heal hca e
A icle
P o ession D i en Imp o emen o he Quali y o Pha macy
P ac ice—Implemen a ion o Communi y Pha macy Se ices
Quali y Guidelines in Es onia
K is iina Sepp 1,* , A onso Miguel Ca aco 1,2 , Ain Raal 1and Daisy Volme 1


Ci a ion: Sepp, K.; Ca aco, A.M.;
Raal, A.; Volme , D. P o ession D i en
Imp o emen o he Quali y o
Pha macy P ac ice—Implemen a ion
o Communi y Pha macy Se ices
Quali y Guidelines in Es onia.
Heal hca e 2021,9, 804.
h ps://doi.o g/10.3390/
heal hca e9070804
Academic Edi o : Ji end a Singh
Recei ed: 27 May 2021
Accep ed: 24 June 2021
Published: 26 June 2021
Publishe ’s No e: MDPI s ays neu al
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Licensee MDPI, Basel, Swi ze land.
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A ibu ion (CC BY) license (h ps://
c ea i ecommons.o g/licenses/by/
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1Ins i u e o Pha macy, Facul y o Medicine, Uni e si y o Ta u, 50411 Ta u, Es onia;
[email p o ec ed] (A.M.C.); [email p o ec ed] (A.R.); daisy[email p o ec ed] (D.V.)
2Depa men o Social Pha macy, Facul y o Pha macy, Uni e si y o Lisbon, 1649-004 Lisboa, Po ugal
*Co espondence: [email p o ec ed]; Tel.: +372-5112195
Abs ac :
Cons an imp o emen o he quali y o communi y pha macy se ices is impo an in
he de elopmen o con empo a y pa ien ca e. A na ional and olun a y Communi y Pha macy
Se ices Quali y Guidelines (CPSQG) was de eloped o o mula e he p inciples o con empo a y
pha macy se ices, including quali y c i e ia o se ice p o ision. The pu pose o his s udy was o
iden i y he implemen a ion o he CPSQG as a p o ession-d i en ini ia i e owa ds imp o ing and
ha monizing communi y pha macy se ices in Es onia. Th ee c oss-sec ional elec onic su eys we e
conduc ed among communi y pha macies in Es onia in 2014 (N = 478 pha macies), 2016 (
N = 493
),
and 2019 (
N = 494
), and he CPSQG indica o s we e used o e alua ion o he se ice quali y. In his
s udy, he agg ega ed da a, collec ed in h ee s udy yea s we e used o iden i y he implemen a ion o
guidelines in o p ac ice. Fo da a analysis, he One-Way ANOVA es and Pos -hoc mul iple compa -
isons we e used. The esul s demons a ed slow implemen a ion o he CPSQG, bu guidelines-based
e alua ion enabled a de ailed o e iew o he communi y pha macy ac i i ies and p o ided se ices.
In o de o de elop communi y pha macy se ices mo e e icien ly, he use o implemen a ion science
p inciples, con inuous in oduc ion o he CPSQG o he pha macis s, and mo e ac i e in ol emen
o he s a e could be conside ed in he u u e.
Keywo ds: communi y pha macy se ice; quali y indica o s; sel -assessmen ; pha macis s; Es onia
1. In oduc ion
Communi y pha macy se ices a e easily accessible heal hca e se ices designed o
p o ide counselling abou sel - ea men , sa e and e ec i e use o medicines, heal h p o-
mo ion, and eliable heal hca e esou ces [
1
]. The e is a wide di e si y in se ice names
and classi ica ion, such as adi ional and ex ended pha macy se ices. In he pos -socialis
coun ies, wi h a low o une en implemen a ion o pha maceu ical ca e se ices, dis-
pensing and counselling o non-p esc ip ion and p esc ip ion medicines, compounding
o medicines, and heal h p omo ion could be seen as co e o adi ional se ices. In he
g oup o ex ended se ices, i is possible o inco po a e managemen o ch onic diseases,
including medicines use e iew; new medicines se ice; ea ly sc eening and es ing; acci-
na ion; smoking cessa ion; and poin o ca e es ing o measu e blood p essu e, choles e ol,
and glucose amongs o he s [
2
,
3
]. In e na ionally, he p o ision o comp ehensi e pha -
macy se ices is no always egula ed, o he scope o communi y pha macies ac i i ies
is limi ed o he p o ision o adi ional pha macy se ices [
4
]. Howe e , in heal h ca e
sys ems ocusing on p ima y heal h ca e, he ole o communi y pha macis s in counselling
and moni o ing d ug he apy o he pa ien is becoming inc easingly impo an . Also,
communi y
pha macis s a e aking a mo e signi ican ole in heal h p omo ion and p e-
en ion, pa ien educa ion, ch onic disease managemen , and immuniza ions, imp o ing
access o p ima y heal h ca e se ices [5].
Heal hca e 2021,9, 804. h ps://doi.o g/10.3390/heal hca e9070804 h ps://www.mdpi.com/jou nal/heal hca e
Heal hca e 2021,9, 804 2 o 24
In 1999, he Good Pha macy P ac ice (GPP) s anda d, de eloped by he In e na ional
Pha maceu ical Fede a ion (FIP) and he Wo ld Heal h O ganiza ion (WHO), laid he oun-
da ion o quali y o ca e in communi y and hospi al pha macy se ings [
6
,
7
].
Following
his join guideline, many coun ies ha e es ablished a na ional amewo k o quali y
s anda ds. Depending on he scope o he GPP s anda d, he guidelines could be de el-
oped as independen documen s, in eg a ed in o pha maceu ical legisla ion, o used as
ecommenda ions suppo ing legisla i e ac s. Fo example, in Li huania and Slo enia,
he pha macy egula o has adop ed GPP s anda ds, while in Se bia, GPP guidelines mus
be app o ed by he minis y o heal h. In Uzbekis an, he GPP guidelines, desc ibing
adi ional communi y pha macy se ices a e op ional [4].
Cons an imp o emen o he quali y o communi y pha macy se ices is expec ed in
he de elopmen o con empo a y pa ien ca e. A he beginning o 2021, 479 communi y
pha macies we e ope a ing in Es onia, wi h an a e age o 2700 inhabi an s pe pha macy,
simila o o he Eas e n Eu opean coun ies [
8
–
10
]. Communi y pha macies in Es onia
ha e his o ically ocused on adi ional se ices such as compounding and dispensing
medicines and p o iding d ug in o ma ion o pha macy cus ome s [
11
]. Exis ing ex ended
se ices comp ise disease p e en ion, e.g., lu accina ion, smoking cessa ion, measu ing
blood p essu e and choles e ol [
12
–
14
]. Medica ion use e iew was i s pilo ed in 2019 [
15
].
Fo he p o ision o communi y pha macy se ices, he basic p inciples o WHO/FIP
guidelines ha e been ecognized by Es onian p o essionals and academic o ganiza ions.
Besides, a na ional guideline was de eloped o complemen he exis ing egula ions,
and ensu e and e alua e he quali y o pha macy se ices. P o ession-d i en Commu-
ni y Pha macy Se ices Quali y Guidelines (CPSQG) we e i s compiled in 2012 and
upda ed in 2016 and 2021, in coope a ion wi h p ac icing pha macis s and p o essional
o ganiza ions, s a e and educa ional ins i u ions. The CPSQG aims o o mula e he p inci-
ples o con empo a y pha macy se ices, including quali y c i e ia o se ice p o ision.
