By Gina Shaw
Immediate-use compounding continues to be one of the most common pain points during Joint Commission surveys, according to new data the group presented at the ASHP Pharmacy Futures 2025 meeting, in Charlotte, North Carolina.
Contributing factors include unclear “ownership,” inconsistent staff training, gaps in competency validation, and policies that don’t align with actual practice, noted Jeannell Mansur, RPh, PharmD, a specialty principal consultant for medication management for Joint Commission Resources.
“When I ask hospitals about who is leading their immediate-use compounding initiatives, sometimes I get a blank stare from the pharmacy department, and often an even more blank stare from nursing, anesthesia and other departments,” Dr. Mansur said. “And that seems to be the very first stumbling block. Whose responsibility is it to implement training and competencies?”
Nobody outside of the pharmacy knows the details of USP <797>, “so is it up to the pharmacy to work with other departments to interpret the definition and help identify roles [that] may be involved in immediate-use compounding—according to the definition within USP <797>” she continued. “Ideally, pharmacy can [help support] the development of an SOP [standard operating procedure] for sterile compounding, which can be used to develop training and, finally, a competency assessment.”
Joint Commission permits a quiz that assesses understanding of key concepts as an alternative to demonstration of competency for immediate-use compounding. “Even though the USP <797> chapter states a demonstration competency, Joint Commission has said that you could do a one- or two-question quiz and that will suffice,” Dr. Mansur said. “You can still choose to do a demonstration of competency, but that’s going to be a much bigger lift for you.”
An ASHP audience poll on immediate-use compounding echoed some of the compliance gaps seen in Joint Commission field surveys. In the poll, 58% of session participants reported that their institution had implemented immediate-use training and competencies; 20% were unsure; 14% said they had started implementation but had not completed it; and 8% had not started.
During the ASHP session, Dr. Mansur presented several additional top-line results of Joint Commission field surveys. Cleanroom viable sampling, for example, is an area where survey issues frequently crop up, she noted. Surveyors will inquire about monthly sampling results, and organizations are expected to have clear documentation and action plans in place for any unusual growth patterns that reach actionable levels identified. “I always recommend keeping it simple,” she advised. “Describe the problem. Describe the steps you took to resolve that problem. Tell me what the end status is and provide the documentation that it’s resolved.”
IU Health’s Experience
Allison Young, PharmD, the director of pharmacy, Centralized Compounding, at Indiana University Health in Plainfield, [KJ1.1]a co-presenter during the ASHP session, agreed that monitoring can be a pain point for health-system compounders—but one that can be relieved by taking an intentional approach to the practice. Front-line staff are busy and focused on the task at hand, so it is easy for them to overlook seemingly minor breakdowns that creep up over time, she noted. “It takes a few hours to walk through all our spaces, and we have found that it requires several sets of eyes.”
In response, “we’ve started alternating our monthly walkthrough with our compliance technician, our infection prevention specialist and our facilities supervisor,” Dr. Young said. “When you don’t work in those spaces every single day, it’s easy for these things to pop up if you are not being intentional and proactive.”
Editor’s note: for an in-depth look at recent Joint Commission survey findings on compounding, see an expanded version of this article in our October print issue.
