Q&A on Workflow
with Don Grove Jr., RPh, Owner, J&D Pharmacy, Truman Village, LLC
1) How long has J&D Pharmacy been operating?
My first pharmacy was Grove Pharmacy, started and purchased from my father in 1971. Over the years I opened 2 more pharmacies in smaller towns and opened J&D Pharmacy in 1979 in Warsaw, Mo. In 2004 we moved from our original location into a 28,000 sq. ft. medical building we built, Truman Medical Village. We also own an additional HME store in Sedalia, MO. My brother, Gary Grove, RPh, now owns the original Grove Pharmacy.
2) What do you mean when you use the term workflow?
The normal definition of workflow (WF) is the flow or progress of work done by a company, industry, department, or person and sometimes it specifically refers to the rate of such flow or progress. Our definition is: assigning the correct employees with the right IT systems in a modern redesigned environment which will minimize turbulence and maximize output and employee attitude thereby eliminating errors caused by loss of focus through unnecessary interruptions. I have expanded the definition to include the words “redesign maximization” since WF limits the discussion and in our industry usually only refers to the function of computer software. A simple definition would be everything that happens from receiving the doctor’s Rx to the patient getting the medication. But there is so much more. Never set limits on WF. There are many different parts required to make it come full circle within the pharmacy and bring positive effects to your profit and loss statement.
3) How and when did you decide to change your workflow from a traditional pharmacy setup?
Several years ago we came up with a serendipitous workflow since I didn’t like being next to the technicians due to a hearing problem and their unceasing banter. I asked the pharmacy manager, Jennifer Jelinek, to design me my own verification station apart from the technicians. We also separated our filling process into 4 distinct physical areas: intake, tech filling station, pharmacy checking station and an OTC sacking station. Years later we decided to revamp the entire workflow since margins were decreasing and I needed to be two places at once and needed a way my other pharmacist could do both our verification volume and not sacrifice accuracy. I also decided to give the technicians their own work stations closer to the inventory and reduce their walking and talking. This resulted in vertical inventory carousels with stock bottle dividers so the bottles couldn’t intermix, making them easier for the techs to locate and replace, and with a smaller footprint than previous shelving. The older Rx baskets kept falling over and wouldn’t stack as our volume increased and we ran out of horizontal counter space, so we reinvented the plastic transparent bags that could hang on a vertical bag rack by time in. The bags are color coded to avoid the increasing stress of higher volume with our drive up window. We added pockets on the front and back of each bag for tickets and auxiliary labels. Red means stop what you are doing as the patient is here, yellow means they will get here soon or at least in a 3-5 hour time slot so don’t slow down, green means it is environmentally friendly so enjoy each other and the day as patients won’t arrive till tomorrow, and purple means this is probably going to cause a problem if you don’t pay attention. All the bags hang on one carousel awaiting the pharmacist’s final verification and have a much smaller footprint since it is vertical and not all horizontal space. During the time we were developing this system, Computer Rx had developed their work flow software, which we then added ScriptPro robotics 3 years ago to our existing voice Tech IVR and combined this technology to our separate and unique work stations. We helped bring MTM videos from Montreal CA to the U.S. and built our own Lego kiosk and made available an education center so patients can be counseled more professionally and consistently, making the perception of waiting time shorter.
4) Why is workflow so important?
The main reason is time. By saving time you should ultimately increase your net profit. If it is done right, it will triple the pharmacist’s verification rate and the technician’s fill rate. This helps to control the 2nd largest expense in the pharmacy, payroll. Many are losing Rx volume due to competition, restricted PBM contracts and 3rd party mandatory mail order, so the only solution is adding niches and lowering expenses. On a busy day it may only take 1 ½ pharmacists to verify 700+ Rx’s. Compare that to pharmacies employing 4 pharmacists filling only 500+ a day. Proper workflow with a redesign can save a minimum of $140,000 a year on your highest paid employee and one technician saving another $30,000. The time savings translates to staying in business in the future and not having to sell out to a chain since no one else may want your pharmacy when you want to get out. By adding efficiency and speed, pharmacists can have time to do more what they were trained to do: counseling, vaccinations, MTM, medication adherence, compounding, consulting, physician detailing, etc.
