurring for all patients and Designated Managers should be ensuring that their pharmacy team has the capacity to meet the standards of practice for all patients.

Although many factors might influence the work of an individual pharmacy professional, time constraints and business pressures have been identified as a key factor affecting ability to meet the standards of practice.

How Pharmacy Operational Assessments Are Changing

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 outcome of pharmacy assessments are posted to the public register.

Starting this year, we’ve launched a pilot project to test how we can expand our focus during community pharmacy operational assessments to include outcomes.

This helps better identify if any aspect of pharmacy operations is creating or leading to challenges that get in the way of the delivery of quality, ethical and safe patient care. It also allows a better assessment of whether the pharmacy has organized staffing and workflow to enable pharmacists to fulfill standards of practice and optimize patient care.

Currently, the College’s operations advisors look for evidence that the pharmacy has organized staffing and workflow to enable pharmacy professionals to fulfill standards of practice and to optimize patient care.  Specifically, the operations advisors are confirming that appropriate processes are in place:

• The pharmacy must develop a process for staff to gather relevant information for new prescriptions to ensure patient files are complete and comprehensive including information such as indication, allergies, medical conditions, prescription history, use of over the counter/natural health products and changes to health status.

• The pharmacy must develop a process for staff to gather relevant information on refill prescriptions to ensure patient files are complete and comprehensive including information such as changes to allergies, medical conditions, prescription history, use of over the counter/natural health products, changes to health status and indication.

Under the pilot project, operations advisors will also look for whether the identified processes are being used consistently.

To accomplish this, operations advisors will conduct a random audit of patient profiles. For each of the patient profiles, the advisor will look for documentation of:

• Allergies
• Medical conditions

For new prescriptions, advisors will look for documentation of:

• Indication
• Communication with patient/counselling

For refill and blister pack prescriptions, advisors will look for documentation of:

• Check in with the patient on any issues with their medication or changes to their health status

How to Self-Assess Your Pharmacy

A great way to prepare for your next operational assessment and ensure your practice and pharmacy enable you and/or your staff to meet the standards of practice is to conduct a self-assessment.

If you are a pharmacist: select a number of patient profiles, both new prescriptions and refills, and assess whether you have documented the above information.

If you are a Designated Manager: select a number of patient profiles, both new prescriptions and refills, and assess whether the pharmacy team has appropriately documented the above information.

Follow the steps below to conduct a pharmacy self-assessment:

Step 1: Randomly select approximately 20 patients with new prescriptions.

Step 2: For each patient, identify whether allergies and medical conditions were documented.

Step 3: For each patient identify one new prescription.  For the new prescription, identify whether indication was documented and whether patient communication / counselling was documented.

Step 4: Randomly select 2-5 additional patients who have refill or blister pack prescriptions.  For each one, identify whether there was a documented check in with the patient (e.g., over the last 3-6 months) to determine whether there were any changes to their health status or issues with their medication.

Sample Audit Form

The table below provides an example of an audit form you can use to keep track of the patient records and whether the information was appropriately documented.

Part 1: Documentation of Information on Patient Profiles and for New Prescriptions.

Select at least 20 patients.

Patient	Allergies	Medical Conditions	Prescription Number	Indication for New Prescriptions	Counselling for New Prescription	Comments
Patient #1	Yes	No	112233	No	Yes
Patient #2	Yes	Yes	445566	Yes	No
Patient #3	Yes	Yes	778899	No	Yes
Patient #4	Yes	No	778899	No	Yes
Patient #5	No	No	665544	Yes	Yes

Continue to add rows for additional patients

Part 2: Check Ins with Refill or Blister Pack Patients

Prescription Type	Check In Documented (within last 3-6 months)
Refill #1	Yes
Refill #2	No
Refill #3	No
Blister Pack #1	No
Blister Pack #2	No

What Happens Next

The pilot project testing the expanded focus on outcomes during operational assessments will continue throughout 2025 and into 2026. Pharmacies will be selected to participate on a random basis. Data will be collected throughout the pilot phase to inform program revisions.