36E77619R0019-011.pdf

5.0 APPENDIX

PG 18-12 – PHARMACY SERVICE DESIGN GUIDE APRIL 1, 2018

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5.0 APPENDIX

TABLE OF CONTENTS

5.1 SITE VISITS 5-5

5.1.1 Introduction 5-5

5.1.2 Jesse Brown VAMC, Chicago, Illinois 5-7

5.1.3 Edward Hines Jr. VAMC CMOP, Hines, Illinois 5-16

5.1.4 University of Chicago Medical Center, Chicago, Illinois 5-20

5.1.5 Elmhurst Memorial Hospital, Elmhurst, Illinois 5-28

5.1.6 Rush University Medical Center 5-38

5.1.7 Orlando VAMC, Orlando, Florida 5-44

5.1.8 James Haley VAMC, Tampa, Florida 5-56

5.1.9 Malcom Randall VAMC, Gainesville, Florida 5-68

5.1.10 Washington DC VAMC, Washington, DC 5-78

5.2 STORAGE STUDY 5-87

5.2.1 Jesse Brown VAMC Storage Survey 5-88 5.2.2 Orlando VAMC Storage Survey 5-89 5.2.3 Orlando VAMC Storage Survey 5-90 5.2.4 Tampa VAMC Storage Survey 5-91 5.2.5 Gainesville VAMC Storage Survey 5-92 5.2.6 UCMC Storage Survey 5-93 5.2.7 UCMC Storage Survey 5-94 5.2.8 Elmhurst VAMC Storage Survey 5-95 5.2.9 Rush VAMC Storage Survey 5-96

5.2.10 Washington DC VAMC Storage Survey 5-97

5.3 TEST FITS 5-99

5.3.1 Consult Room 5-100

5.3.2 Phonebank, Telepharmacy 5-101

5.3.3 Storage, Prosthetics and Supplies 5-102

5.3.4 Filling/Assembly, Shelving Storage 5-103

5.3.5 Work Area, Sterile Compounding 5-104

5.3.6 Storage, Sterile Compounding 5-105

5.3.7 Workstation, Clinical Pharmacy Teaching Coordinator 5-106

5.3.8 Workstation, Intern/Student 5-107

5.3.9 Workroom, Resident 5-108

5.3.10 Pharmacy Cache 5-109

5.1 Site Visits

5.1.1 Introduction

As a beginning step to updating the Space Criteria and Design Guide for the Pharmacy chapter, the team embarked on two site visits to conduct post occupancy evaluations of existing pharmacies. In order to gain an understanding of the way the VA currently operates, the team toured multiple VA-operated pharmacies in addition to several State-operated Veteran Homes across the country. In addition, the team toured a number of private pharmacies to see a variety of solutions and work flows. The group also focused on adjacencies of spaces, finishes, and architectural details. The analysis was intended to be a learning experience for the design team which would translate into modifications, additions, or deletions from the existing chapter criteria and design guide.

5.1.2 Jesse Brown VAMC, Chicago, Illinois

Figure 5.1 Aerial of Jesse Brown VAMC

JESSE BROWN VAMC

Location Chicago, Illinois

Total Area 240,000 SF

Floors 8

Beds 200

Pharmacy Size Not Available

Construction Cost $82,000,000

Opening Date May 2008 Outpatient Pharmacy renovated 2011

Owner Veterans Health Administration

Architect/Engineer SOM/Ellerbe Becket

Figure 5.2 Main Concourse in Jesse Brown VAMC

Medical Center Overview The Jesse Brown VA Medical Center consists of a 200-bed acute care facility and four community based outpatient clinics (CBOCs). Jesse Brown VAMC provides care to approximately 62,000 enrolled veterans who reside in the City of Chicago and Cook County, Illinois, and in four counties in northwestern Indiana. In FY10, the medical center had over 8100 inpatient admissions and 560,000 outpatient visits. A budget of over $355 million supports approximately 2,000 full-time equivalent staff, including 200+ physicians and 450 nurses, with 500+ volunteers providing service and care at Jesse Brown VAMC and CBOCs.

In May 2008, the medical center opened its new inpatient bed tower pavilion, which includes seven surgical suites, cystology, intensive care, inpatient dialysis, an outpatient surgical center and a chapel. The medical center’s strategic priority is the “heart of the Veterans Community” and as Provider of Choice for veterans in the Chicago area. JBVAMC established a “We Are Here” outreach campaign to inform veterans about the health care benefits they have earned through their service to our country and the specific services available to them at Jesse Brown VA Medical Center.

