VISION:

The vision of the Department of Pharmacy is to be a valued member of the Aljazeerah Hospital patient care team; to make a unique contribution to high quality, cost-effective patient care, and to have a local reputation and leadership role resulting from the outstanding quality of our services.

MISSION:

The Department of Pharmacy is a medical care department whose mission is to ensure the provision of safe and optimal drug therapy outcomes in patients and to educate patients, healthcare practitioners and students about optimal drug therapy.

VALUES:

1. Provide a competent care to the patient.
2. Protect the patient's right of confidentiality and maintain patient’s personal privacy.
3. Pharmacists must honor the teamwork; accept responsibility to work with colleagues, health care professionals, and others, to promote safe and effective pharmacy care.
4. The pharmacist must commit to lifelong learning designed to maintain relevant knowledge and skills.

I. Scope of Services

Types of Customers Served:

1. External Customer : who receive the hospital services but is not an employee or part of the hospital. For example : patients, families, sub contractor and vendors,.

2. Internal Customer : is an employee within the hospital who receive services produced elsewhere in the hospital as inputs to their work.

Types of Patients Served:

The Department of Pharmacy provides medication therapy patient care services for patients of all age groups and levels of acuity within Aljazeera Hospital. All services are conducted in accordance with accepted ethical and professional standards of practice and meet all legal requirements.

Major Conditions/Most Frequent Diagnoses Treated:

Pharmacists provide patient care services to all patients requiring medication therapy, regardless of diagnosis or acuity.

Typical Services, Treatments, Procedures, and Activities Performed:

As part of daily activities, pharmacists routinely assess pertinent patient information, such as demographic data, vital signs, laboratory values, medication regimens and medication compliance. Pharmacists collaborate with all members of the healthcare team, patients, and their caregivers to provide value-based, patient-centered care. Pharmacy technicians, and pharmacy students assist in the delivery of pharmaceutical care under the direct supervision of a pharmacist.

Established policies, procedures, protocols, therapeutic guidelines, and standards of pharmacy practice are followed as part of the pharmaceutical care services process.

Pharmacist patient care services are provided to all patients in Aljazeera Hospital who receive medications. Pharmacists provide collaborative and interdisciplinary care in a cost-effective, evidence- based manner to improve patient outcomes. Standards of practice established by the Saudi Food and Drug Authority and the Saudi Central Board for Accreditation of Healthcare Institutes as a guide for establishing pharmacy services. The processes by which these services are provided are as follows:

1. Upon admission, Pharmacists reconcile inpatient medication orders with the patient’s pre-hospitalization medication regimen to improve accuracy and quality at transitions of care. This medication history is used by the pharmacist and other providers to reconcile medication orders throughout the continuum of care.

2. All new medication orders are reviewed for appropriateness by a pharmacist to determine the presence of medication therapy problems in a patient’s current medication therapy.

3. Pharmaceutical needs of the patient are reassessed on an as-needed basis as the patient's condition changes. Ongoing assessment of the individual patient’s needs through patient interviews, review of the electronic medical record, daily review of medication profiles and laboratory data, and consultation with team members ensures optimum medication therapy is prescribed. In addition, pharmacists coordinate the ordering, timing, and evaluation of serum drug concentrations, adjust doses for altered renal function, convert routes of medication administration, modify therapy to standardized doses as needed, and provide recommendations for pharmacokinetic follow-up for appropriate drugs.

4. Pharmacists direct appropriate medication use and administration through the development and maintenance of guidelines, protocols, and other references for clinical personnel.

5. Pharmacists initiate (prescribe) drug therapy regimens as authorized by protocols, including the ordering of laboratory tests to monitor drug therapy for safety and efficacy. Pharmacists also adjust medication start times to reflect appropriate continuity of care based upon medication history information obtained from the patient or other sources.

6. Recommendations regarding medication use are communicated to the primary provider and documented in the clarification notes.

7. Pharmacists play a key role in the development and implementation of discharge plans of care for patients. Responsibilities include educating patients and/or caregivers, facilitating safe transitions of care and providing medication adherence aids. Pharmacists provide medications to patients and/or caregivers at the time of discharge when appropriate. Pharmacists reconcile discharge medication orders with the patient’s inpatient and pre- hospitalization home medication regimens to assure safe transitions of care and appropriateness of medication use to reduce the risk of readmissions due to inappropriate medication use or follow up.

8. Pharmacists control the drug distribution systems to ensure that the right medication and dose are administered via the right route to the right patient at the right time, and maintain the safety and efficiency of the medication use system.

9. Pharmacists assist in the monitoring, prevention, reporting and coordination of performance improvement activities across the continuum of care. Pharmacists especially provide oversight for adverse drug events, drug interactions, and medication errors.

10. Pharmacists develop, maintain, monitor, and enforce medication use policies, guidelines, and formulary restrictions in order to decrease variability, improve quality, and decrease cost. Patient population assessments are accomplished through medication use evaluation studies and reviewing compliance with established therapeutic and clinical guidelines. These evaluations are used to improve organizational performance through collaborative performance improvement initiatives. All medication-related information distributed within the health system is reviewed by the Pharmacy Department to ensure accuracy of information and consistency with restrictions, guidelines and standards of practice.

