Design Rx: Delivering Operationally Efficient Pharmacies
Moving away from small satellite locations, hospitals pharmacies are being built in centralized locations to better leverage clinical pharmacists’ expertise as part of the medical team, and to more efficiently fill, package, and deliver medication to patient units. Meanwhile, more complex medical inventories, regulations mandating strict handling procedures, and the need for tight stock control have raised the bar for risk management, essentially requiring pharmacies to create and apply well-vetted operational models for these critical spaces.
“Design and planning strategies must incorporate specific measures to ensure the highest air quality for preparation, regulate consistent interior environments to maintain product quality, and incorporate appropriate security to monitor and protect inventory,” says Dorothy Lloyd, global director, healthcare practice, at HOK (San Francisco).
To help hospitals meet these demanding requirements, more automated systems are being incorporated to virtually eliminate prescription filling errors and boost workflow efficiencies, and design teams are more actively utilizing planning and analysis strategies, such as Lean and Six Sigma, to create spaces that best support these approaches.
While the operational model that defines product flow from the loading dock all the way to the patient can vary significantly among pharmacies, the underlying commonality is a goal to optimize workflow, prevent overlap in processes and space utilization, avoid double-handling of product, and maximize safety. “Understanding the order, delivery, and administration process allows waste to be reduced in each area, allowing significant reductions in time from prescription order to patient administration,” explains Tina Larsen, principal at Corgan (Dallas).
In order to achieve this, healthcare designers recommend a number of planning and design strategies proven to be effective in pharmacy settings. For example, a commonly used Lean strategy is the Kaizen event, defined as an intensive, often week-long workshop where staff come together to thoroughly analyze the workflow process with a focus on eliminating waste. “This is particularly useful in pharmacies because there are a limited number of types of processes, and there’s a lot of data tracked to support the analysis,” explains Jim Albert, principal and vice president at Hord Coplan Macht (Baltimore).
Case in point, at the Greater Baltimore Medical Center, Hord Coplan Macht built a full-scale cardboard mock-up of the pharmacy in a parking garage. The team then ran simulations of every task, identified potential areas of waste, refined the processes, and ultimately, modified the overall design. “The team documented a 19 percent reduction in pharmacists’ hours, an 11 percent reduction in pharmacy tech hours, and a 90 percent reduction of drugs that had to be picked and processed by hand,” Albert says.
For example, by running simulations of proposed layouts and locating bulk storage inside the pharmacy, as opposed to remote locations, staff travel distances were reduced. In a similar vein, by maintaining an easily measurable and visible inventory, subsequent inventory waste was reduced, as well.
(For more on using Lean design in pharmacy projects, see sidebar below.)
Another way in which designers can help hospital pharmacies capture greater operational efficiencies is by designing spaces that are supporting of provider’s specified automated systems. “Pharmacies are increasingly using automation for preparing and dispensing medications,” says Bhargav Goswami, principal and senior medical planner at WHR Architects (Houston). “These require large, uninterrupted floor space with adequate clearances and structural capacity.”
For instance, some systems will individually package, bar-code, and store medication. After receiving prescriptions electronically, other automated machines will pull that medication and load it onto secure carts for distribution. “This equipment can be very large and noisy, but [the machines] are incredibly efficient, increasing productivity and improving accuracy and safety,” Larsen says.
By employing automated pill counters, another popular automated system, hospitals can minimize errors and reduce the workload placed on pharmacists who spend long periods of time and high level of focus on sorting and counting pills and compounding powders and ointments.
Meanwhile, EwingCole has also seen positive results from robotic intravenous automation boosting pharmacy productivity for the preparation of IVs. However, on one recent project, Mary L. Frazier, principal of EwingCole (Philadelphia), explains that installing this robot required the building team to enlarge an adjacent room and its required clearances. Fortunately, the pharmacy was located in the basement on a slab-on-grade area, so the 7,000 pound machine didn’t need additional structural reinforcement. However, consideration should be given to weight as well as necessary increases in room size and additional heat load and HVAC system modifications that will be required to accommodate this technology.
While more and more robotic systems are available for pharmacies, perhaps the most commonly used technology is the equipment used to deliver medication from the pharmacy to the nurses’ station. For example, at Dallas County’s New Parkland Hospital, a large pneumatic tube system transports first doses—defined as new medication added to a patient’s regimen—and stat medication, which is physician-prescribed medication that must be administered as soon as possible. Orders are transmitted electronically and the system then brings up the requested medication within a short timeframe. As for regularly scheduled medications, robotic equipment at Parkland is used to group each patient’s daily medications together. A pharmacy tech then manually transports the order to a medication dispensing unit located near the patient.
