Pharmacy leaders are rethinking what it means to be “compliant” — and, increasingly, what it doesn’t.
During a panel at Becker’s Spring Chief Pharmacy Officer Summit, leaders from multiple health systems described a shift away from treating compliance as a periodic checkpoint and toward embedding it into daily operations.
“It’s as if our behavior changes when we expect the Joint Commission to come in,” said Wendy Washington, director of drug diversion prevention and regulatory compliance at MedStar Health.
That reactive cycle — tightening processes ahead of inspections, then easing once they pass — is exactly what many organizations are trying to move away from.
At Duarte, Calif.-based City of Hope, that shift starts with how compliance is defined.
“Compliance for us is the floor,” Erica Marchese, PharmD, program director for contracting and sourcing, said.
Rather than treating regulatory requirements as a target to reach, leaders are working to embed them into daily operations — through structured oversight, consistent communication and systems designed to identify risk early.
That approach has been tested through rapid growth. After expanding to five standalone hospitals and multiple outpatient centers, the organization faced the challenge of aligning regulatory practices across sites that each had established workflows and strong compliance cultures.
“We weren’t starting from scratch,” Dr. Marchese said. “We were trying to take two right ways and make one consistent, compliant model.”
Instead of relying on policy standardization alone, pharmacy leaders built a layered governance structure to drive alignment. A clinical governance group was formed to bring together coordinators across sites and standardize formulary decisions, treatment plans and evidence-based practices. Leaders identified early that without clinical alignment, operational and regulatory consistency would be difficult to sustain.
That foundation was followed by a pharmacy operations council made up of system pharmacy directors, responsible for decisions related to workflow, staffing models, system build and compliance. More recently, a systemwide medication safety committee was established to centralize event reporting, risk identification and continuous improvement efforts.
“It didn’t come from us just pushing policies out,” she said. “It was building that governance, building that trust and building accountability into our everyday operations.”
Leaders said that kind of structure is necessary in part because compliance rarely lives in one place.
“That’s a barrier,” said Ursula Tachie-Menson, PharmD, director of pharmacy services at Memorial Hermann The Woodlands (Texas) Medical Center. “It’s not a pharmacy issue — it’s an organizational issue.”
Medication safety, diversion prevention and documentation processes extend across nursing, anesthesia and other clinical teams, making siloed approaches difficult to sustain.
At UCSF Health in San Francisco, that has led to a more interdisciplinary model, with physicians, nurses and operational leaders involved in both governance and technology decisions tied to compliance.
“We need buy-in from all departments,” said Kelsey Waier, PharmD, director of pharmacy enterprise systems.
To reinforce consistency, some organizations are also rethinking how oversight is carried out. At MedStar Health, for example, diversion prevention efforts include routine rounding, audit programs and multidisciplinary committees designed to identify gaps across sites.
Those efforts are framed as collaborative rather than punitive — a distinction leaders said has helped shift how compliance teams are perceived internally.
“When it first started, we were seen as the police,” Ms. Washington said. “Now they realize we’re their partner and their ally.”
However, even as organizations explore tools like AI and advanced analytics to strengthen oversight, leaders cautioned that technology alone won’t address underlying gaps.
“I think we all want to use AI — it’s the new cool thing,” Dr. Tachie-Menson said. “But fundamentally, you need to decide if it’s actually an AI problem or a process problem.”
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