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Designing an Effective and Efficient Central Pharmacy
for a Large Hospital

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A thesis submitted in partial fulfillment of the requirements
for the degree of Master of Science in
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the James L. Winkle Collage of Pharmacy
the University of Cincinnati

By
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Jingyi Wang, Pharm D

Cincinnati, Ohio
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Supervised by

Alex C. Lin, BPharm, M.S., Ph.D., Chair

Jeff Guo, BPharm, Ph.D.
Kevin Li, Ph.D.
Bingfang Yan, Ph.D.

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Abstract
Statement of Problem
The Christ Hospital (TCH) central pharmacy planned to install a new automated dispensing system
(ADS) to fill non-IV orders. TCH pharmacy wants to gain additional benefits of the new ADS by
implementing a new facility design. Project objectives are: (1) designing an effective and efficient
new pharmacy system including new ADS, (2) a new facility design, and (3) a theoretical evaluation
of the new pharmacy system. The effectiveness is measured by reducing the orders filled manually
and pharmacist checking time. The efficiency is measured by a reduction in distance traveled.

Method
A project team was formed including University of Cincinnati College of Pharmacy, TCH pharmacy,
and an architect. TCH pharmacy fills approximately 7,800 non-IV orders daily, filled by the existing
robot and manual pick-up. Functional programming was applied to analyze and document possible
changes, in terms of workflows, workload, storage/inventory, equipment, and special arrangement.

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Observation, interview, workload analysis, indoor tracking technology, lean and human factors
principles were applied Data were collected between October-December 2020. A theoretical
evaluation determined the effectiveness and efficiency of the new system.
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Result
The new pharmacy system including new layout design was developed. The results indicated 41%
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of orders are being filled by the existing robot. Whereas 68.18% of orders including Pyxis refills and
first doses will be filled by the new robot XR2, plus there will be a reduction of 9.6 pharmacist
hours daily for checking doses dispensed by the new robot. The indoor tracking data indicated that
the new layout design would reduce distance traveled by 2.29 miles daily.
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Conclusion and Future Study

Overall, functional programming is a useful approach to designing a hospital central pharmacy. The
new facility layout design can help the pharmacy save more process time during medication
preparation and dispensing. The new layout design will be implemented in 2021; a post-occupancy
evaluation will be conducted.

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Acknowledgements
I would like to thank to my advisor Dr. Alex C. Lin for his mentorship, guidance, and support
throughout my graduate study. Thank for this opportunity to study in Health Outcomes graduate
program, the James L. Winkle College of Pharmacy, University of Cincinnati. I am very appreciative
of the assistance from my committee members of Dr. Jeff Guo, Dr. Kevin Li, and Dr. Bingfang Yan.
Furthermore, I am grateful to the faculty members of the Collage and the Department of Pharmacy
Practice & Administrative Sciences, and all the incredible people assisted me during my study in
Cincinnati. Additionally, I would like to acknowledge all the Christ Hospital pharmacy management
team, especially Dr. Justin Gamble, and staff for their support, assistance, and friendship when I
was conducting the study. I also would like to thank Lucas Scharf, my classmate, who helped me in
collecting data and generating the final functional program. Finally, I would like to thank to my

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friends and my family who supported me to finish my study in the United States.
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Table of Contents

Abstract
Acknowledgments
Chapter One: Introduction 1
1.1 Background
1.2 Objective
1.3 Omnicell Robot XR2 an Omnicell Carousel system
1.4 Operational definition
1.5 Significance
Chapter Two: Literature review 5
2.1 Method for the Literature review
2.2 Hospital pharmacy challenge
2.3 Robot XR2 and OPCS
2.4 Facility layout design

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Chapter Three: Method 9
3.1 Study site IE
3.2 Approach
3.3 Workload and time unit analysis
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Chapter Four: Results 13
4.1 Objective 1: Functional program
4.2 Objective 2: Layout design
4.3 Objective 3: Theoretical evaluation
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Chapter Five: Discussion 38