While pneumatic systems and manual deliveries are still very much in play, some hospitals have already upgraded to more advanced robotics. Such “robotic-tug” systems can be helpful for transporting delicate medication not appropriate for a pneumatic system and that would otherwise require manual delivery. Such items include drugs that can’t be shaken; substances that require tracking; large or heavy items; or hazardous drugs, such as those used for chemotherapy, which would contaminate the tube system if broken during transit, Albert explains. “Depending on the system and the extent of integration into the facility—for example, are they also using robotics for delivery of other items in the hospital?—there can be a need for dedicated elevators for the system’s highest payback,” Frazier says. “However, at minimum, the robots need dedicated parking and charging areas within the pharmacy and other areas in the facility.”
At your service
With the patient experience currently ranking high on a hospital’s list of priorities, the customer service aspect of pharmacies is becoming another way to answer that call. As a result, patient privacy, comfort, and education are key aspects of pharmacy design, says Dave Haraminac, associate and senior medical planner at SmithGroupJJR (Detroit).
he last people to interact with a patient prior to discharge, the pharmacy staff have an opportunity to properly instruct patients and reduce the risk of readmission from improper use and/or failure to take medication. Fortunately, newer operational models have freed up clinical pharmacists from drug preparation and filling orders to more directly lend their expertise to the medical team and patients.
To support these important pharmacist-patient interactions, more and more pharmacies are incorporating open, spacious areas in place of small windows off of public corridors. “The number one amenity that a hospital-based retail pharmacy can offer patients is a small, private consultation space where a pharmacist can explain how to use the medication, potential side effects, and potential drug interactions,” Albert says. According to Frazier, this space can be as simple as a desk-height counter with full-height divider panels and acoustic treatments, or a small consult room near pick-up or drop-off areas.
To add design interest, while still maintaining patient privacy, Larsen suggests decorative dividers such as phenolic panels. In order to reduce voice transmission across these semi-open spaces, white noise machines are also a recommended strategy.
Optimizing work environments
While optimizing workflow, incorporating automation, and supporting patient interactions are all central aspects of today’s hospital pharmacy designs, improving comfort for pharmacy staff is also coming into play. But it’s easier said than done. Hospital pharmacies are traditionally riddled with a number of workplace challenges.
For starters, many of these pharmacy processing spaces are located deep inside the core of large buildings, or in the basement, with little to no daylight access. Furthermore, automation equipment can be very noisy, thereby contributing to employee discomfort and stress. “Creating a pharmacy that’s open enough to allow visibility across the space, while providing work areas that offer appropriate seclusion to minimize distractions, can be challenging,” Larsen says.
Case in point, Parkland’s former pharmacy was located in the basement of its existing building, with very low ceilings and no natural light, whereas the hospital’s new space is located on a floor above grade where daylighting is a key part of the design. “It is an open environment with high ceilings and high-performance acoustical ceiling tiles to improve the acoustics of the space,” she says.
Similar to Parkland’s efforts to improve the comfort and well-being of its pharmacy staff, hospitals are investing more energy in upgrading the efficiency and productivity of these key spaces inside their campus. In addition to benefit the bottom line, smoothly running pharmacies enhance patient safety and satisfaction, and supports hospitals in bettering better health outcomes.
Barbara Horwitz-Bennett is a contributing editor for Healthcare Design. She can be reached at email@example.com.
SIDEBAR: Steps to streamlining
Jim Albert, principal and vice president at Hord Coplan Macht, provides an overview of the Kaizen step-by-step process that can be used to Lean pharmacy operations:
- Identify the full process being analyzed.
- Observe the process in action by touring where it is done.
- Map out each step of the process looking for waste.
- Develop an ideal process flow.
- Identify items needed to create an ideal process flow that may not be under the building user’s control.
- Map out, on paper, the space needs of the ideal process flow.
- Prototype the space in 3-D.
- Simulate the process in the space.
- Refine the prototype and repeat.
- Develop a homework list of follow-up items.
SIDEBAR: The basics
Tina Larsen, principal at Corgan, offers a punch list of key pharmacy workplace features aimed at boosting staff productivity and comfort:
- Shield pharmacists from noise, interruptions, and uncomfortable temperatures.
- Reduce stress through optimal lighting and appropriate color/work surfaces to mitigate visual fatigue.
- Minimize wasted time, motion, and space.
- Reduce fatigue and risk of injury by carefully locating task areas and selecting appropriate flooring materials.
- Facilitate workflow through decreased fill time, optimized staff utilization, and reduced clutter.
- Provide flexibility to adapt to future changes.