Due to recurring issues pertaining to the certification process for Pharmacy Sterile Compounding Clean rooms, The Joint Commission posted a blog and issued a letter in 2018 informing sites that this would be a focus of the survey. Atrium Health, Central Division, with over 1,000 patient beds and just under 20 pharmacy clean rooms, conducted a multidisciplinary review of requirements, roles and responsibilities around clean rooms. Through this webinar, they will provide a roadmap for developing a program for continual certification and share lessons learned from going through The Joint Commission survey in 2018.

Learning Objectives:

• Identify the Pharmacy Sterile Compounding Clean Room environment certification
  
• Develop a roles and responsibility matrix and flow chart
  
• Define when certification is required, beyond every 6-months, i.e., “whenever the device or room is relocated or altered or major service to the facility is performed.”
• Provide requirements to the agency performing the required certifications