5.1 Effect of automatic dispensing system (ADS)
5.2 Effect of facility layout design
5.3 Limitation
5.4 Future study

Chapter 6. Conclusion 41

References 42

Appendix A: Functional Program, Central pharmacy, the Christ Hospital

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 Chapter 1. Introduction
1.1 Background
This research aimed to design an efficient and effective the Christ hospital (TCH) central
pharmacy facility by using a scientific approach, called the Functional Programing approach, and
conducting a theoretical evaluation before the implementation of the new facility. TCH Central
Pharmacy is responsible for dispensing all medications to the entire hospital. TCH pharmacy
management decided and was approved to upgrade their existing robot dispensing system,

RobotRx®, by the latest technology of Omnicell XR2 Automated Central Pharmacy System (to be
called Robot XR2), and Omnicell Pharmacy Carousel system (to be called OPCS). OPCS to replace
the storage function of the traditional shelves. Furthermore, the TCH pharmacy management team
believed a well-planned new facility would enhance the efficiency and effectiveness gained from

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the Robot XR2 and the OPCS. The University of Cincinnati College of Pharmacy's (UCCOP) research
team which has involved in several hospital pharmacy, chain drugstore, and independent
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pharmacy facility design projects was invited to involve in this facility design project.
The Christ Hospital is a 555-bed acute care hospital located in downtown Cincinnati, OH. TCH
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was funded in 1888 and employed approximately 6,500 team members to serve for the greater
Cincinnati area. TCH offered the services included cardiovascular care, spine treatment, women’s
health, major surgery, cancer, behavioral medicine, orthopedics, emergency care, kidney transplant
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and others in one main hospital and seven outpatient centers during this study period. The
Pharmacy Department employed approximately 89 full time equivenlent (FTE’s) of pharmacy
technicians, staff pharmacists, and clinical pharmacy specialists to support the main hospital and
some specialty medications used in outpatient center during this study.
1.2 Objective
The specific objectives of this study were: (1) to generate the functional program of the new
central pharmacy featuring Robot XR2 and OPCS for the architect/designer, (2) to propose the
effectiveness and efficient layout design of the new central pharmacy system, and (3) to conduct a
theoretical evaluation for the new central pharmacy system including new automatic dispensing
system (ADS) and facility design, in terms of efficiency, effectivnesss, and distance traveled. The 1st
objective was to generate the functional program which was used to communicate with the

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architect to achieve a better new pharmacy design. The 2nd objective was to propose the facility
layout design and its new workflow patterns. The 3rd objective was to conduct a theoretical
evaluation, in terms of efficiency and effectiveness of the new central pharmacy system. The
efficiency means to increase output with the same resources which was measured by reducing the
valuable distance traveled by pharmacy staff. The effectiveness means applying the right resources
to the right activities, which was measured by the increasing orders filled by Robot XR2, reducing
pharmacist time involved in inspection and reducing technician time involved in filling,
respectively.
1.3 Omenicell Robot XR2 an Omnicell Crousel system
The Omenicell Robot XR2 (Figure 1,2) is a shelf contained robotic warehouse that stores and
dispenses medications, automating the repetitive logistical tasks of inventory storage and

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management without requiring human involvement5. The existing pharmacy uses McKesson
RobotRx® for patient cart fill which fills 3,700 doses over the night (10 pm to 5 am) (data provided
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by the TCH pharmacy leadership team). The RobotRx® requires 8 hours for restocking and needs
one technician to pack the RobotRx specific unit doses in the weekday daytime. The Robot XR2 can
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fill 6,300 doses per day and needs 8.5 hours for restocking (Table 1). The unite dose package used
in Robot XR2 will be provided by the manufacturer and there will be one technician needed for
restoking and picking up from the Robot XR2. Omnicell Carousel system (Figure 3) utilizes vertical
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storage and retrieval technology to condense the storage space and reduce the travel distance
during the filling and restocking processes.
Table 1: McKesson RobotRx® vs Omnicell Robot XR2
RobotRx® Robot XR2
Non-IV doses per day (dose) 3,700 6,300
Filling time (hour) 7 13.7
Restocking time (hour) 8 8.5

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 Figures 1, 2, and 3: Omenicell Robot XR2 and Carousel

https://www.omnicell.com/products/xr2-automated-central-pharmacy-system

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1.4 Operational definition:

Facility Layout Design: The facility design process usually includes Master Facility Plan,
Functional Programming, and Architectural Design. The goal for facility layout design is to maximize
the layout effectiveness.
Functional Programing: Functional programming is an organized and systematic approach to
determine the facility's demands. “Functional Programming” which is based on the principle of
“Form follows Functions”. In this TCH research, the functional program summarized and analyzed
the functions and operational requirements for each functional area in the TCH central pharmacy
and documented how and why the modification of the workflow, environment, or manpower
might be delivered a more efficient and effective facility design.

