“Lick, stick, and pour”-common words used to envision the work of pharmacists-white-coated men and women toiling away in the dispensing pharmacy in the hospital basement or behind the counter of a community pharmacy, counting out pills and affixing labels for prescribed medications. This was the predominant image in our minds when we, the research team of Nurture by Steelcase, began a deep-dive into the topic of pharmacy. We quickly realized that we couldn't consider “pharmacy” as a space for assembling drugs, but as a complex system whose design and implementation deeply impacts the way care is delivered in both inpatient and outpatient environments.

As human-centered design researchers, we follow a six-step process to uncover issues, develop insights and create product, process and environmental solutions within healthcare. For pharmacy, we conducted extensive secondary research, interviewed experts and observed in 13 different facilities where pharmacy services are delivered. These included inpatient and outpatient pharmacies within hospitals, community pharmacies belonging to retail chains, as well as independent, pharmacist-owned pharmacies. While the solutions we developed vary from type to type of pharmacy, we found that there are four main issues that affect them all. These issues are error, efficiency, attraction and retention and compliance to rules and regulations.

To err is costly….

Error is certainly the issue that receives the most media attention. More than 1.5 million preventable medication-related adverse events occur each year in the US, with costs of more than $177 billion annually for associated care. These events range from minor errors, causing little or no harm, to major errors leading to patient death. There are many potential causes for error; some are transcription-based due to poorly written prescriptions or misunderstood abbreviations, while others are due to mixed-up drug names. There are 3,170 pairs of drug names which look or sound dangerously alike.

Poor working conditions for pharmacy staff can also contribute to error. Disruptions from noise, bad traffic flow and interruptions compromise their ability to focus and perform their work accurately. Physiological stress is accompanied by psychological stress, with pharmacists reporting that they work in fear of making mistakes and feeling underappreciated. Traditionally, individuals were penalized for errors, but current trends see hospitals and pharmacies moving instead toward recognition of the systemic nature of errors. This approach has proven effective in other industries, such as the airline industry.

As we explored the issues we identified, we found that they were not discrete. In fact, factors which contributed to error were also factors in poor efficiency. Efficiency in pharmacy is a major concern because Americans are taking more prescription drugs every year.

In a study conducted by Express Scripts, the number of people with at least one prescription increased from 67% to 74% between 2000 and 2006 and the number of prescriptions per person rose to 14.3 from 10.8 in 2000-a 32% jump. This results in pharmacists having an increased workload. On average, community pharmacists have 5.5 minutes per prescription, while inpatient pharmacists have 3 minutes. Even when a pharmacist avoids an error by deciphering an illegible prescription, the time it takes to do so causes further inefficiency in the system.

Because the work is heavily task-oriented, the layout of the pharmacy may also have an enormous impact on efficiency. Automation has been used to increase efficiency in certain steps in the process, but the cycle time from when an order is written to when it is received by the patient may not be improved due to bottlenecks and gaps along the way.

Where are the pharmacists?

While automation is one approach to increasing capacity, it will not adequately compensate for the current and growing pharmacist and pharmacy technician shortage. In 2020, there will be an estimated 157,000 unfilled pharmacy openings. As in other healthcare professions, there are several contributing factors for the shortfall. More extensive education requirements (all new pharmacists must have a PharmD) are leading to a decreasing number of graduates who are needed to replace the retiring generation of baby-boomer-age pharmacists.

There are also increased opportunities for pharmacists to work in nontraditional roles in labs, pharmaceutical companies and the hospital itself. Pharmacy students are specializing in areas such as Geriatric, Intensive Care, and Pediatric Pharmacy which require residencies based on the medical school model. These emphasize the pharmacists' role as members of the clinical team and as a resource for patients who need medication counseling and chronic disease management. Healthcare organizations need not only to find new staff to meet the demand for filling prescriptions; they need to ensure that their staff remains capable of performing their jobs. Because of the repetitive nature of the work, pharmacists and technicians are at risk for musculoskeletal injuries. Much of the work is performed standing, leading to fatigue and circulation problems.