5) What are some of the big mistakes that pharmacy owners or businesses make with respect to workflow?
Independents and chains are making a mistake by thinking walls are a barrier to the pharmacist and the patient. Patients want speed and accuracy and the option of counsel, but on their own terms. The chains want patients to hang around for 1-2 hours and buy more stuff the independents don’t sell. Erect a POS bagging area as a privacy wall so patients don’t get to watch and listen, which allows speed with less interruptions, leading to more accuracy. Pharmacies need to be closed more to the public rather than within talking distance to patients. I call it the fish bowl effect where the pharmacist and technicians are behind a glass in a fish bowl. Patients hear and see everything going on behind the counter so there is no privacy and numerous patient interruptions during the filling process. Can you imagine a physician wanting patients to hear his interaction with other physicians and patients and worse yet watch him or her operate? It is a concept independent pharmacists bought into in the 80s and now successful Walgreens is pushing it even more, trying to make their pharmacists more accessible, which will decrease their speed and increase their errors. We closed down our pharmacy and the only 2 areas the patients interact are at the drop off station and the counseling windows. The rest of the area is closed off by the POS sacking areas which has a closed wall. This has virtually eliminated errors caused by disruptions. The other big mistake is pharmacist/owners try to function as technicians and do jobs a technician can actually do better and faster. With high wages and reduced 3rd party reimbursements, every employee should function where they give the owner the highest ROI. Pharmacists should work in the areas in which they were trained and are meeting the Board of Pharmacy legal requirements. The pharmacist should never stop working to personally receive a prescription unless there is a request for the pharmacist. Realize there are production and clinical pharmacists and there are production and clinical technicians. Each feels more comfortable either doing tasks or solving problems and few, who I call hybrids, can do both equally well. Cannibalize some of the front end and give it to the pharmacy department where 90% of most independent's sales originate. Separate privacy tech filling stations should be clutter free with more horizontal counter space, headsets instead of phones, Rx bags instead of trays, and close proximity to robotics to save steps. Rx inventory can be on vertical carousels within feet of the technicians so the techs move less. Every bag should be color coded so Rx’s move quickly according to urgency and pick up times to lessen stress on techs, pharmacists and OTC bagging clerks. Use technology such as IVRs to stay off the phone and robotics to help technicians work faster and more accurately. It is not unusual for us to verify 400-700 Rx’s with 1½ pharmacists and still give vaccinations. This economy of time allows us to also do MTM, compounding, and outside consulting.
6) What are some of the innovations that you have implemented at J&D pharmacy to improve the workflow?
A customized work station for each technician with a touch screen computer and bars to hang multiple Rx bags that are all color coded. Circular, vertical inventory carousels close to techs with a small footprint carry most all the Rx inventory not contained in the ScriptPro robot allowing us to remove the 50 year old antiquated metal fixtures and reduce walking. A bag rack holds the recently filled color coded Rx’s by time received. Metal bundling clasps can double or triple the volume of the bags should you have 20-30 Rx’s and OTCs for one family or patient. Each transparent bag has easy access additional external pockets on both sides for Rx tickets and internal auxiliary house labels and notes from pharmacists. Tech stations have drawers for tech’s personal items, auxiliary labels and tickets, keeping them out of sight and avoiding clutter and mistakes. We use a profile analysis called the Winslow Report to help ensure higher paid employees are in the area or skill set they are most suited for which increases employee satisfaction and efficiency. A digital picture frame is provided for technicians so they can see pics of their family, avoiding the 2 sided taped up pictures that make the technician area more professional. Special drawers keep used labels off the counters to avoid HIPAA problems The pharmacist work station has more clinical oriented materials for handouts rather than bags and Rx bottles, but the same large horizontal counter with a touch screen computer and off counter counting tray. Our Education Area has sit down kiosks with accessible iPad videos that further educate our patients on medications, devices and disease states and self-service BP kits. These 2 minute professionally produced videos are back up and can actually counsel better than a pharmacist due to their clarity and consistency. These same videos are automatically or manually sent to smart phones, home computers, and tablets for additional viewing by patients and family.
