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RESEARCH ARTICLE

The transformation of pharmacy concepts into building and organization Mark P. Mobach

Pharm World Sci (2005) 27: 329–338

ª Springer 2005

M.P. Mobach (correspondence, e-mail: [email protected]): Faculty of Management and Organization, P.O. Box 800, 9700 AV Groningen, The Netherlands Key words Architecture Building Community pharmacy Design Organization Pharmaceutical care Pharmacy concept Abstract Objective of the study: To explore the transformation of soft systems pharmacy concepts, with a special attention for pharmaceutical care, into hard systems properties of building and organization in community-based pharmacy practice in The Netherlands. Method: The applied methods for data-collection were interviews. The interviews were conducted at eight community pharmacies and four architectural firms. The central topics in the questionnaire were the building and the design process. The role of the architect was included in the questions for the pharmacist and the role of the pharmacist was included for the architect. The data were completed with simple observations, relevant documents, designs, photographic material and bills of quantities of best, ordinary and worst case practices. The data were used to address the coherence between pharmacy, building, and organization. Main outcome measure: The main outcome measure was the relevance for the objective of the study. Data-selection was based upon its supposed connection with the transformation of soft into hard systems. The main focus was on documentation, classification, and derivation that would improve the current understanding of the transformation of a pharmacy concept, especially pharmaceutical care, into building and organization. No further data-selection was made. Results: The results show that architectural and organizational designs are actually used in the support of pharmaceutical care. A large variety of soft and hard systems were observed. However, pharmacists seem to agree on the use of the soft systems key words ‘professional’, ‘accessible’, and ‘transparent’, and also on the activities with respect to the provision of information and the cooperation with other disciplines. Although most observed transformations appear sensible, hard evidence provided by the pharmacist is very poor. The full impact of the implemented changes on pharmaceutical care or other concepts remains a mystery. There is a large variety of different hard properties in building and organization, reflecting different (but still related) soft pharmacy concepts. The connections in building and organization are regarded as the resources that make the provision of care possible. Observed were resources to support the provision of written and oral information, the conversation setting, and the cooperation with other professionals. Potentially important developments for pharmaceutical care are the separate consultation room, the multi-disciplinary health centre, and robotization. Conclusion: This study has revealed some of the interdisciplinary relations between pharmaceutical, architectural, and organizational designs in Dutch community pharmacy practices. From this study we can conclude that interventions in building and organization are actually used in the support of pharmacy concepts, specifically of pharmaceutical care. However, the hard evidence of supposed improvements remains poor and mostly absent. Accepted April 2005

Introduction Every year, in the Netherlands e15 million is invested in the construction and reconstruction of community pharmacies1. It is presupposed that in this specific setting, community pharmacy is designed on the

crossroads of pharmaceutical, architectural, and organizational sciences. Modern systems theory is useful in this setting: a study where scientific disciplines appear to be interwoven. It was introduced as a meta-framework that could connect different scientific disciplines2. Systems theory distinguishes soft systems from hard systems. In soft systems, issues such as subjectivity and ambiguity are key; the focus is on different interpretations of reality3. In hard systems, issues such as objectivity and measurability are key; the focus is on the laws that govern reality4. The pharmacy concept behind the construction was regarded as a soft system, expectantly being pharmaceutical care and allowing various interpretations5–12. The pharmacy building and the pharmacy organization were regarded as hard systems. Following the difference between these systems in this specific setting, the general objective of this study was to address the transformation of a leading concept into building and organization; a transformation of soft into hard systems as it were. Therefore, the FArMa-project (Pharmacy, Architecture and Management) has started in The Netherlands in January 2003. The project is a cooperation between the Scientific Institute for Dutch Pharmacists (WINAp), the Royal Dutch Association for the Advancement of Pharmacy (KNMP), and the Faculty of Management and Organization at the University of Groningen in the Netherlands.

Theoretical perspective The theoretical perspective is based upon soft and hard systems. In the soft systems tradition it is argued that a problem is ‘messy’ and created through the attribution of meaning to events3. The soft methodological framework supports clarification and intervention in these so-called messy problem situations. It helps to improve the understanding of these situations and to organize a debate, for example, about key words that reflect the content of a pharmacy concept such as pharmaceutical care, and its transformation into building, organization, and its related activities and atmospheres at the pharmacy13. It is vital that the soft tradition allows different worldviews on the same events14, evidently leading to the disclosure of different opinions. In contrast, in the hard systems tradition it is held that the relation between cause and effect can be visualized since constraints are firm and goals are unambiguous4. A problem is ‘out there’ and can be solved in one best way, mostly by a mathematically sophisticated calculation. For instance, the number and nature of questions at the counter, the efficiency of the pharmacy layout, or the waiting times at the pharmacy15. In addition, the hard decision to have a separate consultation room has the potential to make hard and measurable interventions in the provision of information, perceived privacy, customer satisfaction, and personnel satisfaction. Following systems theory, the outcome of these interventions may be regarded as hard quantifiable systems, allowing exact comparison of the outcome

