36E77618R0055-007.pdf

APPENDIX 5-34

PG 18-12 – PHARMACY SERVICES DESIGN GUIDE JANUARY, 2018

Pharmacy Plan

Legend:

Outpatient

Circulation

Clean Room Inpatient Staff Area Support

Medical carousels store bulk of supply Trial drugs stored and monitored in IRB room Outpatient pharmacy for employees only -no discharge

Ante room is small, would prefer a separate ante room for each clean room Drug cache stored in Home Health Storage also used for Receiving/ Breakdown

Key Notes:

Figure 5.32 Floor Plan of Elmhurst Memorial Hospital Pharmacy

284 SF

FOUNDATION

STOR

107 SF

ELEC

108 SF

STOR

143 SF

SOILED

903 SF

BIO MED

121 SF

OFFICE

434 SF

FACILITIES

STOR 110 SF

CORR

51 SF

STAFF TLT

51 SF

STAFF TLT

60 SF

JC

120 SF

STAFF

LOCKERS

2010 SF

CORRIDOR

123 SF

OFFICE

100 SF

OFFICE

101 SF

OFFICE

101 SF

OFFICE

528 SF

RECEPTION

64 SF

CORR

387 SF

CONFERENCE

128 SF

WAITING

58 SF

PICK-UP

708 SF

EMPLOYEE

PHARMACY

115 SF

OFFICE

100 SF

OFFICE

98 SF

OFFICE

88 SF

IRB

201 SF

IV

198 SF

IV CLEAN

82 SF

ANTE

116 SF

IV CLEAN

123 SF

CHEMO

99 SF

OFFICE

798 SF

HOME

HEALTH

STORAGE

53 SF

STAFF TLT

51 SF

STAFF TLT

369 SF

STAFF

LOCKERS

204 SF

STAFF

LOUNGE

55 SF

CHANGING

333 SF

STAIR D

249 SF

CORRIDOR

805 SF

STORAGE

229 SF

WORKROOM

48 SF

JC

2727 SF

DISPENSING

APPENDIX 5-35

284 SF

FOUNDATION

STOR

107 SF

ELEC

108 SF

STOR

143 SF

SOILED

903 SF

BIO MED

121 SF

OFFICE

434 SF

FACILITIES

STOR 110 SF

CORR

51 SF

STAFF TLT

51 SF

STAFF TLT

60 SF

JC

120 SF

STAFF

LOCKERS

2010 SF

CORRIDOR

123 SF

OFFICE

100 SF

OFFICE

101 SF

OFFICE

101 SF

OFFICE

528 SF

RECEPTION

64 SF

CORR

387 SF

CONFERENCE

128 SF

WAITING

58 SF

PICK-UP

708 SF

EMPLOYEE

PHARMACY

115 SF

OFFICE

100 SF

OFFICE

98 SF

OFFICE

88 SF

IRB

201 SF

IV

198 SF

IV CLEAN

82 SF

ANTE

116 SF

IV CLEAN

123 SF

CHEMO

99 SF

OFFICE

798 SF

HOME

HEALTH

STORAGE

53 SF

STAFF TLT

51 SF

STAFF TLT

369 SF

STAFF

LOCKERS

204 SF

STAFF

LOUNGE

55 SF

CHANGING

333 SF

STAIR D

249 SF

CORRIDOR

805 SF

STORAGE

229 SF

WORKROOM

48 SF

JC

2727 SF

DISPENSING

Main Pharmacy work space is uncluttered with indirect lighting Two pneumatic tube stations - one is on a designated chemo system

8 6

Figure 5.33 Floor Plan of Elmhurst memorial Hospital Pharmacy

APPENDIX 5-36

Figure 5.34 Elmhurst Pharmacy Photo taken at note position #1

Figure 5.35 Elmhurst Pharmacy Photo taken at note position #3

Figure 5.36 Elmhurst Pharmacy Photo taken at note position #7

Figure 5.37 Elmhurst Pharmacy Photo taken at note position #8

APPENDIX 5-37

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APPENDIX 5-38

RUSH UNIVERSITY MEDICAL CENTER

Location Chicago, Illinois

Total Area 830,000 sf

Floors 14

Beds 664 total 376 in new tower

Opening Date new tower opened in 2012

Pharmacy Size Not Available

Project Cost $654 million

Construction Cost $398 million

Owner Rush University Medical Center

Architect/Owner Perkins+Will

5.1.6 Rush University Medical Center

Figure 5.38 Aerial of Rush University Medical Center

APPENDIX 5-39

Figure 5.39 Exterior view of Rush University Medical Center

Overview Rush University Medical Center is a not-for-profit, 664-bed academic medical center which is consistently ranked among the nation’s top hospitals in the U.S. News & World Report. The Medical Center is on the same campus as the university, which has an exclusive focus on the health sciences. This allows for a unique integration of education and patient care.

The medical center offers care for patients of all ages through Rush University Children’s Hospital, the Johnston R. Bowman Health Center, and the Ada F. Addington Inpatient Hospice Unit, as well as the new Tower inpatient unit.

