Sterile Compounding Evaluation Tool

A new sterile compounding evaluation tool is in the works at TJC. At the recent consultant forum they detailed their plan to share it with accredited organizations. This is how it should help you.

Sterile Compounding Evaluation Tool

The Joint Commission develops sharing tools to help organizations better self-evaluate services. It is a great concept and one that we hope TJC continues to use. And, the sterile compounding evaluation tool is now available on your extranet under the Resources tab. Here is one particularly helpful feature. It displays side-by-side requirements for both the 2008 version of USP Chapter 797 and the 2019 version.

2 USP Compliance Options

Since the delay of the new USP Chapter 797 implementation, TJC allows organizations two potential alternatives. You can select either the 2008 or 2019 versions and adhere to one of those two requirements. The 2008 version of USP Chapter 797 had some basic requirements for managing hazardous medications. In 2019, USP separated out and expanded upon the hazardous medication requirements in a new chapter titled USP 800.

But, if you choose to be an early adopter of the new Chapter 797, TJC will also expects this. You must install the USP Chapter 800 requirements since the new 797 refers all hazardous medication issues to Chapter 800. Further, TJC states that if you choose to adopt the new USP Chapter 797, you will need to do so in its entirety. You cannot pick parts of the 2008 chapter and parts of the 2019 versions.

The sterile compounding evaluation tool also has columns identifying specific TJC and CMS standards for surveyors. It details where to score deficiencies relative to compliance with Chapter 797. Unfortunately, if you look up these standards you will not gain greater insight into the requirement because all the standards referenced are generic in nature. They cover environment of care, infection control practices, or safe medication compounding.

Medication Compounding Resources

As we have previously stated, here are two great resources:

• Home care medication compounding standards
• Medication compounding certification standards

Get a copy for more details.

Lastly, be sure to locate this surveyor tool on your extranet and have your pharmacy team self-evaluate for compliance. In fact, this is the same resource your surveyor will use.