CPSQG
indica o s enable he sel -assessmen by pha macis s o se ice quali y and di e -
en ope a ional aspec s o communi y pha macies in Es onia [
16
]. The guidelines se e
as ecommenda ions suppo ing pha macy legisla ion and a e no legally binding o
communi y pha macies. The e o e, i is essen ial o unde s and how he exis ing quali y
indica o s con ibu ed o communi y pha macy se ices and quali y o ca e. Sys ema ic
adhe ence o he p inciples o GPP guidelines could be seen as one o he handy possibili ies
o ha monizing he quali y o communi y pha macy se ices h oughou he coun y in
bene i ing p ima y ca e and pa ien ou comes [
7
]. Despi e se e al pos -socialis coun ies
ha ing epo ed adap ion o GPP s anda ds, he e is li le in o ma ion a ailable on he ole
o communi y pha macies in he heal h ca e sys em, quali y o , and public and p o essional
pe cep ions on se ices p o ided [4].
This s udy aimed o iden i y he implemen a ion o he Communi y Pha macy Se ices
Quali y Guidelines as a p o ession-d i en ini ia i e owa ds imp o ing and ha monizing
he quali y o communi y pha macy se ices in Es onia.
2. Ma e ials and Me hods
2.1. S udy Con ex
In Es onia, he Medicinal P oduc s Ac es ablishes s ic legal egula ions o handling
medicines and he ope a ion o communi y pha macies, o ming an essen ial s uc u e
o he p o ision o high-quali y pha macy se ices. Howe e , he con en o he se ices
(e.g., counselling o medicines) is desc ibed sho ly, and he e was a need o mo e de ailed
guidelines o communi y pha macies. In collabo a ion wi h p o essional and academic
o ganiza ions, he CPSQG was de eloped [17].
The ini ial concep s we e ga he ed om di e en GPP in e na ional guidelines, pa ic-
ula ly he amewo ks o he Uni ed Kingdom, he Uni ed S a es, and Aus alia [
18
–
20
].
In addi ion, he p inciples o he Model o Imp o emen om he Ins i u e o Heal hca e
Imp o emen (IHI) [
21
] we e used in iden i ying he main goals o he de eloped guide-
lines and b ains o ming d i e s o change wi hin CPSQG wo king g oup membe s and
Heal hca e 2021,9, 804 3 o 24
o he s akeholde s, e.g., ep esen a i es o Gene al P ac i ione s Associa ion. The ou -le el
cycle o Plan, Do, S udy and Ac o quali y imp o emen o he communi y pha macy
se ice was conside ed a sui able amewo k o implemen ing he CPSQG.
The CPSQG was o ganized in o 10 chap e s desc ibing he communi y pha macy
se ice o ac i i y and comp ising indica o s o enabling sel -assessmen by pha macis s.
The indica o s we e alida ed in 2013 among 201 communi y pha macies in Es onia.
In addi ion o sel -assessmen , he pha macis s we e also able o p o ide eedback on
he easibili y and ele ance o he indica o s [
22
]. The alida ion p ocedu es sugges ed
ha he dicho omous scale (yes/no) o esponses was no always su icien o assess he
ac ual quali y o se ices p o ided. Thus, he esponse scale was changed o a ou -poin
scale (always/mos ly/occasionally/ne e ) o 1/2 o he indica o s. Also, based on he
esponden s’ commen s, he selec ion o indica o s was upda ed.
The CPSQG was dissemina ed o all communi y pha macies in Es onia in 2014, 2016,
and 2021. An elec onic e sion o he guidelines was also a ailable om p o essional
o ganiza ions and a he S a e Agency o Medicines webpage. Se e al semina s in oducing
he guideline we e held in 2012-19 o aise awa eness abou CPSQG and le e age he
implemen a ion o he guidelines [23].
2.2. S udy Design and Sample
Th ee c oss-sec ional elec onic su eys we e conduc ed among communi y pha ma-
cies in Es onia in 2014 (N = 478 pha macies), 2016 (N = 493), and 2019 (N = 494) o ollow-up
he ecep ion and applica ion o he CPSQG. I was asked o ill in only one su ey pe
pha macy.
2.3. S udy Ins umen
The CPSQG was used as a sel -assessmen ool o communi y pha macis s o e alua e
se ice quali y. In his s udy, he agg ega ed da a collec ed in 2014, 2016, and 2019 we e
used o iden i y he implemen a ion o guidelines in o p ac ice. The sel -assessmen ool
included indica o s wi h a wo-poin (1 yes/0 no) o a ou -poin (0 ne e /1 occasion-
ally/2 mos ly/3 always) esponse scale. Pha macy cha ac e is ics, such as geog aphical
loca ion and pha macy ype (main o b anch pha macy), we e also egis e ed.
In he sel -assessmen , 132 quali y indica o s o 172 in 2014, 137 o 168 in 2016, and 139
o 168 in 2019 we e used. The quali y indica o s conside ed as ecommenda ions o
pha macies (e.g., o ha e a sepa a e locke o each employee) we e excluded om he
sel -assessmen . To assess he implemen a ion o changes in pha macy p ac ice du ing he
s udy pe iod, only hose indica o s wi h esul s a ailable o a leas wo yea s (n= 127)
we e included (Table 1).
Table 1.
Indica o s used in he implemen a ion su ey o he Communi y Pha macy Se ices Quali y Guidelines (n= 127).
Themes (n= 3) Sub-Themes (n= 10) Quali y I ems (n= 127)
T adi ional communi y pha macy
se ices
P esc ip ion-only medicines (POM)
P esc ip ion check (3)
Selec ion o medicines (7)
Pa ien counselling on he use o POMs (14)
Sel - ea men and non-p esc ip ion
medicines and o he pha macy goods
E alua ion o symp oms (6)
Selec ion o ea men me hod (6)
Pa ien counselling on he use o OTCs o
o he pha macy goods (9)
Compounding o medicines
Handling o p esc ip ions o
ex empo aneous medicines (4)
P epa a ion o medicines (3)
Quali y o ex empo aneous medicines (3)
Heal hca e 2021,9, 804 4 o 24
Table 1. Con .
Themes (n= 3) Sub-Themes (n= 10) Quali y I ems (n= 127)
Ex ended se ices Heal h p omo ion
Quali ica ion o pha macis s o p o ision
o ex ended se ices (5)
P o ided ex ended se ices (5)
Pha macy en i onmen and ope a ion
P emises and echnical equipmen o he
pha macy
Condi ions o p i a e and
pa ien -cen ed counselling (7)
Se ice p o ision suppo ing ools (3)
Handling o medicines and
pha maceu ical goods
P ocu emen and ensu ing s ock (3)
S o age and dispensing (5)
Quali y p oblems/managemen (4)
Pha macy managemen
Managemen o cus ome ela ions (6)
Pe sonnel managemen (2)
Manage ’s esponsibili ies (4)
Communica ion
In e nal communica ion (3)
Ex e nal Communica ion (7)
Communica ion obliga ion (2)
Pha macis as a lec u e and au ho o
a icles (1)
Pha macis s’ aining Pha macis s’ li elong lea ning (6)
Pha macy as a aineeship ins i u ion (4)
Legal equi emen s Compliance wi h legal equi emen s (4)
2.4. Da a Analysis
An eFo mula pla o m (h p://www.e o mula .com, accessed on 10 Feb ua y 2021)
was used o da a collec ion and ini ial analysis. Subsequen ly, da a we e impo ed in o
a S a is ical Package o Social Sciences (SPSS
®
), . 27. The esul s o di e en su ey
yea s we e compa ed using he One-Way ANOVA es and Pos -hoc mul iple compa isons,
a e checking he sample homogenei y o a iances wi h he Le ene es . Da a we e es ed
o no mali y using he Kolmogo o -Smi no es , and an alpha alue lowe han 0.05 o
all a iables was ecei ed. The s a is ical signi icance le el was se a p< 0.05. In he Resul s
sec ion, only s a is ically signi ican esul s a e p esen ed. I only wo s udy yea s we e
a ailable, esul s a e p esen ed using he Ano a F alue and p- alue. Howe e , i da a o
h ee e e ence yea s we e a ailable, he p alues o he Pos -hoc compa isons a e used.