The Tower houses both acute and critical care and contains surgical, diagnostic, and therapeutic services. The state-of-the-art design includes

APPENDIX 5-40

patient-friendly features such as rooftop gardens, universal accessibility, and sustainable design. The Tower also includes an entry pavilion to serve as the new front door for the entire medical center. The space is a 3-story, sun-filled design meant to unify existing buildings with the new hospital.

Pharmacy Overview The Pharmacy at Rush was not updated when the new bed tower was constructed. Instead, it resides in the basement of the older building. As a result, the Pharmacy missed an opportunity to implement some key upgrades to improve their workflow and position them for USP 800.

The Pharmacy has three clean rooms, as well as a room for a compounding robot. All clean rooms have shortcomings which make them more or less useful for certain tasks.

The compounding robot, nicknamed “Riva,” sits in its own room which is equipped with a pass-thru to a storage space that is used primarily to support the robot. The primary issue with this workflow is that the robot needs to be cleaned and reconfigured for each new task that it performs, so it is the most efficient only when performing the same task many times over. There is also a walk-in cooler that opens up to the robotic storage area, however the cooler is not necessary for this usage. The cooler would be best accessed from the other side (a storage room), however there is an unused narcotics vault currently blocking access between the storage and the cooler (refer to plan for clarification).

The clean room that opens into the main Pharmacy work area has a large window into the Pharmacy as well as a pass-thru cabinet, so that staff within the clean room can effectively communicate with and pass materials to someone in the Pharmacy. However, the entrance to the clean room is not buffered by an ante room. Therefore, the room can only be used for certain types of mixtures.

The other two clean rooms are accessed via an ante room from the main Pharmacy corridor. These rooms have several issues. Although one room has a window into the main Pharmacy area, neither have visibility to the corridor, with limited visibility to the ante room, and there are no pass-thrus at all. The lack of pass-thru cabinet or refrigerator means that any time a pharmacist transfers materials into or out of the clean room, they must go through the entire gowning process within the ante room. Additionally, the rooms are not outfitted with equipment hoods. Instead, the entire room acts as the filter and exhaust system. The Pharmacy group feels that this substantially increases the amount of time that they are down due to

APPENDIX 5-41

maintenance issues, which must be addressed above the ceiling. If a fan goes down and requires maintenance, the entire room cannot be utilized until the repair is made. The group plans to upgrade the rooms with hoods in the near future to build more redundancy into the process.

In addition to the main Pharmacy workroom, which hosts the pharmacist workstation, two medication carousels, and narcotics storage in a Pyxis vault, there is a large storage room which has two additional carousels.

Because the ceiling height in the storage room is so much higher than in the work room, these carousels are able to handle considerably more medication. This room is also used to store contrasting materials for radiology and neurology, as well as syringes for IV prep. The room is manned by a staff member during peak hours, but lacks sufficient security or a way to communicate effectively with the corridor or rest of the Pharmacy.

The Pharmacy group also expressed a desire for more storage near the Pharmacy. Although the medication is primarily stored in the carousel equipment, the group noted that the automation that they utilize has its own need for parts storage, which is currently not well-accommodated. It was noted that the Pharmacy administrative spaces that are located near the Pharmacy do not necessarily need to be co-located, whereas it would be useful to have additional storage space at that location.

APPENDIX 5-42

STOR

480 SF

MAIL PROCESS

871 SF

ENVIR. SERV.

STOR.

945 SF

STOR.

205 SF

STOR.

161 SF

CLEAN LINEN

HOLD

462 SF

ADMIN

3200 SF

OFFICE

127 SF MAIL RM

169 SF

CORR

142 SF

SOILED

LINEN

369 SF

CORR.

1929 SF

ELEC

37 SF

TELECOMM

32 SF

MECH

319 SF

PHARMACY

STOR

1110 SF

STOR

109 SF

WALK-IN

COOLER

139 SF

COMPOUNDING

STOR.

376 SF GIFT SHOP

STOR.

665 SF

PUMP

RM.

164 SF

STOR.

141 SF

TLT

83 SFELEC

28 SF

TELECOMM

30 SF

STAIR B

205 SF

UP

UP

STAIR A

268 SF

ENVIR

SERV

55 SF

OFFICE

141 SF

PHARMACY

660 SF

TLT

43 SF

CORR

268 SF

CORR

653 SF

COPY RM

164 SF

LOUNGE

187 SF

OFFICE

113 SF

PHARMACY

OFFICE

924 SF

OFFICE

111 SF

INVESTIGATIONAL

DRUG SERV

OFFICE

290 SF

CLEAN ROOM

143 SF

ANTE

208 SF

IV CLEAN RM

212 SF

INVESTIGATION

471 SFOFFICE

114 SF

OFFICE

213 SF

CONF.

RM.

256 SF

CORR

495 SF

ELEV #100

121 SF

ELEV #101

111 SF

ELEV #98

115 SF

TLT

41 SF

MENS LKRS

134 SF

WOMENS

LKRS

133 SF

CLEAN

RM

164 SF

MECH

RM SERV.

