Hospital Standards for Accreditation for Afghanistan

Section 4: Ancillary and Support Services

Hospital Pharmacy Management

 Hospital Standards for Accreditation for Afghanistan:
Assessment of Progress in Achieving the Standards

Hospital Department or Area: Hospital Pharmacy Management

Hospital Facility: __________________________________________

Assessor: __________________________________________ Date of assessment: ____________________

Hospital Pharmacy Management

Compliance in
Basis for Evaluation Grade/
Standard
Standard Criteria for Verification of Meeting Meeting Standard Comments
Number Standard (Score)
Full Partial None
2 1 0
(Circle appropriate score)
1 Pharmacy Verify the existence of: .
Environment: The • Adequate and proper space and storage
space and storage areas area for pharmacy (infrastructure of the
2 1 0
of the pharmacy are Hospital pharmacy should be taken in
adequate, clean and consideration like doors, windows,
maintained properly. ceiling, walls, ground)
• Area is clean and well organized 2 1 0
• Medical refrigerator in working condition 2 1 0
• Refrigerator is clean and properly
2 1 0
organized
• Temperature controlled room for drugs—
thermometer is present and temperature
record available and up-to-date (daily 2 1 0
temperature record for refrigerator and
room temperature record is recorded, is
Section 4: Ancillary and Support Services. Hospital Pharmacy Management
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 Hospital Pharmacy Management
Compliance in
Basis for Evaluation Grade/
Standard
Standard Criteria for Verification of Meeting Meeting Standard Comments
Number Standard (Score)
Full Partial None
2 1 0
(Circle appropriate score)
important to keep room temperature
between 15–25° C)
• No non-medical items found in
2 1 0
refrigerator (e.g. no staff food)
• Stock is properly stored (stock is on
pallets and shelves where the distance
between shelves is at least 30cm, the
height of cartons should not be more than
2 1 0
2.5 meters, pallets height is at least 10cm
off the floor or ground, the distance
between shelves and walls is at least 30
cm)
• Stock containers have correct and
2 1 0
adequate labeling
• Prepackaged medicines clearly labeled
(Manufactured date – Expire date –
2 1 0
information for patients, patients
instruction for use space, etc.)
• Availability of sufficient counting aids
2 1 0
and surfaces
• “No Smoking” signs are prominently
2 1 0
displayed
• Room has adequate light and ventilation 2 1 0
• Proper water supply is in or near the
2 1 0
pharmacy

Section 4: Ancillary and Support Services. Hospital Pharmacy Management

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 Hospital Pharmacy Management
Compliance in
Basis for Evaluation Grade/
Standard
Standard Criteria for Verification of Meeting Meeting Standard Comments
Number Standard (Score)
Full Partial None
2 1 0
(Circle appropriate score)
2 Pharmacy Store and Verify the existence of:
Storage Conditions: 2 1 0
Separate room for drug stores
The pharmacy has a • Drugs not dispensed to patients from store 2 1 0
separate store area that • Room large enough to keep all supplies 2 1 0
is adequate and • Door to store room has two locks−each
properly maintained 2 1 0
lock has a different and separate key
• Store kept locked at all times when not in
2 1 0
use
• Facility is well maintained—no cracks,
2 1 0
holes or sign of water damage in store
• Store ceiling in good condition 2 1 0
• Proper fire prevention and extinguishing
equipment is present—use sand to
extinguish fires where there are no fire 2 1 0
extinguishers. Place buckets of sand near
the door.
• Drugs with shorter expiry date are
2 1 0
exchanged and documented
• Air moves freely in store; fans and screens
2 1 0
in good condition
• Windows have curtains and are secured
2 1 0
with grills
• Store is free of pests (i.e. cockroaches,
2 1 0
rats, mice): no sign of infestations

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 Hospital Pharmacy Management
Compliance in
Basis for Evaluation Grade/
Standard
Standard Criteria for Verification of Meeting Meeting Standard Comments
Number Standard (Score)
Full Partial None
2 1 0
(Circle appropriate score)
• Store is tidy: shelves are dusted, floor is
2 1 0
swept, and walls are clean
• Supplies are stored neatly on shelves or in
2 1 0
boxes
• Shelves and boxes are raised off the floor
2 1 0
on pallets or on boards and bricks.
• Narcotics and psychotropic drugs in a
2 1 0
separate double-locked storage space.
3 Storage Procedures: • Supplies arranged on shelves by
2 1 0
The storage procedures therapeutic class
for the pharmacy are • Tablets and other dry medicines (e.g.,
adequate and properly 2 1 0
ORS) stored in airtight containers
followed • Liquids, ointments and injectables stored
2 1 0
on middle shelves
• Supplies, such as surgical items, condoms
2 1 0
and bandages stored on bottom shelves
• Temperature-sensitive items stored in
2 1 0
refrigerator
• Supplies arranged on shelves in
2 1 0
alphabetical order by generic name
• Items grouped in amounts that are easy to
2 1 0
count
• No expired drugs in the store 2 1 0
• Drugs with shorter expiry dates placed in 2 1 0

