“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.