176 SF

MECH

RM

94 SF

PHARMACY

CENTRAL DISTRIBUTION

1198 SF

ELEV #99

106 SF

ELEV LOBBY

250 SF

Pharmacy Plan

Legend:

Outpatient

Circulation

Clean Room Inpatient Staff Area Support

Vault is not used Narcotics stored here in free-standing vault Anteroom with poor visibility and no pass-thrus

This clean room is negative pressure, used to be used for oncology Pharmacists workstation lacks visibility of clean rooms Clean room is lacking ante room Storage is separated from pharmacy by public corridor

1 4

Key Notes:

Figure 5.40 Rush University Medical Center Pharmacy Plan

APPENDIX 5-43

Figure 5.41 Rush MC Inpatient Note position 3

Figure 5.42 Rush MC Inpatient Note Position 5 (looking south)

Figure 5.43 Rush MC Inpatient Note position 5 (looking north)

Figure 5.44 Rush MC Inpatient Note Position 6

APPENDIX 5-44

ORLANDO VAMC AT LAKE NONA

Location Orlando, Florida

Total Area 1.2 million SF

Floors 5

Beds 134 also includes a 120-bed community living center

Pharmacy Size Not Available

Project Cost Not Available

Construction Cost $600 million

Opening Date February 2015

Owner Veterans Health Administration

Architect/Owner Ellerbe Becket/RLF Architects

5.1.7 Orlando VAMC, Orlando, Florida

Figure 5.45 Aerial of Orlando VAMC

APPENDIX 5-45

Figure 5.46 Main Entry of Orlando VAMC

Overview The Orlando VA Medical Center, serving more than 100,000 Veterans in Central Florida, is one of seven medical centers that make up the VA Sunshine Healthcare Network (VISN 8). Established as a medical center in October 2006, the Orlando VA Medical Center is recognized as one of the Top 100 Companies in Central Florida for working families. The Orlando VA Medical Center includes a 120-bed Community Living Center in Lake Nona, a 60-bed Residential Rehabilitation Program (Domiciliary) in Lake Nona and a 56-bed Residential Rehabilitation Program (Domiciliary) located at Lake Baldwin, Outpatient Clinics in Lake Baldwin, Viera and Daytona Beach and four Community Based Outpatient Clinics located in Clermont, Kissimmee, Tavares, and Orange City. The new Orlando VA Medical Center is part of a 650-acre health and life sciences park known as the Lake Nona Medical City. The 65-acre medical campus has 134-inpatient beds and provides acute care, complex specialty care, APPENDIX 5-46 advanced diagnostic services, a large multi-specialty outpatient clinic, and administrative and support services.

The medical center’s facilities ensure efficient care through emphasizing clinical adjacencies. Single-patient rooms are designed to foster family interaction, and integrated technologies support quality care and education. The site planning allows for views of natural waterways while high-traffic areas of the facility are located close to the main roadway for easy access and parking. The hospital and clinic buildings are connected by an indoor atrium which aids in wayfinding.

Pharmacy Overview The new medical center in Orlando includes a two-story Pharmacy department mainly separated into outpatient services (dispensing and patient interaction) on the lower level, with inpatient and outpatient work areas and administration on the upper level. The outpatient Pharmacy’s location on the lower level means it is well situated to serve the Emergency Department, while in the inpatient Pharmacy on the upper level locates it closer to the inpatient beds. Having the two pharmacies situated directly on top of each other has several advantages: it permits pharmacists working upstairs to serve the outpatient Pharmacy on an as-needed basis after business hours, and it also provides an opportunity for the use of dumbwaiters to assist with transferring supplies between the two locations. The dumbwaiters are a more expedient transportation method than a pneumatic tube system, however they occasionally go out of service and are difficult to repair.

Although the lower level of the Pharmacy serves as the point of service for outpatients, most Pharmacy operations for both services take place upstairs. This includes picking and packaging, as well as all workflows associated with controlled substances, as both the outpatient and inpatient vaults are in the upstairs Pharmacy. The upstairs portion of the Pharmacy also has the only dedicated toilet room for all staff working on both levels.

In addition to not being enough toilets to support the entire Pharmacy staff, this poses a particular issue for the lower outpatient Pharmacy. If the pharmacist working in the lower area must go upstairs for any reason, including the toilet, the lower Pharmacy must be completely closed. This can lead to issues especially for emergency department patients after hours who sometimes arrive at the outpatient Pharmacy to find it shut down without explanation.

The main (upstairs) Pharmacy work area utilizes a three-carousel system. There is one carousel which stores general inpatient medications

APPENDIX 5-47

only. Additionally, one carousel is used to store bulk and pre-packaged medications, as well as to support the inpatient robot. The third carousel stores outpatient medications and supports the Optifill automation system. The staff find that the carousel works well as support for Optifill automation, however the carousel’s ability to do only one thing at a time makes it a less desirable solution for manual picking, where open shelf storage allows multiple people to access multiple medications simultaneously.

The inpatient work side of the Pharmacy includes both an IV and a Chemo prep room with a shared ante room. The rooms all include no-touch faucets and doors, as well as hands-free communication technology to allow staff to work efficiently and safely in the space and when transferring materials between the clean rooms and the rest of the work area.

The inpatient Pharmacy follows a “cabinet-centric” workflow. This means that Pyxis machines reside in every inpatient unit and are kept stocked with first doses. The Pyxis cabinets are also supported by a robot which resides within the main Pharmacy. The robot processes and fills first doses which can be transferred to the inpatient units via the pneumatic tube system. Within the Pharmacy, the robot is supported by one of the three carousels as well as a dedicated workspace for an automation tech.