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Distance Traveled - The distance traveled by pharmacy staff in each phase was collected and
analyzed by an innovative indoor tracking technology, called ultra-wideband (UWB) real-time
location system which is an innovative technology used in the hospital pharmacy.
Travel Frequency – UWB real-time location system can detect the travel frequency between two
functional areas in the existing pharmacy.
1.5 Significance
The significance of this research was applying a scientific and comprehensive evaluation of the
effect of functional programming design facility layout design to install ADS in a real-world setting.
No research has been conducted by using the scientific approach of functional programming to
design a new pharmacy facility design to maximize the benefits of adoption a new carousel and
ADS in a central hospital pharmacy.

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 Chapter 2. Literature review
2.1 Key words and database used for the literature review
The keywords used for the literature search in google scholar, PubMed, and the American
Journal of Health-System Pharmacy (AJHP) includes:
Hospital Pharmacy challenge: hospital pharmacy, hospital pharmacy management, hospital central
pharmacy value
Robot XR2 and OPCS: automation dispensing system in pharmacy, pharmacy robot, pharmacy
RobotRx®, pharmacy Robot XR2, pharmacy carousel, robotic dispensing system central pharmacy
Facility layout design: Facility design pharmacy, facility design health care, layout design pharmacy,
layout design health care, functional program health care, functional programming pharmacy
design, functional programming architecture

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2.2 Hospital pharmacy challenge
Hospital pharmacist roles have been transited from product-focused to a patient-focused
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model, since the 1960s. Breland indicated hospital pharmacy has been dealing with many
challenges including limited staffing, high pharmaceutical cost, more clinical services, clinical
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quality improvements, meeting regulatory and accreditation standards, and medication safety
during this transition1. Those challenges affect the pharmacy ability to carry out the
patient-focused practice models in which pharmacists actively engage in direct patient care and
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collaborating with other healthcare providers could effectively improve the cost-effective use of
medicines, promote healthy living, and improve clinical outcomes2. How to develop a
patient-focused practice model with a safe and efficient drug distribution system is one of the
major challenges for the pharmacy manager1. Many innovative process-improvement techniques
and technologies, such as automatic dispensing systems (ADS), inventory control systems, and lean
processes that have already been successfully applied to improve the hospital pharmacy
operations3,4. Also, TCH Pharmacy has been facing the same challenges as other hospitals and
decided to apply more advanced technologies, Robot XR2 and OPCS, to improve the medication
dispensing operations.

2.3 Robot XR2 and OPCS

An effective robotic prescription filling system could reduce prescription filling time6. Lin et al

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conducted a study by using a robotic prescription filling system, ScriptPro SP-200, in an outpatient
setting located in Michigan that filled a daily average of 350-450 prescriptions on weekdays in
20016. The pharmacy decided to incorporate a ScriptPro SP-200 to deal with the increasing
workload and proposed to redesign its layout 6. The result indicated that the robot system can
reduce prescription-filling time but required staffing adjustments to optimizer the efficiency
gained6. The time spent by pharmacy staff and prescription-filling time were selected as indicators
of effectiveness6. Pharmacist activities were categorized as direct prescription filling, indirect
prescription filling, and nonproductive activities. Comparing the pharmacy staff prescription-filling
times before and after using the ScriptPro SP-200, pharmacist prescription filling time was
decreased, and technician prescription filling time was increased6. At the same time,
nonproductive time was increased in both pharmacists and technicians after the ScriptPro SP-200