The comple e analysis o he h ee s udy yea s (i.e., mean alues o di e en s udy yea s
and p- alue) can be ound in Appendix A.
2.5. E hical Conside a ions
The esea che s ollowed he p inciples o medical e hics highligh ed by Beauchamp
and Child ess in he 1970s [
24
] and Helsinki’s Decla a ion [
25
]. The s udy o ganiza-
ion and aims, including he pa icipan s’ igh o wi hd aw om he s udy a any ime,
we e explained. The esponden s’ anonymi y and da a con iden iali y we e gua an eed;
only cha ac e is ics as egional loca ion and pha macy ype (b anch o cen al pha macy)
we e asked. Da a collec ion, s o age, and da a analysis comply wi h he Pe sonal Da a
P o ec ion Ac [26].
Heal hca e 2021,9, 804 5 o 24
3. Resul s
3.1. Desc ip ion o Responden s
In 2014 and 2016, mo e han 40% o communi y pha macies ope a ing in Es onia
pa icipa ed in he sel -e alua ion exe cise (Figu e 1). In 2019, he numbe o esponden s
dec eased o a qua e o all communi y pha macies. Compa ed o he o he egions,
he e we e mo e pa icipan s om he capi al a ea (p≤0.01).
Heal hca e 2021, 9, 804 5 o 20
3. Resul s
3.1. Desc ip ion o Responden s
In 2014 and 2016, mo e han 40% o communi y pha macies ope a ing in Es onia pa -
icipa ed in he sel -e alua ion exe cise (Figu e 1). In 2019, he numbe o esponden s
dec eased o a qua e o all communi y pha macies. Compa ed o he o he egions, he e
we e mo e pa icipan s om he capi al a ea (p ≤ 0.01).
Figu e 1. The numbe o communi y pha macies pa icipa ed in he sel -assessmen based on he Communi y Pha macy
Se ice Quali y Guidelines in 2014-19 compa ed o all pha macies ope a ing in Es onia.
3.2. T adi ional Communi y Pha macy Se ices
Analysis o adi ional communi y pha macy se ices e ealed no signi ican
changes in counselling p ac ices o bo h p esc ip ion-only medicines (POM) and o e - he-
coun e (OTC) medicines du ing he s udy pe iod. To some ex en , he counselling quali y
was highe o OTC medicines and lowe o POM medicines (Figu e 2). Howe e , his
di e ence canno be di ec ly ela ed o he implemen a ion o he CPSQG; as he e we e
no signi ican changes in counselling quali y p o ided in he wo g oups o medicines
men ioned abo e wi hin he yea s he s udy was unde aken. The mos conce ning esul
was insu icien isk communica ion (ad e se d ug eac ions, in e ac ions, and con ain-
dica ions) o pa ien s wi h POMs (2014-19 Tukey p = 0.015) and OTCs (2014-19 Tukey p =
0.038), also wi h a dec easing end om 2014 o 2019. Besides, compa ed o he i s s udy
yea , he consul a ion abou di e en medical de ices (e.g., inhala o s) has dec eased in
he las wo s udy yea s (2014-16 Tamhane p < 0.001; 2014-19 Tamhane p = 0.003).
The compounding o medicines had dec eased h ough he yea s a communi y pha -
macies in Es onia (F = 3.341, p = 0.036). In a pha macy whe e he compounding o medi-
cines was no obliga o y (pha macies ope a ing in an a ea wi h less han 4000 inhabi an s
o b anch pha macies), no o he pha macies we e sough whe e he pa ien s could ha e
hei medicine p epa ed (F = 165.948, p < 0.001). On he o he hand, when he medicine
was p epa ed, he pa ien ecei ed i wi hin wo days a he la es , and du ing s udy yea s,
his ime has sho ened (2014-16 Tamhane p < 0.001; 2014-19 Tamhane p = 0.004).
Figu e 1.
The numbe o communi y pha macies pa icipa ed in he sel -assessmen based on he Communi y Pha macy
Se ice Quali y Guidelines in 2014-19 compa ed o all pha macies ope a ing in Es onia.
3.2. T adi ional Communi y Pha macy Se ices
Analysis o adi ional communi y pha macy se ices e ealed no signi ican changes
in counselling p ac ices o bo h p esc ip ion-only medicines (POM) and o e - he-coun e
(OTC) medicines du ing he s udy pe iod. To some ex en , he counselling quali y was
highe o OTC medicines and lowe o POM medicines (Figu e 2). Howe e , his di -
e ence canno be di ec ly ela ed o he implemen a ion o he CPSQG; as he e we e no
signi ican changes in counselling quali y p o ided in he wo g oups o medicines men-
ioned abo e wi hin he yea s he s udy was unde aken. The mos conce ning esul was
insu icien isk communica ion (ad e se d ug eac ions, in e ac ions, and con aindica-
ions) o pa ien s wi h POMs (2014-19 Tukey p= 0.015) and OTCs (2014-19 Tukey
p= 0.038
),
also wi h a dec easing end om 2014 o 2019. Besides, compa ed o he i s s udy yea ,
he consul a ion abou di e en medical de ices (e.g., inhala o s) has dec eased in he las
wo s udy yea s (2014-16 Tamhane p< 0.001; 2014-19 Tamhane p= 0.003).
The compounding o medicines had dec eased h ough he yea s a communi y pha -
macies in Es onia (F = 3.341, p= 0.036). In a pha macy whe e he compounding o medicines
was no obliga o y (pha macies ope a ing in an a ea wi h less han 4000 inhabi an s o
b anch pha macies), no o he pha macies we e sough whe e he pa ien s could ha e hei
medicine p epa ed (F = 165.948, p< 0.001). On he o he hand, when he medicine was
p epa ed, he pa ien ecei ed i wi hin wo days a he la es , and du ing s udy yea s,
his ime has sho ened (2014-16 Tamhane p< 0.001; 2014-19 Tamhane p= 0.004).
3.3. Ex ended Communi y Pha macy Se ices
CPSQG indica o s enabled he assessmen o he equency o ex ended se ices
p o ision bu no hei quali y. Simila ly o he adi ional se ices, no signi ican changes
ha e been ound in p o iding ex ended se ices du ing he s udy pe iod. Poin -o -ca e
es ing was he mos common ex ended se ice, o which only blood p essu e measu emen
inc eased du ing he s udy pe iod (2014-19 Tamhane p= 0.020) (Figu e 3).

Heal hca e 2021,9, 804 6 o 24
In o ma ion ela ed o he pha macy-based ex ended se ices (pa ien heal h indica o s
da a) was always documen ed in abou 1/5 pha macies in all s udy yea s. Pa icipa ion
a heal h and en i onmen al campaigns ou side o pha macies dec eased signi ican ly
(2014-16 Tamhane p< 0.001; 2014-19 Tamhane p< 0.001).