The outpatient side of the Pharmacy work area uses several forms of automation as well. In addition to the Optifill system with the support carousel and two automation tech workstations, there is a conveyor belt for prescription processing which has 4 tech and 4 pharmacist stations.

The conveyor belt transfers medications filled by Optifill to be verified by the pharmacists before being processed and packaged by the techs for dispensing. Once packaged, the medications are sent to the outpatient dispensing area on the lower level. The outpatient side of the Pharmacy also includes an area for prosthetics storage and a tech workstation, as well as a dedicated workstation for processing mail-out prescriptions. The staff felt that an additional workspace for making follow-up phone calls to patients would also be helpful.

Other spaces in the main Pharmacy include two secured storage vaults:

one each for inpatient and outpatient medications. The outpatient dispensing area on the lower level also has a vault, however it is used for short-term holding of controlled substances only, not for order processing. The vaults used for long-term storage and order processing are each divided into two spaces: the controlled-access ante room used for processing and packaging, and the main vault storage area. Due to size and layout of these spaces, the outpatient vault functions slightly

APPENDIX 5-48

better with this space configuration than the inpatient vault does. The inpatient vault is smaller and receives less traffic generally than the outpatient vault, and the staff felt that it could more easily function as one open space used for both functions. The outpatient vault is also used to process prescriptions that are returned by mail for any reason. All returned medication packages are opened within the vault to determine whether their contents include any controlled substances before any other processing of the returned medications is completed. One pharmacist as well as two techs work in this vault daily.

The Pharmacy also includes a research area which is positioned well to have easy access to the clean rooms and IV hoods as needed. The general mail receiving area for staff is within the work area as well, although staff felt this would be more appropriately located within the administration suite. The Pharmacy administration area is located directly adjacent to the Pharmacy work area. Although the staff did not feel that the general administration needed to be adjacent to the work area, it was noted that the supervisor workstation was best located within the work area itself. The staff lounge is also located within the Pharmacy footprint but is too small and narrow to properly serve all of the Pharmacy staff.

This results in staff storage overflowing to other areas of the work area.

The outpatient dispensing area on the lower level of the Pharmacy department has more space than dispensing currently requires. The Pharmacy is currently dispensing between 700 and 800 prescriptions per day, but likely has the capacity to handle around 2000 per day. The space has 4 dispensing windows, which are also used for consults. The separate consult rooms are typically not used. Behind the dispensing windows is a wall which separates the Pharmacy work area from the dispensing and patient area. This configuration helps keep the pharmacists “off-stage” but also makes it difficult to see if a line is forming. The Pharmacy also does not have its own dedicated waiting area, but rather uses a “bingo board” system in other waiting areas as well as the canteen to alert patients when their prescriptions are ready.

APPENDIX 5-49

APPENDIX 5-50

Retail Clean Room Work Area Staff Support Circulation

UPUP

G

H

J

K

L

30.2

AS

K.7

3233 A733.6

K.6

OFFICE

SUPERVISOR

CASHIER

OFFICE

LOANS

TRAVEL CLERKTRAVEL CLERK

AGENT CASHIERAGENT CASHIER

ELEC

PHARMACY

WAITING

CONSULT

TLT

DAY COOLER

ASST CHIEF (FOOD)MONEY ROOM

ADMIN CLERKS

CLOSET

VAULT

CONCESSIONS

ATM

O.P. SECURE

PRESCRIPTION

STORAGE

TOILET

CANTEEN RETAIL

WAREWASH

HAC

PICK-UP

WINDOW

CORR

PASSAGE

CORRIDOR

TOILET

SODA CLOSET

AISLE

AISLE

STAIR - PHARMACY

ATM

WORKROOM

COMM

HAC

SERVERY

N

1/8" = 1'-0" GRAPHIC SCALE

4' 8' 24'16'

A1

C2

KEY PLAN

C1

D3

D4

E2

A2 A3

B1 B2

AREA D, ZONE 2

D2

D5 D6

E1 E3

D1

D7

CLINIC

HOSPITAL

P-W P-E

A4

E4

W

Outpatient Pharmacy Plan

Legend:

Outpatient

Circulation

Clean Room Inpatient Staff Area Support

No waiting in front of Pharmacy On-stage/Off-stage concept aided by layout Consult currently not used Hard to see line forming

Large amount of underutilized space Secondary vault used only for dispensing narcotics since dispensing is on a different floor from main pharmacy.