The pharmacy redesign makes the Rx preparation area not as accessible to patients as most pharmacies. Our POS bagging area across the front affords us more privacy. Our employees have more freedom to interact without violating HIPAA. The pharmacists have 2 counseling areas. One is private and the other is semi-private, but we do not attempt to speak to every patient that walks in the pharmacy. We ask if they desire counseling. This allows for more speed and accuracy. Lastly, we were one of the first pharmacists in the nation doing prescription synchronization with the University of Mississippi ground breaking studies 5 years ago. This program made us proactive rather than reactive each day in the way we respond to our walk-in patients, which keeps our pharmacy patient friendly and gives us good PR in the community and with the healthcare professionals.
7) What makes your workflow and redesign unique?
It is a double oxymoron. We have tripled our verification and filling speed for both pharmacists and technicians while increasing accuracy which is an oxymoron. At the same time the employees are asked to do more volume in the same amount of time but it is more relaxed and easier to handle the greater work load which is again an oxymoron.
8) Would you summarize each of your separate WF components?
Here are several components of our workflow system. (Get more info and view photos on the products page.)
Filling Tech Station: Each filling technician works at a private station located near robotics & an inventory carousel containing fast moving drugs. Workflow features include a removable back-to-stock basket, easily accessible vial/lid drawer, hand-out cubbies, built-in HIPAA trash collector, & bag rack for waiting & in-process orders. Stations are constructed to be ready to mount all-in-one touchscreen computers & floating keyboard for the electronic tech check. Employee satisfaction features include digital picture frame, mounted cup holder, & drawer for personal items. Each station is equipped with a fingerprint reader, scanner, label printer, head set, & ample horizontal work space. Bag hook above counter, and bag rack below counter keep bundled prescriptions off work area, freeing up horizontal counter space, especially compared with using trays. Orders are processed as far as possible toward pharmacist work station & finally hung on the bag rack by time received, using color-coded urgency for quick visual recognition & reduced stress on the verifying pharmacists. One or more “urgent care” technicians are assigned waiting patients in queue with red sacks; these technicians should be able to fill 3 times the average of most pharmacy technicians in a traditional pharmacy operation. Our most recent record is 176 fills by one tech in 8 hours. By separating the technicians, they are less apt to interact, meaning less multi-tasking of talk + filling, & thus higher productivity. Many technicians confide that it is harder to concentrate when other technicians talk to them & often promote separation from a traditional crowded line with limited horizontal space, the norm in today’s pharmacies. Clinical techs may be used for conflict resolution.
Pharmacist Work Station: Pharmacist station is a simplified version of the technician work station with a touch screen computer, phone, storage areas and a monitor to display family photos. Separation from filling stations allows for focus with no disruptions of small talk from technicians. Scanners & graphics in WF are available so technicians don’t have to send over stock bottles for verification, minimizing noise levels, thus minimizing hearing problems by pharmacists. Consider placing station in view of all filling stations to allow for better supervision of multiple key employees. Think of the spotter in professional football seated high in the expensive box overlooking the football team; he sees everything, as should the pharmacy manager while s/he works. Station is also near counseling window(s), out of line of sight of patients in waiting area & drive up window, but still very accessible. All handouts, narcotic inventory, & charting are within easy reach of RPh, along with verification rack holding bags waiting to be verified. This frees up more horizontal area for checking, & is next to POS sacking widow where pharmacists hang verified prescription bundling bags. Pharmacist(s) also work by color urgency codes so stress is reduced for technicians, pharmacists, & even OTC clerks.
