Facilities, Equipment, Supplies, Workflow & Facility Re-design

Introduction
This Resource chapter identifies requirements for facilities, equipment and supplies mandated for pharmacies through provincial regulation across Canada. Discussion of technology to support cognitive services is found in the units "Care Plans" and "Documentation". Although regulatory requirements do not specifically refer to space and equipment to support different types of packaging such as blister packaging, if new packaging equipment is being used, Operational Guideline 6.1.2 and construction standards requiring adequate space, are applicable.

This unit also introduces tools and resources to assist in assessing and re-designing your practice site to create innovative environments that improve workflow, communication, patient care and use of personnel.

Standards of Practice
This chapter supports in general Standard #6 of NAPRA's "Model Standards of Practice for Canadian Pharmacists".

"The pharmacist applies knowledge, principles and skills of management as they pertain to the site of pharmacy practice, with the goal of optimizing patient care and inter-professional relations."

Facilities
Premises
The premises should be accessible to the public and by telephone and have space for a patient counseling area.

Appearance
The pharmacist should ensure that the external and internal appearance of the pharmacy inspires confidence in pharmacy services that can be provided. Signage associated with the operation of a pharmacy must not cause confusion to the public.

Construction Standards
Every pharmacy shall be constructed so that:

• it contains a prescription laboratory in which drugs are stored and prescriptions compounded or dispensed, located in a well-defined area having a floor area adequate for the efficient operation of the pharmacy (the minimum requirement varies from province to province);

• it is free from every condition that may be dangerous to health, injuriously affect its efficient operation or injuriously affect the drugs prepared, compounded, dispensed or stored therein;

• a separate room, compartment, locker or cupboard is provided for keeping the wearing apparel of employees;

• floors are of sound construction and floor coverings may be readily cleaned in rooms where drugs are prepared, compounded, dispensed or stored, where equipment is washed or where washing and toilet fixtures are located;

• the walls and ceilings of rooms, passageways are well lighted and ventilated;

• suitable areas are provided for the storage and controlled sale of drugs by the pharmacist;

• the parts of the pharmacy in which prescriptions are compounded and dispensed for the public or drugs are stored or sold by retail shall be so constructed that they may be locked and made not accessible to the public in the absence of a pharmacist.

Dispensary
This area should be accessible only to authorized personnel and contain no products inappropriate to the practice of pharmacy.
The pharmacist should ensure that:

• Drugs and non-prescription medications for external use are stored separately from internal and injectable drugs and non-prescription medications

• Appropriate storage areas are designated for the storage of flammable and hazardous products

• Expired and unusable drugs and non-prescription medications are removed from current inventory and stored in designated areas awaiting proper disposal

• Pharmacy transport of drugs and non-prescription medications has appropriate conditions of sanitation, light, humidity, ventilation, temperature, security.

Equipment and Supplies
Pharmacies must be provided with:

• A supply of hot and cold running water adequate for efficient operation of the pharmacy

• Facilities for washing utensils used in the preparation, service or storage of drugs

• Separate hand-washing facilities available for employees and located in a convenient location in the pharmacy

• A system for filing prescriptions

• A means for mechanically producing labels

• A prescription counter adequate for the efficient operation of the prescription laboratory with not less than 1.12 square metres of free working space

• A refrigerator for the exclusive storage of drugs requiring refrigeration

• Sufficient containers for storing refuse in a sanitary manner

• A quantity of the following dispensing equipment sufficient for the efficient operation of the pharmacy: metric weights, metric graduates, mortars and pestles, spatulas, funnels, stirring rods and ointment pads

• A prescription balance, either torsion or electronic

• A prescription numbering device

• A quantity of consumable material sufficient for the efficient operation of the pharmacy, including bottles and caps, plastic vials with caps (some of each being light resistant), ointment jars with caps, dropper bottles, child resistant packages and distilled or de-ionized water

• Only a potable water supply shall be used in any room where drugs are prepared compounded, dispensed or stored

• All drugs shall be stored in a pharmacy on or in shelves, drawers or fixtures provided for that purpose.

Pharmacies must maintain:

• Furniture, equipment and appliances used in the interior of the pharmacy so that cleaning of all areas is possible

• All furniture, equipment and appliances in a clean and sanitary and orderly condition

• All rooms in the pharmacy, whether used for storage, compounding or dispensing of drugs or not in a clean and sanitary and orderly condition

• The painting and decorating of the interior and exterior of the pharmacy in good condition.

Every room where drugs are prepared, compounded, dispensed or stored in a pharmacy shall be kept free from materials and equipment not regularly used in that room.

