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MQA Q3 2014 - 2015

BALANCED SCORECARD MEASURES

Data source:

MQA Licensing & Enforcement Information Database System (LEIDS)

This measure is calculated using the inspection end date and the inspection deficiency data. The number of

sterile compounding pharmacy inspections completed without serious deficiencies is divided by the number of

sterile compounding pharmacy inspections completed during the specified timeframe. It is important to make

sure sterile compounding pharmacies are in compliance with Florida Statutes and administrative rules and do

not pose a threat to the health, safety and welfare of the public.

Due to the implementation of USP 797, standards for sterile compounding pharmacies were raised. The Board

of Pharmacy adopted the standards into Florida Administrative Code Rule 64B16-27.797, and the Bureau of

Enforcement adopted the standards into their inspection forms. To ensure compounded sterile drugs entering

and leaving the state are safe and adhere to USP 797 requirements, the following action steps will be carried

out. Monthly conference calls will be conducted with MQA inspectors to monitor how new standards are

affecting pharmacy passage rates, and all new senior pharmacists will undergo “boot camp” training. Annual

“boot camp” refresher training will also be mandatory for all senior pharmacists. Inspections will also be used

as an educational opportunity on the new standards, and any deficiencies will be followed up with additional

inspections.

INITIATIVE:

TARGET: 95%

MEASURE:

Percent of sterile compounding pharmacy inspections with no serious deficiencies.

DEFINITION:

16

Sterile Compunding Pharmacy Inspections

89.88

89.92

75.68

89.83

83.54

78.53

% without serious deficiencies

95

90

85

80

75

70

FY 13-14 Q3

FY 13-14 Q2

FY 13-14 Q4 FY 14-15 Q1

FY 14-15 Q2 FY 14-15 Q3

TARGET = 95%

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