Standard Six: Leadership
Standard outcome:
Pharmacy has a clear strategic vision, effective organisational processes, governance, and controls necessary to ensure people using services are safe and get the best from their medicines. This is underpinned by strong personal, professional and clinical leadership.
Descriptor 6.1: Strategic leadership
Descriptor outcome:The pharmacy senior leadership team ensures that the organisation maintains a clear vision for pharmacy services, ensuring timely access to medicines as well as their optimal use across the organisation and wider healthcare system.
Within the pharmacy service, the pharmacy senior leadership team:
- Are accountable for the quality of pharmacy services across the organisation, the quality of medicines used and ensuring that the organisation has safe and legal medicines policies and procedures
- There is board level sign up to the vision for pharmacy services within the organisation
- Provide assurance to the Board about the safe and effective use of medicines within the organisation through routine governance processes and risk management reporting
- Ensure the organisation has a strategy and implementation plan that has Board approval and support to ensure that people get the best outcomes from medicines which is regularly reviewed
- Ensure a long-term plan is in place for succession planning and workforce leadership development at all levels from trainee through to senior posts
- Collaborate on transformation of and innovation in service delivery to better meet people’s needs, including the adoption of national initiatives and guidance, and encouraging active involvement
- Engage with the health community to develop a whole system approach to medicines and public health, including health inequalities, sustainability, interoperability’s, emergency preparedness, resilience, and response.
Descriptor 6.2: Operational leadership
Descriptor outcome: Pharmacy services are safe, effective, and efficiently delivered in line with organisational, regional, and national priorities and performance indicators, and the range and level of healthcare commissioned/purchased.
Within the pharmacy service:
- The statutory role of “Chief Pharmacist” is appointed to someone within the organisation whose duty is to ensure the safe and effective running of the pharmacy service
- The type and level of resources required to deliver a safe, effective, and efficient service are identified and available to support the safe and secure use of medicines
- Agreed key performance and quality indicators are in place to enable internal and external assessment of the operational performance of pharmacy services
- All outsourced and shared pharmacy services, including homecare and supply functions, are performance-managed through Service Level Agreements and contract quality monitoring. Timely action is taken if services fail to meet contracted standards
- There are clear lines of professional and organisational responsibility established which are regularly reviewed
- There are effective feedback systems from people using services, staff, and anyone involved in the service is sought to ensure patient safety, continuous learning, and service improvements
- The pharmacy team is supported to identify and utilize opportunities for adoption, collaboration, networking and sharing of best practice internally and externally.
Descriptor 6.3: Personal and professional leadership
Descriptor outcome: The pharmacy team take responsibility for their work, recognising they have a duty of care to people and to act in their best interests. They are supported to achieve this by the senior leadership team.
Within the pharmacy service:
- Leadership at all levels across the pharmacy team is encouraged and developed
- Clinical supervision is an integral part of pharmacy team development
- The pharmacy senior leadership team lead by example through commitment, encouragement, compassion, and a continued learning approach
- The pharmacy senior leadership team promote a just, open, and transparent culture which recognises and values diversity of background and thought
- Governance arrangements, aligned to medicines regulations, are in place for the management of all medicines. This includes off-label use of licensed medicines, unlicensed medicines, radiopharmaceuticals, Investigational Medicinal Products, Advanced Therapy Medicinal Products and emerging advances in medicines and medicines technology.
- The pharmacy team behave in a candid, open and honest way encouraging diversity, equality, and inclusion
- All members of the pharmacy team are encouraged and empowered to raise any concerns they may have both from within the pharmacy service, and from other parts of the organisation
- All members of the pharmacy team feel safe and able to speak up about anything that gets in the way of delivering safe, high-quality care or affects their experience in the workplace including a clear route of escalation if unresolved
- All concerns are investigated and, if substantiated, dealt with at an appropriate level in line with the organizational policy
- All members of the pharmacy team manage conflicts of interest in line with organisational, national, regulatory, and professional guidance.
Descriptor 6.4: Clinical leadership
Descriptor outcome: The pharmacy team are recognised as leaders on medicines, medicines use, and innovations in medicines technology both within the organisation and across the health system.
Within the pharmacy service, the pharmacy team:
- Provide advice, education, leadership, and support to other clinicians and support staff about safe, appropriate, and cost-effective medicines usage
- Ensure that their input is an integral part of the design of any service involving medicines
- Support the development of integrated care pathways that involve medicines as a treatment option, as well as the utilisation of pharmacy roles across systems
- Provide or seek leadership and education on the introduction of complex therapies, such as genomics, personalised and precision medicine in collaboration with the multidisciplinary team. The potential implications for service delivery are understood and services involving complex therapies are planned and designed around the needs of people using services.
Standard Seven: Systems of work
Standard outcome:
Systems of work are in place and maintained which support the maintenance of good practice, learning from mistakes, and improvement of services whilst having clear business and financial arrangements.
Descriptor 7.1: Systems governance
Descriptor outcome: Systems of work are established that are accountable, safe, regularly audited, and comply with relevant regulations.
Within the pharmacy service:
- All pharmacy team members are trained in information governance to safeguard patient-identifiable information about care/medicines supplied
- Governance systems are in place for working with the pharmaceutical industry
- Working environments are planned and maintained in line with Health and Safety requirements, regulatory, and professional best practice standards
- Equipment and systems are maintained and operated only by appropriately trained members of the team or appropriate external contractors
- Standard operating procedures are in place for the delivery of all pharmacy services across the organisation
- Business continuity plans are developed, tested, and maintained for all services
- Risk registers with appropriate escalation mechanisms are maintained.
