In this article Aileen O’Hare, one of our specialist inspectors, shares examples of good clinical governance in an online pharmacy setting, which have been identified through our inspection work.
Good clinical governance in community pharmacy
The infographic above shows key examples of good clinical governance.
The examples below cover a wide range of good practice identified in one online pharmacy, in relation to risk management, governance meetings, medication safety, staff training, information governance, patient monitoring, evidence-based medicine, clinical audit, patient, and public feedback and finally engagement with the wider healthcare team.
Risk management
In line with our Standards for registered pharmacies and Guidance for registered pharmacies providing pharmacy services at a distance, including on the internet [PDF 153KB]the community pharmacy team had identified a number of risks associated with managing and providing an online service. The focus of the pharmacy service was the provision of contraception (OC) and emergency hormonal contraception (EHC). The service was led by a pharmacist independent prescriber (PIP) and had clinical oversight by a medical director.
The pharmacy team identified several risks which included:
- Ensuring PIPs had a thorough clinical knowledge of the patient’s medical history and the risks of consent refusal.
- Balancing their prescribing decisions and prescribing framework against evidence-based guidance from the Faculty of Reproductive & Sexual Health (FRSH) of the Royal College of the Obstetricians and Gynaecologists.
- Fulfilment in providing nationwide deliveries for EHC and the risks relating to missed or failed deliveries for such time sensitive medications.
Team and governance meetings
The management team conducted daily meetings with the pharmacy staff to manage workflow, service delivery and the internal pharmacy processes. Governance meetings were held monthly and were attended by the superintendent (SI), medical director and prescribers. An action log was maintained by the pharmacy team of agenda items to be tabled at monthly meetings. Minutes were recorded by team members to ensure there was evidence of decision making. Those minutes were circulated to all staff to improve communication. Clinical meetings were used to provide feedback from team members and to discuss concerns from patients and the public.
The service had instigated an internal medicines advisory board which met every six months. A consultant advisor had been employed to sit on the board. Outputs from the board were reviewed by the company managing director. Alterations were made to the company website following any new recommendations and the patient consultation questionnaires were reviewed every 3 to 6 months.
Medication safety
The safety and quality of the service were regularly reviewed at governance meetings. Complaints and concerns were reviewed and discussed. One specific incident involved the delayed delivery of an EHC medication. Staff contacted the patient, provided counselling, and signposted the patient to a local EHC service using the NHS service finder. The outcome of this incident necessitated a review of the delivery process and the service level agreement with the courier.
The team conducted monthly meetings with prescribers who recorded their own prescribing incident logs. The team reviewed the audit reports to identify any key trends and training requirements.
Staff training and engagement
The management team ensured their staff were appropriately trained to provide an online pharmacy service and staff were encouraged to advance their roles and knowledge base. The company had an open-door policy to raise feedback and any personal ideas to enhance the company service provision. The prescribers were expected to complete one continuing professional development record appropriate to their role by attending a FRSH training session. The management team developed new processes to reduce team workload. For example an internal locum handbook was developed and shared with all new members of staff.
There had been significant career progression in the pharmacy team. Most members of the team were initially inexperienced in their roles, and a few members of staff had recently completed the pharmacy technician training qualification. Monthly 1-2-1’s and annual staff appraisals were conducted with team members to review performance in line with their objectives.
The pharmacy had safeguarding policies for vulnerable adults which referred the EHC and OC prescribers to the 2019 online guidance produced by the FSRH.
Information governance
The staff used industry standards for the website design which ensured the transfer of patient data between browser and servers was secure. Approved workstations had been enabled to log onto the back end of the server. Various staff roles were linked to permissions which would enable access to certain levels of patient information relevant to their positions.
Patient monitoring
Patient monitoring was a key component of the online service, but staff did stress that it was reliant upon the patient to input correct/reliable information. The OC service mandated an annual blood pressure (BP) check for all oestrogen containing pills. Ad hoc monitoring of repeat EHC orders was conducted to identify vulnerable adults who may require safeguarding. To improve the quality of the online consultation the pharmacy team were implementing video calls as part of their prescribing service.
Evidence based medicine
The team stressed that it was vital that they had a sound evidence base to support the delivery of their service. They adopted the latest FSRH guidance and kept up to date with training and clinical developments.
Clinical audit
The team conducted internal clinical audits to review the number of patients who regularly provided consent to contact their general practitioner, patients with a history of migraine and the treatment of patients over 40 years of age. The team populated a rejections report which provided a breakdown of the number and types of rejections that the prescribers had made during consultations. The audits identified consultations forms requiring additional information or process improvement.
Monthly meetings were conducted with prescribers who maintained their own incident logs. During the meetings the pharmacy team discussed the outcomes of the internal audit reports to seek further clarification from the prescribers on any specific process changes or training needs.
Patient and public feedback
The company used a WhatsApp integration service to aid communication with patients. The service enables WhatsApp messages to be sent directly from their IT backend to patients’ mobile phones. The team found that direct messaging led to a better response rate from their patient group.
Staff stressed that most of the feedback and complaints were delivery related issues linked to third party postal services and couriers. The pharmacy team routinely meet with account managers from the postal and courier services to highlight and address any ongoing delivery complaints or concerns from patients.
Visit our Knowledge Hub for more examples of notable practice
Our Knowledge Hub also has further examples of good practice in online pharmacies seen during inspections. We encourage people working across pharmacy to use these examples, to learn from them, and to continuously improve outcomes for people using online pharmacy services. The examples only take a few minutes to read and cover areas including managing risk, remote prescribing, communication and supporting vulnerable people in decision making.