Organizations also need to be concerned with the various rules and regulations that govern pharmacy work. The Joint Commission expected all organizations to be in compliance of USP 797 as of January 1, 2008. USP is the US Pharmacopeia, the official public standards-setting authority for all prescription and over-the-counter medicines, dietary supplements, and other healthcare products manufactured and sold in the United States. USP 797 is the standard governing sterile compounding environments. Among the other regulations that concern pharmacy are the Resource Conservation and Recovery Act (RCRA) which governs the disposal of hazardous waste, DEA regulations around the storage, dispensing and return of controlled substances, as well as compliance with HIPAA.
Inpatient, Lean Non-Automated. 1. Plan for short-term and long-term changes: Utilizing modular systems enables workstations to be tailored to the current work process, yet adaptable to future changes. 2. Support critical thinking: Pharmacists entering orders are shielded from surrounding noise and interruptions, while maintaining a sightline to the order fill and check areas. 3. Mitigate physical and emotional stressors: The pharmacists switch between order entry and order check, breaking the monotony of repetitive work. 4. Apply Lean principles throughout the pharmacy system: The new role of Waterspider improves efficiency by providing a steady stream of meds to be processed by the techs.

Inpatient, Lean Non-Automated. 1. Plan for short-term and long-term changes: Utilizing modular systems enables workstations to be tailored to the current work process, yet adaptable to future changes. 2. Support critical thinking: Pharmacists entering orders are shielded from surrounding noise and interruptions, while maintaining a sightline to the order fill and check areas. 3. Mitigate physical and emotional stressors: The pharmacists switch between order entry and order check, breaking the monotony of repetitive work. 4. Apply Lean principles throughout the pharmacy system: The new role of Waterspider improves efficiency by providing a steady stream of meds to be processed by the techs.

The Rx for pharmacy design

Developing an understanding of these issues through our readings and observations allowed us to create design principles, which we then used to guide our solution concepts. We share a few of them here in conjunction with the solutions we created.

Design Principle #1: Apply Lean principles throughout the pharmacy system. As mentioned previously, filling prescriptions is task-intensive, which led us to consider what we know about improving processes in manufacturing. Although pharmacy isn't manufacturing work, Lean strategies can be applied to minimize waste of time, waste of motion, and waste of storage space. New roles like the “waterspider” can be used to improve flow. In manufacturing, waterspiders are responsible for ensuring a steady stream of parts is supplied to the people assembling the product. They need to be skilled and knowledgeable to be able to anticipate the needs of the line to maintain standard work and keep the process moving. In pharmacy work, this role can be used to avoid batching of orders and eliminating bottlenecks.

Design Principle #2: Promote efficient handoffs. Most pharmacies are operating at maximum capacity, a state worsened by the fragmented nature of the system. Multiple channels of incoming and outgoing orders, via computers, faxes, pneumatic tubes, robots and couriers, lead to the potential for unbalanced workloads and delays in priority cases. The elimination of redundancies and gaps can promote efficient handoffs and distribution of medication throughout the hospital.

Design Principle #3: Plan for short-term and long-term changes. Because the pharmacy doesn't operate in a vacuum, its processes need to be designed to interrelate with the hospital's clinical practices, as well as its equipment and facility management systems. No matter how well a pharmacy may be planned, however, processes will inevitably change within the pharmacy or throughout the hospital, and the system needs to be able to adapt. Levels of flexibility can be implemented in the built environment to respond to immediate and long-term changes.
Inpatient, Automated. 1. Promote efficient handoffs: Providing technology allows the order fill and check areas to be combined, minimizing a potential gap between the steps. 2. Support critical thinking: Enclosed enclaves enable the pharmacists to enter orders without being distracted by the noise of the robot. 3. Plan for short-term and long-term changes: While automation drives the design, not building in the surrounding furniture allows the space to be adapted to future changes in technology. 4. Plan for the impact of barcoding on systems and spaces: A fully-implemented barcoding system minimizes the number of checks the pharmacist needs to perform.

Inpatient, Automated. 1. Promote efficient handoffs: Providing technology allows the order fill and check areas to be combined, minimizing a potential gap between the steps. 2. Support critical thinking: Enclosed enclaves enable the pharmacists to enter orders without being distracted by the noise of the robot. 3. Plan for short-term and long-term changes: While automation drives the design, not building in the surrounding furniture allows the space to be adapted to future changes in technology. 4. Plan for the impact of barcoding on systems and spaces: A fully-implemented barcoding system minimizes the number of checks the pharmacist needs to perform.