Inventory Carousel: This vertical storage unit holds fast movers not in robotics. Easy retrieval reduces walking & increases accuracy & speed. A typical pharmacy fixture is made in such a way that if you measure the square inches of horizontal space the bottles are sitting on, the loss of space behind just a single stock bottle & the loss of height (since each bottle is a different height), the wasted space is about 80% or more. There is a huge savings on smaller footprints with cylindrical carousels. Rx labels include guides to the carousel & the particular quadrant containing targeted medication. Lights on quadrants are additional guides for the technician, ensuring greater accuracy & quicker recognition on which of the 32 quadrants per carousel the correct medication resides. Light guides will also allow for easier & more consistent return to the right quadrant after counting the medication. Carousels are stocked alphabetically. In most pharmacies, the remainder of the non-robotic inventory can be stored on 3-4 inventory carousels. Liquids, topicals, injectables, OTC’s, diabetic products, boxes of asthma & COPD breathing solutions, & backup inventory for robotics can be stored on traditional metal shelving due to size & weight irregularities. Fully adjustable bottle dividers keep SKUs separate, preventing overstock & providing easier stock bottle retrieval & replacement for technicians.
Verification Rack: Reinvented from a previous carousel design, our new pharmacist bag racks have been streamlined for maximum efficiency, lower cost, and smaller footprint. After the technician fills the prescriptions, he/she delivers them to the bag rack next to the pharmacist work station(s) where they are hung on bars to remain organized & conveniently located for the pharmacist to check. They are hung by time frame so all employees know when the prescriptions were received. All colors except red are hung on the bag rack. Red bags are immediately given to the pharmacist to check & moved to the front of the line since these mean the patient is here, so STOP & get it ready as they are in a hurry. The pharmacist bag rack is the transfer point to allow techs to retrieve & return inventory bottles to shelves after they drop off completed bundling bags. Stock bottles, pints, or cream jars used to fill prescriptions are placed on the bag rack shelves below completed Rx bag. After RPh verification, stock bottles are returned to carousel to be returned to inventory, avoiding mistake of thinking items are out of stock.
Urgency Color-Coded Transparent Bundling Bags: Pharmacist is able to find any patient’s prescription bag quickly as it is hanging & no longer in cumbersome trays. Color coded system allows orders to be filled according to patient urgency, lowering stress levels of all employees. Red signifies patient waiting (urgent-stop & fill it ASAP), yellow for next 3-6 hours (caution), green for the next day (relax), & purple for unusual issues such as insurance rejects, need diluents, downed 3rd party IT systems, special orders, & special counseling on specialty drugs (danger). When a technician looks for patient’s prescriptions, they are now found much easier than when the former trays were stacked & unorganized. Vertical hanging bags free up so much more horizontal work space & provide much needed organization. In order to increase bag volume & not have to carry multiple sized bags for our hanging areas, we have incorporated large metal clasps to allow technicians to combine up to 3 bags for patients with numerous Rx's, & to bundle one final checked bag to a new, incoming order. Pouches on the front and back of each bag allow for easy storage & retrieval of pricing & auxiliary labels.
Education Kiosk: Sit-down kiosk for patients & care providers to educate themselves & spend wait time increasing patient adherence as they view Rx videos, browse health & wellness apps, or take blood pressure. This lessens perception of wait time, especially in rural high volume pharmacies that have many waiting patients. Rx videos on tablets are automatically delivered to the iPhone, personal computer, or tablet for further viewing after patient &/or caregiver leaves pharmacy. Kiosks can be linked, placed back to back, or flipped upside down in multiple configurations to fit your space. They may be purchased as single units, then arranged with 1, 2 or 3 semi-private stations equipped with movable benches with storage drawers. Built-in hidden speakers provide enhanced sound for those who have trouble hearing, and electric power poles with built-in power supply keep tablets continually charged. Future opportunities include using kiosks for ordering refills, telemedicine, BP and BMI measurements.
iPad Stand: Similar to education kiosk but simplified, lightweight, portable, stand-up unit for pharmacies with limited space. Features include adjustable mount for iPad/tablet, small countertop surface, and built-in power supply to keep tablets continually charged.
