Pharmacy by Design

Pharmacy renewal, a process that will start in earnest in this year of 2015, cannot occur without shop refitting or modification along with design changes reflecting the shape and style of the workflows that have to be accommodated.
Major designers, stimulated by Afffordable Care Legislation in the US, have turned their attention on healthcare as a whole and they are looking at the systems employed in a particular space, the optimum area needed, the equipment and furniture that should populate that space and what colours would be attractive to various patient populations.

Not surprisingly designers have focused on the most expensive healthcare sector which is tertiary care (hospitals), then the scaled down versions for primary health care – the patient home.

Because you cannot divorce pharmacy from patient homes, designers are finally tackling that enigma called pharmacy.
Good designers have to completely understand the industry they are servicing, so the preparatory work begins long before the first client becomes available.
A good designer will subscribe and read the same journals that a pharmacist would read, and because designers are “outsiders” to pharmacy, the first question asked by a good designer is “why?”.
This poses challenge to established thoughts, and clients have to then justify why they do things the way they do.
This results in a second challenge, which is “what?”.

At this point a designer is injecting thoughts on how they view a pharmacy process which enables a client to explain why an offered process would not work.
But it creates debate and delivers constructive solutions as the “think tank” begins to work and take shape.

Pharmacy design is all about work-flows and how they relate one to the other.
Over time, work is displaced in some way, even disrupted.
An example of disruption would be the installation of an automated dispensing machine to replace a traditional system.
It’s not just “plug and play” and if work flow design is not thought through prior to the installation of an automated machine, disaster may be the result.

So with the purchase of a disruptive system the total price should factor in the new equipment, furnishings and partition replacement that accompanies such disruption.

A good designer will look beyond the purveyed image of “lick, stick and pour” promoted by pharmacy detractors and begin to quantify and amplify the real underlying image that most pharmacists “feel” but have difficulty portraying in words and images themselves.
It is the complexity of pharmacy and the ease with which skilled pharmacists perform their work that mystifies detractors, who not having the ability to understand and visualise the substance of pharmacy, become suspicious and put out their own explanation. This is usually one of suspicion, negativity and simplicity and the image is often amplified by competitors in the primary health care space, usually medical doctors.

That this type of practice is unethical seems to escape these people, and downstream difficulties of collaboration become more pronounced.

It is probably best to retain a designer who is independent from a shopfitter for the same reason you employ an architect to design your private home.
Sometimes a designer will favour a specific shopfitter to do work for them because of past experience.
This is all right provided there is “arms-length” in the relationship.
In Australia, shopfitters commonly have their own internal design department.
This arrangement may be cheaper, but does not always deliver the wide range of options that are available at any given time.
It tends to service the manufacturing problems of the shopfitter rather than the design requirements of the client.

The following is an experience by a US design group called “Nurture by Steelcase”, well-known in US health circles.

“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 realised 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-centred 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.
It is very obvious that apart from the totally new aspect for pharmacy design that is required for differentiation, some attention must be given to the education of patients in understanding and accepting a new design.”

Regular public relations campaigns need to precede any new design and its outcomes need to generate new stories on a regular basis.
Only a systematic approach to the problem of an adverse or confused image that pharmacy currently portrays will overcome the various problems and ensure the solutions are permanent.

To this end focus groups of pharmacists should be regularly encouraged to deliver annual responses for upgrade suggestions and the other very important focus groups relating to groups of local patient participants, who should be prepared to come along and ask “Why?” to a specific issue they deem pertinent.
The pharmacists conducting those focus groups should be prepared to answer the why’s with “What?” or “What about?”.

Flow on research created the following knowledge bank by the “Nurture by Steelcase” design group and probably has a parallel application in Australian pharmacy:

“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.”

Australian pharmacy design has a lot of catch-up to do because the lopsided design of leadership organisations has resulted in the balance of power being held in too few hands.
Coupled with the lack of imagination and understanding by past PGA leaders, we find ourselves well behind the rest of the world in just about all departments.
We have had over a decade of mismanagement to overcome.
We have had knowledge of how to run clinical service programs in pharmacies for well over 30 years, yet this is not currently reflected in pharmacy design.

Pharmacists currently in practice must now rely on imagination and faith to visualise a clinical service program design if they are to succeed post 2015.
This means taking a leap in establishing clinical spaces and hope that everything else will catch up eventually.
As much as possible create designs with flexibility and modularity to ensure the ability to cope with design changes inflicted by disruptive technologies.
Those who rely totally on the PGA for direction may find themselves continually disappointed.

For example, pharmacists are encouraged to leave dispensaries and apply themselves elsewhere.
Where do they go and what will they do?
Will the dispensary run smoothly given that script volume will probably increase, but gross profit will not be sustainable unless automation or some other alternative is considered.

Even the US design group commented:

“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.”

Additional and continuous education will be a major factor in sustaining a clinical pharmacy service.
The medical profession continually lobbies government for grants to fund medical education and more doctors.
This is one reason that the AMA denigrates pharmacy clinical services, because they compete with their vision for all things clinical to be controlled by doctors.
For that, they need a continual stream of medical graduates, a decentralised education stream and the money to adapt them to community need.
These are identical objectives for pharmacy, and pharmacies are already “health central” in the community, but with the PGA advising members to delete pharmacists that are deemed “excess” rather than develop productive work for them, is simply wasting opportunity.

Decentralised education to a Masters level is required on a health region basis’’.
It is a “must”, and should be economical in cost.

The loss of senior pharmacists could be stemmed by one simple measure – allow them to sit down and use their patient engagement skills, rather than punish them for not being able to dispense as fast as younger pharmacists.

When will dispensing speed cease to be a measure of the skill of a pharmacist?

Certainly future pharmacy design demands that we retain all pharmacists and develop creative activities for them to perform.
Even the above US research points to that!
This requires a certain level of autonomy to trigger creativity, which is another facet of pharmacy management design that has to be updated.

So much to do in such a small window of time.

Just do it!


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