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 Hospital Pharmacy Management
Compliance in
Basis for Evaluation Grade/
Standard
Standard Criteria for Verification of Meeting Meeting Standard Comments
Number Standard (Score)
Full Partial None
2 1 0
(Circle appropriate score)
front of those with later expiry dates
(FEFO)
• Supplies with no expiry or manufacture
date stored in order received (FIFO—first 2 1 0
in, first out)
• No damaged containers or packages are
2 1 0
stored on shelves
• No overstocked or obsolete items on
2 1 0
shelves.
• Disposal of drugs is recorded and includes
amount value ,date, time witness and 2 1 0
reason's).
4 Ordering of drugs • Orders consumption based and respond to
2 1 0
and supplies: The expected needs of patients
drugs and supplies • Appropriate frequency in distributing drug
needed are ordered in a 2 1 0
orders
timely manner and are • Calculation and use of lead time in
based on usage and ordering and receipt of drug shipments to 2 1 0
expected needs of determine when drugs are to be ordered
patients. • Calculation of Average Monthly
Note: For more 2 1 0
Consumption (AMC)
complete explanation
• Stock out periods taken into consideration
on good practices for 2 1 0
when calculating AMC
ordering of drugs, see
• Maximum Stock calculated by
Managing Drug Supply
multiplying AMC by Maximum Stock 2 1 0
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 Hospital Pharmacy Management
Compliance in
Basis for Evaluation Grade/
Standard
Standard Criteria for Verification of Meeting Meeting Standard Comments
Number Standard (Score)
Full Partial None
2 1 0
(Circle appropriate score)
Factor
• Maximum Stock calculated for each item 2 1 0
• Maximum Stock recorded on each item's
2 1 0
stock card
• Order placed when stock balance is less
2 1 0
than Maximum Stock
• Quantity to Order formula used when
2 1 0
ordering
• All orders placed in writing using
2 1 0
prescribed forms
• All information on requisition complete,
2 1 0
accurate, and written clearly
5 Receiving supplies: Verify whether:
Proper procedures are • Deliveries are received by a health worker 2 1 0
followed for receiving overseeing the delivery
supplies. • Condition of boxes at time of delivery
2 1 0
checked by a health worker
• Deliveries acknowledged and dated on
2 1 0
standard forms
• Delivery person signs form before leaving
2 1 0
the facility or warehouse
• Supplies received match items listed on
2 1 0
delivery form
• Expiry dates of all items checked before 2 1 0

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 Hospital Pharmacy Management
Compliance in
Basis for Evaluation Grade/
Standard
Standard Criteria for Verification of Meeting Meeting Standard Comments
Number Standard (Score)
Full Partial None
2 1 0
(Circle appropriate score)
final acceptance of delivery
6 Receiving supplies: Verify whether:
Prompt and proper • There are regular inspections to determine
action taken if if there is any deterioration of drugs (e.g.
2 1 0
deterioration of drugs unusual odors of tablets and capsules,
received is suspected. damaged tablets or capsules, injectables
with small particles that reflect light)
• All discrepancies are documented and
reported: unacceptable expired drugs or 2 1 0
drugs of poor quality identified
• As soon as supplies are stored, all receipts
2 1 0
recorded on stock cards
7 Stock cards are used Verify the existence of stock cards and their
for proper inventory proper usage by ensuring: 2 1 0
control: Stock cards • Stock card exists for each item in store
are used to control • All information on stock card up-to date
inventory and are used 2 1 0
and accurate (verify calculations)
continually • Stock card kept on same shelf as item 2 1 0
• Information recorded on stock card at
2 1 0
time of movement of drug or item
• Accurate running tally kept in balance
2 1 0
column
• Physical count made at regular intervals
(at least once a month) and regular 2 1 0
verification and cross-check by hospital
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 Hospital Pharmacy Management
Compliance in
Basis for Evaluation Grade/
Standard
Standard Criteria for Verification of Meeting Meeting Standard Comments
Number Standard (Score)
Full Partial None
2 1 0
(Circle appropriate score)
director or inspection team at least twice a
year.
8 Drugs are dispensed Verify that:
properly to patients: • Patients are greeted and treated with 2 1 0
There is an appropriate respect
system for dispensing • Pharmacy staff are appropriately dressed
drugs to patients--- and have a clean appearance while on 2 1 0
inpatients and duty
outpatients • All medicines dispensed are checked by a
second staff member before issuing the 2 1 0
prescription to a patient
• A proportion of prescriptions are cross-
checked for accuracy in listing of the 2 1 0
patient’s name at point of receipt
• Dispensing containers are cleaned before
use
2 1 0
• Records of delivery of drugs to patient
maintained
• Records of unsatisfied demands
2 1 0
maintained
• Pharmacist explains to patients the
dosage, side effects, and possible adverse 2 1 0
reactions in use of their medication
• Dosage of the prescribed drug written on
2 1 0
medicine envelopes

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 Hospital Pharmacy Management
Compliance in
Basis for Evaluation Grade/
Standard
Standard Criteria for Verification of Meeting Meeting Standard Comments
Number Standard (Score)
Full Partial None
2 1 0
(Circle appropriate score)
• Pharmacist or dispenser has confirmed
that patient knows how and when to take 2 1 0
the drug properly
• Patients are able to repeat and remember
2 1 0
the instructions for taking their medication

Row Scoring compliance with the standards

A Total Score (sum total checks for full, partial and no compliance)
B Score for each category (Full compliance =2, Partial compliance =1 and
Non-compliance =0) 2 1 0
C Score of Full, Partial and Non-compliance (Multiply Row A times
Row B)
D TOTAL: Sum of scores for Full, Partial and Non-compliance—(Add all
three columns in Row C)
E Score possible (Total criteria times 2—less any N/A) 158 Total criteria 79 x 2 pts =
maximum 158 point s
F Percentage Compliance with these standards (Divide Row D by Row E) %
possible (less any N/A)

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