To be able o p o ide quali y ex ended se ices addi ional aining is equi ed. In abou
a hi d o pha macies, pha macy s a p o iding ex ended se ices had comple ed he
ele an aining; howe e , pa icipa ion in u he aining has dec eased signi ican ly in
he las su ey yea (F = 10.876, p< 0.001).
Heal hca e 2021, 9, 804 6 o 20
Figu e 2. Pa ien counselling abou OTCs and POMs based on he e alua ion o he Communi y Pha macy Se ice Quali y
Guideline ( ou -poin scale) in 2014-19.
3.3. Ex ended Communi y Pha macy Se ices
CPSQG indica o s enabled he assessmen o he equency o ex ended se ices p o-
ision bu no hei quali y. Simila ly o he adi ional se ices, no signi ican changes
ha e been ound in p o iding ex ended se ices du ing he s udy pe iod. Poin -o -ca e
es ing was he mos common ex ended se ice, o which only blood p essu e measu e-
men inc eased du ing he s udy pe iod (2014-19 Tamhane p = 0.020) (Figu e 3).
In o ma ion ela ed o he pha macy-based ex ended se ices (pa ien heal h indica-
o s da a) was always documen ed in abou 1/5 pha macies in all s udy yea s. Pa icipa-
ion a heal h and en i onmen al campaigns ou side o pha macies dec eased signi i-
can ly (2014-16 Tamhane p < 0.001; 2014-19 Tamhane p < 0.001).
To be able o p o ide quali y ex ended se ices addi ional aining is equi ed. In
abou a hi d o pha macies, pha macy s a p o iding ex ended se ices had comple ed
he ele an aining; howe e , pa icipa ion in u he aining has dec eased signi i-
can ly in he las su ey yea (F = 10.876, p < 0.001).
Figu e 2.
Pa ien counselling abou OTCs and POMs based on he e alua ion o he Communi y Pha macy Se ice Quali y
Guideline ( ou -poin scale) in 2014-19.
Heal hca e 2021, 9, 804 6 o 20
Figu e 2. Pa ien counselling abou OTCs and POMs based on he e alua ion o he Communi y Pha macy Se ice Quali y
Guideline ( ou -poin scale) in 2014-19.
3.3. Ex ended Communi y Pha macy Se ices
CPSQG indica o s enabled he assessmen o he equency o ex ended se ices p o-
ision bu no hei quali y. Simila ly o he adi ional se ices, no signi ican changes
ha e been ound in p o iding ex ended se ices du ing he s udy pe iod. Poin -o -ca e
es ing was he mos common ex ended se ice, o which only blood p essu e measu e-
men inc eased du ing he s udy pe iod (2014-19 Tamhane p = 0.020) (Figu e 3).
In o ma ion ela ed o he pha macy-based ex ended se ices (pa ien heal h indica-
o s da a) was always documen ed in abou 1/5 pha macies in all s udy yea s. Pa icipa-
ion a heal h and en i onmen al campaigns ou side o pha macies dec eased signi i-
can ly (2014-16 Tamhane p < 0.001; 2014-19 Tamhane p < 0.001).
To be able o p o ide quali y ex ended se ices addi ional aining is equi ed. In
abou a hi d o pha macies, pha macy s a p o iding ex ended se ices had comple ed
he ele an aining; howe e , pa icipa ion in u he aining has dec eased signi i-
can ly in he las su ey yea (F = 10.876, p < 0.001).
Figu e 3.
P o ision o ex ended se ices based on e alua ing he Communi y Pha macy Se ice Quali y Guideline ( wo-
poin scale) in 2014-19.
Heal hca e 2021,9, 804 7 o 24
3.4. Pha macy En i onmen and Ope a ion
A ew pha macies (in 2019 16%) in Es onia ha e a sepa a e consul a ion oom o p i-
a e counselling possibili ies in he sales a ea o POM and OTC medicines. This si ua ion
did no change du ing he s udy pe iod. On he o he hand, many pha macies p o ided
cus ome s wi h a sea ing a ea and d inking wa e o adminis e he medicine (2014-16
Tamhane p< 0.001; 2014-19 Tamhane p< 0.001) (Figu e 4).
Use o di e en se ice p o ision suppo ing ools, e.g., o assess he s ock (2014-16
Tamhane p= 0.006; 2014-19 Tamhane p= 0.017; 2016-19 Tamhane p< 0.001), o moni o ex-
pi y da e o medicines (F = 4.561, p= 0.033), o p e en e o s du ing dispensing medicines,
o check po en ial in e ac ions and ad e se d ug eac ions has dec eased wi hin he s udy
pe iod. A he same ime, pha macis s did no ha e di ec ex e nal channels o ecei e
quick in o ma ion abou medica ion sho ages, which has inc eased du ing he s udy yea s
(2014-16 Tukey p= 0.033). Also, i he p oduc was no a ailable in he pha macy s ock,
i was ime-consuming o ind i om he medicine wholesale s, and pha macis s’ will-
ingness o make inqui ies o esol ing he si ua ion has signi ican ly dec eased (2014-16
Tamhane p= 0.033; 2014-19 Tamhane p= 0.005).
Heal hca e 2021, 9, 804 7 o 20
Figu e 3. P o ision o ex ended se ices based on e alua ing he Communi y Pha macy Se ice
Quali y Guideline ( wo-poin scale) in 2014-19.
3.4. Pha macy En i onmen and Ope a ion
A ew pha macies (in 2019 16%) in Es onia ha e a sepa a e consul a ion oom o p i-
a e counselling possibili ies in he sales a ea o POM and OTC medicines. This si ua ion
did no change du ing he s udy pe iod. On he o he hand, many pha macies p o ided
cus ome s wi h a sea ing a ea and d inking wa e o adminis e he medicine (2014-16
Tamhane p < 0.001; 2014-19 Tamhane p < 0.001) (Figu e 4).
Use o di e en se ice p o ision suppo ing ools, e.g., o assess he s ock (2014-16
Tamhane p = 0.006; 2014-19 Tamhane p = 0.017; 2016-19 Tamhane p < 0.001), o moni o
expi y da e o medicines (F = 4.561, p = 0.033), o p e en e o s du ing dispensing medi-
cines, o check po en ial in e ac ions and ad e se d ug eac ions has dec eased wi hin he
s udy pe iod. A he same ime, pha macis s did no ha e di ec ex e nal channels o e-
cei e quick in o ma ion abou medica ion sho ages, which has inc eased du ing he
s udy yea s (2014-16 Tukey p = 0.033). Also, i he p oduc was no a ailable in he pha -
macy s ock, i was ime-consuming o ind i om he medicine wholesale s, and pha ma-
cis s’ willingness o make inqui ies o esol ing he si ua ion has signi ican ly dec eased
(2014-16 Tamhane p = 0.033; 2014-19 Tamhane p = 0.005).
Figu e 4. P i a e counselling a ailabili y, sea ing possibili ies, and d inking wa e o pha macy cus ome s a communi y
pha macies based on he e alua ion o he Communi y Pha macy Se ice Quali y Guidelines ( wo-poin scale) in 2014-19.