Figure 5.3 Entrance Lobby in Jesse Brown VAMC

Formerly known as the West Side VA Medical Center, the facility was renamed in 2004 for the Honorable Jesse Brown, who served as Secretary for Veterans Affairs from 1993 to 1997.

Pharmacy Overview Pharmacy services are spread throughout the medical center to best serve the facility at the necessary points of access. Pharmacy services are divided into 5 separate locations: Outpatient, Inpatient, DDTC, Drug Cache, and OR Satellite.

The outpatient Pharmacy is located on the 1st floor, which provides it easy access to and from the loading dock. The space is large enough that it is able to handle inpatient discharge prescriptions as well, to help alleviate space constraints in the inpatient Pharmacy. The move for discharge from inpatient to the outpatient Pharmacy was critical to provide enough room to support the use of robotics, which are now used heavily for discharge prescriptions. Locating the outpatient Pharmacy on the first floor also makes it convenient for pick-up by vets. As the medical center is located conveniently to public transit, the system does not need to contract out any pharmaceutical work to external pharmacies. The Just-In-Time delivery service used means that the Pharmacy currently has no need for a medications carousel. Noted space constraints include those in the waiting area where urgent care patients often contribute to crowding, and the space necessary to keep various drugs segregated per regulating while they are awaiting disposal. Space for staff lockers and personal storage is also an issue.

The inpatient Pharmacy is located on the 3rd level within the bed tower, and is much smaller than the outpatient Pharmacy. It typically supports 130 patients (200 maximum) at any given time. It has two clean rooms with an ante room, each with two hoods, which were built according to best practices in 2007. As a result, few to no alterations are anticipated to be necessary once updated standards are adopted. There is a pick-up window for nurses near the clean room which allows the compounding pharmacist to remain in the clean room area at all times. The inpatient Pharmacy also includes a narcotics vault, an oncology research workstation, and a pick-up window that can be used for after-hours outpatient pick-up services. Although space is limited, it is used effectively and the Pharmacy benefits by sharing discharge services with the outpatient Pharmacy. However, the inpatient and outpatient services each have their own receiving processes and area, which does occupy valuable space within the inpatient Pharmacy.

The DDTC (drug dependence treatment center) Pharmacy resides on the second floor and supports the medical center’s methadone program.

The room has enough space to prepare and administer pick-up and take-home doses of methadone. The workstation near the large pick-up window assures that patients can watch their dosage being prepared before it is administered.

The drug cache occupies two rooms on the second floor of the medical center. The entrance has a two-step security system requiring both a key and a code for entry, although a code may be entered without the key in an emergency (however an alarm will sound). The rooms have ample space for the cache and are therefore also used for overflow storage, including several overflow refrigerators and storage for flu vaccines.

The OR satellite Pharmacy can be used as contingency space, if needed, by the other Pharmacy services. However, the satellite was not observed

R

(CUBICLE)

(CUBICLE)

FEC

FEC

WALL

GUARD

WALL

GUARD

WALL

GUARD

WALL

GUARD

FEC

WALL

GUARD

WALL

GUARD

CLEAN STORAGE

ALCOVE

1266A

WHEELCHAIR

STORAGE

1249A

MAIN

ENTRANCE

CORRIDOR

CHAIR

STATION

CUBICLES

1259A

HALLWAY

TEMPORARY

NURSES

STATION

PATIENT

WAITING

AREA

PATIENT

TEMPORARY

SOILED

UTILITY

CLEAN

STORAGE

(WET)

CLEAN

STORAGE

NURSE

MANAGER

SOCIAL

WORKER

CHAIR STATION

CUBICLES

STAFF

TOILET

LOCKERS

1264A

CONFERENCE

LUNCH RM

BIO-MED REPAIR

EXIST SHAFT

MECH RM

WATER TREATMENT

STORAGE

(DRY)

CHIEF

PHYSICIAN

on this site visit, as the program is covered by the VA Surgical Services Design Guide.