1 6

Key Notes:

Figure 5.47 Orlando VAMC Outpatient Dispensing Floor Plan

APPENDIX 5-51

Figure 5.48 Orlando VAMC Outpatient Note Position 2

Figure 5.49 Orlando VAMC Outpatient Note Position 4

Figure 5.50 Orlando VAMC Outpatient Note Position 5

Figure 5.51 Orlando VAMC Outpatient

APPENDIX 5-52

Retail Clean Room Work Area Staff Support Circulation

2627282930

G

H

J

K

L

AS

29.4 28.4 27.6

K.7

J.6

H.7

G.7

26.8 26.427.5

K.6

N

1/8" = 1'-0" GRAPHIC SCALE

4' 8' 24'16'

A1

C2

KEY PLAN

C1

D3

D4

E2

A2 A3

B1 B2

D2

D5 D6

E1 E3

D1

D7

CLINIC

HOSPITAL

P-W P-E

A4

E4

W

3233 A733.6

OPEN TO

BELOW

OPEN TO

BELOW

OPEN TO

BELOW

CORRIDOR

CORRIDOR

CORRIDOR O.P. ROBOT SUPPORT

CLERK

ASST. CHIEF OFFICE, CHIEF SECRETARY PHARM PHARM PHARM PHARM PHARM SUPV

PHARM UNION

OFFICE

UNION

OFFICE

PRIVACY PRIVACY

UNION

OFFICE

CBI

OFFICE

CBI

OFFICE

ISO

SHARED

CLERICAL UNASSIGNED ELECTRICAL

ELECTRICAL

ELECTRICAL

INVESTIGATIVE

DRUGS

CLERK

STUDY CUBICLES CHEMO PREP

CONF

STOR

CORR

CORR

WAITING

CLOSET

CLOSET

STAFF TLT

ELEC COMM

EXAM

SECRETARY

CHIEF

RESP

CLEAN

UP

EQUIPMENT

STOR

CHIEF

THER

REPORT

CALC ROOM

EXAMTLT

OFFICE

SCREENING OFFICE

OFFICE

OFFICE

OFFICE

OFFICEOFFICE

OFFICE

CAFE COORDINATION

OFFICE

TELEPHONE

OPERATOR’S ROOM

PSA/FILES

CORR

CORR

CORR

WARD MAN

WARD MAN

SECRETARY WAITING

WARD

CHIEF

WORK

TRAINING

TRAINING

CORRIDOR

CORRIDOR

OFFICE,

CLINICAL

PHARM

CORRIDOR

CORRIDOR CORRIDOR

O.P. ROBOT

O.P. VAULT ANTE

ROOM

I.P. VAULT

ANTE ROOM

I.P. VAULT

O.P. VAULT STAIR

STAIR

COMM

STAFF LOUNGE

ELEC.

I.P. ROBOT

I.P. CHECKING

HAC

HAC

DSS SUPV SAFETY

STORAGE

SAFETY

OFFICE

SAFETY

OFFICE

OFFICE CODING CODING CODING

SUPV

STAFF

LOUNGE

FEMALE

LOCKERS

MALE

LOCKERS

SECRETARY HIMS

CHIEF

CLASSROOM EMS STOR MAA

STAFF

TLT

DRUG

RECEIVING

PREPACKAGING

ADMIX

STORAGE

ANTE

ROOM

IV PREP

SUPV PHARM

O.P. FILLING &

ASSEMBLY

PERSONAL ID

VERIFICATION

I.P. ACTIVE

STORAGE

CORRIDOR

PRESCRIPTION

REC.

EXTEMP.

COMPOUND

Inpatient Pharmacy Plan

Legend:

Outpatient

Circulation

Clean Room Inpatient Staff Area Support

Research Pharmacy has easy access to clean rooms Lounge is too narrow Receiving techs could use more workspace Procurement station too exposed

Carousel currently not maximizing space due to structural concerns Pneumatic tube is far from most of work area Single dose robotics Outpatient filing robotics and conveyor system Outpatient vault with robotics

Key Notes:

Figure 5.52 Orlando VAMC Main Pharmacy Floor Plan

APPENDIX 5-53

Figure 5.53 Orlando VAMC Main Pharmacy Note Position 5

Figure 5.54 Orlando VAMC Main Pharmacy Note Position 9

Figure 5.55 Orlando VAMC Main Pharmacy Note Position 4

Figure 5.56 Orlando VAMC Main Pharmacy Note Position 7

APPENDIX 5-54

Figure 5.58 Orlando VAMC Main Pharmacy Note Position 8

Figure 5.59 Orlando VAMC Main Pharmacy Note Position 8

Figure 5.57 Orlando VAMC Main Pharmacy Note Position 2

APPENDIX 5-55

APPENDIX 5-56

JAMES HALEY VAMC

Location Tampa, Florida

Total Area Not Available

Floors Not Available

Beds 504 also 118 nursing home care unit beds

Pharmacy Size Inpatient: 3100 SF Outpatient: 9000 SF

Project Cost Not Available

Construction Cost Not Available

Opening Date 1970

Owner Veterans Health Administration

Architect/Engineer HDR Architecture

5.1.8 James Haley VAMC, Tampa, Florida

Figure 5.60 Aerial of James A. Haley Veterans’ Hospital

APPENDIX 5-57

Figure 5.61 Main Entry of James A. Haley VH Outpatient Pharmacy

Overview James A. Haley Veterans’ Hospital and Clinics (JAHVH) is a clinical referral, level 1a facility in Tampa serving a four-county area of west central Florida, including Hillsborough, Pasco, Hernando and Polk counties. JAHVH is one of the nation’s largest and most complex integrated medical facilities in the Veterans Health Administration.