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installation6. This finding indicated that adjustment in pharmacy staffing after the ScriptPro SP-200
installation was needed6. In addition, the time spent on filling was significantly reduced after using
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the ScriptPro SP-2006. In conclusion, using ADS in the pharmacy can reduce prescription-filling time
but required staffing relocation to maximize the efficiency of ADS6.
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Franklin et al. evaluated two different ADS, Swisslog Pack Picker automated dispensing
machine and Rowa Speedcase, on safety, efficiency, and staff satisfaction in two hospital sites with
450 beds located in the UK7. The researchers observed and documented the dispensing errors at
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the final-check stage, the time taken to label, pick, and assemble dispensed items during the
process, and turnaround time for different types of prescription before and after the ADS
installation7. The researchers also assessed the storage space efficiency and staff experience for
the new ADS7. The results showed the ADS installation significantly decreased the dispensing error
on each step, especially in wrong content errors7. The researchers also observed a decrease in time
to pick up and dispense medications7. There was an increase in storage capacity and staff
satisfaction in one site after the ADS installation7. However, they did not find any difference in
turnaround times7.
Oswald conducted a study in a 613-bed acute and tertiary care university hospital to compare
the filling and dispensing error rates before and after the implementation of the pharmacy
carousel system (PCS)8. The errors were collected in the following process: first dose or missing
medication fill, automated dispensing cabinet fill, and interdepartmental request fill 8. Filling errors
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were observed during the pharmacist verification step and dispensing errors were observed after
verification8. After the PCS installation, the percentage of filling error rate reduced from 2.1% to
1.8% in first dose filling and 1.6% to 0.4% in automated dispensing cabinet filling8. There was only
one error observed in interdepartmental request fill and it was no big difference in the dispensing
error rate8. The pharmacy carousel system decreased medication filling errors related to
automated cabinets8.
Temple’s study evaluated the carousel dispensing technology (CDT) used in Wisconsin Hospital
and Clinics (UWHC)9. In UWHC pharmacy, CDT was used in automated dispensing cabinet refills,
first dose filling, supplemental cart fill, and medication procurement9. They compared the data
collected before and after implementation which included process time for medication refills, labor
requirements, inventory turns, and accuracy rates9. The results showed that the estimated

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labor-saving was 2.6 full-time equivalents (FTE), and the actual labor reduction is 2 technician
FTEs9. The processing time for the first dose filling decreased from 56 seconds to 24.6 seconds.
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More than 95% of doses were filled in less than 20 minutes after installing CDT9. The average
accuracy rate for all dispenses requests increased from 99.02% to 99.48%9. The inventory carrying
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cost was reduced by $25,0599. In conclusion, CDT used in the central pharmacy increased the
overall efficiency and accuracy of medication dispensing9. Overall, a centralized ADS could improve
the quality and safety of the medication process in the hospital central pharmacy10.
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Berdot et al. study the return of investment (ROI) after seven years using the ADS in the
hospital pharmacy11. In 2008, the projected RO1 was +$410,786 and the real payback period was 6
years. In 2015, the real ROI was +$163,331 after seven years of use11. The following process
provided economic saving: optimization of drugs stock management, greater efficiency of the
dispensing process, securitization of the medication process, and redeployment of pharmacy
staff11. Batson et al. conducted a systematic review in 2021 for an automated in-hospital pharmacy
dispensing system and suggested that the published evidence supported a positive impact of ADS
in improving the reliability and efficiency of the hospital pharmacy medication process, however,
clinically relevant outcomes are limited12.
2.4 Facility layout design
Facility layout design is an important piece in daily business operation used to maximize the
effectiveness of the production and improve the efficiency of the output13. In general, the
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objective for facility layout design is to create a safe and comfortable working space that applies a
smooth relationship between material, equipment, employee, and product at a minimal cost14. In
the health care system, an effective and efficient facility layout and design can improve the quality of

care and reduce the cost of providing care15,16. Functional programming is also known as facility
programming or space programming. This is not a new concept in the world of architecture. The
earliest application could be found in 1865 in a set of instructions for architects competing to
design a new Court of Justice in London17. The goal for functional programming was to achieve the
specific objective, to inventory the artifacts to be housed, and to specify the expected building
performance before initiation of architect selection and design18. Some well-knowing architectures
used functional programming during the design phases such as the museum, supermall, court
office, college campus, etc.18,19,20

