Our mission at Maimonides Medical Center, a 100-year-old community, nonprofit, teaching hospital located in Brooklyn, New York, is to provide the highest level of compassionate and quality care to the communities we serve. This goal of our 711-bed, award-winning facility provided the impetus to creating a design for a full-scale pharmacy renovation plan in 2008; the renovation was completed successfully in the first half of 2011. 

A 24-hour pharmacy with 90 employees, including 50 pharmacists, the Maimonides pharmacy department serves 29 patient areas, including our infants and children’s hospital, cancer institute, obstetrics and gynecology units, stroke center, geriatrics division, and cardiac institute. Prior to the renovation, we manually filled medication carts to supply all 29 patient areas, a time intensive and laborious process. We also had outgrown our space and needed to expand the pharmacy’s footprint to accommodate growth within the hospital. Clearly, it was time to automate our distribution method. After analyzing the decentralized model driven by automated dispensing cabinets (ADCs) versus a centralized model built on robotic technology, we chose the latter approach.  The primary factors driving our choice of the centralized model included the space requirements on the nursing units for ADCs, the need for a decentralized inventory, and the lease cost of the ADCs. The centralized robot also allowed us to streamline distributive functions, improve accuracy and safety, and increase customer satisfaction by decreasing the potential for medication errors and adverse drug events. Patient safety was significantly enhanced by the adoption of a bar coded medication distribution platform in preparation for bedside bar code medication administration (BCMA). With space available in the warehouse adjacent to the pharmacy, we had the opportunity to expand, and since we were starting with a clean slate, this allowed us to acquire new automation technology and design the most efficient workflow possible. 



Renovation Timeline
After reviewing the bids based on cost and design solutions, our choice of casework vendor was ultimately determined by the extensive pharmacy experience of the vendor. Not only did the vendor efficiently incorporate new automation and workflows into the design, but they also reviewed our compounding processes and suggested the design of a new IV dispensing area that provided defrosting stations with sufficient counter space to accommodate the necessary racks and trays. Our pharmacy staff and hospital engineers worked closely with the chosen casework vendor to plan the timeline and to design an optimally efficient workspace that would meet our particular workflow needs, health and safety considerations, appropriate building codes, and the unique requirements of a large New York City hospital. The pharmacy design incorporated our new automation acquisitions, comprising an automated packaging machine, robot, carousel, and refrigeration units. 

The hospital finance department, senior administration, facilities and support services, information technology department, performance improvement services, and the P&T committee chair thoroughly reviewed the proposed plan in 2008 and agreed that a pharmacy renovation and the implementation of advanced technology would result in improved safety for patients and greater all-around efficiency; a budget of approximately $2 million was subsequently approved, with half of the budget allocated to automation acquisition and half allocated to renovation. 

The pharmacy renovation proceeded through three phases, all of which needed to work around the implementation of the hospital’s new computer system and to progress while the pharmacy remained operational, safe, and dust-free. Phase 1 commenced in 2010, and entailed construction to expand into the adjacent empty space; the robot was built onsite by the vendor in this space and then enclosed, and the robotic technology went live in October 2010. Phase 2 construction, which began in early 2011, connected the new automation area with the old pharmacy space and became the location of our first dose and manual pick areas. In March 2011, we embarked on Phase 3, which entailed full renovation of the old pharmacy, as well as construction of a new IV dispensing area to augment our cleanroom, complete with customized defrosting stations and a stainless steel workbench, to fill IVs more efficiently.

