How to Make a Policy and Procedure Manual for a Pharmacy

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When looking to update policies and procedures for a pharmacy, there are many factors that should be taken into consideration. First and foremost, it is essential to ensure that all of your pharmacy’s legal obligations are outlined in a clear and accessible manner. You must also be certain that employee rules and conduct expectations are clearly stated while also avoiding any sort of unconscious bias. You will also need to discuss equipment and its use, filling procedures, closing procedures and security considerations.

Pharmacy Procedures Manual Preparation

Medication storage policy and procedure and pharmacy security policy and procedure creation might seem daunting to someone who is working on a manual for the first time. Fortunately, the process is fairly straightforward. To keep things simple, it is best to proceed one section at a time.

Pharmacy Manual Safety Section

One of the most important parts of your operating manual should deal with safety procedures. If your organization has any safety officers, this is an excellent time to utilize them and their institutional knowledge.

Many medical networks, hospitals and pharmacies have safety officers who are tasked with keeping up with legal policies and procedures, chemical policies and procedures and anything else that could cause harm to an individual or to the pharmacy. If you do not have a safety officer at your location, check with your parent company and see if they have someone who fills that role.

In the event that you do not have access to a safety officer, you will have to do some research on your own. Federal pharmaceutical regulations depend on the schedule of drugs to which your pharmacy has access. If you cannot dispense schedule one drugs, for example, then you will not have to discuss those regulations.

Privacy Concerns for Pharmacies

Your policy manual should contain information about dealing with patient and customer confidentiality. For instance, you will need to discuss how employees deal with HIPAA-protected information. All medical personnel and pharmacy staff members have to understand and respect HIPAA laws and regulations.

HIPAA is the acronym for the Health Insurance Portability and Accountability Act of 1996. It is the United States legislation that ensures data privacy and offers security provisions for safeguarding medical information. In today’s world of cyberattacks and hacking, it is even more important to follow proper procedures.

For the protection of your company’s reputation and the privacy of your customers, it is essential that everyone on staff, even janitorial employees, has read, understands and can obey HIPAA regulations and procedures. If a patient’s personally identifying information is not protected, you open up yourself and your individual employees to legal action and fines.

Sharps Policy Requirements

Does your location deal with sharps? In medical terminology, the word “sharps” is a category that includes anything that can stick into the skin. Syringes and glucose pricks are both examples of sharps.

If your location deals with sharps, you will have to write out a specific policy on what happens to your sharps after they are used. You will need to have a safe, well-labeled and secure place to store your sharps and have a company come to get them for disposal. Under absolutely no circumstances should you throw them into the trash.

Chemical-Handling Policy

These policies dictate the way that chemicals are to be stored, labeled and used. If your location deals with any hazardous materials, then you will need to outline what your company policy is on handling them. For example, you should store acid or other dangerous products low to the ground. This reduces the chance of their spilling onto a person and causing harm or even death.

Bloodborne Pathogen Policies

In a hospital setting, even people who do not deal with patients are required to have bloodborne pathogens training. Bloodborne pathogens is an umbrella term that includes infectious microorganisms that are found in human blood and can spread or cause disease in humans. Bloodborne pathogens cannot be found in animal blood. Pathogens that are considered a risk to humans include hepatitis B and C, human immunodeficiency virus and syphilis.

Whenever a health care professional has a sharps-related injury, he may have been exposed to bloodborne pathogens. This means that your manual needs to have specific regulations and instructions with which your employees will need to comply, including tests they will need to take and whether they are expected to report to work in the interim.

Employee Immunization Policy

Outside of the legal requirements for immunization, you can also insist that your employees follow specific guidelines depending on the types of customers or drugs with which they will be dealing. When you explain the policy in your manual, stress that it is in place for the safety of patients and staff alike.

Sick and Personal Time Policy

You will need to prepare a sick and personal time policy that both supports the well-being of your employees and protects the interests of your pharmacy. Many health care facilities frown on employees coming to work while they are sick, and this is for good reasons.

Hospitals generally forbid their employees from coming to work with a fever and require employees to have an average temperature for 24 hours before they return to work. While a pharmacy is not a hospital, you will still deal with ill patients who will be exposed to your staff while they get their prescriptions filled.

