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.
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
MHA, SASHE, CHFM,
Director, Facilities Operations,