The intent from JCI is that you cover all aspects of a medication journey from selection to administration/monitoring. They want to see if there are written policies and procedures for each of these areas – selection, procurement, storage, prescribing, preparation, dispensing, administration, monitoring, quality & safety, etc. It is important to note that having policies and procedures is important, however, disseminating information to all caregivers/staff is essential. You should also develop and share look-alike-sound-alike list; high alert medication list, etc and make it available to all users within your institution.
Medication management and use is a chapter in JCI manual for hospitals accreditation. It contains the required quality standards that cover all pharmacy functions (from procurement till administration and monitoring) with accompanying measurable elements for each standard. Usually it’s kept in quality department.
My advice is the following:-
1- Make a file that’s divided as per medication management standards (selection and procurement, storade, ordering, transcribing, preparation and dispensing, administration and monitoring)
2- Under each standard, put the relevant policy/policies to each measurable element. Note that policies pertaining to certain standards, e.g ordering and administration; may be under physicians and nursing policies.
3- Make sure to prepare separate files(To be kept in pharmacy) showing the documentation for applying the policies pertaining to measurable elements for each standard.
As per attached example, under measurable element (3), you should prepare a file containing signed forms of continuous training on the compliance with garbing and use of aseptic technique while working in IV admixture.