Outpatient Pharmacy Plan

1 8

2 4 6

5 7

Figure 5.4 Jesse Brown VAMC Outpatient Pharmacy Floor Plan

Key Notes / Photo Locations:Legend:

Outpatient 1 Receiving/breakdown 6 Waiting space: can become overcrowded with urgent careClean Room 2 Bulk storage patients Inpatient 3 Automation 7 Consulting stations Staff Area 4 Pick-up window 8 Staff coats hung here on wall asSupport 5 Call center they do not fit in lockers Circulation

Figure 5.5 Jesse Brown VAMC Outpatient Figure 5.7 Jesse Brown VAMC Outpatient Photo taken at note position #3 Photo taken at note position #8

Figure 5.6 Jesse Brown VAMC Outpatient Figure 5.8 Jesse Brown VAMC Outpatient Photo taken at note position #5 Photo taken at note position #5

Inpatient Pharmacy Plan

Figure 5.9 Jesse Brown VAMC Inpatient Pharmacy Floor Plan

Key Notes:Legend:

Outpatient 1 Compounding pharmacist and 5 Main work area pick-up windowClean Room 6 Receiving Inpatient 2 Inpatient pick-up window Staff Area 3 Pyxis restocking Support 4 Research Oncology

Figure 5.10 Jesse Brown VAMC Inpatient Figure 5.12 Jesse Brown VAMC Inpatient Photo taken at note position #1 Photo taken at note position #5

Figure 5.11 Jesse Brown VAMC Inpatient Figure 5.13 Jesse Brown VAMC Inpatient Photo taken at note position #3 Photo taken at note position #6

5.1.3 Edward Hines Jr. VAMC CMOP, Hines, Illinois

Figure 5.14 Aerial of Edward Hines Jr. VAMC

HINES CMOP

Location Hines, Illinois

Total Area ~115,000 SF Currently not all area is in use

Floors 1

Beds N/A for CMOP

Pharmacy Size ~115,000 SF

Construction Cost Not Available

Project Cost Not Available

Opening Date 1995

Architect/Engineer Not Available

Figure 5.15 Front facade of Edward Hines VAMC

Overview Edward Hines, Jr. VA Hospital, located 12 miles west of downtown Chicago on a 147-acre campus, offers primary, extended and specialty care and serves as a tertiary care referral center for VISN 12. Specialized clinical programs include Blind Rehabilitation, Spinal Cord Injury, Neurosurgery, Radiation Therapy and Cardiovascular Surgery. The hospital also serves as the VISN 12 southern tier hub for pathology, radiology, radiation therapy, human resource management and fiscal services.

Hines VAH currently operates 471 beds and six community based outpatient clinics in Elgin, Kankakee, Oak Lawn, Aurora, LaSalle, and Joliet. Over 600,000 patient visits occurred in fiscal year 2010 providing care to over 54,000 veterans, primarily from Cook, DuPage and Will counties. In FY 2010 the budget for Hines was over $510 million.

Figure 5.16 Robotic picking in Hines CMOP

CMOP Overview The Central Mail Order Pharmacy located near the Hines campus is one of six such facilities in the country, which in aggregate handle about 85% of all outpatient prescriptions for the VA. Since 2006 the CMOP facilities have comprised their own organization separate from the purview of the VA hospitals. They are funded by payments from the hospitals and operate at a cost of about $1.63 per prescription. The hospitals typically handle their own discharge prescriptions before the prescription is automatically transferred to the CMOP system. The CMOPs process close to 90 million prescriptions a year. At the Hines CMOP specifically, the facility processes roughly 120,000 prescriptions every day, and has a turn-around rate of 48 hours.

The current workflow for the Hines CMOP, including the administrative area, occupies only about half of the total area of the building. The current system was installed in 1995 and has undergone numerous updates and upgrades in the intervening years to add more capacity and functionality.

There are several components to the system, which includes robotic picking for medications that can be ordered in the correct doses for prescription filling, a dispensing area for filling bottles with individual pills, a line of stations for pharmacist verification of each prescription, and a line of stations for packaging and preparing each package for shipment.

Once the material is packed, it is stored on carts until it can be picked up by a contracted consolidator and sorted for shipping. The CMOP does not handle shipping itself. As no compounding or IV prep is done at the facility, there are no clean rooms. However, there are several mechanical hoods for handling of some specific medications.

An entire replacement system is currently planned for the empty space in the CMOP warehouse. As a result, the CMOP expects to be able to handle any future increases in demand easily, and is not space-constrained.

