During fiscal year 2010, the Veteran’s Health Administration (VHA) announced a request for proposals to support and facilitate the transformation of VHA into a culture of patient-centered care. VHA created the Office of Patient-Centered Care and Cultural Transformation that is directed by Dr. Tracy Williams Gaudet.

According to Gaudet, “The Office of Patient-Centered Care and Cultural Transformation will be a living, learning organization in which we will discover and demonstrate new models of care, analyze the results, and then create strategies that allow for their translation and implementation across the U.S. Department of Veterans Affairs (VA). VA will continue to be a national leader in innovation, and, in this way, we will provide the future of high-quality healthcare to our veterans.”

The Office of Patient-Centered Care and Cultural Transformation selected four regional implementation teams across the country to implement VHA veteran-centered care principles. Each VA medical center was selected for excellence already demonstrated in producing cultures of patient-centered care based on established criteria. VA New Jersey Health Care System (VA NJHCS) was selected as one of the regional sites.

VA NJHCS was awarded a VHA Patient-Centered Care Innovation Grant in 2010 to redesign its outpatient pharmacy as a Pebble Project using an evidence-based design (EBD) process. This facility provides comprehensive tertiary care services to veterans throughout the state as a consolidated facility comprised of two main campuses—one in East Orange, New Jersey, and the other in Lyons, New Jersey—and 10 community-based outpatient clinics.

The East Orange campus (the focus of the grant proposal) is a general medicine, surgical, and psychiatry level 1b facility located in the Northeast, immediately adjacent to the city of Newark, New Jersey. Participating in this Pebble Project are VA NJHCS; The Center for Health Design; Planetree; and Array Healthcare Facilities Solutions. This partnership is centered on the understanding that the physical environment and other veteran-centered care principles should be considered in order to achieve the desired outcomes.

The EBD project goals for redesign of the outpatient pharmacy will enhance:

• Patient safety, quality of service, and information access by reducing distractions and wait times, and improving privacy;
• Patient and staff interactions through modified programming and the redesign of medication counseling and dispensing areas, as well as encouraged involvement of family and friends;
• Information and education through the availability of educational resources and My HealtheVet in-person authentication;
• Physical and environmental comfort with a focus on interior design, positive distractions, and healing arts in waiting/reception areas;
• Space planning and workflows using EBD and Planetree healing environment principles that support patient outcomes;
• Workforce engagement by improving the work environment to reduce noise, distractions, stress, and fatigue; and
• Efficiency of processes through the employment of recent technologies. 

Studies show that the performance and attitude of healthcare staff are influenced by the physical environment in which they work.1, 2, 3 In pharmacy environments, there are many potential causes for error, including unintelligible prescriptions; misunderstood abbreviations; look-alike/sound-alike medications; and inefficient environmental design that negatively impacts noise and flow, and causes bottlenecks and interruptions.

Employees are negatively impacted by an environment that compromises accuracy of work, inhibits timely delivery of medications, and impedes the delivery of optimum education and information for veterans and family members. Through environmental design interventions, the likelihood of such latent errors can be reduced. Implementation of an open pharmacy in another VA facility resulted in quicker prescription processing times, decreased average waiting times from one hour to 30 minutes, and increased patient satisfaction.4  

Medication errors may result from latent conditions inherent in the environment that result from decisions by designers, builders, procedure writers, and top-level management. Latent conditions involve noise, inadequate light, interruptions, distractions, and the volume of prescriptions filled per hour. Environmental design interventions can enhance safety in the pharmacy by reducing sound and noise, providing adequate illumination, creating medication safety zones, and incorporating ergonomic principles in the redesign.

Attempts were made to innovate EBD concepts using Lean principles. Lean recommendations for pharmacy redesign involve efficient handoffs, plans for short-term and long-term changes, support for decentralized/specialized pharmacy work, bar codes on systems and spaces, incorporation of regulatory criteria early in the design process, support for critical thinking, and moderation of physical and emotional stressors.5

The current physical environment for the East Orange campus pharmacy is not compatible with veteran-centered principles. Staff members deliver pharmacy services in work areas that are not shielded from noise, traffic, and interruptions. Veteran dissatisfaction results from inadequate waiting spaces, lack of privacy for patient education, and excessive noise as measured by acoustical assessments. Marred bulletproof glass impedes communication during prescription dispensing.

Public waiting areas for the pharmacy are not contiguous, and one waiting area is located in a prominent circulation area of the facility. Poor configuration and location of waiting and counseling areas leads to confusion regarding the patient process flow (counseling versus pickup). The inability of the pharmacy staff to communicate through bulletproof Plexiglas leads to frustrated patients being sent between the two areas without resolution of their problem.

