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Implementing a Pharmacy Policies and Procedures Manual

 Based on a presentation by Joe Cunningham, R.Ph at the Iowa Pharmacy Association’s Pharmacy Management Conference, 2007
Many states have laws that require every pharmacy to have a current policy and procedures manual. Creating such a manual can seem overwhelming, and ensuring that it works and maintaining it can make it seem every more so. However, when broken down into its individual pieces, constructing one becomes much less daunting!
What is a Policy?
A policy is a course or plan of action, especially of administrative action. Policies are based on the self-interest of the pharmacy team who is responsible for the dispensing of prescriptions. Policies benefit the pharmacy team even more than the pharmacy owner because they keep the pharmacy operations running efficiently. Thus, policy development and implementation should involve all team members in order for the process to work smoothly.
What is a Procedure?
A procedure is simply a course of action intended to achieve a result; it is a manner of proceeding or acting. Writing down the procedures is helpful in conducting business as a team and knowing which team member is responsible for each aspect of a procedure. Team members are able to work together more effectively when they know expected outcome for various scenarios.
Why do we need a policies & procedures manual?
A policies and procedures manual is a very useful tool! Although there are laws in some states that require that a manual be on file, there are many of different ways to create and utilize this document..
Including working policies and procedures can protect a pharmacy if liability issues arise. Furthermore, the existence of written policies and procedures may lessen a pharmacist’s or pharmacy’s exposure because standards of practice or quality/compliance measures protect against error.
A policies and procedures manual is also an excellent reference source for standards of practice or instructions for accomplishing certain tasks within the pharmacy. It is also a beneficial tool during training of new employees. For example, policies and procedures for tasks such as automated dispensing equipment can also be a good starting point for training new employees or employees who are expanding their responsibilities.
Also, having specific policies and courses of actions for different situations can improve the safety in the pharmacy since every team member knows exactly what should occur in various situations. Policies and procedures relating to health issues in the pharmacy can include anything from hand washing to staying home due to illness, and can make the employment place safer for employees and patients.
As pharmacies develop new policies and procedures, or make an ultimate decision on what to do in certain situations, it is easy to forget the other policies that are in place or the policies for scenarios that do not frequently occur. A polices and procedures manual will help prevent both management and employee absent-mindedness in all situations and is worth the effort that must be expended. In actuality, writing policies and procedures and placing them in the manual is much easier than writing, posting, and keeping track of memos!
What Activities Require Policies & Procedures?
There are several topics that should be addressed when creating and implementing a policy and procedures manual. 
For example, the Iowa Board of Pharmacy Law Manual states “pharmacists in charge shall be responsible for establishing and implementing policies and procedures for all operations of the pharmacy” (657-6.2 (155A) page 132, 2006). While one should not just rewrite the Law Manual, it is important to consider regulations when developing a pharmacy’s policies and procedures manual.
Problem areas should be included in a pharmacy’s policies and procedures manual, which requires that the manual be customized to specifically address the challenges faced by an individual pharmacy. Common problems that should be addressed could include prescriptions not being ready for patients at pickup, inventory control (too much or too little of a given drug), or issues with phoned-in prescriptions. Targeting these areas in a pharmacy’s manual will help the entire team be aware of the potential issues and the course of action that needs to be taken when these situations occur.
Policies and procedures manuals not only help one define the problem areas in an individual pharmacy, but they also assist in the resolution of them. It is a good idea to define the tasks of each technician and pharmacist; this eliminates confusion and allows for work to flow more smoothly. Another problem that can be resolved in the policies and procedures manual is to designate a specific time for the pharmacy to be cleaned. For example, if the pharmacy is the busiest between 4 and 6 pm, it would be best to set up a cleaning procedure that avoids that time frame. Customize the manual to an individual pharmacy in order to resolve the unique challenges faced in the practice.
Policies and procedures are also helpful with regard to third party contracts, particularly those that require the existence, implementation, and maintenance of policies and procedures. For example, pharmacies that accept Medicare PDP (?) plans must have policies in place for fraud and program abuse. Iowa Medicaid suggested in a "Dear Pharmacist" alert that pharmacies review their policies and procedures relative to the collection of co-pays when patients claim that they do not have funds for the co-pay.
Another important area to address in a manual is the personnel policies incorporated into a pharmacy. There are many different policies that can be included in this section. The required attire and grooming tips fit in well here. Use this section to account for policies regarding health and infection. Including these topics in a pharmacy’s policy and procedure manual ensures that everyone understands expectations in all areas.
Continuous Quality Improvement (CQI) is the newest arena requiring documentation and training for pharmacists and staff. Many state boards of pharmacy are requiring reportable events to be identified and documented. Policies and procedures can also be developed for analyzing the data collected to assess causes and contributing factors so that findings can be used to improve outcomes.
An example of a set of policies and procedures that could be included in Continuous Quality Improvement to address the potential for dispensing errors of look-alike or sound-alike drugs may look like this:
Policy: “To reduce the chance of a dispensing error with look-alike/sound- alike drugs, we will include the use or indication within the directions on the prescription container label.”
Procedure: “With new prescriptions, the technician shall ask patient why the doctor ordered this drug, and write the patient’s answer on the script for the pharmacist to review. If the patient does not know why he or she has been prescribed the drug, call the pharmacist to visit with the patient to ascertain use.”
Why Update the Manual?
After writing a policies and procedures manual, it is important to keep it updated. The laws involving pharmacy change and many processes in a practice will change over the course of time as new services are added, personnel changes, and new products are released. New third party program mandates will emerge requiring new or updated policies and procedures. Also, updated procedures will protect a pharmacy against liability issues and quality concerns.
Implementing a pharmacy policies and procedures manual can seem overwhelming, but when it is completed, will be an invaluable asset to a pharmacy. For assistance with the creation and organization of a manual, what to include, and valuable resources for getting started, download the policies and procedures toolkit.
If you have some ideas and input that might be helpful to others, log your thoughts onto our pharmacy management discussion board at