11. Pharmacists assist in the development, implementation, and maintenance of decision support software systems aimed at decreasing overall healthcare costs and improving the quality of care provided to patients. These services assist with enforcing standards of care, institutional guideline adherence, and regulatory compliance.

12. Pharmacists provide reliable drug information to physicians, nurses, patients, caregivers, and other members of the health care team to promote the safe, effective, efficient, and patient-centered use of medication therapy.

13. Pharmacists help to educate future caregivers by precepting pharmacy students and pharmacy residents, and are involved with continuing education through the provision of in-services for pharmacists and other healthcare professionals.

14. Pharmacists serve on department- and organization-wide committees to promote patient-centered, value-based care.

15. Pharmacists manage all medication-related information and system functionality within the hospital’s electronic medical record.

16. Pharmacy staff members coordinate the storage, preparation and distribution of all medications, including sterile products, and ensure full compliance with national standards of practice.

17. Pharmacy staff members collaborate with physicians to to monitor medication shortages and determine appropriate alternative therapies. Combined management of the electronic medical record allows rapid dissemination of drug shortage management strategies to providers and allied health professionals across the health system.

18. The pharmacy department periodically conducts patient and internal customer satisfaction surveys to determine customer expectations and to identify performance improvement initiatives. The results of those surveys are used to improve pharmacy services by aligning services with patient needs and expectations.

19. The director of pharmacy is responsible for strategic planning, oversight of operations, financial management, and personnel management.

Sites Where Services are Provided:

Emergency Department

Patient Care areas.

Primary care and specialty clinics Department

Inpatient Pharmacy

Outpatient Pharmacy

Narcotic Pharmacy

Hours of Operations:

Inpatient Areas: 24 hours a day, 7 days a week, 365 days a year

Outpatient Pharmacy: 24 hours a day, 7 days a week, 365 days a year

Narcotic Pharmacy: Hours vary according to clinic and patient needs.

II. Staff Requirements

Type of practitioners/staffing providing care:

Pharmacists:

- should has a bachelor degree in pharmacy from an accredited University.

- Accredited by the Saudi Commission for Health Specialties classification and registration.

- Licensed by the Saudi MOH

- certified in basic life support

Pharmacy Technicians:

- Certified with Diploma in pharmacy from an accredited Institute.

- Accredited by the Saudi Commission for Health Specialties classification and registration.

Method used to determine appropriate staffing levels:

The statistics and workload data for inpatient, retail, and diversified services are analyzed monthly and quarterly. Statistics such as total medication orders and doses prepared are compiled. These numbers are then multiplied by internally-established time standards for these tasks to obtain total workload in minutes. This information is compared to data during the same time periods from previous years, and analyzed in terms of the current year’s allocated budget.

Managers analyze information from these data to determine trends and make both short- and long-term staffing adjustments. These trends are followed for several months in order to identify the need for permanent adjustments. If increased workload indicates the need for increased staff, these data are used to help justify a new position to administration. If data show a decrease in workload volume, adjustments including a decrease in staff positions are made. If increased/decreased workload indicates staffing adjustments for limited periods of time (day to day), stepwise methods are used in the interim to accommodate those needs.

Identify the current number and mix of staff:

Current Staffing Plan and Pharmacy Workload Statistics available upon request.

III. Maintaining staff Competence

Pharmacists and pharmacy technicians are required to have annual performance appraisals and routine competency assessments. The assessment could be in a written, demonstrated, observed or verbal form. The required competency for pharmacists and pharmacy technicians depends primarily on their work areas. These include, but are not limited to, the following:

- Examples of annual and/or new employees assessments

- Pharmaceutical care for patients

- Patient counseling

- E-Mail

- Food/Drug interaction

- Pharmacokinetics and laboratory assessment

- Medication order entry

- Aseptic technique (inpatient pharmacy)

- Drug interactions

- Error prone abbreviations

- Medication occurrence reporting

- Medication ordering system and safe order writing practices

- Medication management policies

During the academic year, pharmacist and Technicians in-services are conducted monthly. The inservices are part of the department’s on-going efforts to educate staff and further enhance performance and improve staff competencies. These in-services are in addition to the annual competency assessments. The educational needs of the department are assessed through a variety of means, including:

- Mission Statement

- Quality Assessment and Improvement Initiatives

- Strategic Planning (Goals & Objectives)

- Medication Safety Plan

- Management of Information

- Changes in Practice

- Regulatory Compliance

Feedback and requests for future topics are regularly solicited from pharmacy staff via e-mail, surveys, inservice evaluation forms, and in person.

Department personnel who attend educational conferences are strongly encouraged to share pertinent information from the conferences with other staff members at inservices. Other internal and external continuing education opportunities are communicated to staff members.

A travel budget for educational meetings and conferences allows staff to pursue areas of interest, keep up with new/current pharmacy trends and network with other professionals.

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