The facility is comprised of a 504 operating bed medical center, which includes medical and surgical inpatient, acute psychiatry, pain/ rehabilitation units and a community living center. JAHVH is one of five Polytrauma Centers within the VA system and is the only VA medical center that has a dedicated ventilation unit for long-term care located in its 100 bed Spinal Cord Injury/Disorder Center. JAHVH also has an off-site domiciliary approximately 10 miles from the campus.

APPENDIX 5-58

JAHVH has multiple outpatient primary and specialty care services. In addition to the four community-based outpatient clinics there are several outpatient off-site locations within a five-mile driving distance of the main hospital campus including a new primary care annex, mental health clinic and a drive-through Pharmacy.

JAHVH is a teaching hospital with a full complement of services and surgical specialties to include primary care, medicine, surgery, psychiatry, physical medicine research and rehabilitation, spinal cord injury, neurology, oncology, dentistry, geriatrics, and extended care. The hospital also has special programs for women Veterans, returning service members and their families, and much more. As a teaching hospital, residency training is provided in all major medical and surgical specialties and subspecialties. The hospital is also a training site for medical, nursing, and other health care professional students.

Pharmacy Overview The inpatient Pharmacy within the hospital building is divided up into three spaces: the main Pharmacy work area including the IV clean rooms and secured substances vault is located on the 1st floor, re-packing and unit dose storage is on the ground floor, and additional storage for both inpatient and outpatient prosthetics supplies is located in the basement.

The Pharmacy drug cache is also split up, with controlled cache substances in the main vault, IV bags and saline storage in the hospital’s warehouse space, and the remainder of the cache in the Pharmacy ground floor storage area. The Pharmacy also relies heavily on Pyxis machines spread throughout the inpatient units, with approximately 90 machines in use throughout the hospital. The Pharmacy’s goal is to use the Pyxis storage for around 90% of first doses, and the machines are restocked daily, with typically between 10% and 25% of their supply being restocked. In additional to all of these storage and work locations, the Pharmacy would benefit from a location to store medications that patients bring with them to the hospital. Due to the large SCI population which corresponds to longer stays, many patients come to the hospital with their own medications which cannot be used during their stay and must be stored.

The main Pharmacy work area is 3100 SF, which would typically be enough space to handle the workload for the hospital. However, the space configuration has many nooks and crannies and very little open space, making the space feel tighter and more cramped overall than it would if it were a simple rectangular space. The entrance to the Pharmacy is completely integrated into the high density storage space, such that everyone entering the space must walk through the shelving.

APPENDIX 5-59

A typical shift has 7 pharmacists on duty, with one working on each patient bed floor along with 2 working in the IV clean rooms along with 4 techs and possible up to 2 trainees. Additionally, a tech stays near the dispensing window and vault area, and monitors both. Although having the dispensing window near the vault is a convenient configuration for the staff, there is relatively little dispensing that occurs. Most orders are either received digitally or through the Pyxis restocking process.

The two clean rooms include an IV Prep room as well as a negative-pressure chemo room, however they would benefit from additional negative-pressure storage to support the Chemo room, as well as additional oncology IV storage. Each room currently has 2 hoods which can handle the capacity necessary for the hospital, although the staff noted that they would easily be able to use 3 hoods in each room. There is no designated compounding space, however very little compounding is done on site. The Pharmacy’s policy is to acquire as much as possible commercially before doing any compounding within the Pharmacy. The Pharmacy also has an investigative drug room which is not built as a clean room but has a hood for working. There is also a small staff lounge.

The outpatient Pharmacy is located off-site from the main hospital, although it is very close. It shares a building with a dermatology clinic, and the Pharmacy side of the building includes a Coumadin clinic, a tele- Pharmacy center, the outpatient dispensing and work areas, a shared waiting area, and a drive-thru dispensing window.

The Coumadin clinic has its own dedicated check-in counter but shares the waiting space with the Pharmacy. It includes a specimen collection area off of the waiting room with 2 blood-draw chairs, and has a small lab on site for analysis. Its five consult rooms are well-used, with 3 rooms full at any given time. Three pharmacists work in the clinic during a shift, giving around 60 consults along with 80 labs per day. Patients typically arrive to the clinic about an hour before their appointment time to have their blood drawn an analyzed, which can lead to a busy waiting room.

Reduced lab analysis times may help to decrease crowding in the waiting area.

The call center has two dedicated offices for one pharmacist along with 5 techs. All together they handle around 1200 calls per day. The calls are from providers; the call center does not handle patient consults.

Most of the calls are easily addressed, such as for regular prescription refills or similar issues that can be handled by a tech without requiring a pharmacist. The call center functions as its own entity which could easily be located elsewhere on the medical campus without issue.

APPENDIX 5-60

The outpatient Pharmacy operations has another 4 pharmacists and 12 techs working on a typical shift, which includes a Tele-Pharmacy which is separate from the call center. The pharmacists rotate between operations and phone care in 4-hour shifts. Many of the pick-up windows in the waiting area are used for phone care purposes, while two are used for in-person pick-ups. Although there is no dedicated consult room, there is space in the blood draw area and in nearby offices to use for consult if necessary. The high volume of phone consults (up to 1000 per day) compared to the walk-in consults is likely due to the Pharmacy being located off site from the hospital. The drive-thru is well-used by patients and well-liked by everyone. It especially benefits the large spinal cord injury population that uses the medical center.

