How to use this self-assessment
This self-assessment tool helps pharmacies evaluate their clinical governance maturity, identify opportunities for improvement, and prioritise actions to support accreditation readiness. For each statement, select the maturity level that reflects your pharmacy and identify how you demonstrate this in practice.
Once completed, review the results with your team and celebrate areas of strength as well as opportunities for improvement. Prioritise the changes that will have the greatest impact on patient safety, quality of care, team confidence and accreditation readiness. Review actions regularly and update progress as improvements are implemented.
Use the results to identify priorities for improvement, agree and implement actions, support the team, and monitor whether those actions have been effective. Repeat this assessment regularly and following significant changes to services or governance arrangements to demonstrate how your pharmacy monitors performance, measures improvement and strengthens its governance systems over time.
Keep completed versions of this checklist to demonstrate how your pharmacy monitors, reviews and continuously improves its clinical governance systems. Make sure that your evidence and examples demonstrate real-world activities.
Evidence might include incident and near-miss records, risk assessments, investigation findings, agreed improvement actions, meeting minutes, team communications and training records, audit results, patient feedback, updated procedures, and records showing that improvements were followed up and reviewed.
