model standards of practice for canadian pharmacists · model standards of practice for canadian...

ModelStandards

of Practicefor

CanadianPharmacistsApri l 2003

National Association of Pharmacy Regulatory Authorities (NAPRA)

© National Association of Pharmacy Regulatory Authorities, 2003. All rightsreserved. No part of this document may be reproduced in any form by anyphotographic, electronic, mechanical or other means, or used in any informationstorage and retrieval system, without the written permission of the author.

The National Association of Pharmacy Regulatory Authorities (NAPRA)222 Somerset Street West, Suite 402Ottawa, ON K2P 2G3Tel: (613) 569-9658 Fax: (613) 569-9659 Email: [email protected]

Publication supported by

ModelStandards

of Practicefor

CanadianPharmacists

Contents

4 Introduction

5 General Attributes Required of Pharmacists to Fulfil the Professional Competencies

6 Professional Competencies Required of Pharmacists

6 • Professional Competency #1: Practise Pharmaceutical Care

15 • Professional Competency #2: Provide Drug Information

19 • Professional Competency #3: Educate

20 • Professional Competency #4: Manage Drug Distribution

22 • Professional Competency #5: Apply Management Principles

25 Optional Advanced Professional Competency #6: Undertake Research

26 References

27 Appendix A

Introduction

The following Model Standards of Practice were developed byNAPRA’s National Competency-Based Standards of PracticeWorking Group, a group of practising pharmacists from acrossCanada (see Appendix A). Members of the Working Group wereselected from nominations submitted by provincial and territorialPharmacy Regulatory Authorities (PRA) and national stakeholderorganizations in response to a campaign to recruit skillful, proficientpractising pharmacists with various numbers of years of experience,educational backgrounds, practice sites and geographical locations.This selection process was meant to ensure that the Working Groupcould develop realistic standards of practice that truly representedwhat all pharmacists must be able to do in community and hospitalpractice to ensure patient safety.

The Working Group met in October 2001 after having discussedbackground information on competency-based standards of practice,NAPRA’s Professional Competencies for Canadian Pharmacists at Entry toPractice (NAPRA, 1997)[1] and NAPRA’s Model Standards of Practicefor Canadian Pharmacists (NAPRA, 1998) [2]. Using these twodocuments as a starting point, a draft of the revised Model Standards ofPractice was developed. Although the draft modifies the order andstructure of the competencies from that listed in the original NAPRAdocuments, all competencies detailed within the ProfessionalCompetencies for Canadian Pharmacists at Entry to Practice are included.The primary change in these revised Standards limits the professionalcompetencies to the roles or tasks performed by pharmacists as part ofprofessional practice (e.g. providing pharmaceutical care, supervisingdrug distribution). These roles differ from the general attributes (e.g. knowledge and its application, communication, professionalism or ethics) that are necessary to fulfil the professional competencies [3].Although the professional competencies and general attributes aredefined separately, they are linked or integrated via performanceindicators as described below. This approach has been used by anumber of professions in Canada and in other jurisdictions [1, 3, 4, 5,6, 7] and there is literature supporting such an approach to thedevelopment of Standards of Practice [3, 5, 6, 8].

In February 2002 a Consultation Paper containing WorkingGroup recommendations was circulated to 28 stakeholders includingthe 12 provincial and territorial licensing bodies, provincial andnational pharmacy advocacy organizations and national educationalgroups. The draft Model Standards were then revised based on thecomments received from these reviewers. The final report of theWorking Group was presented to the NAPRA Board of Directors inNovember 2002.

Cognizant of the fact that regulatory authorities will adopt thesestandards, the Working Group attempted to ensure that the revisedstandards are realistic and will ensure patient safety. The standardsare competency-based and define the levels of achievement requiredby pharmacists for competence in key areas of pharmacy practice [3].Licensed pharmacists (those licensed for active practice) are expectedto maintain their ability to perform the five competencies to thestandards specified.

Although national review indicated that the revised ModelStandards were, in general, set at an appropriate level, severalreviewers expressed concern that they represented a minimum levelof expected performance. The Working Group agreed with thiscomment, but a key, literature-based decision had been made early inthe development process that the revised Model Standards ofPractice would define what all licensed pharmacists* must be able todo during daily practice to ensure patient safety. This use of a

common minimum standard for all licensed pharmacists is consistentwith other health professions and with the public protection mandateof NAPRA’s Members [9]. The Working Group also recognized,however, that individual pharmacists and the profession as a wholeaspire to continuously improve practice performance beyond thestandard of what all pharmacists must do to ensure public safety.Therefore, to assist pharmacists in identifying areas for individualcontinuing professional development, the Working Group alsoidentified a series of guidelines for advanced and / or exemplarypractice. NAPRA offers these guidelines as benchmarks againstwhich pharmacists might compare their own practice andperformance when identifying strengths, weaknesses and areas forindividual continuing professional development [10], [11]. Since therange of advanced roles for pharmacists is quite broad, no attemptwas made to set exemplary practice guidelines for all potential roles.Focus was maintained on common roles assumed by experiencedpractising pharmacies. The inclusion of these advanced or exemplaryguidelines aims to both encourage and reward continuing professionaldevelopment by individual pharmacists.

The following revised Model Standards of Practice for CanadianPharmacists includes five components [3]:

1. a statement of the major professional responsibilities of thepharmacist ( i.e. competency units);

2. a description of the situations in which all pharmacists must beable to perform each competency;

3. the steps required to successfully fulfil each competency unit (i.e.competency elements);

4. the level of performance expected of all pharmacists for eachcompetency element in order to be considered competent ( i.e.required performance indicators), and;

5. to further clarify these performance indicators, practical examplesof specific pharmacist activities that could demonstrate thefulfilment of each required performance indicator.

To be clear, it is not expected that pharmacists would perform eachand every one of the examples of activities. These are included tofacilitate the understanding of the practical, realistic nature of therequirements.

Through the course of revising the Model Standards of Practice,a number of changes to the competency units and elements listed inNAPRA’s Professional Competencies for Canadian Pharmacists at Entryto Practice were recommended. However, the NAPRA Board ofDirectors agreed with the Working Group’s recommendation that theProfessional Competencies not be revised at this time as theseCompetencies are currently being used by a number of provincial andnational organizations. Instead, the Working Group provided all ofthe suggested revisions to NAPRA for future use by the NationalAdvisory Committee on Licensing during their review of theProfessional Competencies for Canadian Pharmacists at Entry to Practice(scheduled for 2005).

Working Group members wish to thank all respondents, andemphasize that all comments received were reviewed and consideredfor inclusion in these final Model Standards of Practice. TheWorking Group also recognized that these Model Standards will bereviewed regularly and altered as practice responsibilities change andthe profession evolves.

4 Model Standards of Practice for Canadian Pharmacists

* All pharmacists licensed in the active part of the Register in those jurisdictions with a two-part Register

Model Standards of Practice for Canadian Pharmacists 5

General Attributes Required of Pharmacists to Fulfil theProfessional CompetenciesKnowledgeable

Pharmacists must possess and be able to apply a broad, integratedknowledge of the core functional information associated with theprofession of pharmacy. Such functional knowledge focuses on anunderstanding and ability to apply the information that is requiredduring daily practice, and does not focus on detailed facts that areeasily located in references (such as doses, costs of medications, tradenames, names of management theories). The possession of suchknowledge and the ability to apply this knowledge to solve problemsand make appropriate decisions, is the base upon which competencyas a pharmacist is built. Without knowledge and the ability to applyit, pharmacists will not be able to fulfil their professionalresponsibilities.

Pharmacists must:• have and be able to apply functional knowledge while solving

problems and making decisions during completion of theirprofessional responsibilities. This functional knowledge includesknowledge from the biomedical sciences (e.g. physiology,microbiology, pharmacology), the pharmaceutical sciences (e.g. medicinal chemistry, toxicology, pharmacokinetics andpharmacotherapeutics), the behavioural and social sciences (e.g. psychology, communications, ethics and illness behaviour),the administrative pharmacy sciences (e.g. pharmacy managementand health care systems), and pharmacy practice (e.g. pharmaceutical care, compounding & dispensing, structuredpractical training).

Professional

Pharmacists must function professionally when fulfilling theirresponsibilities. Professionalism is defined as altruism, accountability,excellence, duty, integrity and respect for others, therebyincorporating the concepts of ethics, self-directed learning andprofessional identity [12].

Pharmacists must:• consistently accept responsibility for actions and decisions.• consistently demonstrate respect for others.• consistently provide professional pharmacy care to individual

patients that complies with the ethical guidelines governing theprofession.