The main work area in the outpatient Pharmacy uses both ScriptPro and Optifill automation technology, though does not have a conveyor belt system. The Optifill handles the 200 most-used medications. Most of the medications prepared in the Pharmacy are directly distributed, either through the pick-up windows or the drive-thru. Only about 10% of the prescriptions are mail-order, as the CMOP handles most mail orders unless they are out of stock of a specific medication or if the mail order includes narcotics.

The secured storage cage is not built with vault construction, but is a controlled-access space with C2 cabinets that store the controlled substances. The cage includes 4 workstations, but usually houses 1 pharmacist and 1 tech on a typical shift. Space constraints within the cage mean that work is best distributed over multiple shifts. The staff also noted that a window between the secured room and the rest of the work area would allow labeling to take place of a package once it is packaged, which would help to minimize the work which must take place within the cage itself. Controlled substances which are to be mailed out are held in the cage until the driver arrives. The distance and lack of communication technology between the loading area and the secured storage can sometimes cause issues with getting the medication out to the dock in time to be mailed. A storage solution for packaged medications outside of the cage could alleviate space constraints as well as ameliorate the communication issues with the mail trucks.

Other spaces within the Pharmacy include administrative space as well as a “Resolution Room” which helps take tasks necessary to resolve issues out of the main workflow, and is a space that can be used for Community Care / Choice management. There is also a staff break room which is shared with the dermatology clinic in the building, and therefore is not quite large enough.

APPENDIX 5-61

APPENDIX 5-62

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Outpatient Pharmacy Plan

Legend:

Outpatient

Circulation

Clean Room Inpatient Staff Area Support

Only 2 desks used for in-person check-ins Coumadin clinic Multiple access points to work areas create security issues

Drive-thru well-used and liked Vault is far from loading and space inside is limited Tight work space creates issues, especially with storage

Figure 5.62 James A Haley VH Outpatient Pharmacy Floor Plan

APPENDIX 5-63

Figure 5.63 James A Haley VH Outpatient Note Position 1

Figure 5.64 James A Haley VH Outpatient Note Position 4

APPENDIX 5-64

Figure 5.65 James A Haley VH Outpatient Note Position 5

Figure 5.66 James A Haley VH Outpatient

APPENDIX 5-65

APPENDIX 5-66

ELEVATOR

LOBBY

221 SF

ELEVATOR

LOBBY

332 SF

ELEVATOR

LOBBY

435 SF

STORAGE

402 SF

STORAGE

502 SF

LOUNGE/

LOCKERS

369 SF

VAULT

140 SF

ELEC

255 SF

STOR

122 SF

WOMEN

51 SF

MEN

42 SF

MEANS

182 SF

MEANS

184 SF

MECH

51 SF

COMM

52 SF

FIRE STOR

17 SF

OFFICE

72 SF

STORAGE

380 SF

EXAM

120 SF

EXAM

120 SF

EXAM

120 SF

EXAM

120 SF

EXAM

120 SF

EXAM

120 SF

EXAM

120 SF

IV PREP

205 SF

NURSE

SUPER

155 SF

BUS OPS

VISN

154 SF

137 SF

126 SF

163 SF

125 SF

ANTE

174 SF

CORRIDOR

376 SF

CORRIDOR

729 SF

CHEMO IV

141 SF

STOR

31 SF

PICK-UP

Inpatient Pharmacy Plan

Legend:

Outpatient

Circulation

Clean Room Inpatient Staff Area Support

Vault/Pick-up window configuration is convenient Irregular space layout created inefficiencies Storage blocks path to compounding areas

Flammable storage does not need to be built-in Ante room to clean rooms is also egress route

Figure 5.67 James A Haley VH Inpatient Pharmacy Floor Plan

APPENDIX 5-67

Figure 5.68 James A Haley VH Inpatient Note Position 1

Figure 5.70 James A Haley VH Inpatient Note Position 2

Figure 5.69 James A Haley VH Inpatient Note Position 5

APPENDIX 5-68

MALCOM RANDALL VAMC

Location Gainesville, Florida

Total Area Not Available

Floors 5

Beds 220

Pharmacy Size Inpatient: 6300 SF Outpatient: 7300 SF

Project Cost Not Available

Construction Cost Not Available

Opening Date 1970

Owner Veterans Health Administration

Architect/Engineer Flad Architects

5.1.9 Malcom Randall VAMC, Gainesville, Florida

Figure 5.71 Aerial of Malcom Randall VAMC

APPENDIX 5-69

Figure 5.72 Main Entry of Malcom Randall VAMC

Overview The North Florida/South Georgia Veterans Health System serves veterans across a large geographical area in North Florida (33 counties) and South Georgia (19 counties). In addition to our two medical centers in Gainesville and Lake City, it offers a number of services to our patients in several satellite outpatient clinics and community-based outpatient clinics. The system represents the largest Pharmacy workload of the VA system, with 5 outpatient and 2 inpatient pharmacies.

The Malcom Randall VA Medical Center (VAMC) is one of two VAMCs in the North Florida/South Georgia Veterans Health System. The Malcom Randall VAMC provides a full range of comprehensive health care, including: primary care, specialty care, tertiary care, and long term care.