Figure 5.17 Current assembly line at Hines CMOP

5.1.4 University of Chicago Medical Center, Chicago, Illinois

Figure 5.18 Aerial of University of Chicago Medical Center

UNIVERSITY OF CHICAGO MEDICAL CENTER - CENTER FOR CARE AND

DISCOVERY

Location Chicago, Illinois

Total Area 1.2 Million SF

Floors 10

Beds 240

Pharmacy Size 6,600 SF

Project Cost $700 Million

Construction Cost $470 Million

Opening Date February 2013

Owner University of Chicago Medicine

Architect/Owner Rafael Vinoly/CannonDesign

Figure 5.19 Main Entry of University of Chicago Medical Center

The University of Chicago Medicine is an academic medical center based on the campus of the University of Chicago. The not-for-profit corporation offers the full range of specialty and primary care services for adults and children that includes the Center for Care and Discovery.

The new hospital is a 10-story “hospital for the future” that serves as the new core of the campus of the University of Chicago Medicine. The Center for Care and Discovery provides a home for complex specialty care with a focus on cancer, gastrointestinal disease, neuroscience, advanced surgery and high-technology medical imaging.

It has the internal capacity to rapidly and economically adjust to changes in technology and medicine, and to the facility needs, for decades to come.

At 1.2 million square feet, the hospital is one of the largest buildings on the University of Chicago campus, changing the skyline of the South Side of Chicago. It occupies the north end of two city blocks, along the south side of 57th Street between Cottage Grove and Drexel Avenues. Each floor provides 100,000 square feet of space.

The architects created flexibility and adaptability by designing the entire hospital structure on a grid system. The grid is organized into 85 modular cubes that repeat on each floor. At 31 feet wide by 18 feet high, these large cubes, or “bays,” can be re-purposed over time to accommodate technological advancements and changing needs. For example, one bay can enclose two patient rooms, one operating room or one interventional procedure room–without changing the basic framework of the building.

The hospital’s innovative design also extends to its public spaces. The main lobby is located on the 7th level and is referred to as the “Sky Lobby.” The space has floor–to–ceiling glass walls, filling the space with natural light and providing panoramic views of the campus and downtown Chicago. The Sky Lobby houses central reception, family waiting areas, a chapel, the gift shop, dining areas and other public spaces. The ground level of the new hospital, open to the public, enhances the street-scape and includes cafés and other retail businesses.

The new hospital contains 240 single-occupancy inpatient rooms including 52 intensive care beds; space for 28 operating rooms with leading-edge technology; and an integrated diagnostic and interventional platform including cardiac, gastrointestinal, neurological and vascular services.

The building also has two floors of expansion space that could be used for additional patient care units as well as future leading-edge, technology-based interventional or surgical suites.

Figure 5.20 Lobby at UCMC Center for Care and Discovery

Pharmacy Overview The project team visited three separate Pharmacy spaces at University of Chicago: the inpatient Pharmacy in the Center for Care and Discovery, the inpatient Pharmacy within the Comer Children’s Pediatric Hospital, and the outpatient Pharmacy near the main lobby.

The Comer Children’s Pediatric Pharmacy currently serves as the main inpatient Pharmacy to support all of the beds on the medical center campus. However, as there are additional beds planned, it is anticipated that the Center for Care and Discovery Pharmacy will play a larger role in supporting the inpatient population in the future. The Comer Pharmacy includes several clean rooms as well as a compounding robot, though staff find that the robot provides the maximum benefit if it can be employed to do a single task. The clean rooms and compounding robot together provide sufficient capacity for most of the medical center’s current needs.

The Center for Care and Discovery Pharmacy has three additional medication carousels, staff and administrative space, an investigational drug service space, and a built-in narcotics vault. There are three additional clean rooms in this Pharmacy which all share an Ante room, however these rooms are currently only used as contingency and overflow space for the Comer Pharmacy clean rooms, and their capacity is anticipated to be needed once the hospital grows to accommodate an additional several hundred inpatient beds. This Pharmacy was originally planned to include picking robotics, however the hospital ultimately opted to utilize the medication carousels instead.