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Lin’s study showed that the use of Baker drug counter and Systamodule pharmacy fixture,
independently or combined could reduce the prescription-filling time (0.123, 0.159, and 0.28
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minutes per prescription) and average distance traveled per prescription (102 feet to 14 feet) in
the Clinical Center in the National institution of Health (NIH) Outpatient Pharmacy which was a
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federal government hospital outpatient pharmacy21. In another study, Lin conducted a computer
simulation study for a chain drug in US. The results indicated that the new pharmacy layout design
and the prescription filling system could increase patient counseling time without requiring
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additional personnel22. McDowell’s study evaluated the use of a step-by-step design process to
develop the facility layout design for hospital pharmacy was superior to the current layout in terms
of feasibility, cost, patient safety, employee safety, flexibility, robustness, transportation distance,
employee utilization, objective adherence, maintainability, usability, and environmental impact23.
The step by step process included observing and analyzing the existing pharmacy operation,
working space, completing activity flow charts of the pharmacy processes, completing
communication, and material relationship charts to detail for each work area in the pharmacy and
emphasizing how they were related, researching applications if other pharmacies or in scholarly
works that could be beneficial, numerically defining space requirements for each pharmacy work
area, measuring the available space within the pharmacy, developing the preliminary layout design
and modifying the preliminary layout design with pharmacy staff’s request. Some of the
step-by-step process is like the functional programming.
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Chapter 3. Method
3.1 Study Site
TCH central pharmacy is located at 2139 Auburn Ave, Cincinnati, OH 45219. TCH is a 555-bed,
non-profit acute care facility which serves patients in more than 100 locations throughout the
Greater Cincinnati area13. The existing pharmacy had its last major renovation in the early 1990s
and RobotRx® was installed around 1997. The pharmacy department employed approximately 89
FTE’s with a group of pharmacy technicians, staff pharmacists, and clinical pharmacy specialists.
The existing pharmacy utilized a centralized staffing model utilizing the RobotRx® system and
Pyxis dispensing cabinets, but they did not contain a carousel dispensing system. TCH pharmacy
averagely dispensed 7,036 doses daily, 7,488 doses on weekdays and 5,927 doses on the weekend,
based on the data provided in October 2020. The average daily dispensing workload was proposed

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about a 10% increase as compared to 2019. The research team predicted TCH pharmacy would fill
around 7,800 (including a 10% increase) doses daily. (More details see result objective 1, workload
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analysis) In the existing pharmacy, generally routine medications (cart fill) were dispensed by
RobotRx®, 1st dose (stander dose) was dispensed by manually picking, and C2 or as needed
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medications were dispensed by the floor Pyxis and manually refilled in the central pharmacy. The
existing TCH central pharmacy required a major renovation of the pharmacy layout to install Robot
XR2 and OPCS and to obtain the most benefits from the new ADS. With this renovation opportunity,
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TCH central pharmacy will be able to expand to two pharmacy areas, intravenous (IV) and non-IV
pharmacy areas. The IV pharmacy was completed in 2020 and all IV-related functions were moved
to that IV pharmacy area.
Table 2: TCH main pharmacy schedule

Pharmacist Technician (includes intern) Buyers

1st shift 5 7 2

2nd shift 4 4 n/a

3rd shift 1 1 n/a

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 This was the collaboration among TCH Pharmacy management team, the University of
Cincinnati College of Pharmacy (UCCOP), and Champlin Architecture in designing the new
pharmacy facility. UCCOP team collected the related data to generate the functional program and
conducted the theoretical evaluation of the layout design. A functional programming pharmacy
approach was used to collect and analyze the data for generating the functional program. The
UCCOP team conducted interviews, observation, workflow analysis, workload analysis, storage and
equipment analysis, personnel analysis, and applied the latest technology of ultra-wideband (UWB)
collected pharmacy staff every second movement in the Central Pharmacy, etc., to generate the
Functional Program document which used to communicate with the architect for proposing the
new scientific sound central pharmacy facility layout. The data collection period was between
October 1st to December 20th.