Refrigerators for the storage of drugs in the pharmacy must be maintained at a temperature between 1.3 and 10 degrees Celsius, be kept in a clean and sanitary condition and be located in an area not accessible to the public.

All refuse and waste materials in pharmacy must be removed from the premises at least twice weekly and more often if necessary to maintain a sanitary condition. Full refuse containers shall be removed from any room in which drugs are prepared, compounded, dispensed or stored.

Every pharmacy in which sterile products are compounded shall be provided with the following equipment and supplies:

• A grade A (Class 100) horizontal or vertical laminar airflow hood which is certified at least once annually

• A limited access, well-lighted preparation area with a washable counter, walls and floor

• A sink with hot and cold running water in close proximity to the compounding area

• A refrigerator of adequate size to store compounded products

• Clean, low particle-generating coats or gowns with elastic cuffs

• Head and facial coverings

• Clean, non-powdered gloves

• A supply of antimicrobial scrub or soap

• A supply of 70% isopropyl alcohol solution

• Adequate storage space for materials.

Quality Improvement Program
Pharmacy services, processes, equipment and supplies should be assessed routinely to ensure that quality is maintained and enhanced. A quality improvement program should encompass the purchase, preparation and distribution of pharmaceuticals and should include but not be limited to:

1. Adequate documentation of the processes and evaluation criteria used and the outcomes measured

2. Microbiological environmental monitoring of surface, air, and environment, where appropriate

3. Routine validation of staff, facility equipment and product, and

4. Facility designs and processes that meet Good Manufacturing Practices (GMP) of Health Canada, where appropriate.

An organized quality improvement program is the definition, measurement, evaluation, maintenance and improvement of the quality of services rendered. The processes involved include:

1. Defining quality (standards and criteria)

2. Assessing performance (audits)

3. Determining compliance to standards

4. Taking corrective action when required

5. Reassessing performance

6. Redefining quality.

Workflow and Facility Re-design
Powerful tools to assist in assessing your practice facilities and embark on re-design and renovations are available from several sources described in this unit. Facility design to minimize the risk of medication error is found in an upcoming unit on minimizing dispensing errors.

Apotex's "Embrace Your Space" document, pharmacy literature and pharmacists who have received Commitment to Care Awards for Design Innovation from Pharmacy Practice are all valuable resources for information in this area.

As stated by Fuller et al in "Embrace Your space", a publication authored and edited by Apotex's Professional Affairs, patient-focused care requires rethinking the way pharmacists use their space to optimize the use of personnel time and contact time with the patient. There is a clear need for patients to discuss their health and drug therapy with the pharmacist in a comfortable private area. Taylor (1994) showed that consumers have to feel comfortable seeking advice and many hesitate because of existing barriers. This study showed that a pharmacist in front of the prescription counter leads to more consumer-pharmacist interaction, but increases significantly if the pharmacist offers assistance proactively.

An innovative pharmacy practice demonstrates your commitment to the community in which you practice. Virtually all pharmacists mentioned or interviewed in the resources in this kit enjoyed significant return on their investments in terms of increased patient numbers and enhanced patient loyalty. As well, staff satisfaction increased.

All resources in this unit recommend that before embarking on a practice renovation, you hire a designer to help you express your abilities and professionalism through design. They also recommend that pharmacy renovations be designed primarily to meet the needs of patients.

Common Findings among available tools and resources
In reviewing the many innovative designs highlighted in the Apotex document, the "Commitment to Care Award" winners and other references listed in the bibliography, several common design and floor plan elements emerged. Pharmacists are urged to consider these when redesigning their facilities to meet standards of practice.

Design recommendations

• Define your objectives for the renovation, base the design on patients' needs and employ a designer

• Designs should enhance the visibility and availability of the pharmacist and promote interaction between pharmacist and patient for both non-prescription and prescription drugs

• Keep the dispensary at floor level to place the patient and pharmacy on an equal level - physically and psychologically

• Consider placing the dispensary near the front and centre of the pharmacy. One design award-winner stated that customers shouldn't have to walk all the way to the back

• Provide convenient access for seniors and parents carrying small children

• Return to a "neighbourhood drug store" look - a look that blends comfortable surroundings with the professional service aspects - softer colours, wood grain fixtures, imaginative interior signage

• Project a professional health care environment in which customer feels at home

• Semi private and private counseling areas

• Play area for children

• Seminar and waiting area which might include blood pressure monitoring, patient resource area with VCRs for Health related videos for waiting patients

• Clear view of staff and patients around store

• No cash register at the prescription counter

• Private room for blood sugar and BP testing and support garment fitting

• Position pharmacists in the forefront so they are accessible to patients and free from technical activities of the dispensary

• Facilitate the provision of pharmaceutical care by creating a clinical space that functions separately but works effectively with dispensary.