To ensu e a high-quali y se ice, a compe en and capable pha macy manage and a
su icien numbe o p o essional s a a e equi ed amongs o he esou ces. Abou hal
o he pha macies ha pa icipa ed in he sel -assessmen in all s udy yea s epo ed con-
sis en ly o ha e implemen ed all he ac i i ies needed o e icien managemen , includ-
ing a suppo i e and mo i a ing wo king en i onmen . Fo ins ance, all employees ol-
lowed uni ied cus ome se ice p inciples, egula eedback om cus ome s and s a
membe s abou se ice p o ision was ob ained, and an exis ing sys em o dissemina ing
impo an in o ma ion was in ope a ion. Howe e , abou 2/3 o he esponden s epo ed
0 0.2 0.4 0.6 0.8 1
D inking wa e is a ailable a he pha macy
o he immedia e adminis a ion o a
medicine (p≤0.01)
The sales oom has sea s o cus ome s
wai ing o hei u n o be se iced
The cus ome has a place o si while a
p esc ip ion medicine is being dispensed
The cus ome has a place o si while an OTC
medicine is being dispensed
The pha macy has a sepa a e oom o
counselling
P i a e counselling while dispensing OTC
medicines is ensu ed
P i a e counselling while dispensing
p esc ip ion medicines is ensu ed
Mean
2019
2016
2014
Figu e 4.
P i a e counselling a ailabili y, sea ing possibili ies, and d inking wa e o pha macy cus ome s a communi y
pha macies based on he e alua ion o he Communi y Pha macy Se ice Quali y Guidelines ( wo-poin scale) in 2014-19.
To ensu e a high-quali y se ice, a compe en and capable pha macy manage and
a su icien numbe o p o essional s a a e equi ed amongs o he esou ces. Abou hal
o he pha macies ha pa icipa ed in he sel -assessmen in all s udy yea s epo ed con-
sis en ly o ha e implemen ed all he ac i i ies needed o e icien managemen ,
including
a suppo i e and mo i a ing wo king en i onmen . Fo ins ance, all employees ollowed
uni ied cus ome se ice p inciples, egula eedback om cus ome s and s a membe s
abou se ice p o ision was ob ained, and an exis ing sys em o dissemina ing impo an
in o ma ion was in ope a ion. Howe e , abou 2/3 o he esponden s epo ed a sho age
o p o essional s a in hei pha macy and his p oblem inc eased du ing s udy yea s
(2014-19 Tamhane p= 0.003). Despi e he sho age o p o essional s a and less lexible
Heal hca e 2021,9, 804 8 o 24
managemen o human esou ces, he pa icipa ion in he con inuous p o essional de elop-
men o pha macis s h oughou he yea s had become mo e sys ema ic, and he in e es o
pha macis s in acqui ing knowledge had g own (Figu e 5).
Heal hca e 2021, 9, 804 8 o 20
a sho age o p o essional s a in hei pha macy and his p oblem inc eased du ing s udy
yea s (2014-19 Tamhane p = 0.003). Despi e he sho age o p o essional s a and less lex-
ible managemen o human esou ces, he pa icipa ion in he con inuous p o essional
de elopmen o pha macis s h oughou he yea s had become mo e sys ema ic, and he
in e es o pha macis s in acqui ing knowledge had g own (Figu e 5).
Figu e 5. Following he p inciples o li elong lea ning by communi y pha macis s based on he e alua ion o he Commu-
ni y Pha macy Se ices Quali y Guidelines ( ou -poin scale) in 2014-19.
4. Discussion
In pos -socialis coun ies, he e o ms in he pha macy sec o s a ed wi h he p i-
a iza ion o communi y pha macies. Du ing he las hi y yea s, communi y pha macy
sys ems ha e unde gone libe aliza ion wi h owne ship and es ablishmen o communi y
pha macies no limi ed o he pha macy p o ession and he opening o pha macy chains
[27–29]. Wi hin his speci ic con ex , he leading p o essional ask has been assu ing he
quali y o adi ional communi y pha macy se ices, no p ima ily he de elopmen o
new o ex ended se ices [27,28]. Ne e heless, he e ha e been p o essional and p ac ice
de elopmen s in Li huania and Bulga ia, a emp ing o in oduce pha maceu ical ca e
se ices in o communi y pha macy p ac ice, d i en mainly by p o ession and wi h li le
go e nmen in ol emen [30,31].
In e na ionally, GPP s anda ds ha e de ined he s uc u e, p ocess, and ou come
measu es o co e o adi ional se ices, such as dispensing and counselling POMs and
OTCs, and compounding medicines [32–34]. Based on simila p inciples, he communi y
pha macy sec o in Es onia has de eloped he Communi y Pha macy Se ice Quali y
Guidelines (CPSQG) amewo k, a p o essional ini ia i e o s anda dize and imp o e he
quali y o communi y pha macy se ices. Measu able quali y indica o s enable pha ma-
cis s o assess he s anda d o se ices o e ed and o unde ake espec i e changes, i nec-
essa y. The CPSQG allows ac i e moni o ing o he quali y o se ices and suppo s he
implemen a ion e o s owa ds he necessa y changes. The CPSQG sel -assessmen e-
sul s om 2014 o 2019, ca ied ou h ee imes a e in oducing he guidelines in 2012,
demons a ed a slow change in he quali y o communi y pha macy se ices. This inding
sugges s he CPSQG was applied o e alua e he ac i i ies and se ices o pha macies in-
s ead o using he amewo k o imp o e he quali y o he se ice. Implemen a ion sci-
ence migh help o explain he de eloped si ua ion whe e he only use o a quali y ame-
wo k is no su icien o olun a y p ac ice imp o emen s. Compliance wi h new and no
law en o ced p o essional beha io s may be low due o he sho implemen a ion pe iod
o he s anda ds.
4.1. Ope a ion o and Se ice Quali y a Communi y Pha macies
This s udy highligh ed an icipa ed issues bu demons a ed new de elopmen s in
se ice p o ision a communi y pha macies and he p o essional ac i i y o communi y
pha macis s in Es onia. Fo example, compa ed o p e ious s udies, d ug communica ion
0.00 0.50 1.00 1.50 2.00 2.50 3.00
In o ma ion abou aining oppo uni ies
eaches all pha macis s
All pha macis s ha e equal oppo uni ies o
a end aining cou ses (p≤0.01)
In o ma ion sou ces a e used egula ly
(p≤0.01)
Mean
2019
2016
2014
Figu e 5.
Following he p inciples o li elong lea ning by communi y pha macis s based on he e alua ion o he Communi y
Pha macy Se ices Quali y Guidelines ( ou -poin scale) in 2014-19.
4. Discussion
In pos -socialis coun ies, he e o ms in he pha macy sec o s a ed wi h he p i-
a iza ion o communi y pha macies. Du ing he las hi y yea s, communi y pha macy
sys ems ha e unde gone libe aliza ion wi h owne ship and es ablishmen o commu-
ni y pha macies no limi ed o he pha macy p o ession and he opening o pha macy
chains [
27
–
29
]. Wi hin his speci ic con ex , he leading p o essional ask has been assu ing
he quali y o adi ional communi y pha macy se ices, no p ima ily he de elopmen o
new o ex ended se ices [
27
,
28
]. Ne e heless, he e ha e been p o essional and p ac ice
de elopmen s in Li huania and Bulga ia, a emp ing o in oduce pha maceu ical ca e
se ices in o communi y pha macy p ac ice, d i en mainly by p o ession and wi h li le
go e nmen in ol emen [30,31].