• maintain appropriate inter-professional relationships required toprovide quality pharmacy care to individual patients.

• consistently provide care and services that place the best interest ofpatients before their own self-interest.

• continuously strive to improve professional competence throughthe use of appropriate learning to address areas identified forprofessional improvement / growth.

• consistently demonstrate personal and professional integrity.• undertake non-pharmacy practice-related activities that are

consistent with, and do not take advantage of the influence of,their status as a health professional.

• reject the acceptance of gifts / advantages that give the appearanceof bias or conflict of interest.

Proficient Communicator

Pharmacists effectively use the communication skills required to fulfileach of the required professional competencies in the expectedsituations and to the level of performance specified.

Pharmacists must: • consistently demonstrate respect, sensitivity and empathy when

communicating with others.• consistently demonstrate appropriate verbal, non-verbal and

listening skills.• routinely demonstrate effective patient-interviewing techniques

including: initiating a session, exploring problems, understandingthe patient’s perspective, structuring the discussion, building apatient relationship, facilitating the patient’s involvement,explaining, planning, and closing the discussion [13].

• consistently select and appropriately use communicationtechniques when communicating with peers, other health careproviders, and staff.

• display effective writing skills. • demonstrate comprehension and fluency in written and verbal

English or French.

Professional Competencies Required of Pharmacists:

1. Practise pharmaceutical care: Pharmacists in partnership withpatients and other health care providers, use their uniqueknowledge and skills to meet patients’ drug related needs and toachieve positive patient outcomes by maintaining or improving thepatient’s quality of life.

2. Provide drug information: Pharmacists assume responsibility forinformation retrieval, evaluation and dissemination to ensure safeand effective provision of pharmaceutical care and to promotehealth.

3. Educate: Pharmacists educate individuals to support optimalpatient care and to promote health.

4. Manage Drug Distribution: Pharmacists manage drug distributionby performing or supervising the functions of acquisition,preparation, and distribution of drugs to ensure the safety, accuracyand quality of supplied products.

5. Apply Management Principles: Pharmacists apply knowledge,principles and skills of management as they pertain to the site ofpharmacy practice with the goal of optimising pharmaceutical careand professional relations.

It is assumed that in fulfilling their responsibilities as pharmacists asdefined by the standards of practice, all activities will be performed inaccordance with relevant federal, provincial and territoriallegislation, and regulatory authority policies and by-laws regardingthe practice of pharmacy.


Professional Competency #1:Practise Pharmaceutical CareCompetency unit

Pharmacists in partnership with patients and other health careproviders, use their unique knowledge and skills to meet patients’drug related needs and to achieve positive patient outcomes bymaintaining or improving the patient's quality of life.

Situations in Which All Registered Pharmacists Must Fulfil thisCompetency:

Pharmacists ensure that all patients have access to the care requiredto address their drug related needs. This means that: • for patients with actual needs or potential problems related to drugs

that are routinely used to manage common1 diseases, and for thosepresenting common ethical or communication challenges,pharmacists possess the functional knowledge and skills required toprovide pharmaceutical care and may use resources to confirmdetailed or specific disease or drug information.

• for patients with actual needs or potential problems related to drugsthat are used infrequently to treat common diseases, or drugs usedto treat uncommon diseases, or uncommon or complicated ethicalor communication challenges, pharmacists may consult with otherpharmacists or health care providers and may use resources toacquire or review necessary drug, disease or other information.

• for patients with drug related needs or problems that are theresponsibility, or within the scope of practice, of other health careproviders, pharmacists refer for management; and

• for all patients, pharmacists provide medications and/or pharmacyservices

Pharmacists provide this care and these services to patients whodesire the pharmacist’s participation in their care and who are willingand able to accept the responsibilities required by this care.Pharmacists fulfil this competency in all sites where they provide theproducts and/or services that legally constitute pharmacy practice.

1.1 A pharmacistmust develop aprofessionalrelationship with thepatient.

Offer all patients the opportunity to engage in aprofessional relationship by consistentlydemonstrating him/herself to be a caring healthcare professional.

The pharmacist is available and makes time to answerpatient’s questions; provides privacy for patients who desireand/or require it; offers professional assistance in selectingnon-prescription drug therapy & natural health products;presents a professional appearance; respects a patient’sdignity, education, culture, beliefs, interests and desires;shows unbiased behaviours regarding, for example, race,religion, sex, language, and age of patients.

Effectively use interpersonal skills to overcomecommon challenges to communication.

The pharmacist speaks at an appropriate level to children orcognitively impaired patients; summarizes frequently toclarify information and facilitate discussion with poorhistorians; minimizes the use of jargon; calms anxiouspatients; pacifies angry patients.

Clearly establish the normally accepted roles andresponsibilities of him/herself and of the patient,including explaining their common goal of ensuringthat the patient appropriately takes the right drug inthe correct dose and dosage form, on the bestschedule, for the appropriate duration of therapyand that side effects and / or lack of efficacy areidentified and managed appropriately

The pharmacist introduces self and explains that (s)he ishere to teach the patient how to use a medicationappropriately; requests patients to call the pharmacist ifthey have side effects or questions.

Competency Element Required Performance Indicators Examples of activities that might prove fulfilment of Required Performance Indicators

— Continued

Optional Performance Indicator reflectingadvanced or exemplary practice:Consistently develop professional relationshipswith patients who demonstrate uncommon orextreme challenges.

Examples of activities that might prove fulfilment ofOptional Performance Indicator: The pharmacist overcomes uncommon communicationchallenges (illiterate, deaf, mentally-handicapped,foreign-language only, combative patients); managesethical dilemmas; convinces reluctant patients of thevalue of a professional relationship with pharmacistsand develops such relationships.

1. The term “common” is used throughout this document in its pragmatic sense to focus on issues that are frequently occurring rather than infrequent or obscure. No attempts have been made to definecommon diseases or drugs as these will change over time.


1.2 A pharmacistmust gather patientinformation andassess its relevanceto patient care.

Routinely use appropriate communication skills toobtain a clear understanding of the patient’sperceived needs or questions.

The pharmacist asks if the patient is having any problemswith or questions about their medications; listens attentivelyto patient’s questions / complaints; asks clarifyingquestions to ensure understanding of the patient’s concerns.

Routinely collect the information necessary toaddress the patient’s drug related needs orquestions, such as:• when not obvious, the condition, symptoms or

signs to be treated and / or the patient’s selfdiagnosis

• the practitioner’s diagnosis• the seriousness of symptoms, particularly when

addressing problems associated with self care /non-prescription drugs

• the patient’s desired outcomes (implied orexplicitly stated)

• relevant patient demographics• relevant family medical history• relevant social history (e.g. alcohol or nicotine use)• the existence of relevant medical conditions • the history of current condition, particularly when

addressing problems associated with self care /non-prescription drugs

• known patient risk factors for adverse drugreactions, drug allergies or sensitivities

• known contraindications to prescription and non-prescription drug use

• relevant dietary restrictions• other medications or treatments that the patient

has tried for this condition and effects,particularly when addressing problems associatedwith self care / non-prescription drugs

• other medications or treatments that the patientis currently taking that may affect the condition orinteract with therapy

The pharmacist inquires about the severity and duration ofdiarrhea in an infant; asks about previous use ofantihistamines when recommending management forseasonal allergies; asks the age and weight of a child;checks the patient’s profile for previous use of antibioticsand reactions; contacts the physician to clarify the diagnosiswhen a dosage does not match the indication explained bythe patient; asks the patient or checks his profile foradditional therapies for hypertension; reviews phenytoinlevels for prevention of toxicity; checks patient’s serumcreatinine when reviewing aminoglycoside dosing.

Routinely acquire the information necessary todetermine if the patient’s needs / problems fallbeyond the domain or scope of pharmacy practice.

The pharmacist reviews the profile of a patient who has hadmultiple high BP readings on several different days to see ifhe is taking an antihypertensive; asks a patient requestingthroat lozenges if she has fever in addition to a very sorethroat; asks a patient with tooth pain and fever if he hasseen a dentist.


Optional Performance Indicators reflectingadvanced or exemplary practice:Routinely collect the required information in anefficient manner while maintaining aprofessional, caring relationship with a patient.

Maintain an accurate knowledge of theavailability of, and services offered by, healthorganizations and health care professionalswithin the community, including alternativehealth care providers.

Examples of activities that might prove fulfilment ofOptional Performance Indicator:The pharmacist uses a mixture of questioningtechniques to limit excessive, unrelated discussion.

