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  this section in pharmacorner illustrates the application of quality management concept in pharmacy. 
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Home > Hospital Pharmacy > Quality & Performance Improvement  > Pharmacy Quality Improvement Program

Prepared by:  Abier Hamami. RPH. CPHQ








Quality Improvement QI is defined as an ongoing study of processes in a system, to improve performance and get best outcomes. Therefore, one can say, a Pharmacy QI program is designed to monitor, evaluate and continually improve the care and services delivered to patients, across the full spectrum of pharmacy services. It is revolved around the departmental mission, and should be integrated with the hospital QI program in regards to goals/objectives setting, information flow, and Communication.


Usually the pharmacy QI Program is developed cooperatively, and considers inputs from various supervisors or managers and front line staff. It is documented in a form of plan or a policy and procedure, and should be regularly evaluated, at least annually, and updated for new objectives and quality/performance QI/PI improvement activities.


Scope and Components:

The scope of the program is comprehensive in nature and many of the pharmacy activities fall under its framework such as, preparing intravenous medications, patient counseling, profiling physicians’ orders, compounding, and dispensing medications, inventory auditing, monitoring medication effects, and intervening physicians orders.


Also, it encompasses services rendered in ambulatory, and inpatient settings and is designed to resolve identified areas of concern on an individual, and system wide basis.


Components of the QI Program include, but are not limited to, the following:




Goals and Objectives:


A goal is usually defines as A desired future state that the organization attempts to realize. As an example, the goal of a pharmacy QI Program could be:


To ensure the delivery of high quality, safe, appropriate, efficient, timely, and cost-effective pharmaceutical care.


An objective is defined as a measurable step taken to achieve certain goal. Examples of pharmacy QI Program objectives are:


§         Meet external pharmacy regulatory and accreditation requirements.

§         Enhance medication safety practices through establishment of proper medication errors and adverse drug reactions reporting systems, and regular evaluation of the medication use system.

§         Adopt international patient safety goals related to medication-use and develop strategies to achieve them.

§         Identify opportunities for improvement through monitoring and evaluation of pharmacy activities and identified root causes of medication errors.

§         Promote and enhance multidisciplinary quality improvement activities.

§         Continue to address improvements in patient and staff satisfaction scores.

§         Establish quality indicators to measure pharmacy performance in both clinical and non-clinical services.

§         Promote education and training of quality/performance QI/PI improvement models and tools.  


Roles and Responsibilities:

The pharmacy director has the ultimate authority, accountability and governance for the QI Program. A quality Coordinator usually manages, and coordinates all pharmacy quality improvement activities, and develops a documented plan for the QI program implementation. He also, participates in interdepartmental activities related to quality, safety and regulatory compliance.


It is essential to have a QI/PI team or committee charged to direct, and oversee the implementation of the program, prioritize the selection of QI/PI activities, review regular reports, and provide recommendations or take action to improve. In small pharmacy departments, the same administrative team could have an agenda item for quality improvement in their regular meetings; in other bigger departments a special QI Committee or team is assigned. In both cases, all members should be well educated about quality management.


There are other roles and responsibilities at the level of QI/PI activity or project team, which are:

Team Leader:

          Provides direction and support.

          Not responsible for decision making.

          Not responsible for teams success or failure.

          Prepares and conducts meetings.

          Assigns activities and assesses progress.

          Communicates with other teams and with the management.


Team Facilitator:

          Serves as a coach.

          Focuses on the team purpose.

          Aids in applying QI/PI tools.

          Summarizes and provides feedback.


Team Member:

          Attends and participates in all meeting activities.

          Shares knowledge and experience.

          Collects and analyzes data.

          Identifies problems and recommends solutions.


Team Recorder

          Either rotating or fixed position.

          Documents minutes of meetings.



The QI/PI Plan Format

A written Quality/ Performance Improvement (QI/PI) plan in alignment with the hospital QI/PI plan, and pharmacy mission is developed to describe and outline the structure, processes, and responsibilities to implement the quality improvement program. It gives direction and unifies methodology used for the QI activities in all pharmacy areas or sections.

The plan outline includes:

1.       Introduction to define the following:

  • Purpose of the plan.
  • Pharmacy Mission, vision, values, and definition of quality.
  • Quality goals and objectives.


2.       Overview and planning to identify and define the following:

§         Pharmacy customers ( external and internal ).

§         Pharmacy functions (clinical and non-clinical)

§         Dimensions of performance.

§         Criteria for performance improvement activities prioritization


3.       Structure and Design

§         Quality organization structure and flow of information

§         Roles and responsibilities of pharmacy director, quality coordinator, QI committee , Supervisors, assigned QI projects teams, and more; according to the size of the pharmacy department.


4.       Description of the quality/ performance improvement model/s used.


5.       List of the performance measures/indicators and specific quality controls.


6.       List of the QI/PI activities and projects.


7.       Documentation and reporting methods.


8.       Evaluation mechanism and timeline.


9.       Appendices and Documentation Forms.


10.   Approvals.





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