A generous sick policy can go a long way toward keeping your employees happy. While many businesses require employees to provide proof that they were ill, in the U.S., this could be prohibitively expensive for some of your employees. It also demotes your employees to feeling like they are guilty until proven innocent. Instead, keep track of when employees are out sick and deal with anyone who is frequently ill in private.

Legality of Requesting Health Information

It is illegal to ask for specifics about an employee’s health, so do not ask for those details. Instead, focus on the performance issues that absences have caused. If there are no performance issues, then there is little reason to speak with an employee. The bottom line with a sick policy is that you should treat your employees like adults whom you can trust.

Employee Interaction Policies

You owe your employees a safe place to do their jobs, and they owe you the ability to do their jobs with a measure of politeness and courtesy. They do not have to get along with everyone on the staff. However, they do have to work with them, and politeness is required for that job.

Do not allow an attitude to get in the way of someone doing her job properly. Very often, managers see soft skills as a “take it or leave it” sort of issue. This can be harmful to your employee morale, procedures and other critical daily tasks. In your policy, you should be firm about how interpersonal interactions should operate and indicate that you will treat violations as a performance issue.

You should also include an unambiguous policy for harassment. Be aware that there can be legal requirements for you to uphold at a minimum, so do some research to ensure that you do not omit anything important. It goes without saying that a company can fire someone for harassment or for creating what is called an “unsafe work environment.”

Employee Dress Code

More and more often, dress codes are being phased out. However, your pharmacists should be able to represent your pharmacy professionally in their customer-facing roles. This could mean, for instance, that they must wear a dress shirt along with their white coats. They should also always have their name displayed for the benefit of both the customer and your company’s liability.

Dress codes do not need to be complicated, but you should be aware while you are writing it that you must treat all employees the same. This means that there should not be a “for women” and “for men” section. If you have ever seen a dress code, you may have noticed that if it does single out employees by binary gender, the women’s dress code is far longer and more restrictive than the “for men” section. Instead, make blanket statements such as “only wear closed-toed shoes while working.”

Security Policy and Procedures

Your security needs should be based on what sort of pharmacy you run, your area of operation and general safety concerns. Pharmacies are in a unique position because they have to worry about both medical security and the same security requirements that any retail store would have. Your primary concern when drafting your security procedures should be your employees. Outline robbery procedures to stress the importance of your employees’ safety.

The most complex security procedures will likely surround controlled substances. These substances must be securely stored in a locked drawer or cabinet. That drawer or cabinet must be of substantial construction.”

That means that wherever they are stored needs to be a place from which it is difficult to steal and get into without a code or key. While laws do not specify details for locking the cabinet or for the construction of the cabinet, the intent of the law is to ensure that any controlled substance is adequately safeguarded.

Controlling Access to Drugs

You should also account for the number of people who have access to the controlled substances. Depending on how many employees work at your location, you may need to require that controlled substances only be accessible by certain ranks of employees. Other considerations to include in your security policy include:

  • What is criminal activity like in your location? Are you in a high or low crime area?

  • What alarm system do you use? Is it considered adequate based on what you know of your area?

  • What is the quantity and type of controlled substances you will have in your location?

  • What is the history of your area? This information should include whether you have ever had a theft or robbery, what happened during the crime and any relevant details that would pose a security threat.

While these issues are certainly not everything that you will have to include in your procedure manual, they are an excellent base. Legal requirements could require you to have far more information in a procedure manual, so be sure you are familiar with regulations in your area. By keeping employees and customers top of mind during the preparation of your manual, you are likely to stay on the right track.

References

About the Author

Danielle Smyth is a writer and content marketer from upstate New York. She has been writing on business-related topics for nearly 10 years. She owns her own content marketing agency, Wordsmyth Creative Content Marketing (www.wordsmythcontent.com) and she works with a number of small businesses to develop B2B content for their websites, social media accounts, and marketing materials. In addition to this content, she has written business-related articles for sites like Sweet Frivolity, Alliance Worldwide Investigative Group, Bloom Co and Spent.