The pharmacist maintains knowledge about servicesavailable to seniors such as Meals on Wheels, socialgroups, transportation services, home care; knows ofavailability of physiotherapists, nutritionists, acupuncturepractitioners; links patients with disease basedorganizations that provide information for public.

Collect information in an effective, professionalmanner.

The pharmacist reviews patient profiles for medicationhistories of prescription drugs; asks only relevant questionsthat provide necessary information; seeks information abouta patient’s health only when it is required to provide care to,or appropriately refer, the patient.

— Continued


Effectively establish realistic therapeutic outcomesconsistent with the patient’s desires.

The pharmacist explains to the patient that there is no curefor the common cold but that products are available torelieve symptoms; explains to the patient that manyantidepressants take 4-6 weeks before their best effects areseen; explains to the medical team that gum hyperplasiawill not resolve with continued use of phenytoin.

Correctly identify when no confirmation of desiredoutcomes is necessary.

The pharmacist presumes that a patient with pneumoniawants it cured; presumes that a patient receivingaminoglycosides wants a therapeutic / non-toxic dose.

1.4 A pharmacistmust identify apatient’s actual andpotential drugrelated problems.

Effectively review every patient’s profile to identifyactual and potential drug related problems prior todispensing a prescription, including the types ofdrug related problems listed below 3..

Effectively use the information collected in 1.2 and1.3 above to identify a patient’s actual and potentialdrug related problems, including the types of drugrelated problems listed below 3..

• Untreated / continuing signs or symptoms For example: lack of bisphosphonate for a patient onchronic prednisone therapy; lack of aspirin therapy for apatient following a myocardial infarction; persistent fever ina patient taking amoxicillin for pneumonia (plus seeexamples requiring referral, 1.6)

• Contraindications for drug use For example: amoxicillin for a patient with a documentedpenicillin allergy.

• Drug interactions For example: treatment with erythromycin when takingtheophylline; treatment with ibuprofen for a patient with ahistory of gastric ulcers; the use of cotrimoxazole for apatient on warfarin.

• Inappropriate doses, or signs / symptoms oftoxicity or sub-therapeutic treatment

For example: acetaminophen 1000 mg q4h for more thanseveral days; blurred vision with digoxin; increasingfrequency of seizures while on carbamazipine.

• Side effects For example: diarrhea during treatment with amoxicillin; GIbleeding with NSAIDs; rash with cotrimoxazole.

• Non-compliance For example: lack of understanding of the need to finish acourse of antibiotics; failure to remove nitroglycerin patch forappropriate period each day to prevent tolerance; asnecessary use of steroid inhalers rather than scheduled,regular use.

• Drug use for no valid indication For example: inappropriate use of dimenhydrinate; excessiveuse of narcotics, sedatives or hypnotics; use of diuretics forweight loss.


1.3 A pharmacistmust identify apatient’s desiredtherapeuticoutcomes.

Optional Performance Indicator reflectingadvanced or exemplary practice:Routinely inform long term clients of newtherapies that offer similar or enhancedtherapeutic outcomes

Example of an activity that might prove fulfilment ofOptional Performance Indicator:The pharmacist informs female patients of availability ofbisphosphonates as an alternative to hormonereplacement therapy for post-menopausal osteoporosisprevention

— Continued

3. The types of drug related problems that pharmacists must be able to identify independently and without the extensive use of resources, versus those for which consultation can be used, are specified inthe range statements at the beginning of the competency.


Routinely use resources and / or consultation tofacilitate the timely identification of less commondrug related problems.

The pharmacist uses the Internet to rapidly locate druginformation; contacts the cancer treatment centre to askabout new chemotherapy dosing guidelines; contacts thepharmaceutical company for information on potentialinteractions; discusses availability of special compoundingwith ‘specialist’ pharmacist

Prioritize patient’s drug related problems accurately. The pharmacist considers patient preference, medicalsignificance and urgency; recognizes drug related problemsthat the patient believes are important; recognizes urgent orsevere drug related problems that the patient or other healthcare providers want to ignore and educates them about theimportance of these problems; recognizes drug relatedproblems that are less critical or which do not requiremanagement.

When requested by a patient, provide accurateinformation concerning efficacy, toxicity, side effectsor interactions of natural health products.

The pharmacist provides information on echinacea formanagement of colds; provides information on valerian forinsomnia.

Effectively explain the mechanism / cause of apatient’s drug related problem(s).

The pharmacist uses the appropriate terminology to explainwhy a penicillin should not be used by a patient with adocumented penicillin allergy or why nitroglycerin patchesshould be removed for a period of time each day.


1.4 (Continued)

Optional Performance Indicators reflectingadvanced or exemplary practice:Complete full medication reviews to identifymultiple drug related problems.

Accurately and efficiently identify multiple,complex drug related problems based onextensive knowledge base and experience.

Maintain and utilize an efficient network ofresources to facilitate identification of lesscommon drug related problems.

Examples of activities that might prove fulfilment ofOptional Performance Indicator:The pharmacist schedules patient appointments tocomplete work-ups of drug therapy; createscomprehensive patient records to facilitate identificationof drug related problems; uses a systematic approach toidentifying multiple drug related problems.

The pharmacist immediately recognizes and confirmsdrug related problems based on extensive experienceand is able to explain the therapeutics / pharmacology /pathophysiology underlying the drug related problem.

The pharmacist maintains contacts with physicians,pharmacists, industry and specialist treatment centresto quickly obtain information required to identifycomplex or uncommon drug related problems.

Routinely recommend appropriate non-drug therapyin addition or as an alternative to, drug therapy.

The pharmacist recommends the use of ice for a sprainedankle in addition to NSAIDs; suggests the use of ahumidifier in addition to a topical decongestant.

Routinely recommend the use of appropriate drugdevices to ensure effective drug use.

The pharmacist recommends the use of aerochambers forchildren or infants using inhalers.

Routinely develop and/or recommend the use ofappropriate tools and products to aid in patientcompliance.

The pharmacist develops written summaries of dailymedication requirements; recommends the use of dosingreminder aids (e.g. Dosettes‚); recommends the use ofspecialty lids to facilitate opening of vials; providesmedication counselling cards.

1.5 A pharmacist must developtherapeutic plans, recommendingtherapeutic options, doses,scheduling / administration,required drug devices andcompliance aids.

— Continued


Consistently recommend therapeutic options thatare compatible with the patient’s desired outcomes,rational and cost effective.

The pharmacist, if appropriate, recommends nitroglycerinpaste rather than nitroglycerin patches for a patientconcerned about the cost of the patches.

Effectively consult with a patient’s other health careproviders regarding the patient’s therapeutic plan.

Routinely provide continuing pharmacy care andservices to a patient who has refused arecommended change in drug therapy.

The pharmacist contacts a patient’s physician to managehis/her drug related problem; obtains refill authorizations asnecessary; obtains changes in prescription drugs asnecessary; releases patient information only when necessaryto provide continuity of care to that patient.

Accurately identify when patients’ problems arebeyond the scope of pharmacy practice and referthem as appropriate to their family physician,dentist, optometrist, physiotherapist, nutritionist orsocial worker.

The pharmacist refers seniors having problems maintainingactivities of daily living; patients complaining of chronicback pain; consistently elevated BP readings from pharmacyautomated BP machine in a patient not taking anti-hypertensives.

Effectively manage routine conflicts between idealpatient care and relevant health system policy.

The pharmacist contacts the physician for a change inprescription when financial problems would prevent thepatient from taking a required medication.

Effectively justify his/her therapeutic recommendation. The pharmacist explains the therapeutic rationale forrecommendations (e.g. pathophysiology or cause of diseaseand mechanism of action of drug); provides any referencesused to develop a recommendation.


1.5 (Continued)

Optional Performance Indicators reflectingadvanced or exemplary practice:Consider emerging, appropriate therapeuticalternatives when selecting therapeutic options.

Examples of activities that might prove fulfilment ofOptional Performance Indicator:The pharmacist maintains and uses knowledge ofcurrent research and new drug therapies.

Efficiently develop accurate therapeutic plansbased on extensive knowledge base and patientexperience.

Efficiently develop therapeutic plans forcomplex, specialized drug related problemsbased on extensive knowledge base andexperience in a specialized field of practice

The pharmacist immediately ‘knows’ appropriatetherapeutic recommendations based on extensiveexperience and knowledge and is able to justify therecommendation.

Accurately and efficiently identify patients withsigns/symptoms of potential medical emergenciesand recommend they seek immediate medicalattention.

The pharmacist recognizes the urgency of vomiting, diarrhea,fever and lethargy in an infant; severe, unrelenting headachein a patient with no history of migraines; unrelenting chestpain; palpitations in a patient taking high doses oftheophylline.