It houses approximately 220 operational inpatient beds, including three ICUs: cardiothoracic surgical, and medical.

APPENDIX 5-70

Pharmacy Overview The Pharmacy within the Malcom Randall VAMC has three separate spaces: an outpatient Pharmacy, and inpatient Pharmacy, and a separate oncology Pharmacy consisting of several IV clean rooms.

The oncology Pharmacy operates only Monday through Friday for a regular day shift, and processes approximately 40 IV bags a day, or around 125-150 bags in a typical week. It includes an ante room, a work room, an IV transfer room with a pass-through window into the work room, and one room for chemo processing. The space is not at present USP- 800 compliant and will require upgrades in the near future. In addition, it is currently experiencing significant mechanical issues and the chemo room is not able to maintain the negative pressure required. As a result, hooded glove-boxes are used for completing all work in these rooms. The staff noted that the space would benefit from a hands-free intercom system, as there is currently no intercom due to concerns over cleanliness. An additional decontamination shower was also desired on top of the existing one which is currently located in the ante room.

The outpatient Pharmacy processes approximately 1000 prescriptions per day, although many of them (up to 800), are processed for mail-out rather than an in-person pick-up. The medical center does much of its own mail order filling rather than sending the orders to the CMOP due to cost and availability differences in medications between the medical center itself and the CMOP. For in-person pick-ups, the Pharmacy has 2 dispensing windows and a consult room. There is no dedicated window for drop off, as most prescriptions are sent digitally or phoned in. The consult room has two consult spaces inside, however there are concerns with HIPAA privacy regulations when both spaces are in use at the same time. The staff would prefer to have two consult spaces which are acoustically separated from each other.

Within the outpatient Pharmacy workspace, the Optifill automation system works in conjunction with a conveyor belt to process the majority of the prescriptions. The Optifill can hold up to 608 medications. When an order is placed, the robot fills and labels the bottle, which is then dropped into a bin on the conveyor belt. If any additional medications are needed for the order that cannot be filled by the robot, the bin is routed to a technician station for these remaining items. Then, the robot or the tech forwards the bin on to a pharmacist station for verification of the order. All together, the conveyor belt connects the robot, 4 tech stations, and 3 pharmacist stations. The main complaint with this system by the staff is the noise level. Despite this layout, the typical staffing level is only 2 pharmacists

APPENDIX 5-71

and 2 techs on the conveyor belt at any one time, with another pharmacist and tech working in the narcotics vault.

The outpatient narcotics cage is not actual vault construction, but is a controlled-access space with a work area and controlled substances stored in Pyxis C2 safes. These safes are restocked from the inpatient vault as needed. The Pharmacy work area also includes a staff lounge and conference area which is open to the main work space, and staff restrooms including a shower. The staff would prefer a lounge that is separated from the work area, and also noted that their large residency program would benefit from a conference room large enough for up to 35 or 40 individuals. The medical center has one of the largest residency programs in the country, including 20-30 residents at all times. A presentation space that includes a projector and a conference table would be a key asset to the program.

The inpatient Pharmacy includes the main work area, as well as pharmacist offices in each 30-bed unit. Each bed unit also has 2 meds rooms, each which contain a Pyxis machine, and most units have a third machine in a corridor alcove. The main Pharmacy space includes a high-density storage area as well as a drug disposal collection area which is easily accessed by the main work space. There is one small area of the Pharmacy, approximately 90 square feet, which houses the repacking equipment, the pneumatic tube station, the flammable storage cabinet, the compounding workstation, and a pill splitter. Ideally, the compounding workstation could be moved out of this zone to a location where there was access to a hand sink and an eyewash.

There is an IV prep clean room area in the inpatient Pharmacy which supplements the oncology Pharmacy. The prep area includes two pharmacist workstations. There are problems with this room as well, possibly in part because it is situated on top of a building control joint. The staff finds that the room has almost constant mechanical and plumbing issues.

There is no automation within the inpatient Pharmacy and therefore 2 procurement techs handle inventory manually with a daily count. Currently the procurement workstation is exposed to the main work area, and the staff finds this configuration difficult, as the procurement techs would benefit from a quieter environment. The staff noted that use of a meds carousel would permit the techs to more easily work from a remote location.

APPENDIX 5-72

Other spaces within the Pharmacy include a dedicated space for crash cart refill, which is useful to have but could function with even slightly less space than it currently has available. The dedicated crash cart tech is also responsible for maintaining the drug cache. There is also an investigational drug program, which typically has between 20 and 25 ongoing studies, with desk space for a pharmacist and a tech, some storage space, and two hooded glove-boxes. The controlled-substance vault houses substances for inpatient, outpatient, surgical and anesthesia services. Saline storage also takes up space within the Pharmacy. It was noted that some space constraints in the department could be alleviated by using an equipment-based solution for storing controlled substances rather than having a built-in vault, and by storing saline within the main hospital logistics space, which is a typical solution for many hospitals. The Pharmacy has already eliminated space for a library of drug information, most of which is available online, choosing only to store paper copies of MSDS sheets as needed. The Pharmacy would also benefit from having a dedicated staff toilet room accessible from within the department.

APPENDIX 5-73