In e na ionally, GPP s anda ds ha e de ined he s uc u e, p ocess, and ou come
measu es o co e o adi ional se ices, such as dispensing and counselling POMs and
OTCs, and compounding medicines [
32
–
34
]. Based on simila p inciples, he communi y
pha macy sec o in Es onia has de eloped he Communi y Pha macy Se ice Quali y
Guidelines (CPSQG) amewo k, a p o essional ini ia i e o s anda dize and imp o e
he quali y o communi y pha macy se ices. Measu able quali y indica o s enable pha -
macis s o assess he s anda d o se ices o e ed and o unde ake espec i e changes,
i necessa y. The CPSQG allows ac i e moni o ing o he quali y o se ices and suppo s
he implemen a ion e o s owa ds he necessa y changes. The CPSQG sel -assessmen
esul s om 2014 o 2019, ca ied ou h ee imes a e in oducing he guidelines in 2012,
demons a ed a slow change in he quali y o communi y pha macy se ices. This inding
sugges s he CPSQG was applied o e alua e he ac i i ies and se ices o pha macies
ins ead o using he amewo k o imp o e he quali y o he se ice. Implemen a ion
science migh help o explain he de eloped si ua ion whe e he only use o a quali y
amewo k is no su icien o olun a y p ac ice imp o emen s. Compliance wi h new
and no law en o ced p o essional beha io s may be low due o he sho implemen a ion
pe iod o he s anda ds.
4.1. Ope a ion o and Se ice Quali y a Communi y Pha macies
This s udy highligh ed an icipa ed issues bu demons a ed new de elopmen s in
se ice p o ision a communi y pha macies and he p o essional ac i i y o communi y
pha macis s in Es onia. Fo example, compa ed o p e ious s udies, d ug communica-
ion and pa ien consul a ion ha e inc eased o OTC medicines [
35
]. On he o he hand,
POM counselling quali y has no changed, and his migh be explained by he limi ed
Heal hca e 2021,9, 804 9 o 24
access and/o use o pa ien heal h eco ds. In Es onia, pha macis s can access an ag eed
heal h da a se (all p esc ibed POMs and since 2018 wi h diagnosis codes) o a pa ien [
36
];
howe e , he use o his in o ma ion in pa ien counselling seems o need mo e implemen-
a ion in o p ac ice. Acco ding o he in e na ional expe ience, in ol ing a pha macis in
counselling on p esc ip ion medicines has an impo an impac on pa ien heal h ou comes,
sa es cos in i s - ime medicines use s, and co e s pha maco igilance aspec s [37].
Poo communica ion o sa e y- ela ed in o ma ion (con aindica ions, ad e se d ug
eac ions, and in e ac ions) o he pa ien had al eady been epo ed in p e ious s udies in
Es onia [
38
,
39
] and was also con i med in he CPSQG-based sel -assessmen . This is no
a p oblem accessing eliable and up- o-da e d ug- ela ed in o ma ion since pha macis s
in Es onia may use he o icial da abase o iden i y d ug in e ac ions and ad e se d ug
eac ions (Inxbase). Also, he Es onian Heal h Insu ance Fund allows ee da abase access
and ope a ion o pha macis s o e alua ing he in e ac ions be ween OTC medicines and
ood supplemen s [
40
]. Howe e , mos pha macies do no seem o be able o use his ool,
and i hey do, i emains unclea how o en his sou ce is used, wha sec ions, and o
wha easons. To p o ide high-quali y and pa ien -cen e ed pha macy se ice, pha ma-
cis s should ha e access o he same da abases and he same ex en as o he heal hca e
p o essionals.
Di e en echnology ools o sys ems (e.g., o assess he s ock, moni o expi y da e o
medicines, p e en e o s while dispensing medicines) o se ice p o ision dec ease ad-
minis a i e bu den and allow mo e pa ien - ocused ca e in communi y pha macies [
5
,
41
].
Al hough all communi y pha macies in Es onia a e compu e ized and 99% o p esc ip-
ions a e e-p esc ip ions [
42
], he compa ison be ween he s udy yea s showed a sligh
dec ease in exploi ing di e en daily ope a ion ools. O pa icula conce n is he dec eas-
ing ac i i y o pha macis s in dealing wi h medicines sho ages and s ock-ou s. Acco ding
o he Pha maceu ical G oup o Eu opean Union (PGEU) medicines sho ages su ey,
his p oblem may a ec communi y pha macy businesses by educing pa ien s’ us and
inancial loss due o ime in es ed in mi iga ing sho ages and educing employee sa is ac-
ion [
43
]. The una ailabili y o medicines has a c ucial impac on pa ien heal h ou comes,
whe e pha macies should show highe ini ia i e a he pa ien -ca e le el. Fo example,
ac i e communica ion wi h d ug egula o s and o he s akeholde s, including o he pha -
macies and p esc ibe s, could be inc eased o sha e in o ma ion abou medicines sho ages
and ind ( empo a y) solu ions o ensu e con inui y o pa ien ca e.
4.2. Compe ency o Communi y Pha macis s and Pha macy En i onmen
Cipolle e al. ha e highligh ed ha communi y pha macis s we e mos com o able
and con iden while dispensing medicines [
44
]. Sel -con idence and highe p o essionalism
a e ela ed o p o essional knowledge and con inuous sel -de elopmen [
45
]. Following
li elong lea ning p inciples a e essen ial h oughou he p o essional ca ee o ensu e up-
o-da e knowledge and skills. Resul s ha e shown ha he o ganiza ion o con inuous
p o essional de elopmen (CPD) has signi ican ly imp o ed du ing he s udy. This can
be explained by he ac ha since 2015 i is manda o y o all pha macis s in Es onia
o collec 40 CPD hou s wi hin wo yea s. Howe e , he impac and applica ion o he
aining o he ac ual pha macy p ac ice has no been e alua ed o moni o ed o da e [
17
].
Mo e CPD ea u es should be implemen ed, including sel - e lec ion and documen a ion as
well as skills demons a ion by simula ed p ac ice. This would equi e mo e e o om he
lea ne and p o ide mo e p ecision in p o essional p og ess [
45
,
46
]. Addi ionally, a com-
muni y pha macy sec o ision documen ill 2030 ou lined he impo ance o a uni ied and
in eg a ed sys em o unde - and pos g adua e educa ion o pha macis s in Es onia [47].
The p o ision o ex ended se ices has no changed du ing he s udy pe iod, and mos ly
poin -o -ca e es ing was o e ed. Howe e , since 2018 communi y pha macies ha e
con ibu ed o lu accina ion and since 2019, o ha m educ ion se ices i.e., needle ex-
change [
14
,
48
]. In 2019-20 a medica ion use e iew (MUR) pilo se ice wi h a s anda dized
s uc u e and documen a ion o m was in oduced in i e communi y pha macies. Acco d-
Heal hca e 2021,9, 804 16 o 24
Quali y o
ex empo ane-
ous
medicines (3)
O ganolep ic analysis is
pe o med on all
subs ances used o
p epa ing medicines be o e
hei i s use.
2 - 0.93
±0.26
0.85
±0.36
0.89
±0.31 0.096
Acco ding o he
inspec ions o he S a e
Agency o Medicines, he
medicines p epa ed a he
pha macy ha e me he
quali y s anda ds du ing
he pas h ee yea s.
20.35
±0.48
0.84
±0.37
0.78
±0.42
0.55
±0.50 <0.001
I a medicine is ound no
o mee he equi emen s,
he eason o he
noncon o mi y is always
iden i ied
20.36
±0.48
0.89
±0.31
0.71
±0.46
0.53
±0.50 <0.001
Ex ended
pha macy
se ice
Quali ica ion
o employees
and
p o ision o
ex ended
se ices (5)
All s a who p o ide he
ex ended se ice o heal h
p omo ion and illness
p e en ion ha e comple ed
he equi ed aining and
ha e a co esponding
ce i ica e.
2 - 0.44
±0.50
0.27
±0.44
0.37
±0.48 0.001
All s a who measu e
heal h indica o s ha e
comple ed aining o his
pu pose and ha e a
co esponding ce i ica e.