Accurately address patients’ inquiries about theneed to contact their physician if they areexperiencing signs or symptoms associated withcommon diseases addressed in health promotioncampaigns.

The pharmacist supports a patient’s decision to see his/herphysician about a breast lump or excessive thirst andurination.

1.6 A pharmacist must referpatients to other health careproviders when required.

— Continued


Accurately identify patients whose self-diagnosisappears questionable and refer them as appropriateto their primary care practitioner.

The pharmacist refers a patient requesting moredecongestant nasal spray for congestion with purulentdischarge that has worsened over the last two weeks; refersa diabetic patient requesting a topical antibiotic cream foran infected cut on foot; refers a patient requesting NSAIDsfor swelling and pain around a tooth.

Offer accurate information to patients about the roleof family physicians, dentists, optometrists,physiotherapists, nutritionists and social workers.

The pharmacist provides information about the role ofnutritionists in the management of diabetes; explains thedifference between optometrists and opticians.

Accurately identify patients whose self-caretreatment has failed to remedy a condition withinthe expected time frame and recommend that theycontact their primary care practitioner.

The pharmacist refers a patient with continued constipationwith no bowel movements despite one week’s treatment withpsyllium.


1.6 (Continued)

Optional Performance Indicators reflectingadvanced or exemplary practice:Routinely refer patients to appropriate healthorganizations and health care professionalswithin the community, including complementaryand alternative health care providers.

Examples of activities that might prove fulfilment ofOptional Performance Indicator:The pharmacist refers seniors to Meals on Wheels, socialgroups, transportation services, home care; referspatients to support or education groups; refers patientsto appropriate acupuncture practitioners.

Develop and routinely utilize referral systems The pharmacist routinely writes referral notes forpatients to take with them to their physician; maintainsprofessional contacts and relationships with a variety ofhealth care providers and service providers availablewithin the community.

Routinely and accurately identify the degree ofmonitoring required by a patient according to thehealth risks posed by the patient’s medication, drugrelated problem, or disease.

The pharmacist identifies that a patient with a history ofnon-compliance with antibiotics may require a follow-uptelephone call when prescribed erythromycin for 10 days;recognizes that a patient controlled on chronicantihypertensive medication and no new complaints requiresminimal monitoring; identifies that a patient taking longterm tamoxifen for breast cancer should be asked aboutside effects and compliance on a regular basis; identifiesthat a patient being started on warfarin requires frequentmonitoring during the stabilization phase; identifies that apatient on an aminoglycoside requires monitoring of renalfunction and possibly aminoglycoside levels; recognizes thata patient admitted with acute renal failure may needfrequent dosage adjustment of their drug therapy.

Routinely and accurately identify the amount andtype of education desired / required by patients tomaximize their chances of solving or preventing theirdrug related problem(s).

The pharmacist recognizes that minimal information isnecessary for a patient taking chronic medication and nonew complaints; recognizes that a patient experiencing amigraine requires minimal immediate counselling (andadditional information at a later point); identifies that apatient beginning hormone replacement therapy requireseducation on short term benefits relative to long term risks;recognizes that a patient with severe asthma requiresoccasional review of inhaler-use instructions.

1.7 A pharmacist must develop,implement and fulfil plans tomonitor the patient’s progresstowards desired therapeuticoutcomes

— Continued


Routinely, effectively and, in consideration of theabove two statements, appropriately educatepatients on the following when dispensingprescription and non-prescription drugs, whenpatient counselling on discharge medications orwhen providing recommendations aboutmanagement of specific drug related problems:• name and class of the drug (e.g. antibiotic,

pain reliever)• directions for use including education about drug

devices• special storage requirements • common or important drug-drug or drug-food

interactions


1.7 (Continued)

Consistently fulfil responsibilities for monitoringpatients.

The pharmacist completes required patient contacts (asabove) on the schedule agreed upon.

Analyze monitoring data obtained to determine thesuccess of the therapeutic plan or the developmentof new drug related problems.

The pharmacist compares patient’s status to desiredoutcomes; ensures continued care if new drug relatedproblems are identified.

• when appropriate, the actions the pharmacist willundertake to monitor the patient’s progress

The pharmacist asks the patient if (s)he would like thepharmacist to call a week after starting antibiotics.

• the reason for the drug 4 and the intendedtherapeutic response and associated time frames

The pharmacist discusses the use of metoprolol forprevention of a second myocardial infarction versus thelowering of blood pressure; that the frequency and pain onurination should resolve within 24 hours of startingamoxicillin for a urinary tract infection.

• what the patient should do to monitor his/hertherapeutic response or development of sideeffects

The pharmacist recommends that a patient keep a diary ofheadache times, intensity and duration.

• common or important side effects and associatedtime frames

The pharmacist discusses diarrhea that could start after theend of treatment with clindamycin; transient headache thatmay develop at the start of therapy with nifedipine.

• actions the patient should take if the intendedtherapeutic response is not obtained or sideeffects develop

The pharmacist asks the patient to call if her constipation isnot relieved in three days; recommends that the patientcontact his physician if his fever has not resolved in threedays; asks the patient to contact the pharmacist orphysician if he develops diarrhea while taking or within twoweeks after completing the treatment with clindamycin.

Consistently communicate with covering pharmaciststo inform them of individual patient needs formonitoring.

The pharmacist leaves a summary of patients who shouldbe contacted during the next shift, the reason for thecontact and the expected outcome.

Communicate with patients’ care providers asnecessary regarding the results of patientmonitoring.

The pharmacist contacts patient’s physician if the patientexperiences persistent cough after starting an ACE inhibitor

— Continued

4. It is recognized that pharmacists do not always have access to the therapeutic indication for the drug.



1.7 (Continued)

1.8 A pharmacist mustdocument information.

Document the above information in a usable,retrievable, timely manner.

The pharmacist writes on prescription that patient has beencounselled; enters allergies into patient profiles; notes onprescription or in profile that doctor was called to changethe prescription and why; documents subtherapeuticphenytoin levels and dosing recommendations in ahospitalized patient’s chart; documents clarifications of drugallergies or medications prior to admission.

Consistently identify situations that requiredocumentation to promote patient safety and / orto meet legal requirements.

The pharmacist identifies the need to document theexistence of allergies; previous serious adverse drugreactions or interactions; commitments to complete follow-up contact with patients at a specific time; changes in aprescription made to prevent a drug related problem (e.g.changes in dose, changes in drug to one covered byinsurance; changes in drug to one with fewer side effects);the refusal of a physician to change a prescription; therefusal of a patient to allow contact with his/her physician.

— Continued

Optional Performance Indicators reflectingadvanced or exemplary practice:Consistently use appropriate techniques to gainacceptance of the therapeutic and monitoringplans by relevant parties.

Examples of activities that might prove fulfilment ofOptional Performance Indicator:The pharmacist uses extensive knowledge to supportrecommendations to patients or other health careproviders; facilitates monitoring by developing simple,yet effective, monitoring plans.

Create systems that facilitate patient monitoring The pharmacist uses software available to create callback lists; uses forms that specify normal monitoringparameters and time frames; uses a system fordocumenting therapeutic and monitoring plans; employsa follow-up appointment protocol as part of a diseasemanagement program; uses a liaison system betweenhospital and community pharmacies to ensure seamlesscare.

Optional Performance Indicators reflectingadvanced or exemplary practice:Document efficiently.

Examples of activities that might prove fulfilment ofOptional Performance Indicator:The pharmacist completes required documentation insuccinct, complete, timely fashion, including onlynecessary information; consistently uses a specificdocumentation protocol or format (e.g. SOAP) forconsistency and ease of retrieval.

Develop and routinely using a system todocument the provision of pharmaceutical careand patient outcomes.

The pharmacist obtains approval to insert a pharmacysection in patient charts; develops software to recordpatient care and outcomes


Optional Advanced Roles: Possible Performance Indicators Examples of activities that might prove fulfilment of Possible Performance Indicators

Drug Therapy/Patient Care

Routinely and efficiently document the provision ofcare and patient outcomes.

Accurately and efficiently identify multiple, complexdrug related problems based on extensiveknowledge base.

The pharmacist immediately recognizes and confirmscomplex, multiple drug related problems based on extensiveexperience and is able to explain the therapeutics /pharmacology / physiology underlying the drug relatedproblem.

Routinely initiate follow-up contact with patients tomonitor their progress towards predeterminedoutcomes.

Routinely summarize data on patient managementto ensure continuity of care and to document thevalue of pharmacy services.

