Clinical governance is the system through which healthcare organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which clinical excellence will flourish.
Community pharmacies are increasingly providing a broader range of clinical services, including those provided by pharmacist prescribers. Current plans to expand the role of registered pharmacy technicians to supply and administer medicines under a patient group direction (PGD) will require future governance and risk management considerations. Having good clinical governance systems and processes in place is key to pharmacies providing safe, effective, and good quality services to patients and the public.
Our standards and guidance support clinical governance in community pharmacies. Principle 1 of the Standards for registered pharmacies outlines the governance arrangements needed to safeguard the health, safety, and wellbeing of patients and the public.
The good clinical governance examples that we identified can be adopted and adapted by pharmacy professionals. This review and its findings are not designed to replace existing standards and guidance but instead sit alongside them, illustrating good practice. We recognise that some pharmacy teams may already have good clinical governance systems and processes in place; others might wish to use our findings to implement or enhance their current processes.
The Royal Pharmaceutical Society (RPS) recently updated their clinical governance pharmacy guide for pharmacy professionals providing NHS and non-NHS services within pharmacies and across organisations.
The clinical fellow and inspectors visited a range of pharmacies around GB that were identified as offering good clinical governance. During the interviews we considered each team’s leadership functions, procedures, policies, practices, and clinical governance models.
Key governance themes
We identified common threads across community pharmacies which we believe are key to driving good clinical governance.
- In pharmacies with good clinical governance, we witnessed an ethos of continuous learning and improvement and those teams placed patients and patient-centred care at the heart of everything they did. Teams described positive leadership cultures such as a 'just culture' or 'no blame culture'.
- We observed that those pharmacy professionals placed governance, risk assessment, clinical audit, training and development, and oversight of prescribing and clinical services on an equal footing to dispensing services.
- Pharmacy teams who adopted automation and digital technologies reported enhanced service capacity, release of workforce, optimal transformation, and improved patient safety. However, pharmacy professionals highlighted a need to align workforce IT training with digital transformation plans to fully realise the benefits of automation and digital technologies.
- Pharmacy professionals were engaging with patients using a wide variety of consultation modes through the harnessing of innovative technology and novel service delivery models. The teams endeavoured to adopt the most appropriate mode of consultation to ensure optimal patient safety and confidentiality, whilst maintaining a person-centred approach to care, particularly for higher risk medications or vulnerable patient groups. Their approach to patient consultations aligned with our guidance on religion, personal values and beliefs.
- We found that the creation of integrated roles, induction handbooks, structured staff training, standard operating procedures, performance development plans, appropriate team skill-mix, and protected learning time optimised workforce recruitment, retention, and good clinical governance.
- Teams suggested that a review of digital health record access rights for private sector pharmacy contractors could benefit patient safety, clinical governance and would enhance integration across healthcare settings. Pharmacy professionals felt that inequity of access to digital health records between the private sector and NHS contractors could potentially impact patient care, integration with other healthcare providers and patient safety.
- Medication safety was a key governance focus for pharmacy teams using a wide range of interventions such as medication safety bulletins, quality improvement schemes, medication safety officers, barcode scanning technology, clinical advisory boards, and medication safety teams.
- As community pharmacy services evolve, the number of pharmacist prescribers and clinically skilled pharmacy technicians will grow. Those pharmacy professionals conveyed a need to access a broader range of medicines information resources to meet the ever-changing clinical evidence and guidance associated with the new service models.
Discussion
From our analysis of the collated data, we have identified some key priorities.
- As stated in Principle 1 of our standards for registered pharmacies, clinical governance arrangements should be defined to include clear definitions of the roles and accountabilities of the people involved in providing and managing pharmacy services. This principle applies to pharmacy professionals engaged in the provision of dispensing, prescribing and clinical services.
- With the advancement of prescribing and service delivery in community pharmacy, pharmacy professionals’ clinical skills, scopes of practice, education, training, and development would be expected to align with the expansion of those services and meet our standards for the education and training of pharmacists and our standards for the education and training of pharmacy technicians.
- As services evolve across GB, it is essential that pharmacy teams have the appropriate skills, knowledge and experience for their role and the tasks they are asked to undertake. Recruitment of sufficiently trained and competent pharmacy professionals will be necessary to meet the changing needs and conflicting demands of dispensing, prescribing and clinical services.
- Interoperability and standardisation of record keeping and clinical documentation across all settings will aid consistency of consultations, communication with the wider healthcare team, and optimal use of digital information. We welcome the publication of the NHS England community pharmacy standards which define the expected digital records for community pharmacy services and the minimum dataset that should be communicated to general practitioners. Further information on the Pharmacy First service in Scotland includes eligibility criteria, approved items, resources and GP practice guidance.
- Digital integration across systems and between healthcare settings was, on occasions, limited by access rights and commissioning contracts. Improved access to the patient’s digital care records, utilisation of patient data and the ability of pharmacy professionals to read and write into the patients’ notes would enhance integrated working aid communication with the wider multidisciplinary healthcare team and enhance patient experience and care.
We identified further examples of good clinical governance illustrated below. By sharing good practice, we want to enable pharmacy professionals to augment and develop their own clinical governance processes.
Examples of good clinical governance in community pharmacy
Risk management
- Completion of risk assessments
- Participation in pharmacy quality improvement schemes
- Medication safety officers and patient safety champions
- Medication safety bulletins
- Compliance monitoring systems for patient safety initiatives, controlled drugs and standard operating procedures (SOPs)
- Innovative barcode scanning technology
- Clinical advisory boards and medication safety teams
- Pharmacist Independent Prescriber (PIP) prescribing reviews
- Intranet webpages
Education and training
- SOPs - local, organisational, and national pharmacy associations
- Automated SOP compliance monitoring systems
- Intranet training hubs
- Online seasonal E-learning
- Communication and training huddles
- Protected learning time
- Automation training and skill mix review
- Health board governance frameworks for PIPs
Information, data, and IT
- Optimal use of patient medication records (PMRs)
- Access to NHSmail and clinical service platforms
- Use of care records to clarify patient information
- Information governance and GDPR training, secure storage of patient data
- Operational service delivery dashboards
- Intranet and messaging applications
- Clinical governance oversight of PIP data
Clinical effectiveness and evidence-based medicine (EBM)
- PIP prescribing policies, guidance, intranet pages
- Standardised patient group directions adoption
- Medicines information reference sources
- Shortage protocols and stock bulletins
- Central pharmacy governance teams
- Specialist resources for contraception, vaccination and other services
Staff management
- Annual appraisals and appraisal portals
- Staff induction handbooks
- Team meetings and huddles; team meeting templates
- Staff forums and suggestion boxes; skill mix review
- Emerging new clinical services, PIPs and enhanced roles
Patient feedback and involvement
- Complaints procedure, feedback, surveys, and mystery shoppers
- Patient support groups
- Patient and staff suggestion boxes
- Applications, messaging, business phone systems
- New vaccination and clinical services initiated due to customer requests
- Inclusive pharmacy practice
Audit and key performance indicators (KPIs)
- Performance reports
- Key performance indicators from business service authorities
- Scorecards
- Audits assessing dispensing, prescribing and clinical services