CHEMO

COMPOUNDING

198 SF

OFFICE

84 SF

OFFICE

86 SF

OFFICE

84 SF

COPY

84 SF

OFFICE

131 SF

STAFF LOUNGE

247 SF

GENE THERAPY

COUMPOUNDING

89 SF

STAT IV

86 SF

ANTE

155 SF

PACKAGING

199 SF

MULTI-PURPOSE ROOM

367 SF

2 3

IDS

721 SF

CORR

388 SF

MAIN

WORKROOM

1639 SF

CORR

343 SF

NARCOTICS

STOR

159 SF

LOCKERS

331 SF

STAFF TLT

65 SF

EVS

111 SF

MANUAL

WORKSTATIONS

279 SF

Figure 5.21 Floor Plan of UCMC Center for Care and Discovery Pharmacy

Key Notes:Legend:

Outpatient 1 These clean rooms are used 4 Work area tight and doubles as contingency or overflow as receiving and storageClean Room spaces primarily 5 Narcotic vault with automatedInpatient

2 Three meds carousels in main medication dispensing as Staff Area workroom additional secured storage Support 3 Admin spaces arranged in

Circulation ring around work area

Figure 5.22 UCMC Inpatient Figure 5.24 UCMC Inpatient Note position #1 Note position #5

Figure 5.23 UCMC Inpatient Note position #2

Argo Tea

Supply

WAITING

359 SF

DISPENSING

300 SF

SUPPLIES

291 SF

WHEELCHAIR

STOR

166 SF

ORRIDOR

4397 SF

Sub-Waiting

Public Co

Work/Co

TELCOM

154 SF

Valet

OFFICE

90 SF

ORDER

PROCESSING

312 SF

Internal C

OFFICE

141 SF

PUBLIC CORRIDOR

224 SF

Figure 5.25 Floor Plan of UCMC Outpatient Pharmacy

377600 Internal Corridor

377600

Internal Corridor

1574B 377625

Mammography

378500

Clean Workroom

380777

Internal Corridor

1002A 373214 Argo Tea

Reception

Family Resource Library

Security Desk

Reception

Office 234 1013

370300 Office

370300 Office orridor

377625

GenRad - X-Ray

1574A 377625

Internal Corridor

1574E 377625

Internal Corridor

1574D 377625

Mammography

377625

Public Lobby Seating

1204A 378500 Office

378500

Internal Corridor

390777

Public Corridor 1,190

380777

Internal Corridor

1STF

390777 Stairway rridor

1403A 390777

Public Corridor

390777

Public Corridor

377600

Internal Corridor

Internal Corridor

1STD

390777 Stairway

1651CO1

373540

Voice/Data

Public Corridor

1STA

390777 Stairway

378101 Reception

1108A 380777

Internal Corridor

Office

380777 Reception

1STE

390777 Stairway

380777 Office

1EL1

373540

Electrical

Non-Public Elevator

Non-Public Elevator

Public Corridor

Office

Office py

Office

Kitchenette

Consult Room

Sub-Waiting

Office

Office

Conference Room

Elevator

Public Elevator

Public Corridor

Public Elevator

Public Elevator

Public Elevator

373275

Trash Room

377600

Private RR

377600

Locker Room

378500

Exam Room

378500

Exam Room

1218A 378500

Central Storage

378500

Exam Room

378500

Exam Room

378500

Exam Room

378500

Medical Records

378500

Soiled Workroom

378500

Treatment, General

378500

Exam Room

378500

Treatment, VFI

378500

Exam Room

378500 Phototherapy

378500

Phototherapy

378500 Office

378500

Patient Toilet

378500

Treatment, VFI

Office

378500

Work Area, Resident

378500

Patient Toilet

378500

Exam Room

378500

Exam Room

377620 Staff RR

377620 Office

377607 Office

1561A 377620

Internal Corridor

377620 Office

377620 Staff RR

377620 Office

1577A 377625

Patient Toilet

390777

Public RR

390777

Public RR

1115A 373214

Merchandising Service

378500

Internal Corridor

1018A 390777

Public Corridor

Stairway

1109-S3 380777 Office

1109-N1 380777 Office

1109-N2 380777 Office

1109-S4 380777 Office

1108-S3 380777 Office

1108-N1 378101 Office

1108-N2 378100 Office

1108-S4 380777 Office

1108-S5 380777 Office

1108-N3 378100 Office

1109-S1 380777 Office

1109-S2 380777 Office

1108-S1 380777 Office

1108-S2 380777 Office

1115-N1 378101 Office

1109-E1 380777

Work/Copy

1109A 380777

Internal Corridor

380777

Internal Corridor

1005A 378020

Conf Supply

Office 51 Office

Office

Internal Corridor

Closet

1574A2 377625

Changing Area

1574A1 377625

Changing Area

A75

External 72,464.91

A: EXTERNAL, NON-EMPLOYEE

A: EXTERNAL, NON-EMPLOYEE

A: QUASHIE, ANGELA D.

