In our recent webinar, I spoke with three pharmacy leaders from top health systems about their journeys to standardize sterile compounding practices across multiple sites. While each came to this challenge from a different starting point, their experiences revealed clear themes on what works, what to avoid, and how to make real, lasting progress.
Our expert panel included:
- Dr. Kristen March, PharmD, BCPS – Pharmacy Director of Medication Safety, Quality, and Compliance, Antimicrobial and Diagnostic Stewardship, and Investigational Drug Services at Northwestern Medicine
- Dr. David Dakwa, PharmD, MBA, BCPS, BCSCP – Assistant Chief Pharmacy Officer of Acute Care Operations at UC Davis Health
- Dr. Charnae Ross, PharmD, MSHA, BCSCP – Enterprise Pharmacy Regulatory Manager, USP Compliance at New York Presbyterian Hospital
Drawing from the insights shared during our discussion, here are five takeaways that stood out most to me as moderator.
Why sterile compounding standardization matters
Sterile compounding standardization isn’t just about SOPs and checklists, it’s about creating safer, more efficient systems that consistently meet compliance standards and improve patient care.
Sometimes it takes a crisis to get buy-in. Dr. Dakwa shared how a pharmacy flood fast-tracked his organization’s push for systemwide alignment: “When you're in the times of crisis, like with the flood, everybody just had to have all hands on deck. You really must buy in.”
The experience showed how critical it is to have strong policies in place before regulators arrive.
“We really had to look into making sure that we had our procedures and policies in place so that when the Board of Pharmacy or California Public Department of Public Health were in here, we were making sure that we’re compliant and providing optimal patient care.”
Dr. March of Northwestern Medicine added that standardization pays off operationally, especially in the face of staffing shortages: “Think about the technician shortage... If all your practices are standardized, you now have the opportunity to float staff to different locations because the work is the same. The way they document compliance is the same.”
Standardizing pharmacy compounding creates a safer, more efficient health system. However, achieving this requires collaboration, robust tools, and clear alignment across systems. To help, here are five actionable takeaways from the panelists.
Five compounding standardization takeaways from pharmacy leaders
1. Start with a detailed gap analysis
First things first, you need to know where you stand. A systemwide gap analysis can reveal inconsistencies in procedures, supplies, and training and provide a roadmap for alignment. All of the panelists agreed that this approach has been crucial in identifying compliance needs across their health systems.
Dr. March stressed the importance of drilling down into the smallest details: “Do a gap analysis, standardize your SOPs, your policies… down to the level of is everybody using the same PPE? Are we all using the same cleaning supplies?” she said. “Be very detail oriented in your SOPs and in standardization.”
2. Establish a cross-functional oversight committee
Once you’ve identified gaps, centralize your response. Dr. Dakwa of UC Davis Health recommended creating a compounding oversight committee, which acts as a centralized body to align SOPs, policies, and training:
“We're getting all the PICs or designated persons of each area to the table once a month to go over: What are the policies? What are the SOPs? Do we need to make changes?”
Dr. March agreed, and emphasized bringing frontline voices into the process:
“Have representation from all locations, whether that's an infusion center, a health network hospital, maybe even an allergy clinic if they do their own compounding,” she said. “Don’t be afraid to involve everyone, so they feel heard and know who their point person is.”
Committees like this help health systems move from reactive to proactive and build a culture of ownership and accountability.
3. Collaborate across departments and roles
Sterile compounding compliance isn’t just a pharmacy initiative. Nursing, physicians, EVS staff, and others all play critical roles and need to be brought into the fold. “USP is not just a pharmacy thing,” Dr. March reminded attendees. “Engage your nursing and physician stakeholders because they all do immediate use compounding.”
To help teams understand the why behind new practices, Dr. March recommends framing the conversation around patient safety:
“Bring it to them like, ‘this needs to be clean, because if this is not clean, we grow bacteria. We risk contaminating the medication that's going to be infused into a patient. They could get an infection.’” Dr. March said. “Sometimes I think, just providing that basic background really changes their engagement when it comes to standard operating procedures.”
For Dr. Dakwa, celebrating successes was key to stakeholder engagement. “Everybody wants to be celebrated, per se... For us, it’s sharing the inspection reports with the staff members and letting them know, ‘hey, your efforts are actually helping out’,” he said.
Dr. Ross echoed the importance of a “shared vision,” as she puts it, adding that she personally visits sites to build trust and answer questions in real time:
“I also go on the on-site to trace the areas, and that's when I have an opportunity to engage with the frontline team members. And that's a great way for them to ask me any questions that they may have. If there's any changes that they don't understand, I can explain it to them and engage their leadership.”
4. Use the right tools and data
Technology can simplify complexity, but only if it’s embedded into workflows and supported with training. Rather than reinventing the wheel, panelists emphasized using the tools you already have.
Dr. Ross shared how her team is using analytics features in the SoleSource platform to build dashboards for tracking compliance metrics, “[We’re] exploring ways to utilize analytics features with SoleSource to optimize and get better reporting.”
Dr. Dakwa noted how these tools make inspections smoother:
“Inspectors ask for data two weeks before... So, they are actually already reviewing all of our documents prior to being on-site. Inspection actually takes less than an hour.”
Dr. March explained that her health system is in the process of using their compliance tool and analytics team to create a system dashboard, “our plan is to display our metrics at our monthly meetings, so that we can see where we are compliant, where we're doing great, where are our challenges.”
She also emphasized the importance of data transparency:
“People need to know why they're doing what they're doing and that they're actually making a difference, right?” she said. “So, I think if you can provide them with the data that they are doing a great job, they're more likely to continue to do it.”
Using compliance tools like the ones the Simplifi+ Suite offers can make compounding collaboration and training across teams easier and more streamlined.
5. Think detailed, but keep it simple
When it comes to policies and procedures, more isn’t always better. Dr. March closed with a reminder to keep things focused:
“Although, I said think detailed, I also will state think simple. When writing your policies and procedures, think, ‘what am I going to be surveyed on?’ And only include that type of information... because whatever we put in there, we're held accountable for.”
By keeping SOPs clear, focused, and consistent, health systems can cut through complexity and reduce risk without overwhelming staff.
Whether you’re just starting out or refining your current compounding practices, the advice from these leaders is clear: prioritize communication, invest in the right tools, and make sure your policies reflect both your goals and your reality.