The pharmacist schedules follow-up appointments atpharmacy; completes regular rounds on hospital patients;reserves specific time each week to contact patients forfollow-up by telephone.

Complete focussed medication reviews to identifydrug related problems in patients with specificdisease states.

The pharmacist participates in ‘clinic’ days for specificdiseases in order to identify patients who require moreintensive review; schedules patient appointments to completework-ups of drug therapy; creates comprehensive patientrecords to facilitate identification of drug related problems;uses a systematic approach to identifying multiple complex

Maintain and utilize an efficient network of resourcesin a specialty area of practice to facilitateidentification of drug related problems.

The pharmacist maintains contacts with physicians,pharmacists, specialist treatment centres and industry toquickly obtain information required to identify drug relatedproblems in a specific disease or practise area.

Consistently complete full medication reviews, orassessments with patients to identify their multipledrug related problems.

The pharmacist schedules patient appointments to completework-ups of drug therapy; creates comprehensive patientrecords to facilitate identification of drug related problems;uses a systematic approach to identifying multiple drugrelated problems.

Efficiently develop accurate therapeutic plans basedon extensive knowledge base and patientexperience.

The pharmacist immediately ‘knows’ appropriate therapeuticrecommendations based on extensive experience andknowledge and is able to explain the therapeutics /pharmacology / pathophysiology underlying the drug relatedproblem to justify the recommendation

Routinely initiate specific activities to identifypatients with actual or potential drug relatedproblems.

The pharmacist offers brown bag sessions; offers educationsessions on new drugs to identify patients at risk for drugrelated problems; completes home visits.

Disease State Specialization Accept referrals of patients for management of drugrelated problems related to specific disease states.

Accurately and efficiently identify multiple, complexdrug related problems based on extensiveknowledge base in a specialty area of practice.

Efficiently develop therapeutic plans for complex,specialized drug related problems based onextensive knowledge base and experience in aspecialized field of practice.

The pharmacist immediately recognizes and confirmscomplex, multiple drug related problems based on extensiveexperience in a specialty area and is able to explain thetherapeutics / pharmacology / pathophysiology underlyingthe drug related problem.

— Continued


Optional Advanced Role: Possible Performance Indicators Examples of activities that might prove fulfilment of Possible Performance Indicators

Disease State Specialization(continued)

Routinely summarise data on patient managementto provide continuity of care and to document thevalue of pharmacy services.

Encourage the appropriate management of specificdisease states by relevant health care professionals.

The pharmacist develops and uses systems to providephysicians with information to ensure appropriateprescribing according to evidence-based principles.

Routinely and efficiently document the provision ofcare and patient outcomes.

Establish and utilize systems to efficientlyimplement therapeutic and monitoring plans.

The pharmacist manages drug treatment according todisease state guidelines; accepts appropriate and lawfulresponsibility for delegated medical acts; obtains requiredtraining / certification for actions required for disease statemonitoring (such as diabetic counselling, blood pressuremonitoring, asthma monitoring); establishes a follow-upappointment protocol as part of a disease managementprogram; creates or leads support groups for clients withspecific disease states.

— Continued

Professional Competency #2: Provide Drug InformationCompetency Unit

Pharmacists assume responsibility for information retrieval,evaluation and dissemination to ensure safe and effective provision ofpharmaceutical care and to promote health.

Situations in Which All Registered Pharmacists Must Fulfil thisCompetency 5:

In response to requests from individual patients or individual healthcare professionals, pharmacists provide:• information about all drugs, including herbal therapies;• recommendations concerning commonly used drugs in the

management of common diseases, and;

• information about commonly recommended, evidence-baseddisease prevention and health promotion strategies.

Pharmacists use appropriate, readily accessible secondary and tertiary6

medical and pharmaceutical resources, Internet-based informationand / or consultation with other pharmacists or health careprofessionals when fulfilling this competency. Pharmacists fulfil thiscompetency in all sites where they provide the products and servicesthat legally constitute pharmacy practice, or where they are identifiedas pharmacists when providing such information orrecommendations.

2.1 A pharmacist mustidentify sources of relevantinformation.

Accurately determine the depth of informationrequired to answer a question.

The pharmacist accurately differentiates between aphysician’s request for a standard dose of an antibiotic anda physician’s request for recent changes in the treatment ofchoice for otitis media; differentiates between a patient’sand a physician’s question as to how Zyban® works in thetreatment of smoking cessation.

Accurately identify whether tertiary, secondary orprimary literature is necessary to appropriatelyrespond to the request for information orrecommendations.

The pharmacist differentiates between a patient’s request forinformation on new antibiotics for treating urinary tractinfections and a physician’s request for information oninvestigational antibiotics for managing chronic urinary tractinfections.


5. This competency differs from the provision of information to individual patients as part of patient counselling during the provision of pharmaceutical care (Competency #1). It also differes fromCompetency #3 which relates to the education of students or groups regarding drugs, drug use and health promotion.

6. Although pharmacists are encouraged to use primary literature, they must, at a minimum, use appropriate secondary and tertiary literature.


2.1 (Continued) Accurately identify and name the tertiary andsecondary resources available to appropriatelyrespond to the request for information orrecommendations.

The pharmacist assesses whether the Compendium ofPharmaceutical Specialties, American Hospital FormularyService Drug Information or Therapeutic Choices providesappropriate information; determines if reference must bemade to provincial antibiotic guidelines; identifies ifinformation should be accessed from drug information orgovernment web sites.

Systematically access reliable information in atimely and accurate manner.

The pharmacist obtains the appropriate information fromtertiary resources, the Internet, pharmacists or other healthcare professionals.

Accurately manage requests for information orrecommendations that are beyond their capabilities.

The pharmacist identifies other pharmacists or health careprofessionals available to provide required information;consults with the appropriate experts or refers the requestorto the appropriate source of information.

Regularly use professional judgement to determinewhen sufficient, appropriate information has beenobtained

The pharmacist does not rely on a single, general text whennewer references or DI bulletins are available; acknowledgeswhen sufficient reliable information is not available torespond accurately to the request.

2.2 A pharmacistmust retrieveinformation fromrelevant sources.

Consistently recognize and respond appropriately tothe time frame requirements for a question orrequest for recommendation.

The pharmacist responds rapidly to physician’s request forinformation required to prescribe for a patient in his/heroffice; considers workload and time available beforepromising a time frame for a response for more complicatedinformation.


Optional Performance Indicators reflectingadvanced or exemplary practice:Accurately and efficiently locate relevantprimary literature or resources based onextensive knowledge base and experience in aspecialized field of pharmacy practice

Examples of activities that might prove fulfilment ofOptional Performance Indicator:The pharmacist refers to specific studies that addressthe request; maintains a network of contacts inspecialized fields of practice

Optional Performance Indicators reflectingadvanced or exemplary practice:Routinely and efficiently retrieve the informationnecessary to provide recommendations aboutall drugs, including herbal and complementarymedicines.

Obtain the required information in an efficientmanner.

Maintain an up-to-date and complete collectionof primary literature relevant to his/her practice.

Examples of activities that might prove fulfilment ofOptional Performance Indicator:The pharmacist has an extensive knowledge of sourcesand types of drug information and selects theappropriate source; employs a structured systematicapproach for responding to requests; utilizes astructured systematic approach for documentingquestions and responses and makes use of such asystem to facilitate responses to similar questions;completes primary literature searches appropriately andefficiently.

— Continued


2.3 A pharmacist mustevaluate scientificinformation.

Critically review information to ensure itsappropriateness prior to responding to a request.

The pharmacist provides an assessment of the relevance,applicability and accuracy of an article located by a patient;provides only relevant, accurate information to patients.

2.4 A pharmacist mustorganize and disseminateinformation.

Consistently present relevant, accurate informationin a usable form and in a timely manner.

The pharmacist within several days provides a verbalsummary and copies of information located to a physicianasking for information about the use of a new antibiotic forcommunity acquired pneumonia; provides an immediateverbal recommendation to a mother asking about the use ofaspirin for fever in her infant.

2.5 A pharmacist mustprovide information ondisease prevention andhealth promotion.

Support health promotion campaigns related torecognition and management of common, criticaldiseases such as diabetes, cardiac disease, stroke,hypertension and breast cancer.

The pharmacist makes available appropriate pamphlets orother prepared information regarding these conditions; whenrequested, provides verbal summaries of informationcontained in such pamphlets or other prepared information.

Provide accurate information to patients inquiringabout poison prevention.

The pharmacist explains appropriate safe storage ofhousehold products, medications, non-prescription drugsand vitamins around children.