9) How can pharmacies easily redesign their stores for better workflow?
Our redesign team will customize a layout based on your store's needs. First, changing the fishbowl front wall into an OTC sacking area with a wall for privacy and moving back to the closed door pharmacy will create fewer interruptions and thus fewer mistakes due to the new high volume required to stay in business. The OTC sacking area may be designed to separate a drop off point from a separate counseling area. Approximately ten SmartFlow units comprised of new work stations, carousels and kiosks, along with up-to-date hardware and software, will improve speed, accuracy and employee satisfaction.
10) I understand the system is patented and if so what is the name and how does that affect me if I implement the WF system?
This is a Patent Pending system. It is described in our non-provisional patent application as “Method and Apparatus for increasing Workflow in a Pharmacy”. Copying of the system and modules without compliance of the following conditions is expressly prohibited. Separate licensing agreements may be negotiated on a case-by-case basis. Please contact us with any questions or inquiries. We do recommend a redesign to maximize the potential of your workflow. There is a monthly licensing/maintenance/consultation/updating charge to use our SmartFlow System. The SmartFlow Pharmacy Workflow System’s technician work stations, pharmacist work stations, education kiosks, inventory carousels, verification racks, and urgency colored bundling bags are all part of this system. A list of benefits enhancing and exceeding the fixture’s values will be provided prior to implementation. Ask us about our 5-year lease plan which in many cases will make our system free the first year by taking advantage of the Federal Government’s Section 179 Expensing Allowance.
11) Could you give me a simple summary of the reasons for WF and Redesign?
1. Increased net profit results from increased speed and productivity of pharmacists and technicians by decreasing your 2nd largest expense, wages.
2. Better utilization of individual pharmacist skills. Production pharmacist frees the clinical pharmacists to work in their areas of expertise.
3. Increased accuracy assures patients they are being well taken care of and gives fellow health care providers the assurance of safety in this pharmacy, which will increase referrals.
4. Employee satisfaction levels increase dramatically and help with hiring and retaining best of class employees.
5. Redesign of POS reduces the fishbowl viewing of pharmacy staff, allowing more freedom of interaction between pharmacists and technicians, more privacy on the phone with health care providers, and fewer HIPAA concerns.
6. Inventory carousels increase tech retrieval speed while increasing selection accuracy and replacing some metal fixtures with more décor friendly fixtures.
7. Maximum speed and reduced anxiety of all employees is accomplished with urgency colored bags to remain consistent with a balance of patient urgency and receipt of prescription orders.
8. Due to limited pharmacy space the carousels, bags, and work stations increase storage in work areas both horizontally and vertically, allowing for a smaller footprint.
9. In the mathematical world of synergistic pharmacy, redesign plus workflow should equal 3 times a pharmacist’s current verification rate.
10. It will keep you competitive in today’s paradigm shift of reimbursements.
12) It is my understanding you help pharmacies improve their workflow, increase their sales and reduce their expenses with workflow seminars.
Yes. Stay tuned for info on upcoming seminars in 2017.
13) Is there more?
Interested pharmacists can sign up for our mailing list to learn about upcoming events and seminars or contact us for more information and orders. You can watch free previews or purchase videos from our first workflow concept seminar to hear speakers like Mike Coughlin, founder and CEO of ScriptPro, Tim Garofalo, founder and president of voiceTech, and so many others. Go to www.jdpharmacy.com to learn more about our store and why some say we have done to pharmacy what Bass Pro did to sporting goods.