A: UNOCCUPIED, VACANT

A: UNOCCUPIED, VACANT

A: UNOCCUPIED, VACANT

A: UNOCCUPIED, VACANT

A: UNOCCUPIED, VACANT

A: UNOCCUPIED, VACANT

A: UNOCCUPIED, VACANT

A: UNOCCUPIED, VACANT

A: UNOCCUPIED, VACANT

A: ASEVES, FRANK

A: RAGO, JAMES

A: UNOCCUPIED, VACANT

A: UNOCCUPIED, VACANT

A: UNOCCUPIED, VACANT

A: HARRIS, SHARON

A: HUGHES, ROSALIE

A: UNOCCUPIED, VACANT

A: UNOCCUPIED, VACANT

A: UNOCCUPIED, VACANT

A: UNOCCUPIED, VACANT

A: UNOCCUPIED, VACANT

A: DUNCAN, EDNAA: MASON, PATRICIA

A: UNOCCUPIED, VACANTA: UNOCCUPIED, VACANT

A: RYAN, DENAE

A: UNOCCUPIED, VACANTA: UNOCCUPIED, VACANT

A: UNOCCUPIED, VACANTA: UNOCCUPIED, VACANT

A: UNOCCUPIED, VACANT

PUBLIC C

Outpatient Pharmacy Plan

Legend:

Outpatient Clean Room Inpatient Staff Area Support Circulation

Key Notes:

1 ScriptPro automation is primary tool for outpatient Pharmacy services

2 High density storage 3 Outpatient filling

Figure 5.26 UCMC Outpatient Figure 5.27 UCMC Outpatient Note position #1 west Note position #1 east

Figure 5.28 UCMC Outpatient Note position #3

5.1.5 Elmhurst Memorial Hospital, Elmhurst, Illinois

Figure 5.29 Aerial of Elmhurst Memorial Hospital

ELMHURST MEMORIAL HOSPITAL

Location Elmhurst, Illinois

Total Area 866,000 SF

Floors 6

Beds 259

Pharmacy Size 4,000 SF

Project Cost $450 Million

Construction Cost $320 Million

Opening Date June 2011

Owner Elmhurst Memorial Care

Architect/Engineer Albert Kahn Associates/Pratt Design Studio

Figure 5.30 Main Entry of Elmhurst Memorial Hospital

Overview Elmhurst Memorial Healthcare recently took the opportunity not only to replace an outdated, landlocked hospital building, but also to redefine the way they treat patients.

When the system set out to build a replacement facility, it established five main goals for the new building: clinical quality, safety, market growth, financial performance and patient satisfaction. Central to these is the patient experience; throughout the planning process, the health system asked, “How do you put the patient at the center, and make that stick?”

To answer this question, the system worked extensively with health care consulting firm Hammes Company, Brookfield, Wis., to research, map and optimize the patient experience. It also joined the Planetree network, an organization based in Derby, Conn., that promotes patient-centered care, including the idea that physical environments can enhance healing, health and well-being. Planetree’s principles for safe, effective, high-quality care that nurture the body, mind and spirit clearly are evident in the newly opened Elmhurst Memorial Hospital facility, which was designed by Albert Kahn Associates Inc., Detroit, and Pratt Design Studio, Chicago.

The red brick Prairie-style building is adorned with bands of precast concrete molded in the design of a Planetree leaf, a motif used throughout the hospital in tribute to the patient-centered model of care.

Gardens and outdoor seating areas span the front of the building. A water feature is installed just inside the main entrance to provide a serene entry sequence for patients and visitors. Oversized windows fill the first-floor, public concourse with natural light. A number of amenities are located along the concourse, including a flower shop, wellness boutique, Starbucks, Pharmacy and the hospital’s café.

A health education center is available to the public in keeping with the Planetree belief that access to health information can empower people to participate in their own care. The back of this library opens to the physician lounge, giving doctors easy access to research materials.

A nondenominational chapel with a second-story balcony is adjacent to both the emergency department (ED) on the first floor and the intensive care unit on the second floor. Family members and friends of patients in these critical care areas can access the chapel without having to travel far from the patient bedside.

Each room has a computer work station with an articulating arm that allows caregivers to position the monitor where it can be seen easily by the patient. A stool is provided in every room so caregivers can sit down while speaking with patients.

To save hospital staff the time spent fetching extra seats for visitors, a folding chair is stored in a cabinet in the family zone of each patient room.