Place information in perspective to current practice. The pharmacist explains why therapy cannot be based onsuggestions made in popular magazines or un-referencedresources; explains why a single, well done study may not beapplicable to a particular patient’s case.

Optional Performance Indicators reflectingadvanced or exemplary practice:Critically analyze primary or basic scienceliterature as it applies to the provision of druginformation and recommendations.

Examples of activities that might prove fulfilment ofOptional Performance Indicator:The pharmacist assesses the adequacy of researchdesign, relevance, applicability, accuracy, reliability,validity and generalizability of primary literature.

Optional Performance Indicators reflectingadvanced or exemplary practice:Proactively identify and fulfil drug informationneeds of individuals and groups.

Examples of activities that might prove fulfilment ofOptional Performance Indicator:The pharmacist prepares and distributes DI newslettersto patients or other health care providers.

Provide recommendations about all legal drugs,including herbal and complementary medicines.

The pharmacist uses his/her drug information skills toparticipate in the development of formularies or drug usepolicies.

Optional Performance Indicators reflectingadvanced or exemplary practice:Provide recommendations on diseaseprevention and health promotion

— Continued


Optional Advanced Roles: Possible Performance Indicators Examples of activities that might prove fulfilment of Possible Performance Indicators

Drug Policy

Routinely use evidence-based principles to makerecommendations for drug policy.

The pharmacist uses primary literature to assess thetherapeutic and pharmacoeconomic benefits of one drugrelative to another for inclusion in a formulary or coverage ina drug program.

Actively seek or assume leadership roles in policymaking regarding appropriate drug use.

The pharmacist volunteers for membership in policy-makingcommittees; accepts responsibility for developing keyrecommendations regarding reimbursement.

Drug Information Use complex forms of analysis to discover issuesrequiring the provision of drug information or druguse recommendations.

The pharmacist analyses drug use patterns within thepractice setting (from various data sources includingsurveys, data bases); analyses documentation completedfor management of individual patient’s drug relatedproblems; completes surveys of clients to identify need forinformation or recommendations.

Prepare and present routine sources of druginformation.

Routinely assess the outcomes of drug informationprovided to individual clients.

The pharmacist writes review articles, education articles orcontinuing education articles; prepares and distributes newdrugs bulletins or newsletters; offers drug informationcolumns in newspaper or advice shows on TV, radio, orInternet.

Actively promote their role in the provision of druginformation and recommendations by identifyingneeds in populations (communities) beyond theirindividual practice site.

The pharmacist creates linkages with other pharmacies toidentify issues in drug use; completes surveys of clients toidentify needs for information or recommendations.

Undertake specialty employment in a druginformation or related centre.

Regularly offer educational events that focus ondisease prevention and general health promotion.

Health Promotion Routinely work with patients to plan and attainhealth goals related to health promotion.

The pharmacist discusses the value of good nutrition andexercise for an overweight patient and refers him/her to adietician if appropriate; addresses the requirement forbicycle helmets for children.


Professional Competency #3: EducateCompetency Unit

Pharmacists educate individuals to support optimal patient care andto promote health.


Pharmacists participate in the instruction of individual pharmacystudents and interns, however serving as a preceptor to pharmacy

students, interns, or residents is considered to be outside theexpectations for initial and continuing registration, as is educatinggroups of patients, peers or health care providers.7

3.1 A pharmacist mustmaintain an involvement inthe education of pharmacystudents / interns /residents.

Routinely support the instruction of pharmacystudents / interns / residents.

The pharmacist is receptive to requests for assistance fromstudents / interns / residents assigned to the pharmacy;functions as a role model for students / interns / residentsassigned to the pharmacy; shares experience with students /interns / residents

Competency Element Required Performance Indicators Examples of activities that might prove fulfilment of Required Performance Indicator

7. Education of individual patients as part of patient counselling is addressed in Competency #1 relating to the provision of pharmaceutical care. Education of individual patients regarding druginformation or health promotion is addressed in Competency #2, By elimination, this leaves the remaining area of education of students or groups about drugs, drug use and health promotion forconsideration for inclusion in Competency #3.

8. Each Faculty / College uses different terms for such faculty members. This role is meant to encompass all of these titles.

Optional Performance Indicator reflectingadvanced or exemplary practice:Function as a preceptor for students / interns /residents from pharmacy or other healthprofessions


Teaching Associate /Preceptor8

Obtain and maintain expertise in teaching andlearning.

The pharmacist attends conferences on teaching of healthprofessionals.

Actively seek opportunities to teach about drugsand drug use to various individuals or groups.

The pharmacist volunteers as a speaker for support groupsfor patients; offers to provide a continuing education / in-service program for nurses; regularly submits papers orposters at pharmacy or other health care conferences;inquires at pharmacy or other health care Faculties orlicensing bodies about opportunities for teaching orpreceptoring students; offers to participate in career nightsat local schools.

Consistently and effectively use structuredapproaches to design, implement and evaluate aneducational plan.

The pharmacist identifies the learning needs of participants;selects educational methods that are appropriate for thelearners; implements an educational plan for individual orgroups; assesses outcomes.


Professional Competency #4: Manage Drug DistributionCompetency Unit

Pharmacists manage drug distribution by performing or supervisingthe functions of acquisition, storage, preparation, and distribution ofdrugs to ensure the safety, accuracy and quality of supplied products.


Pharmacists take responsibility for the actual functions or delegationof the functions, of the preparation and distribution of

pharmaceuticals in response to a prescription for an individualpatient. This includes the compounding or preparation (orsupervision of) of common dosage forms such as powders, ointments,creams and oral solutions and referral of the patient to an appropriatepharmacy or other provider of less common dosage forms such assterile products, chemotherapy or suppositories. Pharmacistsundertake this competency in all settings that utilize common drugdistribution systems.

4.1 A pharmacist mustperform, supervise and/ orreview drug preparation anddistribution activities.

Fulfil established drug distribution policies andprocedures9.

Appropriately identify and perform professionalfunctions associated with drug distribution, including:

– providing assistance with the selection ofunscheduled* non-prescription drugs whenrequested;

– offering assistance with the selection of Schedule III* drugs when appropriate;

– providing professional information and adviceregarding selection and use of Schedule II* drugs;

– completing professional functions outlined inCompetency #1 when providing pharmaceuticalcare as part of the drug distribution process;

– identifying and resolving problems related toprofessional functions, delegated drug preparationor distribution functions that may prevent thepatient from attaining the desired effects of themedication such as: • interpretation of prescription medication orders;• bioequivalency & interchangeability of multi-source drugs;

• ability to pay (drug plan or formulary issues);• pharmaceutical calculations;• selection of ingredients;• acquisition and supply of pharmaceuticals;• compounding or preparation; • product packaging, storage, handling, stabilityand expiration.

– ensuring accuracy and quality of delegateddistribution functions, including maintenance ofrecords of drug distribution

– ensuring safe and proper disposal of drugs andnon-prescription medications

– correcting dispensing errors as soon as detected,contacting the patient and patient’s prescriber asrequired to correct the error and managesubsequent problems with the patient’s health,and

– reporting adverse drug reactions that have causeda problem with a patient’s health

Competency Element Required Performance Indicators Examples of activities that might prove fulfilment of Required Performance Indicator

9. The preface to this document states that all activities undertaken by pharmacists are in accordance with all relevant laws and regulations.* According to NAPRA’s National Model Drug Schedules — Continued


4.1 (Continued) Appropriately delegate technical and non-professional preparation and distribution functionsas necessary and as according to provincialregulations, while maintaining responsibility for theaccuracy and quality of these functions.

Ensure that patients have access to all required,appropriate medications that are prescribed inaccordance with relevant policies and that areavailable in Canada.

The pharmacist appropriately delegates pre-packaging of unitdose medications; repackaging of medications; data entryinto computer; selection, counting, transfer, labelling of Rxproducts; billing; and compounding according to standardformulae.

The pharmacist locates stock of uncommon drugs; refers thepatient to a different pharmacy that can prepare specialtyproducts; contacts the prescriber for a change in prescriptionfor a drug not available or not readily available.

4.2 A pharmacist must ensurethat problems identified withindividual prescriptions areaddressed within appropriatetime frames.

Routinely identify and address problems withindividual prescriptions that require immediatemanagement.

Consistently attempt to resolve problems that havebeen identified by pharmacists or technicians fromprevious shifts.

The pharmacist immediately calls the patient when it isdiscovered that a wrong medication was dispensed;immediately informs the patient’s physician if a higherstrength of a medication was dispensed and the patientreceived a dose.

Accurately identify situations involving potential drugdiversion or inappropriate use.