• Pharmacists should spend as little time as possible in the dispensary - focus on patient care activities in the consultation areas

• Make the dispensary visible to waiting patients

• Colours and environment designed to promote calm and quiet

• One design incorporated a quarter circle pharmacy taking up one corner of the store

• Low dispensary walls to give open feeling

• Separate area for prescription compounding - visible to public - generates interest

• Work islands rather than linear counter for dispensing

• Fixtures are low to provide better sight lines and emphasize store signage.

Layout Recommendations
The older "linear" pharmacy is not productive: a typical linear layout along the side wall or rear wall, with prescriptions in at one end of a long counter and prescriptions out at the other approximates an assembly line.

More contemporary designs emulate a kitchen concept with work islands in the middle of the dispensary, which is located behind the pharmacist- patient interaction area. Workflow may be circular around the island or transferred from front to back. The refrigerator is located in the middle to decrease the steps involved. For compounding areas, make sure that all supplies are within reach.

At the patient interaction area, prescriptions are dropped off and counseling/dialogue provided. The work area behind the customer interaction area is where dispensing occurs. Computer terminals are located in the customer interaction area to facilitate access to patient profiles. The distribution process should be separated from the cognitive process.

Locate the cash register away from the prescription pick up area to minimize interruptions to the pharmacist while counseling patients.

Private Counseling Areas
An effective way to assess whether your practice offers the necessary degree of privacy to your patients is to ask yourself if you would feel comfortable discussing your own personal health issues in your practice; would you feel your privacy was adequately respected and protected?

Regardless of the time and energy and resources invested in private counseling areas, these areas become useless if the pharmacist has inadequate communication skills. Although not the subject of this toolkit, pharmacists who need to improve these skills can avail themselves of a variety of courses and programs offered in each province.

Private counseling areas range from private rooms to semi-private counseling booths/areas. There is controversy over the necessity and effectiveness of private rooms over semi-private counseling areas. Use of semi-private/open consultation booths addresses the concerns that patients may have about being summoned into walled rooms that may seem inconvenient and create embarrassment at being singled out.

One leading edge practitioner suggested offering "a 'private' area which is not private. A separate room is not necessary and may intimidate some patients; a barrier that separates both visually and for sound is necessary". Another commented that "separate rooms do not usually work; physical barriers/partitions better meet the need for privacy and convenience. It is our experience that customers do not like a confined area, but prefer a semi-private counseling area. One learns to talk quietly."

Other practitioners support the need for a private room, but disagree on visibility: "The ideal would be a relatively soundproofed separate room with lots of clear glass so that other customers could see that a private consultation was taking place." Another view was summarized as "Patients seem to prefer a separate room without windows (i.e. physician examining rooms don't have windows). To some, this may raise the risk of patient harassment charges - but the pharmacy can be structured in such as way as to offer privacy without the inherent risks associated with 'seclusion'."

General suggestions for private counseling areas include:

• All counseling areas should have acoustic privacy. A number of options exist for providing privacy:

  • Counseling booths at a 45 degree angle to the dispensary with sound panels or opaque glass

  • Semi-private areas attached to the dispensary on one end for stand up interaction, with chairs and table for private interaction at the other end of the dispensary

  • Semi private booth adjacent to the prescription pick- up area

  • Office spaces can double as private counseling areas

  • Semi-private counseling area may be an extension of the reception counter - separated by walls that reach the ceiling giving the area a distinct sense of privacy

• Ensure ready access to reference library and patient profile

• Chairs and a table provide space for counseling tools and a seated session may reassure the patient that the pharmacist has made time to counsel them.

• Often family members are with the patients, so the area must accommodate them as well.

• The choice depends on the dynamics of each individual store.

Resources

"Embrace Your Space"

• How to identify and hire a designer

• Importance of planning

• Dispensary layout and space requirements for patient counseling, consultation and dispensary.

Finally, advice is given on flooring, cabinetry, and colours and their effects on the environment.