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3.2 Approach
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A functional program included goals and design assumptions, functions performed and to be
performed, workflow analysis, functional area, workload analysis, inventory/storage analysis, and
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equipment/storage space analysis. Some other information contains in the functional program
included personnel and special requirements, function areas relationship, space determination,
and schematic plans. Researchers collected the data required for the functional program.
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Ultra-wideband (UWB) real-time location system was used to collect in-door tracking data, which
included the distance of traveled and travel frequency between two work areas, used for
theoretical evaluation and support the functional programming.
Ultra-wideband (UWB) real-time location systems were used to collect in-door tracking data.
This technology was first developed by the U.S. Department of Defense and commercially available
in 199024. UWB radio spectrum can provide a high-speed data rate of up to 100 Megabits per
second (Mbps) that communicate between two personal networks25. The high bandwidth and
extremely short pulses waveforms help in reducing the effect of multipath interference 25. The low
frequency of UWB pulses allows the signal to pass through the non-metal objective25. The UWB
technology we used in the TCH pharmacy detected the objective by calculating the time difference
of arrival (TDOA) between two or three anchors to determine the location of the specific objective.

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The accuracy for location is between 0.3-0.9 feet and the signal can be sent out by every second.
Currently, UWB has been widely used in the manufacture and NBA sports team to provide
advanced in-door tracking data for management, training, and COVID-19 prevention26, 27. This was
the first time UWB was used in a hospital pharmacy setting.
The Installation and equipment debugging took about 2 weeks, between Nov 14th to Nov
29th. Pharmacy staff’s every second movement data was collected between Nov 30th to Dec 20th.
The installation sketch map (Figure 4) shows the location for each anchor. The pharmacy staffs were

carrying the tag during the daily practice. Anchors detected the tags and calculated the distance

between the anchor and the tags to locate the position in real-time. Identifying one location required

at least 3 anchors (Figure 4).

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Figure 4: Anchors’ locations in the existing pharmacy

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3.3 Workload and time unit analysis

Pharmacist checking time, technician filling time and reduced distance of travel was

collected to evaluate the new layout design. The number of doses filled by new ADS was estimated
based on TCH central pharmacy’s October 2020 non-IV medication dispensing data. The total daily
non-IV workload in the new central pharmacy was proposed 7,800 doses (includes a 10% increase).
The existing dispensing data provide the percentage of medications dispensed in three dispensing
routs, RobotRx®, Pyxis, and standard drug shelf. Medication will be relocated in the new central

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 pharmacy and dispensed by Robot XR2, Central Pyxis, and OPCS + drug shelf. (Medication
relocation decision see appendix A Functional program, Chapter 5 Workload Analysis). The new
percentage of medications dispensed by different dispensing routes were estimated.
Pharmacist checking time and technician filling time were calculated based on the number of
prescriptions dispensed by the new dispensing route. Time and motion study were used to
calculate pharmacist checking time and technician filling time in the existing pharmacy. There were
44 checking cases (applied by the pharmacist) and 34 filling cases (applied by the technician) was
observed and documented in a video. In the existing pharmacy, on average technicians spend 1.07
mins to fill one order and pharmacists spend 0.25 mins to check one order. The existing pharmacy’s
1st dose filling time is pharmacist checking time + technician filling time = 1.32 mins. The new
pharmacy technician filling time was calculated based on robot filling speed (mins) + time spent on

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travel (mins) + time spend on sort and pack medications (mins). The average walking speed of a
human is 3.1 miles per hour (273 feet/mins)28. The distance between the robot and working stating
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1 1st dose storage side was measured from new pharmacy layout by using PDF measuring tool
(33.11 feet). Time spends for sort and packaging the medication was observed from the video
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which was 0.33 mins on average. The new pharmacy pharmacist checking time was 0.25 mins. The
total time saved in the new pharmacy layout was calculated as (exciting pharmacy 1 st dose filling
time– new pharmacy 1st dose filling time) x daily Robot XR2 dispensed 1st doses.
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Following data were collected in the existing central pharmacy by UWB system: (1) total
distance traveled by pharmacy staff (miles per day), (2) travel frequency between two functional
areas. Distance between two working areas was measured from existing and new pharmacy
layouts by using a PDF measuring tool. Travel frequency times distance between two functional
areas were considered as valuable distance traveled. Valuable distances traveled in the existing
pharmacy were compared with the distances traveled in the new pharmacy. The hypothesis was
valuable distances traveled by pharmacist staff would decrease in the new pharmacy layout. Data
analysis was conducted through Excel 2013.

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