The pharmacist identifies double doctoring; polypharmacy;excess prescription quantities; overly frequent refills; forged oraltered prescriptions.

Systematically identify and communicate problemprescriptions to subsequent pharmacists.

The pharmacist flags concerns with specific prescriptions;completes a summary of issues that need to be addressed atshift change.

Identify issues in the preparation or distribution ofindividual prescriptions that may represent asystematic problem

The pharmacist recognizes that if a technician dispenses aprescription before a pharmacist has checked it, this mayrepresent the lack of a consistent plan for checking ofprescriptions.

Investigate, document and report such situationswere appropriate.

The pharmacist contacts the doctor to confirm authenticity ofprescription or prescription quantity; reviews stolen triplicateprescription reports, pharmacy alerts and fan outs; initiatesfan outs as appropriate; contacts police where appropriate.

Identify and address situations that have thepotential to create distribution problems.

The pharmacist addresses a lack of documentation regardingchecking of filling of dosettes; pre-packaging / advancedpreparation of unlabelled syringes by allied healthprofessionals.


Optional Performance Indicator reflectingadvanced or exemplary practice:Use formal processes to identify and resolvesystematic problems in drug preparation and/ordistribution.

Examples of activities that might prove fulfilment ofOptional Performance Indicator:The pharmacist compiles and analyses drug error reportsto identify patterns and develops projects to investigate /correct these problems.

Optional Performance Indicators reflectingadvanced or exemplary practice:Develop and utilize expertise in management ofdrug misuse and abuse.

Complete analyses of patient profiles /prescription records to identify areas of drugdiversion or misuse.

Examples of activity that might prove fulfilment ofOptional Performance Indicator:The pharmacist provides information to a patient caughtin a cycle of abuse so they can obtain professional help.

— Continued

4.3 A pharmacist must managesituations involving drugdiversion or inappropriate use.



Compounding / SpecialtyPreparations

Establish and routinely utilize programs to test,report and assure the quality of compoundedpreparations.

The pharmacist obtains any specific certification suggestedfor specialty compounding.

Maintain ready access to appropriate facilities,equipment and ingredients required for specialtycompounding / preparation.

The pharmacist has laminar flow hoods installed for sterilepreparation; purchases moulds for suppositories;establishes appropriate, designated compounding areas;maintains an inventory of products necessary for home IVantibiotic or specialty compounding.

Maintain a ‘library’ of resources required to supportquality specialty compounding.

Professional Competency #5: Apply Management PrinciplesCompetency Unit

Pharmacists apply knowledge, principles and skills of management asthey pertain to the site of pharmacy practice with the goal ofoptimizing pharmaceutical care and professional relations.

Situations in Which All Registered Pharmacists Must Fulfil thisCompetency

Pharmacists apply the basic principles of human, financial andphysical resources management required to maintain a safe practice

environment that ensures patients have access to the services andproducts required to meet their drug related needs. They ensure thatall staff members for whom they are directly responsible perform inaccordance with these same requirements. Pharmacists fulfil thiscompetency in all sites where registered pharmacists provide theproducts or services that legally constitute pharmacy practice.

5.1 A pharmacist mustsupervise personnel suchthat delegated functions arecarried out to meet acceptedstandards.

Consistently demonstrate the basic interpersonalskills required to maintain good workingrelationships with personnel.

Constantly demonstrate a clear knowledge of, andadherence to, policies, standards, and requirementsrelated to delegated functions (see Competency #4).

The pharmacist demonstrates respect for personnel; listensattentively to their concerns or problems; is open tosuggestions from staff; facilitates discussion among staff asnecessary; demonstratse appropriate non-verbal behaviour;deals sensitively with embarrassing or disturbing topics;gives information regarding responsibilities in a clear, well-organized, complete manner; ensures an understanding ofdelegated responsibilities (also see Competency #4).

Consistently encourage a professional environmentwithin the pharmacy that places the safety and thewell-being of the patient as a priority.

The pharmacist accepts responsibility for medication errors(including errors committed by support personnel); dealsimmediately with medication errors that pose a risk to a patient;ensures that patient confidentiality is explained, expected andpromoted within the pharmacy; places products with potentialrisks or questionable benefits in a manner to discourage selfselection; clearly explains the risks and ramifications ofsubstance abuse by staff; maintains appropriate professionalrelationships with staff and co-workers.

Required Competency Elements Required Performance Indicators Examples of pharmacist activities that could prove fulfilment of Required Performance Indicators

Optional Performance Indicators reflectingadvanced or exemplary practice:Function as an advocate for other employees tomanagement. Form and promote strong teamrelationships in a practice setting.

Examples of activities that might prove fulfilment ofOptional Performance Indicators:The pharmacist identifies professional, social andinterpersonal activities that contribute to the optimalperformance of staff as a team meeting a common goal.

— Continued


5.2 A pharmacist mustmanage workflow within thedispensary and professionalareas of the pharmacy.

Routinely recognize staff and staffing limitations thatstrain the ability to fulfil professional competenciesrelated to drug distribution and the provision ofpharmaceutical care, drug information andeducation.

Regularly identify and suggest or implementsolutions to staff and staffing limitations.

The pharmacist offers to have a prescription delivered oncetime is available to address problems with the prescription;encourages the legal use of fax or electronic transfer ofprescriptions to minimize technical distribution time duringpeak hours; suggests hiring of part-time staff to cover peaktimes.

Effectively and routinely resolve interpersonalproblems that affect the workflow of the pharmacy.

The pharmacist identifies that pharmacist coverage isinadequate during peak prescription times; recognizes thata technician has been inadequately trained to fulfilexpected functions.

5.3 A pharmacist mustapply management systemspertaining to the site ofpharmacy practice.

Identify and report to management the lack oflegally required resources (references, texts, space,facilities, equipment, storage systems) or recordswithin the pharmacy.

Appropriately identify and obtain resources requiredto fulfil the professional competencies related to theprovision of information, education andpharmaceutical care.

The pharmacist identifies tertiary references relevant to theneeds and interests of the practice population (e.g. herbaltherapies texts); documents the need for access tocomputerized or Internet based information sources.

Ensure financial accuracy of individual prescriptions. The pharmacist ensures that medication costs areconsistent, accurate and competitive with the market place;ensures that prescription prices are appropriate; ensuresthat prescription accounts are responsibly submitted whenadjudicated by a third party payer.

Complete professional responsibilities in anefficient, appropriately prioritized order.

The pharmacist completes searches for information duringoff peak times and when no patients are waiting; avoidscompleting chart reviews during nursing shift changes; usesquiet times to complete all authorized refills (e.g. doesn’twait to prepare refills for all five prescriptions if only oneneeds an authorization from the doctor).

Demonstrate authority in prioritizing short-termworkflow issues to ensure smooth and consistentworkflow.

The pharmacist assigns telephone-answeringresponsibilities to a specific technician during peak times.


Optional Performance Indicator reflectingadvanced or exemplary practice:Develop and implement a plan to addressworkload problems

Examples of activities that might provefulfilment of Optional Performance Indicator:The pharmacist investigates and proposes thepurchase of robotics; develops and implementsa policy to see pharmaceutical representativesby appointment only; develops and organizes apatient appointment system to provide more in-depth care.

Optional Performance Indicator reflectingadvanced or exemplary practice:Develop or modify a policy and proceduremanual for the workplace.

— Continued


5.4 A pharmacist mustinterpret and apply the drugutilisation, reimbursementand pharmacoeconomicspolicies of health carefacilities and agencies, andfederal, provincial and thirdparty drug insurance plans.

Consistently provide prescription drugs inaccordance with terms of third party payers andapplicable formularies.

The pharmacist refuses a request to inappropriately billthird party payers for non-prescription items.

Consistently and appropriately follow relevantpolicies for generic substitution and therapeuticsubstitution.

When requested or necessary, explain in generalterms the concept of co-payments and deductiblelimits.

When requested or necessary, explain in generalterms the concept of a professional fee and theservices to which it applies.

Consistently and appropriately dispenseprescriptions in accordance with prescriptionquantity limitations.

The pharmacist dispenses trial prescriptions; 100 day versus30-day supplies; adequate supplies for ‘snowbirds’.


Optional Performance Indicators reflectingadvanced or exemplary practice:Maintain active involvement in development offormularies.

Seek alternate / additional forms ofreimbursement for required, appropriateprescriptions not covered by routine third partypayers.


Pharmacy manager /designated manager 10

Ensure that all inventories are managedappropriately.

Resolve any systematic problems in the preparationor distribution of individual prescriptions that havebeen identified by pharmacy staff.