Descriptor 7.2: Research, audit, and quality improvement
Descriptor outcome: The pharmacy team actively participate and conduct research, audit, or quality improvement projects to improve outcomes of pharmacy services.
Within the pharmacy service:
- The continuous improvement and development of pharmacy services is informed by a programme of research, audit and/or other improvement techniques/methodologies
- The pharmacy team is supported to develop skills to participate in, conduct, and lead research, audit, and quality improvement projects
- The pharmacy team is supported to identify gaps in the evidence base
- The pharmacy team seek opportunities for collaboration at system, regional and national level to work with academia and other research partners, including involving and engaging with patients and the public
- A named individual ensures there are appropriate governance mechanisms in place for conducting research, audit, and quality improvement projects
- Care contributions are documented and audited to demonstrate the impact of the service on patient outcomes.
Descriptor 7.3: Business and financial management
Descriptor outcome: Effective business and financial planning alongside sustainable cost improvement programmes and reporting are assessed and evaluated on a regular basis.
Within the pharmacy service:
- A business plan incorporating finance, service, capacity, and workforce plans, linked to the organisation’s corporate plan is developed, implemented, and monitored
- Local, regional, and national initiatives and guidance relating to medicines and pharmacy are incorporated into service planning activities
- Medicines use and expenditure reports are regularly interpreted and used to support budget management and monitoring of prescribing and service data
- The pharmacy team regularly engages with commissioners and primary care to review prescribing to deliver value across the health system
- Proactive horizon scanning is undertaken to identify and understand emerging transformational technologies and services and the impact of these on business and financial planning
- Operational performance is benchmarked against other relevant organisations using key information sources.
Standard Eight: Workforce
Standard outcome:
The pharmacy team has the right skill mix, capability, and capacity to provide safe, quality services to people whilst being supported to maintain their personal development and health and wellbeing.
Descriptor 8.1: Workforce planning
Descriptor outcome: The pharmacy team has appropriate levels of staff available to deliver a safe, high-quality service now and in the future.
Within the pharmacy service:
- Workforce data is collected and analysed, with trends identified and acted upon. This is linked to the organisational strategic workforce plan
- The pharmacy senior leadership team maximise the use of systems, such as digital rostering, to inform optimum use of pharmacy staff resource dependent on hospital workflow
- The training pipeline secures sustainable numbers within all parts of the pharmacy team through collaboration with local commissioners
- Imbalances in supply and demand for pharmacy staff are understood and corrective measures put in place considering quality, accessibility and acceptability for people using services and the organisation
- Succession planning arrangements are in place and are linked to workforce training and personal development plans
- Modelling is undertaken to predict future workforce requirements.
Descriptor 8.2: Workforce development
Descriptor outcome: The pharmacy team is supported to develop new skills and attributes to meet the needs of people using services, their families, and circles of support across the health and social care system.
Within the pharmacy service:
- Workforce development is included in the pharmacy strategic plan. This is linked to the organisational strategic workforce plan
- Workforce development takes a needs-based approach focusing on future service needs and new models of care, and engaging with local service planners, education commissioners and members of the multi-disciplinary team
- Skill mix is reviewed across the pharmacy and wider clinical team considering changing demographics, advances in technology, and the effective use of available and future staff resources
- All staff are given appropriate training to their role to ensure they can provide a safe and effective service
- Roles are designed that support models of integrated care that enable collaboration across the wider multi-disciplinary team in all sectors
- The outcomes of workforce development plans deliver cost-effective use of staff practising at their highest skill level
- The development of advanced pharmacy roles achieves the right balance between generalists and specialists necessary to meet the needs of people and the organisation.
Descriptor 8.3: Workforce quality assurance
Descriptor outcome: Operational policies, procedures, and plans are in place to ensure that the pharmacy workforce is managed and appropriately resourced to support service quality, productivity, and safety.
Within the pharmacy service:
- All members of the pharmacy team are clear about their role and responsibilities and aware of their level of performance and competency as part of a robust annual appraisal, and performance and talent review process. Personal development plans highlight appropriate professional, managerial and leadership frameworks, tools, and assessments
- Staffing levels are reviewed and set to ensure the delivery of safe services. The senior leadership team determines levels locally taking account of national guidance where it exists
- A culture of continuous learning is apparent, and all members of the pharmacy team acknowledge their role as learners, educators, and trainers. Tutors, mentors, and supervisors are trained appropriately and meet any relevant standards and guidance
- Continued learning and professional/personal development opportunities are provided for all members of the pharmacy team
- Pharmacists, pharmacy technicians and non-registered pharmacy staff have access to early years vocational training and development programmes and support.
Descriptor 8.4: Inclusion and wellbeing
Descriptor outcome: The pharmacy team has a culture of belonging which champions inclusive and authentic leadership, challenges inclusion and diversity barriers and promotes positive mental health and wellbeing.
Within the pharmacy service, the pharmacy team:
- Champion an inclusive, diverse culture of belonging by treating their team with kindness and respect, ensuring the diverse voices of colleagues are represented, heard, valued, and included in decision making
- Commit to better understand and respect each other’s backgrounds, experiences, beliefs, boundaries, and choice. They support all to be their authentic self when at work
- Understand their own personal biases and look to be an ally for under-represented groups
- Have zero tolerance for any form of discrimination, bullying or harassment and can raise concerns without fear of repercussions
- Collect and understand workforce data relating to equality and diversity and have an action plan to address any identified inequalities
- In partnership with the senior leadership team commit to providing a healthy work-life balance for the pharmacy team through encouraging them to take their full allocation of breaks and flexible working options where appropriate
- Feel empowered to look after their own mental and physical health and wellbeing and can speak up when work expectations and demands are too much
- Are actively aware of what support is provided for wellbeing and how to access it.