To order the guide contact:
Pharmacy & Apotex Continuing Education
4100 Weston Road
Toronto ON  M9L 1T9
Tel: (416) 749-9300

" Physical Barriers to the Practice of Pharmaceutical Care in the Retail Setting"
Fortner et al evaluated seven pharmacy designs from across Canada, working with students from the Canadian Association of Pharmacy Students and Interns and the College of Pharmacy and Nutrition, University of Saskatchewan. The report provides sample floor plans with discussions of strengths and weaknesses of each. It also describes 14 identified physical barriers to pharmaceutical care, including:

• Elevated dispensary: prevents a relationship of trust to develop because it places the patient and pharmacist on unequal footing

• Location of cash register: patients remain concerned about cost and don't hear what's being said until after they've paid - separate payment from counseling area

• Lack of space

• Location of dispensary within the store: travelling to the back of a large store for patients in a hurry is a barrier

• Lack of privacy: patients prefer privacy -- can use counseling booth, an alcove in the counter or simply a desk in a location where there is a reasonable amount of privacy - Ideally the pharmacist has access to the patient's profile while speaking with the patient

• Height of shelves: decreased accessibility of pharmacist who can't be seen. Also the pharmacist should be able to see easily throughout the store - lower shelves create a more open and inviting atmosphere

• Height of the counter in front of the dispensary: if the patient and pharmacist can't make eye contact, the patient won't ask questions. The pharmacist should be able to see patients and offer assistance.

• Location of the computer: need access to patient profile at prescription drop-off, pick up and counseling area

• Aisle width: must not prevent people from reaching dispensary (e.g. wheelchairs, baby carriages, walkers)

• Need for comfortable waiting area: provision of patient-focused care may increase time it takes and thus may increase waiting time

• Pharmacists appearance: white jacket vs. more casual - no consensus; determine according to clientele

• Parking availability: need access to the pharmacy and time to wait to receive pharmaceutical care

• Atmosphere: warm and inviting to allow for patients to open up and develop relationship of trust

• Wheelchair accessibility: correct door width, minimal floor obstacles and accessible washrooms.

The Report, complete with blueprints, is available from the Saskatchewan Pharmaceutical Association. 

Other Information Sources

US experiment with two-tier dispensary
Pharmacy Practice describes an experimental two-level dispensary designed to minimize interruptions during dispensing process. The double-decker design is intended to allow one pharmacist and several technicians to fill prescriptions in distraction free area while another pharmacist provides patient counseling on the busier lower level.

Optimal Dispensary Function
Janke (1997) provides advice on analyzing pharmacy systems to optimize dispensary functioning for the provision of Pharmaceutical Care.

Bibliography

1. Alberta Pharmaceutical Association, Standards of Practice, 1996

2. Drugs and Pharmacies Regulation Act, 1996, Ontario

3. Saskatchewan Pharmaceutical Association Bylaws, 1998

4. Manitoba Pharmacists' Association, Pharmacy Standards, 1997

5. Setting the Pace. CPhA/Apotex PACE Innovative Practice Award 1998; (1) 1

6. Fuller J, Watters L, Mann J, Daniels S. Embrace Your Space, Innovations in Pharmacy Design, Optimal Use of Space and Staff to Facilitate Effective Communications with Patients, Apotex Professional Affairs, 1996.

7. Commitment to Care Award Winners. Pharm Pract. 1996; (11): 9: 50-54.

8. Keeping Pace. Reprofessionalizing Pharmacy: Pharmacies of the Future NOW 1996 (2): 1; 3-4.

9. Keeping Pace. Reprofessionalizing Pharmacy: Pharmacies of the Future NOW 1997:(3)1: 3-4

10. Keeping Pace. Reprofessionalizing Pharmacy: Pharmacies of the Future NOW 1997:(3)2: 3-4

11. Kyriakos, T. Pharmacy Design; Can Pharm J Oct 97; 59-61.

12. Taylor J, Stevenson M. The effect of a front-shop pharmacist on NPM Communications. Journal of Social and Administrative Pharmacy 1995 (12)3: 154-158

13. Taylor J. Reasons consumers do not ask for advice on non-prescription medicines in pharmacies. Int. J Pharm Pract. 1994;2:209-14

14. Fortner K. Physical Barriers to the Practice of Pharmaceutical Care in the Retail Setting. CAPSI; College of Pharmacy, University of Saskatchewan.

15. Commitment to Care Award Winners - Innovative Design. Pharm Pract. 1996 (12): 11; 48.

16. Commitment to Care Award Winners - Innovative Design. Pharm Pract. 1997 (13): 11; 63-64.

17. Two-Tier Dispensary on Trial in US, "Openers", Pharm Pract. 1996 (11):9;18

18. Janke KK. Analyzing pharmacy systems and optimizing dispensary functioning .Can Pharm J 1997.130(2):37-8