The pharmacist ensures the appropriate removal anddisposal of out of date inventory; ensures the appropriatestorage, checking and record keeping of narcotics andcontrolled substances.

The pharmacist schedules appropriate numbers and types ofstaff; hires part-time staff to cover peak times; ensures thata registered pharmacist is working during all hours ofoperation of the dispensary; ensures that staff areappropriately trained or certified to perform their jobresponsibilities; identifies and manages/reports problems inprofessional competency.

Ensure the availability of all legally requiredresources (space, facilities, equipment, storagesystems, references, texts) or records within thepharmacy.

The pharmacist has installed laminar flow hoods for sterilepreparation; purchases moulds for suppositories;establishes appropriate, designated compounding areas;maintains an inventory of products necessary for home IVantibiotic or specialty compounding.

Ensure the appropriate staffing of the pharmacy.

10. Modified from Association of Faculties of Pharmacy of Canada Educational Outcomes — Continued



Pharmacy manager /designated manager(Continued)

Apply the components of a marketing strategy(price, product, place and promotion) in aninstitutional pharmacy setting.

The pharmacist documents and describes the value of druginformation or pharmacist monitoring services to counterrequests to reduce staff.

Apply a detailed knowledge of purchasing andinventory control.

The pharmacist prepares the specifications for tendering thepurchase of drugs from several potential suppliers.

The pharmacist assesses the financial health of anenterprise and gives an estimate of the valuation of thebusiness; calculates the real cost to dispense a prescriptionin a particular pharmacy and compares it with industrynorms.

Develop a customized marketing plan for a specificpharmacy

The pharmacist proposes specific short or long termmarketing objectives (such as increasing consumerawareness, increasing prescription demand, developing newservices, altering market segments of customers); delineatesspecific and strategic initiatives based on marketingprinciples to achieve objectives.

Apply a detailed knowledge of financialmanagement / controls, cash and assetsmanagement, accounting methods and indicators offinancial performance, budgeting, property andliability insurance and risk management.

The pharmacist prepares an annual business plan for apharmacy operation; prepares a strategic plan.

Apply a detailed knowledge of strategic planning.

Optional Advanced Professional Competency #6: Undertake Research11

Advanced Competency Unit

Pharmacists apply the principles of scientific inquiry to addresspharmacy practice issues.

Situations in Which Pharmacists Might Fulfil this Competency:

At the initial level, pharmacists initiate research using their owndatabase / patient population. At an intermediate level they complete

projects as part of a group of investigators or organise group researchprojects. At an advanced level they undertake formal researchprojects with external funding, peer / ethics review, and publicationof results.

6.1 Apply the principles ofscientific inquiry to addresspharmacy practice issues

Use scientific method of inquiry to plan aninvestigation of a pharmacy problem encountered inpractice.

The pharmacist identifies a practice problem; suggestsappropriate research questions and hypotheses; suggestsmethodology for evaluation of a hypothesis; suggestspossible analyses of data; provides valid interpretations ofthe results of data analysis.

6.2 Understand and adhereto ethical research principles

Develop research plans to investigate pharmacypractice problems that comply with all major ethicalprinciples

The pharmacist determines ethical principles that arerelevant to a particular pharmacy practice researchproposal; includes fundamental principles such as informedconsent, ethical selection / exclusion / randomisation ofparticipants, ethical methodological designs, confidentiality,seeking of project approval.

Optional Advanced Possible Performance Indicators Examples of activities that might prove Competency Element fulfilment of Possible Performance Indicators

11. Modified from Association of Faculties of Pharmacy of Canada Educational Outcomes

— Continued


6.3 Prepare and defend aresearch plan

Prepare a complete, succinct report of a researchplan.

The pharmacist includes all required details of the project;organises the report properly and in accordance withrequirements of journals; follows the scientific method.

Conduct the study.

Prepare written reports that meet publishablestandards.

Present results of research projects completed to The pharmacist presents research projects and results toexternal audiences; local pharmacy meetings; regulatoryauthority committees.

Optional Advance Possible Performance Indicators Examples of activities that might prove Competency Element fulfilment of Possible Performance Indicators

Present a research project in an appropriate,scientific manner to faculty and peers.

The pharmacist follows the scientific method whenorganizing the presentation; uses appropriatecommunication and educational strategies; usesappropriate technology to enhance presentation.

1. Professional Competencies for Canadian Pharmacists at Entry-to-Practice. Ottawa, Canada: NAPRA 1997

2. Model Standards of Practice for Canadian Pharmacists. Ottawa,Canada: NAPRA 1998

3. Gonczi, A., Hager, P., Oliver, L. Establishing Competency-basedStandards in the Professions. Research Paper No. 1. NationalOffice of Overseas Skills Recognition. Canberra, Australia:Australian Government Publishing Service 1990

4. Association of Faculties of Pharmacy of Canada. EducationalOutcomes and Levels of Performance Expected of PharmacyGraduates in Canada. 1998

5. Masters, G.N., McMurry, D. Competency-based Assessment inthe Professions. Research Paper No.2. National Office ofOverseas Skills Recognition. Canberra, Australia: AustralianGovernment Publishing Service 1990

6. Heywood, L., Gonczi, A.., Hager, P. A Guide to Development of Competency Standards for Professions. Research Paper No.7.National Office of Overseas Skills Recognition. Canberra,Australia: Australian Government Publishing Service 1992

7. Kiely, P.M., Chakman, J., Horton, P. Optometric therapeuticcompetency standards 2000. Clinical and ExperimentalOptometry. 2000; 83(6): 300-314

8. Sadler, D.R. Specifying and Promulgating AchievementStandards. Oxford Review of Education. 1987; 13(2):191-209

9. Cunnington, J.P.W., Norman, G.R. Certification and re-certification: are they the same thing? Academic Medicine.2000; 75(6): 617-9

10. Boud, D. Enhancing Learning Through Self-Assessment.London, UK: Kogan Page 1995

11. Bennett, N.L., Davis, D., Easterling, W.E., Friedmann, P., Green,J.S., Koeppen, B.M., Mazmanian, P.E., Waxman, H.S.Continuing Medical Education: a new vision of the professionaldevelopment of physicians. Academic Medicine. 2000; 75:1167-1172

12. American Board of Internal Medicine. Project Professionalism.Philadelphia, USA: American Board of Internal Medicine,Philadelphia 1998

13. Calgary-Cambridge Observation Guide. In: Teaching andLearning Communication Skills in Medicine. Kurtz, S.,Silverman, J., Draper,J. Oxon, UK.: Radcliffe Medical Press Ltd. 1998

References


Appendix AWorking Group MembersCarole Beveridge, BScPhmCommunity pharmacistCambridge, ON Nominated by Canadian Pharmacists Association

Erin Mackenzie, BScPhmCommunity pharmacistCharlottetown, PEINominated by Canadian Council for Continuing Education in Pharmacy

Rob Jaska, BScPhm, CAECommunity pharmacistBrandon, MBNominated by the Manitoba Pharmaceutical Association

Andrée Mallet, BScPhmCommunity pharmacistWhitehorse, YKNominated by Yukon Government

Midge Monaghan, BScPhmCommunity pharmacistHamilton, ON Nominated by the Ontario College of Pharmacists

Brenda Schuster, BSP, PharmD Hospital Pharmacist/Academic DetailerRegina, SKNominated by the Saskatchewan College of Pharmacists

Zebrina Suleiman, BScPhmConsultant PharmacistToronto, ONNominated by Canadian Association of Chain Drug Stores

ConsultantNancy Winslade, BScPhm, PharmD, MHPEConsultant in Health Professions Education and AssessmentThe Netherlands(now Montreal QB)

NAPRA Liaison and Project DirectorBarbara Wells, BScPhmExecutive Director, NAPRAOttawa, ON

Cathy Biggs, BScPhmCommunity pharmacistSherwood Park, ABNominated by the Alberta College of Pharmacists

Tinka von Keyserlingk, BScPhmCommunity pharmacistSmithers, BCNominated by the College of Pharmacists of British Columbia

Eric Lee, BScPhmHospital pharmacistWinnipeg, MBNominated by the Manitoba Pharmaceutical Association

John McNeil, BScPhmCommunity pharmacistSydney, NSNominated by the Nova Scotia College of Pharmacists

Cathy Purvis, BScPhmCommunity pharmacistWoodstock, NBNominated by the New Brunswick Pharmaceutical Society

Regis Vaillancourt, CD, BPharm, PharmDCommunity and hospital pharmacistQB, ONNominated by the Department of National Defense and NAPRA

model standards of practice for canadian pharmacists · model standards of practice for canadian...

Documents