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The Compliance Team
Key Elements of Evaluating Immunizations Services
- Charles Lager, RPh, MBA, Senior Pharmacy Advisor

Between 1998 and 2011 the number of pharmacy-based adult immunizations increased 13% (National Adult & Influenza Immunization Summit, 2013). That number continues to grow as more pharmacies take the necessary steps to become certified and accredited to provide immunization services. Pharmacies that provide these services have a great opportunity to increase the value and service that they offer their patients by meeting public health needs and advancing patient care.

Pharmacists should administer vaccines only after thorough training and certification. Certification provides a quality process for administering injections and controlling infection. Accreditation takes certification to the next step by verifying and validating your processes. Accreditation proves to your clients and to your payors that you have implemented and are maintaining the processes and policies to ensure best practices for all aspects of immunization procedures and for the safety of your clients.

When providing Immunization Services in your pharmacy, your accreditation organization (AO) will evaluate key elements to successfully meet PTS 3.0 Standard, which states “Patient Care Services are provided and developed by the Pharmacy under the guidance of the Pharmacist. Evidence-based guidelines and best practices are followed for the following programs (if provided by the pharmacy).”

Evidence of the following practices is required when accrediting your pharmacy for immunization services:

  1. The organization has written policy and procedures for an Immunization Services Program.
  2. The organization practices infection control techniques by utilizing the following:
    1. Hand washing before and after each patient contact.
    2. Utilization of gloves and aseptic technique while preparing and administering shots.
    3. Utilization of Universal/Standard Precautions when at risk for exposure to Blood-borne pathogens.
    4. Immunization services should adhere to Recommendations and Guidelines developed by:
      1. American Pharmacists Association Immunization Guidelines
      2. Centers for Disease Control Immunizations Recommendations and Guidelines
      3. State Board of Pharmacy as applicable
Below are the key elements of The Compliance Team’s on-site accreditation evaluation:
  1. Does the pharmacy have policies & procedures for the Immunization Service?
  2. Have the pharmacists providing immunizations completed certification training?
  3. Do the pharmacists providing immunizations have a current CPR certification?
  4. If providing immunizations within the pharmacy, is the area clean and organized for patients?
  5. Is aseptic technique (Universal/Standard Precautions) utilized in preparation and proper disposal after immunization?
  6. Does the immunization area provide for patient privacy?
  7. The pharmacist should be able to describe their process / setup / immunization for a typical patient.
  8. Are the proper documents provided to patients (i.e. information about the vaccine, side effects, patient signed consent to immunization)?
  9. Does the pharmacy have the appropriate references available?

If you would like more information on The Compliance Team’s Exemplary Provider® Community Pharmacy program, which includes immunization services, call 215-654-9110 or fill out the form on our website.

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