Although the Children’s Minnesota hospital pharmacy was renovated 10 years ago to achieve USP <797> compliance, we have continued to struggle with a cramped workspace, hemmed in by support columns. During this time, prescription volume has steadily increased, making an efficient workflow a high priority.
Children’s Minnesota is a two-hospital health system with an extensive network of owned and affiliated clinics. The Minneapolis campus, our larger facility with approximately 250 beds, specializes in neonatal and pediatric intensive care, cardiovascular intensive care, internal medicine, hematology/oncology, and cystic fibrosis. The hospitals use a centralized, unit-dose drug distribution model, with automated dispensing cabinets (ADCs) located in the nursing units. Patient-specific doses are prepared using a cart fill process; the Minneapolis campus requires nine IV batches and one oral batch each day.
While our hospital’s previous renovation resulted in a compliant cleanroom and IV process, several other important factors were not addressed:
- Increased Work and Storage Space. We were unable to increase the pharmacy’s square footage due to the pharmacy’s location within the hospital. In addition, the anteroom was too small for a pharmacist to work in comfortably. These space limitations, coupled with a growing pharmacy workload resulting from the initiation of a number of collaborations—including a partnership with the Mother Baby Center—made additional space a high priority. Because of the increase in volume resulting from these collaborations, additional space was necessary to ensure efficient service and orderly medication storage.
- An Open Floor Plan. The pharmacy space had a significant number of columns, which resulted in poor lines of sight and a labyrinth of work spaces that were not conducive to a smooth workflow.
- Centralized Location. The hospital’s outpatient pharmacy operates Monday through Friday from 8am to 8pm and on weekends from 9AM to 5PM. When the outpatient pharmacy is closed, the inpatient pharmacy fills prescriptions for patients leaving the ED. However, because of the distance between the pharmacy and the ED, patients were often confused about where to go to fill their prescriptions upon discharge from the ED.
Simply put, we had outgrown our pharmacy in terms of workflow, efficiency, and medication storage capacity. Thus, our primary goals when renovating the pharmacy were to increase its square footage, create an open floor plan, gain additional storage space, and locate the pharmacy in proximity to the ED.
Setting the Project in Motion
Funding for the renovation project was secured through the hospital’s capital fund. Gaining approval from the hospital’s executive team was not difficult, as they were well aware of the space constraints we were experiencing in the old pharmacy location. In selecting a vendor, our primary goal was to identify a knowledgeable company with excellent customer service that could customize durable installed products and fixtures to fit our needs at a competitive price.
In the old pharmacy space, to offset the significant space constraints, we utilized six separate work cells: ADC fill, compounding/pre-packing, cart fill, first fill, outpatient, and IV room/anteroom. Visibility from one work cell to another was inadequate, making each area feel isolated and confined. Duplicate caches of medications were stored throughout the pharmacy due to limited maneuverability. Some medications were stored in up to three locations, which complicated inventory management.
A new space for the pharmacy was identified adjacent to the ED (see PHOTOS 1-3). This location facilitated patient flow from urgent care to outpatient pharmacy services on evenings and nights. Once the location was selected, the pharmacy layout was designed to provide clear lines of sight, which permit the pharmacists in-charge to quickly direct workflow to the areas of greatest need. A central medication storage area was designed to allow staff to easily pull stock to refill the other areas.
As part of the design process, we also had to consider facilitating the night shift’s ability to work in the new, larger space with minimal staff. The goal was to minimize walking distance around the areas of the pharmacy most frequently used by the night shift pharmacist, namely the outpatient area, IV room, pneumatic tube station, first fill counter, and first fill product area. The new pharmacy was designed to allow the night pharmacist to easily see into these areas. The new anteroom has a pass-through window so the technician can pass medications to the pharmacist; there also is a pass-through window directly into the IV room for emergencies (see PHOTOS 4-7).
Children’s Hospital has an Active Simulation Center team, which is responsible for improving workflow by simulating patient care unit moves throughout the organization. To help pharmacy staff envision the new work space, the team suggested that we simulate the major pharmacy workflows based on the planned dimensions of the pharmacy. We reserved a large conference room for 2 days and used tape to delineate the new IV room/anteroom and the oral cart fill area. This exercise was extremely useful in helping pharmacy staff understand the size of the new space. We also were able to reconfigure parts of the plan based on staff feedback.
In addition, Children’s has been in the process of updating and expanding multiple units in the hospital, and has a team dedicated to physical improvement processes. The facilities project manager is responsible for organizing and managing the team, which includes the architect and leadership from the builders, information technology, infection control, safety, and pharmacy. To facilitate a smooth process, multiple meetings were held as the pharmacy was designed, as well as weekly meetings once the build was underway. Having all parties in one space on a regular basis was instrumental to facilitate communication and resolve challenges.
Results and Benefits
The pharmacy design and build process progressed smoothly. The new pharmacy opened in September 2015, and thus far, we have identified only two structural items that in retrospect we could have designed differently. Of the two pneumatic tube stations, one is a superstation; had the locations of the superstation and the auxiliary tube station been switched, our workflow would improve. Additionally, including a walkway through the center of the cart fill cell would have been helpful to allow easier access to the stock shelves.
One of the main improvements we have realized as a result of the renovation is increased efficiency for the oral cart fill process. In the old pharmacy, oral cart fill required about 5.5 hours each day; in the new pharmacy it takes only 3.5 hours. This improved efficiency came as a surprise, as the design of the area was not altered, although its size increased. We believe the time savings is a result of the larger work space available for technicians to draw up products; staff is no longer physically bumping into each other, and supplies are more easily accessible.
Increased visibility resulting from the open floor plan allows staff to quickly identify and come to the aid of a coworker whose area has become busy. Staff also spends significantly less time searching for medications, given the efficiency of the central medication area, and inventory management has markedly improved.
We are quite pleased with the results of the renovation, and the positive changes in the pharmacy have appreciably increased teamwork and morale within the department.
Amy Commers, PharmD, BCPS, is the inpatient pharmacy site manager at Children’s Hospital and Clinics of Minnesota in Minneapolis. Her professional interests include pediatrics, medication safety, and intensive care pharmacy.
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