2 - 0.43
±0.50
0.33
±0.47
0.39
±0.49 0.079
Ex ended se ices he
pha macy o e s a e
documen ed and s o ed a
he pha macy.
2 - 0.23
±0.42
0.15
±0.36
0.20
±0.40 0.055
Du ing he pas wo yea s,
he pha macis s ha e
o e ed he se ice o
measu ing heal h
indica o s also ou side
he pha macy.
2 - 0.11
±0.31
0.09
±0.29
0.10
±0.30 0.611
Du ing he pas wo yea s,
he pha macy has aken
pa in heal h and
en i onmen al campaigns
20.49
±0.50
0.23
±0.42
0.16
±0.37
0.31
±0.46 <0.001
P o ided
ex ended
se ices (5)
Blood p essu e
is measu ed. 20.52
±0.50
0.56
±0.50
0.67
±0.47
0.57
±0.49 0.026
Blood suga le el
is measu ed. 20.30
±0.46
0.23
±0.42
0.30
±0.46
0.27
±0.45 0.215

Heal hca e 2021,9, 804 17 o 24
To al choles e ol le el in
blood is measu ed. 20.27
±0.45
0.19
±0.40
0.26
±0.44
0.24
±0.43 0.113
Haemoglobin le el in
blood is measu ed. 2 - 0.09
±0.29
0.15
±0.36
0.12
±0.32 0.121
Body composi ion
is analysed. 20.17
±0.37
0.11
±0.31
0.19
±0.39
0.15
±0.36 0.080
En i onmen
and
ope a ion
Condi ions
o p i a e
and pa ien -
cen ed
coun-
selling (7)
P i a e counselling while
dispensing p esc ip ion
medicines is ensu ed.
20.17
±0.37
0.15
±0.35
0.16
±0.37
0.16
±0.01 0.854
P i a e counselling while
dispensing OTC medicines
is ensu ed.
20.11
±0.31
0.09
±0.29
0.11
±0.32
0.10
±0.31 0.839
The pha macy has
a sepa a e oom
o counselling.
20.15
±0.35
0.13
±0.33
0.16
±0.37
0.14
±0.35 0.649
The cus ome has a place o
si while a p esc ip ion
medicine is being
dispensed.
20.62
±0.48
0.58
±0.49
0.64
±0.48
0.61
±0.49 0.525
The cus ome has a place o
si while an OTC medicine
is being dispensed.
20.49
±0.50
0.48
±0.50
0.52
±0.50
0.50
±0.50 0.739
The sales oom has sea s
o cus ome s wai ing o
hei u n o be se iced.
20.79
±0.41
0.79
±0.41
0.80
±0.40
0.79
±0.40 0.928
D inking wa e is a ailable
a he pha macy o he
immedia e adminis a ion
o a medicine.
20.81
±0.39
0.98
±0.15
0.97
±0.17
0.91
±0.28 <0.001
Se ice
p o ision
suppo ing
ools (3)
A da abase o in e ac ions
and ad e se d ug eac ions
is used.
20.86
±0.35
0.82
±0.38
0.82
±0.38
0.84
±0.37 0.566
The pha macy has all ools
o p epa ing medicines. 20.53
±0.50
0.89
±0.32
0.86
±0.35
0.72
±0.45 <0.001
All scales and o he
measu ing ins umen s
used a e calib a ed on ime.
20.57
±0.50
0.93
±0.26
0.85
±0.36
0.75
±0.43 <0.001
P ocu emen
and ensu ing
s ock (3)
The pha macy has a sys em
o moni o ing and
supplemen ing s ock.
20.94
±0.23
1.0
±0.07
0.84
±0.36
0.94
±0.24 <0.001
The pha macy has access o
he lis s o unau ho ised
medicines ha a e allowed
o be used upon he eques
o p o essional
associa ions.
21.0
±0.00
0.98
±0.14
0.96
±0.20
0.98
±0.13 0.013
Heal hca e 2021,9, 804 18 o 24
The pha macy has a sys em
o moni o ing he expi y
da es o medicines.
2 - 1.00
±0.00
0.98
±0.14
0.99
±0.01 0.033
S o age and
dispensing
(5)
The pha macy has a sys em
o p e en ing e o s ha
can occu while dispensing
medicines.
2 - 0.96
±0.20
0.92
±0.27
0.94
±0.23 0.161
The pha macy has
he moboxes o o he
simila means o
dispensing he molabile
medicines o ins i u ions.
20.42
±0.49
0.53
±0.50
0.55
±0.50
0.50
±0.50 0.029
In case o medicines ha
equi e addi ional s eps
be o e adminis a ion, he
pha macy always o e s o
p epa e he medicine o
he cus ome .
20.92
±0.27
0.92
±0.27
0.93
±0.26
0.92
±0.27 0.945
The pha macis ad ises he
pa ien (and also he doc o ,
i necessa y) o apply o
he compensa ion o he
medicine by way o
excep ion.
20.78
±0.42
0.79
±0.41
0.34
±0.48
0.67
±0.47 <0.001
Ba code on he package is
used when dispensing he
medicine.
4 - 2.75
±0.57
2.83
±0.41
2.78
±0.51 0.170
Quali y
managemen
(4)
The pha macy documen s
he complain s i ecei es
ega ding he quali y o
medicines.
42.64
±0.79
2.71
±0.65
2.70
±0.69
2.68
±0.71 0.602
P esc ip ions a e
double-checked a he
pha macy o
disco e e o s.
42.32
±0.84
2.09
±0.91
2.04
±0.88
2.16
±0.89 0.005
In o ma ion abou local
was e handling op ions is
a ailable a he pha macy.
20.95
±0.22
0.85
±0.36
0.82
±0.39
0.88
±0.33 <0.001
The pha macy has
sys emised in o ma ion on
complain s, quali y
p oblems, ecalling o
medicines and o he
dispensing limi s.
20.88
±0.32
0.97
±0.18
0.94
±0.23
0.93
±0.25 0.003
Managemen
o cus ome
ela ions (6)
All employees o he
pha macy a e awa e o and
ollow uni ied p inciples o
cus ome se ice and
p oblem sol ing.
21.0
±0.07
0.99
±0.12
0.99
±0.01
0.99
±0.01 0.580
P oblems ela ed o he
pha macy se ice and hei
solu ions a e documen ed
a he pha macy.
42.37
±0.93
2.03
±1.10
2.13
±1.04
2.18
±1.03 0.003
Heal hca e 2021,9, 804 19 o 24
To imp o e he
o ganisa ion o wo k, he
pha macy manage asks o
eedback and sugges ions
om all employees a leas
once a yea .
20.85
±0.35
0.86
±0.35
0.81
±0.40
0.84
±0.36 0.408
The pha macy has
o ganized he collec ion o
eedback (incl. complain s
and sugges ions) om
isi o s (w i en, websi e,
e-mail):
20.60
±0.49
0.73
±0.44
0.72
±0.45
0.68
±0.47 0.005
Du ing he pas h ee yea s,
he pha macy has ca ied
ou a sa is ac ion su ey
among i s cus ome s
2 - 0.09
±0.29
0.36
±0.48
0.20
±0.40 <0.001
All pha macy employees
engaged in cus ome
se ice a e p o icien
in Es onian.
20.97
±0.17
0.96
±0.19
0.97
±0.17
0.97
±0.18 0.843
Pe sonnel
managemen
(2)
The pha macy has
app o ed he p inciples o
pe sonnel managemen
lis ed in CPSQG
42.37
±0.71
2.33
±0.78
2.51
±0.65
2.39
±0.73 0.061
The pha macy has enough
employees o ensu e a
quali y pha macy se ice,
including ho ough
counselling (conside ing
di e en imes o day and
mon h).
