Completion of an Annual Summary of Performance Improvement Continues to Be One of the Most Missed Standards During a Survey

By Lori A. DeVito, RPh., HDDP, PCAB Compounding Pharmacy Specialist

Standard TCRX5-L: There is an annual Performance Improvement (PI) report written.

Interpretation: There is a comprehensive, written annual report that describes the PI activities, findings, and corrective actions that relate to service provided. In a large multi-service provider, the report may be part of a larger document addressing all of the organization’s programs.

While the final report is a single document, improvement activities must be conducted at various times during the year. Data for the annual PI report may be obtained from a variety of sources and methods, such as reports, client/patient questionnaires, feedback from referral sources, and outside survey reports.

Now Is a Good Time to Take Another Look at Your PI Program
The PI activities the pharmacy chooses should be specific to areas needing improvement. In addition to at least one important aspect related to the services the pharmacy provides, the annual PI summary reports on adverse events, complaints/grievances, record review, and infection/communicable disease monitoring.

Throughout the year, data and information is gathered and then compiled into an annual report of the entire year’s PI projects/activities. Now is the time to start thinking about reevaluating your PI program and begin gathering the data needed to complete your annual written report!

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