Hospital Pharmacy Managers – How to Schedule Practice Reviews and Complete a Pre-Review


Hospital Pharmacy Managers – How to Schedule Practice Reviews and Complete a Pre-Review

There are two parts to the Hospital Practice Review: the Pharmacy Review and the Pharmacy Professionals Review.

Pharmacy Managers assist in the delivery of both parts of the practice reviews by completing the Pharmacy Pre-Review, scheduling the Pharmacy Review, and scheduling staff for their individual Pharmacy Professionals Reviews.

The following information is intended to assist Pharmacy Managers in scheduling Hospital Practice Reviews and ensuring you have completed all the preliminary requirements.

Role of the Pharmacy Manager during a Practice Review

As a Pharmacy Manager, when your pharmacy is selected for a Practice Review, you need to:

  • Review Practice Review Program information on the College website
  • Confirm availability for yourself, the pharmacy and your staff for your selected review dates
  • Confirm the number of regulated staff working at the pharmacy during the expected review period by working with the College (by reviewing the staff roster provided to you in the selection email received from the College) 
  • Update staff roster in the College’s eServices Pharmacy Portal
  • Print and post the Practice Reviews in Progress poster to keep staff informed (optional)
  • Request all registered pharmacy professional staff update their College eServices profiles
  • Complete the Hospital Pharmacy Pre-Review (Pre-Review access link provided by College in PRP selection email)
  • Schedule your registered pharmacy professional staff for their Pharmacy Professionals Reviews and provide your Pharmacy Professionals Review Schedule to
  • Be on-site at the start and end of the Pharmacy Review

Notification of a Practice Review

Pharmacy Managers will receive email notification of their upcoming review at least 60 days in advance of the schedule start date.

Pharmacy Managers must confirm their availability for the date range provided or address any scheduling conflicts by responding to   

How to Complete a Hospital Pharmacy Pre-Review

The Hospital Pharmacy Pre-Review is an important step in the practice review process. It assists you, as the pharmacy manager, to prepare for the Pharmacy Review by self-assessing your own practice setting against the College’s bylaws and policies. You can identify and correct (if possible) any areas of non-compliance prior to your on-site Hospital Pharmacy Review.

When on-site, Compliance Officers will use the same review questions as the pre-review, so there are no surprises. If there has been a change in requirements between the pre-review and the Pharmacy Review, the pharmacy will be reviewed using the current standards.

You will need approximately 2 hours to complete The Hospital Pharmacy Pre-Review.

If you are unable to complete the Hospital Pharmacy Pre-Review in one session, you can do so over multiple sessions by using the Save and Continue button to save your progress.

Note: You can only access your saved Hospital Pharmacy Pre-Review from the same link you originally used to open it. If you cannot locate your link, contact

As you complete the pre-review, references to College bylaws and policies are provided. Click on the hyperlink associated with each question to see the applicable requirement. 

Follow these steps to complete the Hospital Pharmacy Pre-Review

  1. Assess your pharmacy’s compliance with the College’s bylaws and policies by selecting either “Compliant” or “Non-Compliant” for each question.

  2. Any instances of non-compliance must include additional comments. 

    • Explain the nature of the non-compliance

    Note: You can still address any areas of non-compliance after you submit your Pharmacy Pre-review for the compliance officer to verify. Any remaining areas of non-compliance following the on-site review will be assigned as “action items” by your Compliance Officer and your pharmacy will be provided with 30 days to address the issue.  

  3. Submit the pharmacy review no later than the assigned date included in your Hospital Pharmacy Practice Review Selection email.

Once you’ve submitted the pre-review, you will be provided with a copy that includes your recorded answers and comments on areas of non-compliance. Use this pre-review document to track and record any corrective changes made prior to your on-site pharmacy review.

During your on-site Pharmacy Review, discuss any areas of non-compliance identified in the pre-review and the corrective changes you have made with your Compliance Officer.

Scheduling Practice Reviews

After completing the Hospital Pharmacy Pre-Review, the College will contact the Pharmacy Manager via email to confirm the exact review date(s).

Once the Practice Review dates are confirmed, Pharmacy Managers need to:

Once you have scheduled your pharmacy’s staff for their individual Pharmacy Professionals Reviews, send the schedule to Schedules should be provided at least two weeks prior to the beginning of the practice review period when a compliance officer arrives on-site.

The two parts of the Hospital Practice Review – the Pharmacy Review and the Pharmacy Professionals Review – each require unique scheduling considerations.

Use the following guidance to help schedule the Pharmacy Review and Pharmacy Professionals Reviews in the least disruptive way.

Hospital Pharmacy Reviews

Time Requirements

  • Schedule 1 to 2 days depending on the size of your pharmacy and the services provided (this will be confirmed by the College).

Personnel Requirements

  • Pharmacy Manager should be available to accompany the Compliance Officer during the pharmacy review.

Hospital Pharmacy Professionals Reviews

Time Requirements

  • Schedule 2-3 hours per pharmacy professional.  
  • Use your existing staff schedule for casual, part-time and full-time pharmacy professionals during the review period to plan practice reviews. Planning practice reviews for casual and part-time staff before permanent staff, and within their existing schedule, helps ensure casual and part-time staff can be reviewed within the review period.
  • You do not need to schedule additional staff during a practice review. Compliance Officers will be observing pharmacy professionals in their practice, allowing pharmacy professionals to work during the review. Compliance Officers will always try to minimize any disruption where possible. 
  • Compliance Officers may accommodate registrants who work outside of regular work hours (i.e. Monday-Friday, 9:00 am-5:00 pm) on a case-by-case basis. This applies to registrants who ONLY work evenings, nights or weekends.
  • Pharmacy professionals on vacation or sick leave during the review period will be reviewed at a later date.
  • Contact if any of your staff members require alternative scheduling arrangements. 

Personnel Exemptions

  • Pharmacy Professionals working solely in support, academic, administrative, IT, or buyer/purchaser roles are exempt from the Hospital Pharmacy Professionals Review.

Personnel Requirements

Pharmacy Managers must schedule individual Pharmacy Professionals Reviews for all registered Pharmacists and Pharmacy Technicians employed by and practising in the licensed hospital pharmacy, where at least one of the following Pharmacy Professionals Review focus areas applies to their job description:

  • Patient Identification Verification,
  • Profile Check
  • Counselling
  • Product Distribution
  • Documentation 

Hospital Pharmacist Focus Areas

  • Patient Identification Verification
  • Profile Check
  • Counselling
  • Documentation

See the questions for these four focus areas in the sample Hospital Pharmacist Review Form.

Hospital Pharmacy Technicians Focus Areas

  • Patient Identification Verification
  • Product Distribution
  • Collaboration
  • Documentation

See the questions for these four focus areas in the sample Hospital Pharmacy Technician Review Form.

Methods of Assessment

Ideally, pharmacy professionals will be reviewed while involved in patient care, such as during dispensary and/or clinical shifts. This allows compliance officers to observe registrants in all focus areas within their practice setting. However, if a pharmacy professional is not scheduled to work in patient care during their practice review, Compliance Officers are still able to complete a review using alternative methods of assessment.

While observation is always the preferred method of assessment, to ensure all pharmacy professionals receive a comprehensive review there are three different methods of assessment that may be used to assess if an individual is meeting the College bylaws and policies.  

Practice Review Methods of Assessment

Observe (action)

  • Watch work performed
  • Interact when clarification is needed

Recall (case)

  • “How did you?”
  • Review recent work (recall charts, orders, computer records, etc.)

Describe (process)

  • “How would you?”