A small table with leaves that fold down for easy storage can be rolled out from beneath a counter on the footwall to give family and visitors a place to work, share a meal or play games with a patient. The idea that families, friends and loved ones are vital to the healing process is important to the Planetree approach. At the far corner of each room, the walls meet in a smooth curve rather than a sharp point, a gesture that has surprising impact on making the room more comfortable.

Integrated, ceiling-mounted patient lifts are installed in each room for staff and patient safety. Large bathrooms include roll-in showers sized to enable staff members to assist patients with bathing. The toilet is positioned away from the corner of each bathroom, providing room for two caregivers, one on each side, to help a patient sit or stand. Fold-down grab bars are installed on either side of the toilet to allow patients to help themselves. A recessed cabinet in the wall of each bathroom stores bedpans and other commonly used items.

The project team followed the 90/5 rule in designing the hospital. This rule, which originated in the aerospace industry, states that 90 percent of supplies should be stored within five seconds of where they are needed.

Nurse servers in each patient room keep supplies close at hand.

Like the patient rooms, the ED exam rooms are private, each with a private bathroom. Two doors lead into each exam room; the staff work area is on one side of the exam rooms and the waiting area is on the other, to reduce noise and chaos.

A six-bed pediatric inpatient unit is located next to the ED on the hospital’s first floor. The rooms here look into a children’s garden filled with fanciful blown-glass globes.

Figure 5.31 Lobby of Elmhurst Memorial Hospital

Model of Care The Planetree Model of Care has been highlighted as a holistic philosophy of care that resonates with every department in the facility, including the Pharmacy.

The hospital is considered a destination care center for community providers. Facility management related that local physicians and surgeons have a choice in their admitting and privileges and surgical case blocks with competition from other area hospitals and surgical centers. Many of the physicians are choosing to operate at Elmhurst and the facility has seen an uptick in procedures related to this. The hospital also has an established partnership with Northwestern University’s Interventional Radiology program.

Because of the Planetree related design, there seems to be a large amount of underutilized public space. Facility staff mentioned that this space was a circulation factor and much of it was not in the program when designed but is part of the Planetree philosophy to provide open, non-restrictive spaces without pinch-points and generous lobby areas for visitors.

Pharmacy Overview The Pharmacy at Elmhurst handles inpatient medications, chemotherapy for their adjacent cancer clinic, some home health care, and employee outpatient prescriptions. Inpatient discharge prescriptions are not a service provided. All Pharmacy services are located in one area in the basement of the main hospital building. During an initial planning phase, the Pharmacy was located near the ICU and OR suite on Level 2. Eventually, planning adjustments were made to co-locate all critical care units, and Pharmacy was left with limited space on Level 2. By moving the program to the basement, they were able to maximize the space that could be made available to the Pharmacy. This also located the Pharmacy to be convenient to the loading dock for daily deliveries.

The Pharmacy group consists of 65 staff members for a total of 45 FTEs. They collectively handle 285 beds which are typically at 70-75% occupancy. Staff are cross-trained to be able to work in both the inpatient and employee outpatient services. Some pharmacists are “roving” on the bed floors with a laptop which takes the place of having any satellite Pharmacy spaces beyond what is located in the basement. There are also two Pyxis stations located in each 25-bed unit. The stations are refilled manually across all three shifts, with a focus on refilling the OR-located

Pyxis machines on the overnight shift to minimize disruption during peak hours.

Although the Pharmacy group considered robotics, they ultimately decided to utilize two medication carousels to automate their process for the inpatient Pharmacy. There are also three pneumatic tube stations within the Pharmacy, with one station for a dedicated tube system which is used exclusively for chemotherapy being sent to the cancer clinic. By isolating the chemotherapy drugs on their own system, the team minimizes risk associated with a container bursting while in transit.

The carousels put out a report for restocking and a delivery is received daily. As a result, the inpatient Pharmacy space is uncluttered and organized, which a large portion of all drug storage occurring within the carousels. Oncology drugs, however, are not handled through the carousel and are therefore restocked manually. There is also a separate room for receiving, breakdown, and additional storage. Due to the packaging and storage needs of some specific medications, the staff would prefer this space to be larger. Although the space has a high ceiling, the tops of shelves are too high to be practically usable on a regular basis. If overflow space is needed, the staff use the Home Health Care space, which also is used for storing the emergency drug cache.