The architectural floor plan (Figure 4) shows public areas (green), staff areas (yellow, blue, purple), and relationships between rooms, spaces, and other physical features at one level of the redesigned outpatient pharmacy. Planning indicated on the flow diagram (Figure 5) was designed with direct yet flexible traffic patterns to enhance efficiency and result in shorter waiting periods, both actual and perceived.
Specific innovations and improvements in this VA outpatient pharmacy setting include:

• Relocation and enlargement of the reception/waiting area away from a highly active and noisy elevator lobby;
• Intuitive wayfinding and positive calming distractions through the use of a water feature and visually accessible complimentary functions;
• Combination of separate reception areas for counseling and pick-up/drop-off functions into a single cohesive space, while continuing to support both functions discretely;
• Counseling positions that are visually accessible, but physically separated from each other and the reception area for patient privacy;
• Removal of barriers at dispensing positions that allow for direct communication of staff with patients without compromising necessary security provisions;
• Provision of a new technology-automated prescription dispensing machine that allows 24/7 patient access without relying on staff availability;
• Provision of clinical staff access to pharmacy staff and dispensing without incursion on patient-focused services;
• Creation of a continuous circular workflow path from receiving, storage, distribution, assembly, and checking through to direct dispensing, automated dispensing, holding, and mail-out programs, resulting in minimized traffic paths and reduced staff
fatigue;
• The benefits of a high-volume workflow conveyor are maintained while the physical barrier to necessary staff circulation is eliminated;
• Provision of staff facilities that are physically segregated, but readily accessible within the secure perimeter of the pharmacy work areas;
• Provision of finish materials that are less institutional in character and exhibit both patient and staff hospitality while being acoustically absorbent and readily maintainable. Specifically effective materials include flooring, ceilings, and systems furniture; and
• Use of modular casework and furniture systems in the pharmacy work areas to allow for future flexibility.

These improvements combined findings of literature review documented herein and focus group interviews, which included VA NJHCS staff from pharmacy and nonpharmacy staff, and veterans.

Metrics being used to continuously measure the success of this pharmacy redesign will include but are not limited to patient satisfaction, waiting time, pharmacy measurements of productivity, and employee satisfaction. National scores for the outpatient pharmacy experience will be monitored for improvement. Patient complaints and compliments as recorded in the national Patient Advocacy Tracking System database, and continuous feedback surveys will be monitored and trended to focus on the impact of remodeling. The current average waiting time will continue to be monitored with a goal of decreasing the patient’s perception of wait time. Pharmacy tracks the number of prescriptions filled per patient per year and will monitor any changes in productivity metrics.  

The redesigned pharmacy area will not only provide quality services in a patient-centered environment that optimizes space and efficiency, but has the potential to enhance the healthcare experience. Research shows that while small changes in the physical environment can impact patient outcomes, for these outcomes to be sustained in the long-run, there should be accompanying changes in processes and in culture. Built into the plan for redesign is the flexibility to innovate as healthcare, technology, and veteran expectations change and improve.

Staff providing services within the pharmacy will continue to participate in education and training, in patient-centered care principles, performance improvement, and systems redesign. Since pharmacy services affect nearly every veteran and his or her interaction with the VHA system, the results of the process and design improvements to the East Orange campus could be easily adapted to other VA facilities. Construction of the redesigned pharmacy is anticipated to be completed during early 2012. HCD

Mary Therese Hankinson, MBA, MS, RD, EDAC, is Planetree coordinator for the VA New Jersey Health Care System. Elizabeth Stanberry, PharmD, is chief, pharmacy service at VA New Jersey Health Care System. Jarod  Machinga, PhD, MBA, is assistant chief, facilities management service, VA New Jersey Health Care System. Jeffrey P. Drucker AIA, is vice president Northeast region, Array Health Facilities Solutions. James J. Blose Jr., AIA, CSI, CCCA, is project manager, Array Health Facilities Solutions. Skye Pirch, LEED AP ID+C, is project designer, Array Health Facilities Solutions.

References
1. Davis, T. R. The influence of the physical environment in offices. Academy of Management Review, 1984. 9(2), 271–283.
2. Bitner,M. J. Servicescapes: The impact of physical surroundings on customers and employees. Journal of Marketing, 1992. 56(2), 57–71.
3. Becker, F. D., Poe, D. B. The effects of user generated design modifications in a general hospital. Journal of Nonverbal Behavior, 1980. 4(4), 195–218.
4. Pierce RA, Rogers EM, Sharp MH, Musulin M. Outpatient pharmacy redesign to improve work flow, waiting time, and patient satisfaction. Am J Hosp Pharm, 1990. 47(2):351-6.
5. Kelly, C., Redman, M. Rx for pharmacy spaces: A user-centered approach.    Healthcare Design, 2009. http:///ME2/dirmod.asp?sid=9B6FFC446FF7486981EA3C0C3CCE4943&nm=Articles&type=Publishing&mod=Publications%3A%3AArticle&mid=8F3A7027421841978F18BE895F87F791&tier=4&id​=8E4C1E5DAAC7484D892A​B0A423B9652F