Get practical insights from pharmacy leaders on building consistent, compliant compounding programs across multiple sites.
In this on-demand panel discussion, pharmacy leaders from leading health systems share real-world strategies for standardizing sterile compounding practices across multiple sites and teams. The conversation explores both the benefits and challenges of aligning documentation tools, workflows, and compliance efforts systemwide. Our expert panelists included:
- Dr. Kristen March, PharmD, BCPS, Northwestern Medicine
- Dr. David Dakwa, PharmD, MBA, BCPS, BCSCP, UC Davis Health
- Dr. Charnae Ross, PharmD, MSHA, BCSCP, New York Presbyterian Hospital
Moderated by Dr. Annie Lambert, PharmD, BCSCP, Clinical Program Manager for Compliance Solutions at Wolters Kluwer, this insightful discussion reveals just how critical systemwide alignment is to achieving safer, more efficient, and USP-compliant operations.
What’s covered
- The impact of health system standardization on regulatory compliance and organizational efficiency.
- Practical tips to create consistent practices, workflows, and compliance strategies that work across locations.
- How to address potential challenges and avoid common pitfalls during implementation.
Key compounding standardization insights from the experts
Start with structure
Standardization begins by identifying and closing gaps. Panelists emphasized the importance of conducting detailed gap analyses and forming cross-functional oversight committees to align policies, SOPs, and training protocols.
Dr. March of Northwestern Medicine stressed the importance of drilling down into the smallest details in these efforts: “Do a gap analysis, standardize your SOPs, your policies… down to the level of is everybody using the same PPE? Are we all using the same cleaning supplies?” she said. “Be very detail oriented in your SOPs and in standardization.”
Collaborate across departments and roles early
From pharmacy to EVS and nursing, cross-department collaboration is essential to compounding standardization cross health systems. These experts agree that early and ongoing engagement helps break down silos, reduce resistance, and foster shared accountability.
Dr. March shared how she helps frontline teams understand the “why” behind new practices by connecting procedures to patient safety:
“Bring it to them like, ‘this needs to be clean, because if this is not clean, we grow bacteria. We risk contaminating the medication that's going to be infused into a patient. They could get an infection.’” Dr. March said. “Sometimes I think, just providing that basic background really changes their engagement when it comes to standard operating procedures.”
For Dr. Dakwa, celebrating successes and showing results was key to cross-team engagement. “Everybody wants to be celebrated, per se... For us, it’s sharing the inspection reports with the staff members and letting them know, ‘hey, your efforts are actually helping out’,” he said.
Keep it consistent, not complicated
The best policies are detailed but simple. Panelists shared that over-engineering procedures can backfire. Focus instead on the essentials — what you’ll actually be held accountable for — and align documentation accordingly.
Dr. March reminded attendees, “Think simple. When writing your policies and procedures, think, ‘what am I going to be surveyed on?’ And only include that type of information.”
Innovate for the future
Technology is reshaping what’s possible in sterile compounding. From real-time analytics to smart hoods and robotics, the panelists are already piloting new tools that could streamline processes and improve safety systemwide.