42.27
±0.63
2.19
±0.74
2.02
±0.72
2.18
±0.70 0.005
Manage ’s e-
sponsibili ies
(4)
The pha macy manage
pe o ms all du ies lis ed in
CPSQG.
42.61
±0.53
2.68
±0.50
2.56
±0.62
2.63
±0.54 0.109
The pha macy has a
de elopmen plan. 2 - 0.48
±0.50
0.37
±0.48
0.44
±0.50 0.034
The pha macy manage
discusses he esul s o
in e nal audi wi h all
employees.
20.95
±0.23
0.93
±0.26
0.91
±0.29
0.93
±0.25 0.386
The pha macy manage is
amilia wi h he
accoun ing o he
pha macy.
20.93
±0.25
0.92
±0.27
0.82
±0.39
0.90
±0.30 0.001
In e nal com-
munica ion
(3)
The pha macy has a
designa ed place o
dissemina ing w i en
in o ma ion (e.g., billboa d,
web en i onmen ).
20.85
±0.35
0.89
±0.32
0.89
±0.31
0.88
±0.33 0.462
The pha macis s a e awa e
o medicine sho ages,
deli e y imes and deli e y
channels.
42.54
±0.50
2.45
±0.51
2.52
±0.50
2.49
±0.51 0.028
Heal hca e 2021,9, 804 20 o 24
The pha macy has a
unc ioning sys em o
dissemina ing impo an
in o ma ion on
medicines/ ea men
me hods as well as
in o ma ion acqui ed
du ing aining cou ses
among colleagues.
20.76
±0.43
0.73
±0.44
0.73
±0.44
0.74
±0.44 0.832
Ex e nal
Communica-
ion
(7)
I a cus ome needs o be
sen o ano he pha macy
o a medicine, he
pha macis i s ag ees on
ha wi h he o he
pha macy.
42.11
±0.762
2.17
±0.69
2.30
±0.61
2.18
±0.70 0.051
I subs ance abuse o poo
medica ion adhe ence can
be suspec ed, he
pha macis con ac s he
doc o , nu se, o social
wo ke .
42.11
±0.93
1.98
±0.98
1.77
±0.94
1.97
±0.956 0.006
The p esc ibe shall be
no i ied i he/she has
mis aken he equi emen s
o he p esc ip ion
p ocedu e.
42.56
±0.67
2.57
±0.64
2.47
±0.70
2.54
±0.67 0.344
The pha macy o wa ds
medicine- ela ed ele an
in o ma ion, including ha
abou sho ages and
cheape medicines, o i s
coope a ion pa ne s.
41.96
±0.84
2.03
±0.82
2.03
±0.93
2.00
±0.86 0.632
The S a e Agency o
Medicines is in o med o
p oblems ela ed o he
supply o medicines
41.20
±1.01
1.13
±0.97
0.97
±0.92
1.11
±0.97 0.104
The da a abou he
pha macis s and assis an
pha macis s o he
pha macy is o wa ded o
he egis y o he Heal h
Boa d on ime.
21.00
±0.00
1.00
±0.07
1.00
±0.00
1.00
±0.04 0.441
The pha macis s´
in ol emen in he
de elopmen o
p o essional and
o ganisa ional ac i i ies.
4 - 1.59
±0.91
1.38
±0.95
1.51
±0.93 0.043
Communica ion
obliga ion (2)
I a w ong medicine has
been dispensed o his can
be suspec ed, he
pha macis immedia ely
con ac s he pa ien and/o
he doc o .
42.98
±0.21
2.98
±0.17
2.99
±0.12
2.98
±0.17 0.863
Heal hca e 2021,9, 804 21 o 24
I subs ance abuse can be
suspec ed, he pha macis
in o ms he S a e Agency
o Medicines (in case o
psycho opic o na co ic
medicines) and/o
he doc o .
42.65
±0.72
2.46
±0.91
2.37
±0.90
2.51
±0.85 0.006
Pha macis
as a lec u e
and au ho o
a icles (1)
The pha macis s ha e
made a p o essional
p esen a ion o w i en an
a icle wi hin he pas
h ee yea s
20.23
±0.42
0.22
±0.42
0.28
±0.45
0.25
±0.43 0.483
Pha macis s’
li elong
lea ning (6)
In o ma ion abou aining
oppo uni ies eaches all
pha macis s.
42.82
±0.43
2.89
±0.32
2.89
±0.34
2.86
±0.37 0.121
All pha macis s ha e equal
oppo uni ies o a end
aining cou ses.
42.71
±0.56
2.87
±0.37
2.83
±0.49
2.80
±0.48 0.003
Each employee has a
aining ca d a he
pha macy.
20.35
±0.48
0.94
±0.24
0.93
±0.26
0.72
±0.45 <0.001
Each employee’s aining
needs a e iden i ied a leas
once a yea .
20.61
±0.49
0.94
±0.23
0.95
±0.22
0.82
±0.38 <0.001
The pha macy has ensu ed
access o essen ial sou ces
o in o ma ion.
20.99
±0.10
1.00
±0.07
1.0
±0.00
0.99
±0.07 0.471
In o ma ion sou ces a e
used egula ly. 42.84
±0.38
2.60
±0.82
2.40
±0.62
2.64
±0.66 <0.001
Pha macy as
a aineeship
ins i u ion (4)
The pha macy has hos ed a
ainee a leas once wi hin
he pas h ee yea s.
20.32
±0.47
0.35
±0.48
0.43
±0.50
0.36
±0.48 0.133
The pha macy p o ides all
pha macy se ices lis ed in
CPSQG.
20.54
±0.50
0.44
±0.50
0.47
±0.50
0.49
±0.50 0.174
The o ganisa ion o wo k
o he pha macy ensu es
ha a supe iso moni o s
he ainee´s wo k.
20.78
±0.42
0.68
±0.47
0.77
±0.42
0.74
±0.44 0.074
Du ing he aineeship
pe iod a he pha macy,
pha macis s communica e
wi h s uden s o iden i y
hei le el o knowledge
and o ganise he es o he
aineeship pe iod.
42.07
±1.24
1.89
±1.40
2.14
±1.24
2.04
±1.29 0.232
Compliance
wi h legal
equi emen s
(4)
The pha macy’s email
add ess is in he mailing
lis s o he Minis y o
Social A ai s, he S a e
Agency o Medicines, and
he Es onian Heal h
Insu ance Fund
21.0
±0.07
0.99
±0.10
0.97
±0.17
0.99
±0.11 0.137

Heal hca e 2021,9, 804 22 o 24
All pha macis s know how
o ind in o ma ion and
legal ac s on he home
pages o Riigi Tea aja, he
S a e Agency o Medicines,
he Minis y o Social
A ai s, he Es onian
Heal h Insu ance Fund, e c.
20.97
±0.18
0.98
±0.15
0.96
±0.20
0.97
±0.18 0.609
In o ma ion on all
impo an amendmen s
ega ding pha macy wo k
eaches all employees.
42.94
±0.42
2.91
±0.29
2.90
±0.30
2.92
±0.34 0.491
The pha macis s a e
well-in o med o changes
in he e e ence p ices and
p ice ag eemen s o
medicines. The cheapes
p op ie a y medicine o he
same ac i e subs ance is
a ailable a he pha macy.
4 - 2.78
±0.42
2.82
±0.39
2.79
±0.41 0.389
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