The clean rooms are built for best practices and therefore the group anticipates that few changes will be necessary for USP 800. However, the group expressed dissatisfaction with the current clean-room layout, which employs a shared ante room for both clean rooms. The preference was to have two separate ante rooms to keep the IV clean room workflow completely separate from the chemo compounding workflow. The clean rooms both have pass-through cabinets and refrigerators.

The project team noted the generally de-cluttered feel of the Pharmacy, the quality of which was made more pleasant by the indirect lighting installed in the main workspaces of both the inpatient and employee outpatient services.

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

201 SF

IV

SF

EAN

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

Pharmacy Plan

284 SF

FOUNDATION

STOR

107 SF

ELEC

108 SF

STOR

143 SF

SOILED

903 SF

BIO MED

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

IV CL

2727 SF

DISPENSING

Figure 5.32 Floor Plan of Elmhurst Memorial Hospital Pharmacy

Legend:

Outpatient Clean Room Inpatient Staff Area Support Circulation

Key Notes:

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

284 SF

FOUNDATION

STOR

107 SF

ELEC

108 SF

STOR

143 SF

SOILED

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

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

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

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

8 6

Figure 5.33 Floor Plan of Elmhurst memorial Hospital Pharmacy

Figure 5.34 Elmhurst Pharmacy Figure 5.36 Elmhurst Pharmacy Photo taken at note position #1 Photo taken at note position #7

Figure 5.35 Elmhurst Pharmacy Figure 5.37 Elmhurst Pharmacy Photo taken at note position #3 Photo taken at note position #8

5.1.6 Rush University Medical Center

Figure 5.38 Aerial of Rush University Medical Center

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

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 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 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.

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

CORR

142 SF

SOILED

LINEN

369 SF

TLT

Pharmacy Plan

169 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

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

Figure 5.40 Rush University Medical Center Pharmacy Plan

Key Notes:Legend:

Outpatient 1

Vault is not used 4 This clean room is negative pressure, used to be used forClean Room Narcotics stored here oncologyin free-standing vaultInpatient

Pharmacists workstation lacksAnteroom with poorStaff Area visibility of clean roomsvisibility and no pass-Support thrus Clean room is lacking ante room Circulation Storage is separated from pharmacy by public corridor

Figure 5.41 Rush MC Inpatient Figure 5.43 Rush MC Inpatient Note position 3 Note position 5 (looking north)

Figure 5.42 Rush MC Inpatient Figure 5.44 Rush MC Inpatient Note Position 5 (looking south) Note Position 6

5.1.7 Orlando VAMC, Orlando, Florida

Figure 5.45 Aerial of Orlando VAMC

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

Architect/Owner Ellerbe Becket/RLF Architects

Figure 5.46 Main Entry of Orlando VAMC

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, 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 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 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.

Retail Clean Room Work Area Staff Support Circulation

G

H

J

K

L

30.2

AS

K.7

3233 A733.6

K.6

OFFICE

SUPERVISOR

CASHIER

OFFICE

LOANS

DAY COOLER

ADMIN CLERKS

VAULT

CONCESSIONS

ATM

CANTEEN RETAIL

CORR

TOILET

AISLE

ATM

WORKROOM

Y

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

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D7

CLINIC

HOSPITAL

P-W P-E

A4

E4

W

Outpatient Pharmacy Plan

AGENT CASHIER

TRAVEL CLERK

CLOSET

WAREWASH

O.P. SECURE

PRESCRIPTION

STORAGE

PASSAGEHAC

2 5 6 ELEC

COMM

HAC

CONSULT

SERVER

4 3

CORRIDOR

PICK-UPWAITING WINDOW

PHARMACY UUPP SODA CLOSET

STAIR - PHARMACY

AGENT CASHIER MONEY ROOM ASST CHIEF (FOOD)

TRAVEL CLERK

TOILET

AISLE

TLT

Figure 5.47 Orlando VAMC Outpatient Dispensing Floor Plan

Key Notes:Legend:

Outpatient 1 No waiting in front of 5 Large amount of

Pharmacy underutilized spaceClean Room 2 On-stage/Off-stage concept 6 Secondary vault used onlyInpatient aided by layout for dispensing narcotics Staff Area since dispensing is on a3 Consult currently not usedSupport different floor from main4 Hard to see line formingCirculation pharmacy.

Figure 5.48 Orlando VAMC Outpatient Figure 5.50 Orlando VAMC Outpatient Note Position 2 Note Position 5

Figure 5.49 Orlando VAMC Outpatient Figure 5.51 Orlando VAMC Outpatient Note Position 4 Note…