Outpatient/Retail Automated. 1. Support decentralized and specialized pharmacy work: A dedicated consultation space supports the expansion of services such as vaccinations, chronic disease management, etc. 2. Incorporate regulatory criteria early in the design process: Adjustable-height counters at drop-off and pick-up allow the pharmacy to meet the needs of customers with different physical abilities. 3. Apply Lean principles throughout the pharmacy system: A small robot in the center of the fill area allows auto fill, manual fill, and checking to happen in the same area, making the workflow more efficient.

Outpatient/Retail Automated. 1. Support decentralized and specialized pharmacy work: A dedicated consultation space supports the expansion of services such as vaccinations, chronic disease management, etc. 2. Incorporate regulatory criteria early in the design process: Adjustable-height counters at drop-off and pick-up allow the pharmacy to meet the needs of customers with different physical abilities. 3. Apply Lean principles throughout the pharmacy system: A small robot in the center of the fill area allows auto fill, manual fill, and checking to happen in the same area, making the workflow more efficient.

Design Principle #4: Support decentralized and specialized pharmacy work. Amongst the trends driving change in pharmacies is the specialization of pharmacists. As the practice of pharmacy becomes more patient-centered and specialized, the pharmacist is taken out of the main pharmacy and becoming more of a presence on the patient floor in the inpatient setting, as well as providing expanded pharmaceutical care directly to patients in the outpatient setting. Environments needed to support this decentralized pharmacy work and communication within an interdisciplinary team of caregivers.

Design Principle #5: Plan for the impact of barcoding on systems and spaces. A change that is driven by regulation is that all medications be barcoded. The use of barcoding to verify the “Five Rights” (right patient, right drug, right dose, right method, right time) at various checkpoints in the process creates a closed-loop system so medication errors don't reach the patient. As a result, the pharmacist can focus on the critical task of order entry instead of being interrupted to perform repeated checks. The implementation of a barcoding system will affect the work process and therefore the design of the pharmacy. Additionally, RFID is being implemented in the hospital to track high-dollar items. As the cost of RFID goes down, this may allow for greater use in tracking all medications.

Design Principle #6: Incorporate regulatory criteria early in the design process. Incorporating the criteria dictated by regulations early in the design planning process can prevent the introduction of after-installation solutions that impede workflow and detract from the overall design. The appropriate solutions integrated into the workflow and environment can minimize the risk of contamination, protect patients' personal health information, and ensure the responsible disposal of pharmacy waste.

Design Principle #7: Mitigate physical and emotional stressors. Pharmacy work requires a high level of cognitive function, such as the ability to concentrate, to make decisions and to recall information. Internal and external stressors may diminish cognitive abilities, leading to a decrease in job performance, which in turn may lead to error. The repetitive nature of the work, the physical demands of the environment, and the fear of making a mistake contribute to the state of chronic stress that can be experienced by pharmacy staff. The design of the pharmacy process and environment needs to mitigate the physical and emotional burdens on the staff.

Design Principle #8: Support critical thinking. As an aspect of the previous principle, supporting critical thinking is focused specifically on the need for pharmacy staff to concentrate. A pharmacy is a hub of activity, with people and orders coming and going, causing distractions to staff. Work areas that shield staff from noise, traffic, and interruptions will support them when they are performing tasks that require critical thinking.

The insights and sketches above represent just a portion of our findings. For those interested in learning more, Nurture offers a CEU and LU credentialed seminar that will discuss all of the insights the team developed during the project and provide attendees with an opportunity for a deeper dive into the research, design principles and accompanying thought starters. For information, please contact Phyllis Goetz at 214.779.0435 or pgoetz@nurture.comHD

Caroline Kelly, Design Researcher, joined Nurture's research team in 2005, after completing the graduate program in Industrial Design at the Georgia Institute of Technology. Her work includes research on outpatient care, technology and point-of-care charting, inpatient nursing units, and the effect of clinical room design on physician-patient interaction. Melanie Redman, Design Researcher, joined the Nurture research team in 2005 and holds degrees in Russian, International Studies, and Graphic Design. She has conducted research on outpatient care, nurses' stations, cancer care environments, and pediatric preoperative care. Additional research for this article was provided by Ritu Bajaj and Pamela Witting. Healthcare Design 2009 November;9(11):68-76