Design Elements Reflect Workflow Process
The design of the pharmacy was expected to both reflect and improve upon the workflow process. To accommodate the first step in our workflow sequence, a packaging room was designed and built next to the automation room that contains our new automated packaging equipment; we now purchase bulk supplies, package them, apply bar codes and standard labels, and store them in a specifically designed wall of inventory, which we then use for the daily robot feed. The picking process is designed in a linear format, so that orders are first sent to the robot. If the product is not available in the robot, the order then goes to the carousel. If it is not stored therein, it may be a refrigerated item, and if not, the order is finally sent to the manual picking station. Other design elements that reflect how we work were planned as part of the initial design or added as the project progressed. For example:  

• A large, flat-screen panel was installed along with the casework to allow us to view the medications to be filled from the carousel.  
• The casework vendor adjusted the height of the countertops to match the level of the carousel, which made the workflow more efficient.  
• Cabinets were installed to the ceiling to avoid having surfaces that would collect dust.
• A wall was removed to create enough space to accommodate fill carts. 
• The location of our first dose and manual picking areas were specifically designed to utilize one staff member for both functions.
• Shelving was designed to organize the medication exchange baskets that we deliver to and store in patient rooms.
• Printers were placed on rollers, providing easier access to change paper or perform maintenance.  
• Counter space was expanded to account for the future addition of a computer terminal that will allow us to double-check bar code label information.

While some of the issues we addressed might appear to be minor, we found that each element of a good pharmacy design contributed greatly to the overall increased efficiency of the operation and to employee satisfaction. As a testament to the quality of the design improvements, the pharmacy continues to look as orderly today as it did on the first day the redesign was completed.

Contributing Ideas
Incorporating the needs and wishes of the staff is a priority in any pharmacy renovation, and we consulted with our staff members to find out how they worked, whether they wanted to sit or stand when performing a job function, and so on, in order to tailor design solutions to their needs. One important goal for us was to design the space so that staff working in the automation area would not be isolated from the rest of the pharmacy. 

Our hospital engineers met with the casework and robotic vendors throughout the process to approve plans and ensure the design adhered to the appropriate building and safety codes, making adjustments throughout as needed. In addition, they worked together on design solutions to minimize the heat and noise generated from the additional technology.

Working Smarter
Because we are located in New York City, it is critical that we always are prepared to handle a large influx of patients in an emergency situation. The renovation of our space has allowed us to purchase and store selected medications in bulk, thus reducing our drug costs and allowing us to maintain additional supplies in the event of an emergency. This preparedness proved to be wise during a recent hurricane when we received an additional 150 patients from neighboring hospitals that were forced to evacuate. Because we built virtual beds into the system, the robot was able to accept the additional orders and our improved workflow allowed us to handle this unexpected situation with minimal effort.

The staff finds the improved environment allows them greater productivity; the pharmacy department has been transformed from a cramped area into a larger and more streamlined space, helping us to work more comfortably and safely. We are now able to dispense a 24-hour supply of medications, as opposed to the 48-hour supply our previous set up required. The quantity of returned medications is significantly reduced, in turn reducing the time dedicated to restocking. Safety also has improved, driven by the robot’s accuracy, the adoption of standardized labels, and the addition of Tall Man lettering.

Most importantly, the combination of efficiencies built into the renovation means that we have been able to reassign our pharmacists to clinical service areas to work directly with physicians, nurses, and patients, allowing the pharmacy department to expand and improve the quality of care it provides to patients. We even created a new job description—pharmacy technician for technology—as a result of this technology acquisition.

The pharmacy renovation at Maimonides was well-planned and received strong support from our hospital administration and our CEO, Pamela Brier, two factors that contributed to the project’s success. The results have exceeded our expectations in every way, and our pharmacy is working smarter and better as a result of the upgrades we have made.

Fredrick B. Cassera, RPh, MS, MBA, is the director of pharmaceutical services at Maimonides Medical Center in Brooklyn, New York, a position he has held since 1999. During his tenure at Maimonides, Fredrick has successfully integrated new technology to create a higher standard of pharmacy practice aimed at enhancing pharmaceutical care and improving patient safety.

Fredrick received his pharmacy degree from St. John’s University College of Pharmacy and his Master of Science and Master of Business Administration from Long Island University. He also holds a position of clinical associate professor of pharmacy, Arnold & Marie Schwartz College of Pharmacy and Health Sciences of Long Island University.