Evidence Based Design Will Encourage Patient Outcomes

A pharmacy environment is a complex one of patients, customers, products and services.
It is a little understood environment because evidence surrounding its structure and presentation is sparse.
All the elements require integration.
It’s one thing to spruce up a space aesthetically, but it’s equally important to address the underlying conditions to support the experience you’re trying to create.
This includes the integration of design with workflow, technology, organisational culture, and leadership.

As the imperative for culture change in pharmacy is looming large, pharmacy has a need to strengthen all of its “parts” to stand firm against its critics, all marching to different agendas.
That the critics all give an appearance of “knowing it all and knowing what’s best” for pharmacy, and communicating their misinformation to all who will listen, in part occurs because of pharmacy’s inability to confidently present any of its facets  – because of lack of evidence to underwrite all that it does, and why.

Our culture is being pointed to that of “patient-centring” and health practitioner collaboration.
Neither of these activities will culminate unless we design pharmacy environments to allow patients to transition seamlessly from one variety of health practitioners to a pharmacy, with redirection to another environment again, if required.

Pharmacy design will need to be carefully thought through; otherwise design flaws may create obstructions (and additional costs) to new work flows.
Operational flow diagrams are the tools required to better understand how a new layout might enhance functionality and staff productivity. The interior pharmacy design needs to support the work flow.
New equipment needs to be configured to open up a space and support a process that would minimise interruptions and distractions (key contributors to medication errors).

Evidence-based Design (EBD) is defined as “the process of basing decisions about the built environment on credible research to achieve the best possible outcomes”.

The broad brush elements of a pharmacy design are categorised as:

1. Adequate and appropriate illumination
This is a safety factor to help prevent errors. Also to improve communications within a particular space e.g. an ageing population requires very bright illumination to be able to read brochures, catalogues, shelf product information and directional signs signifying departments.
Waiting areas may require more subdued lighting reinforced by the addition of reading lamps if magazines are provided to patients to reduce impatience while waiting for a consultation.
Thus, the design recommendations include lighting type, positioning, and illumination levels.

2. Minimising disruptions and distractions
Where a patient can be involved in the process of giving or exchanging information, any waiting time is deemed minimal and starts when they are temporarily disconnected by having to sit in a chair to wait for their prescription or a pharmacist consultation. Establishing “theatre” around processes provides entertainment and evokes interest e.g. mentoring patients to input their own prescriptions using a bar code reader (on arrival) and then briefing the patient on any useful information (at the sales staff level) or even creating a patient registration that fully captures all patient data to particularly include telephone details and email addresses.
This becomes useful time to educate patients on how to access your website and offer incentives for them to access on a regular basis.
This also becomes the beginning for a new type of promotion that does not require market group franchises, and one that you can personalise to your pharmacy.
When the prescription or the pharmacist (or both) turn up to be connected to the patient, there is a pleasant surprise because in the patient’s mind they have hardly started their waiting time.
This is only one of many techniques or policies that can be introduced around disruptions and distractions. For example, telephone calls requesting a pharmacist can be entered to a “call back” log, unless the call is more urgent and time can be set aside to call everyone back at a more appropriate time.
Across the entire business an audit will reveal more efficient ways of handling common disruptions and distractions.
Distractions account for 45 percent of medication errors.

The suggested solutions include setting up focus spaces with minimal distractions, the use of visual cues (like an anti-smoking sign) and staff education and awareness.

3. Reducing sounds and noise
Work spaces that require high levels of concentration such as dispensing areas and clinical interview areas need calm and low noise levels to maintain a focus.
Studies have illustrated that noise can impair performance.
Design interventions to consider are quiet areas for staff during critical medication tasks, the use of sound absorptive materials, the use of “white noise” generators and periodic audits of noise levels.

4. Consider Physical Design and Organization
Poor ergonomics can influence the ability to use information and perform tasks.

Counter and shelf heights affect visibility and clutter has been shown to impact dispensing errors when items become difficult to differentiate.
The design of the space can also influence lighting, noise, and interruptions as previously noted.

Recommendations include specific spacing between distinct drugs, appropriate heights for work counters, and the use of adjustable fixtures.
Work stations need to be a mix of both sitting and standing designs for the health of the person stationed at a computer.
Chairs need to have sturdy arms to accommodate older persons (both staff and patients) to comfortably be able to rise from a seated position.

5. Medication Safety Zones
These are defined as any critical area where medications are prescribed, transcribed, prepared, and administered, medication safety zones can include counters, medication carts, the patient bedside, and even homes where medications are administered depending on the outreach level of your patient services.
If your service requires an external space in any outreach activity be prepared to install some form of mobile fitting to accommodate the pharmacist.

All medication safety zones should be designed on the “cockpit” principle (readily available information, user-friendly, and all together) to support fact finding.
Areas should be organized such that important components are in convenient locations, frequently used items are located where they can easily be found without workarounds, items related functionally are grouped together, and items are placed in an order that supports the sequence necessary to support the task. 

Standardisation is also emphasized, along with the use of design constraints and forcing functions for high-alert medications.
Good pharmacy design relates to good outcomes.

All health professions are being urged into an outcome focussed delivery so the underlying design of both physical aspects and an actual clinical service relies on good design to minimise costs by maximising efficiency.
Collaboration between health professionals in the primary health care space will depend on one health discipline to be able to engage seamlessly with another.

Pharmacists who do not recognise seamless will be setting themselves up for lost future professional expansion and income.
As I have mentioned in earlier articles, pharmacists will be judged harshly by other health professionals if they are not able to integrate successfully.
This means that pharmacists will always have to do it better and also strive to be leaders in the primary health care space.
The medical profession claim the leadership space by default and by political manoeuvrings – but you can beat them by design.

 And as dealings with other health care professionals increase, protocols that will require unique designs and design modification will begin to emerge, with each profession borrowing one to the other so as to keep the patient in a centralised focus.
Patient-centred care is only in its early stages, but patients will quickly adapt to this type of care and will learn to take more responsibility for their care.
Thus it will be patients who will eventually drive this revolution and any health professional not seen to be up to the mark will find themselves quickly disengaged if the transfer points between health professionals are not designed to be seamless and comfortable.

There is limited knowledge and evidence to assist pharmacists in their journey to the new paradigm pharmacy, but unless you begin to experiment now, you leave yourself vulnerable to a new level of competition not previously encountered.
The competition pool will not just be limited to pharmacists, but will also include competition to attract referrals from other competent health practitioners.
And that will only happen if you, in turn, are seen to be competent.
Interesting times ahead, indeed.

Evidence based design does not have a central “home” within pharmacy.
This is more or less virgin territory.
I have recently seen a media release that warns pharmacists that they cannot change the design of their pharmacy without approval.
This form of bureaucracy seems a bit irrelevant given that there are no standards for designs to adhere to.
Perhaps the monies charged for this irrelevant service can be put to use by researching relevant design standards and put back in to the profession rather than just seek rent.
That would serve a useful purpose.