1. Regulatory and Compliance
Accreditation Policy Review Updates
Time-critical scheduled medications - Time-critical scheduled medications are those for which an early or late administration of greater than thirty minutes might cause harm or have significant, negative impact on the intended therapeutic or pharmacological effect.
Accordingly, scheduled medications identified under the hospital’s policies and procedures as time-critical must be administered within thirty minutes before or after their scheduled dosing time, for a total window of 1 hour.
Medication security – This area remains one of the most frequently cited areas by TJC and hospitals need to have a policy that states who is authorized to have access to medication areas and the training that they have received. Emphasis on documentation especially housekeeping.
Minimum requirements for standing orders. (§482.24(c)(3)) - Standing orders containing medications need to reviewed by an interdisciplinary team including a pharmacist and nurse. Cannot just load existing orders without a review.

2. Regulatory and Compliance
Accreditation Policy Review Updates
Time-critical scheduled medications - Time-critical scheduled medications are those for which an early or late administration of greater than thirty minutes might cause harm or have significant, negative impact on the intended therapeutic or pharmacological effect.
Accordingly, scheduled medications identified under the hospital’s policies and procedures as time-critical must be administered within thirty minutes before or after their scheduled dosing time, for a total window of 1 hour.
Medication security – This area remains one of the most frequently cited areas by TJC and hospitals need to have a policy that states who is authorized to have access to medication areas and the training that they have received. Emphasis on documentation especially housekeeping.
Minimum requirements for standing orders. (§482.24(c)(3)) - Standing orders containing medications need to reviewed by an interdisciplinary team including a pharmacist and nurse. Cannot just load existing orders without a review.

3. Accreditation Policy Review
One-hour window: Time-critical meds administered within 30 minutes before or after
Medication security: Who is authorized to access medication areas
Minimum requirements for standing orders: Need to reviewed by pharmacist and nurse

4. Accreditation Policy Review
One-hour window Time-critical meds administered within 30 minutes before or after Medication security Who is authorized to access medication areas Minimum requirements Standing orders reviewed by pharmacist and nurse

5. Accreditation Policy Review
One-hour window: Time-critical meds administered within 30 minutes before or after
Medication security: Who is authorized to access medication areas
Minimum requirements for standing orders: Need to reviewed by pharmacist and nurse

6. Accreditation Policy Review
One-hour window Time-critical meds administered within 30 minutes before or after Medication security Who is authorized to access medication areas Minimum requirements for standing orders Need to reviewed by pharmacist and nurse

7. Accreditation Policy Review
One-hour window Time-critical meds administered within 30 minutes before or after Medication security Who is authorized to access medication areas Minimum requirements Standing orders reviewed by pharmacist and nurse

8. Budgeting Considerations
Sterile Compounding Regulations
Prompted by Compounding Ctr incidents
Federal Requirements
USP Chapter 800 (currently in comment period)
Hazardous medications will need to be compounded in separate area.
Will require use of Closed System Drug-Transfer Devices (CSTDs) from compounding to administration.
State Requirements
New pharmacy class license for pharmacies preparing sterile products
All pharmacists and technicians must be nationally certified to prepare sterile products.
Staff that are not nationally certified will need to register for and complete training.
40 hours of IV prep training for technicians
20 hours of IV prep training for pharmacists
Average expense per staff member is $600
Dead line to complete certification is 2015
Closed System Drug Transfer Devices

9. Budgeting Considerations
Sterile Compounding Regulations
Federal Requirements
Hazardous medications compounded in separate area
Use of Closed System Drug-Transfer Devices (CSTDs)
State Requirements
License and certification for sterile products
Staff needs to take and complete training
40 hours of IV prep training for technicians
20 hours of IV prep training for pharmacists
Average expense: $600/person

10. Budgeting Considerations
Sterile Compounding Regulations
Federal Requirements
Hazardous medications compounded in separate area
Use of Closed System Drug-Transfer Devices (CSTDs)
State Requirements
License and certification for sterile products
Staff needs to take and complete training
40 hours of IV prep training for technicians
20 hours of IV prep training for pharmacists
Average expense: $600/person

11. Additional projects Ongoing Upcoming CAH Integration Bellville cutover
RIE initiatives
Improve Nurse satisfaction scores
Outpatient retail pharmacy go-live
Maintain Regulatory compliance
Monitoring for Drug diversion/Assess weaknesses
Upcoming
Clinical manager review of formulary for additional drug cost savings
Optimize clinical rounding
HCAHPS initiatives

12. Additional projects Ongoing CAH Integration Bellville cutover
RIE initiatives
Improve Nurse satisfaction scores
Outpatient retail pharmacy go-live
Maintain Regulatory compliance
Monitoring for Drug diversion/Assess weaknesses
Upcoming
Clinical review for additional drug cost savings
Optimize clinical rounding
HCAHPS initiatives

13. Additional projects Ongoing CAH Integration Bellville cutover
RIE initiatives
Improve satisfaction scores
Retail pharmacy go-live
Maintain regulatory compliance
Monitoring for weaknesses
Upcoming
Clinical review for additional drug cost savings
Optimize clinical rounding
HCAHPS initiatives

14. Financial Cost Containment Proactive Approach to Drug Shortage
Our clinical programs and protocols, cost-containment strategies, volume-discount drug purchasing and inventory management programs help drive down pharmacy costs
Proactive Approach to Drug Shortage
CompleteRx monitors the marketplace to minimize the cost impact of drug shortages on our facilities. With our buying programs and ongoing communication, we determine where a shortage is expected, swap drugs between our facilities, and save the dollars our clients would have spent buying secondary-market drugs.

15. Financial Cost Containment
Our clinical programs and protocols, cost-containment strategies, volume-discount drug purchasing and inventory management programs help drive down pharmacy costs.
Proactive Approach to Drug Shortage
CompleteRx monitors the marketplace to minimize the cost impact of drug shortages on our facilities. With our buying programs and ongoing communication, we determine where a shortage is expected, swap drugs between our facilities, and save the dollars our clients would have spent buying secondary-market drugs.

16. Financial
Cost Containment Our clinical programs and protocols, cost-containment strategies, volume-discount drug purchasing and inventory management programs help drive down pharmacy costs. Proactive Approach to Drug Shortage CompleteRx monitors the marketplace to minimize the cost impact of drug shortages on our facilities. With our buying programs and ongoing communication, we determine where a shortage is expected, swap drugs between our facilities, and save the dollars our clients would have spent buying secondary-market drugs.

17. Why CompleteRx? Specialize in Hospitals Like Yours
We only work with acute care, inpatient hospital pharmacies
Not with psych, rehab, or critical access facilities
Our services are customized for this type of hospital
Smaller company, more personalized service

18. Why CompleteRx? Specialize in Hospitals Like Yours
We only work with acute care, inpatient hospital pharmacies
Not with psych, rehab, or critical access facilities
Our services are customized for this type of hospital
Smaller company, more personalized service

19. Why CompleteRx?
We specialize in hospitals like yours
We only work with acute care, inpatient hospital pharmacies
Not with psych, rehab, or critical access facilities
Our services are customized for this type of hospital
Smaller company, more personalized service