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Policies,Administrative,UWHC,Department Specific,Pharmacy,Administration

Management of Pharmacy Department Policies (1.22)

Management of Pharmacy Department Policies (1.22) - Policies, Administrative, UWHC, Department Specific, Pharmacy, Administration

1.22

POLICY & PROCEDURE





Effective Date:

October 2001

Chapter: Administration

Chapter:

Policy #: 1.22


Revision 08/16

Page 1
of 3

Title: Management of Pharmacy Department
Policies


I. PURPOSE: This policy and procedure coordinates the development, revision, approval
and distribution of all policies and procedures maintained by the Department of Pharmacy.
To maintain compliance with regulatory standards, this policy ensures all policies will be
reviewed and revised at least once every three years. Only those policies initiated by the
Department of Pharmacy fall under the scope of these procedures.

II. POLICY: The pharmacy department will maintain up to date policies and procedures
which comply with state and federal laws, evidence-based practice standards and other
accrediting body regulations and standards. These policies will be followed when
developing, revising, approving and distributing documents to be included in the Pharmacy
Policy Manual.

III. DEFINITIONS
A. Policy statements will set a broad framework for compliance with and
implementation of processes that support the Department of Pharmacy Mission,
promote efficient operations, and ensure compliance with laws and regulations.
Specific processes used to achieve compliance and implementation should be cross-
referenced to an appropriate Operating Procedure.
B. Operating Procedures provide step by step instructions to perform specific tasks and
ensure consistency in operating practices.
III. PROCEDURE
A. Procedures for New Policies
1. Any department of pharmacy staff may submit topics for consideration to the
manager for regulatory compliance. .
2. Proposed topics for inclusion in the Department of Pharmacy Policy and
Procedure manual will be submitted in draft form to the appropriate
committee(s) or leadership team utilizing the templates and content guidelines
located within this policy.
a. All new policies will be reviewed for content and format by the and
the manager for regulatory compliance and approved by the Director
of Pharmacy prior to implementation.
3. Once approved, the committee chair will forward to designated office staff
that will ensure both electronic and hard copies of the manual will be updated
after policies and procedures are reviewed and approved.

POLICY & PROCEDURE





Effective Date:

October 2001

Chapter: Administration

Chapter:

Policy #: 1.22


Revision 08/16

Page 2
of 3

Title: Management of Pharmacy Department
Policies

4. The manager of regulatory compliance will ensure communication to all staff
regarding new policies.
B. Procedures for Review of Existing Policies
1. The manager for regulatory compliance will ensure timely review and revision
of all content included in the Policy Manual.
a. All policies will be reviewed for content and format at least once
every three years.
b. A 3 year policy review schedule will be provided to all members of
the management team. .
2. Members of the pharmacy department will be assigned areas of responsibility
based on their areas of professional expertise and responsibilities to ensure the
following:
a. That all assigned policies will be reviewed and revised at least once
every three years.
b. That any policies that may be affected by changes in current
knowledge, technology, laws or regulations or other factors are
revised.
c. Any policy revised by non-managerial staff must be reviewed by that
individual’s manager before they are presented to the manager of
regulatory compliance for approval.
3. If the reviewer determines changes to the policy should be made, an updated
document with tracked changes should be sent to the appropriate committee
chair so it can be scheduled for review and approval by the appropriate
committee.
4. If the reviewer determines no changes are necessary, the current document
should be sent to the appropriate committee chair and committee so the
effective date can be renewed.
C. Content and Format for Policies
1. All policies and procedures will follow the format outlined in Appendix A


POLICY & PROCEDURE





Effective Date:

October 2001

Chapter: Administration

Chapter:

Policy #: 1.22


Revision 08/16

Page 3
of 3

Title: Management of Pharmacy Department
Policies


IV. Forms
A. Appendix A: Policy and Operations Procedure Manual Template
V. References and Related Policies, Procedures
A. Administrative Policy 1.10 “Development and Revision of the Administrative Policy
and Procedure Manual”
VI. Coordination
A. Authored by: Michelle Thoma, PharmD
B. Committee Approval: Pharmacy Performance Improvement and Regulatory
Compliance (PPIRC) committee and Operations Committees




Approved By:___________________________
Director of Pharmacy Services

Date:_________________