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systems design23, and interactive planning24 and (2) test and connect various hard measurements that demonstrate current problems, for example, (a) barcodes to measure waiting times and lead times, (b) time interval studies to address the basic division of labour, (c) questionnaires to assess customer satisfaction, personnel satisfaction, and the quality of the building, (d) frequency measurements to address the behaviour of the customer in the waiting room and the nature of questions at the counter and in the consultation room, (e) interviews to address the strengths and weaknesses of the building, to analyse the working system, and the working schedule; all will be performed at the old buildings in 2004. Efforts will be made to solve the observed problems in this stage at the design processes for the new buildings, for instance, in using action research and virtual reality. In the third stage the measurements from stage 2 will be repeated at the new buildings in 2005. This stage allows comparison of the results and a determination of the problems that were actually solved with the design. Moreover, the most successful and unsuccessful Study design design processes and decisions will be derived from The project consists of three stages: an explorative this evaluation. stage in 2003, a pre-test stage in 2004 and a post-test stage in 2005 (Figure 1). The overall aim for all three stages is to develop approaches that guide and Method improve the transformation from a pharmacy con- This current explorative study, stage 1, has been cept, with a special focus on pharmaceutical care, as qualitative in nature including pharmacists and soft systems into the hard systems of building and architects. Since its general objective was to address organization and to develop approaches that prove the transformation of a pharmacy concept into supposed changes. By doing so, the usefulness of the building and organization, the data-collection meththeoretical approach of connecting soft and hard ods done on the pharmacists were the pivot of this study. The most important methods for data-collecsystems is put to the test and further developed. In the first stage described here, it is explored how tion were interviews. Consecutively, the interviews these issues are currently treated in practice. This were conducted, elaborated in a word-document, stage is performed as an explorative case study design send to the respondents for verification, refined, and with qualitative methods of data collection. This cur- finally documented. The central topics in the quesrent stage studies four questions: (1) what concept led tionnaire for the pharmacist were the building, the the construction? (2) how was the chosen concept role of the architect, and the design process. In adtransformed into building and organization? (3) to vance of the interviews a privacy code was presented what extent were hard measurements used to prove and explained to all respondents. It was expected to relevant progress? and (4) what elements of phar- stimulate the openness in the interview. The pharmaceutical care could be derived from the properties macists were interviewed at their pharmacy in order of building and organization? The second stage, cur- to allow a check of the responses with simple obserrently under study in the Netherlands, seeks to ad- vation at their premises and photographs to be taken dress how pharmacy practice can be improved. This for analyses after the visit. Additional general stage is performed at three community pharmacies in information was obtained from the interviews with using a case study design with both quantitative and architects. The central topics in the questionnaire qualitative methods of data collection. It will (1) test for the architect were the building, the role of the various soft systems approaches to transform phar- pharmacist, and the design process. These data were maceutical care into building and organization, for completed with relevant and anonymous examples: example in using interactive management22, social bills of quantities of best, ordinary and, worst case through time. However, the difference between soft and hard has little to offer for the pharmacist with a need to build a pharmacy and to use that opportunity also to change the pharmacy organization. The difference appears to be artificial, an exploration of the coherence seems to be more relevant for pharmacy practice16,17. Therefore, this study should address how soft systems can be transformed into hard systems. For example, the pharmacist’s conceptual ideas where and how this particular pharmacy should change being transformed into a new structure of working, queuing system, and interior design which is consistent with the structures of the dispensing process. The coherence between soft and hard systems is also an important new development in modern systems science18–21. Following this development and its expected relevance for pharmacy practice, it was decided to take the transformation of soft into hard systems as the basic theoretical perspective in all stages of the project.

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Figure 1

Design of the study.

practices at other pharmacies. The data of the architects were used to include general information from the sector. In advance of the study an invitation for participation was published in the Dutch pharmaceutical weekly ‘Pharmaceutisch Weekblad’ (PW) twice. Firstly, as a separate announcement and secondly as a text box in an article on the same subject25. It was required that the pharmacy was constructed or reconstructed recently, preferably within the last 12 months in order to avoid memory problems of the pharmacists and to incorporate the newest developments in the sector. It was also expected that this procedure would stimulate the finding of motivated and open respondents. Construction and reconstruction were expected to be delicate matters, financially, strategically, as well as personally. This had the potential to hinder thorough analyses of its contents. Unfortunately, only two pharmacists responded to these announcements; they met the requirements and were included in the study. These respondents were expected to be open, with motivation as a primary advantage. Four randomly selected pharmacists also met the requirements and were added. They were found after 6 h of random phone calls in the community pharmacy sector. These random responses were expected to be the ordinary practices. In addition, the sample was completed with two recently awarded practices. These responses were expected to be best practices. Four architects with respectable experience and a national reputation in pharmacy design were added in order to collect additional general information about the design process. The final sample size consisted of eight community pharmacists and four architects. The sample was studied with four main research questions. The answers to the first three questions were based on the pharmacist’s interviews. Dataselection was based upon its supposed connection with the transformation of soft systems into hard systems in this specific setting. The answers to the fourth question were derived from the results of the first three. Firstly, the leading concept for the construction was studied. Roughly, in the interviews the pharmacists were asked to identify key words for the construction, explain what it meant, how it could be recognized in building and organization, and how progress was proven. The results of the interviews were documented in a table of soft systems key words and a table with the pharmacist’s commentary on

these key words per case. Secondly, the transformation of these soft systems key words into hard systems properties at building and organization was studied. Be reminded that these properties were argued to be hard systems properties, not necessarily hard as such: they were based on the pharmacist’s perception of reality. Again, the results were documented in a table. Thirdly, the pharmacists were asked to show results of hard systems measurements that could prove relevant progress after the construction process. The observed evidence was also documented in a table. Finally, it was studied what elements of pharmaceutical care could be derived from the properties of the building and the organization. In the interview the pharmacists were explicitly asked to connect the leading concept and its properties in building and organization with pharmaceutical care. The answers to these questions and the general information from the architects were used to derive a classification of pharmaceutical care relevant in this specific building context.

Results The response was eight community pharmacies. Table 1 illustrates how each case was selected, in what stage of the construction process the interviews were performed, whether it was a construction or reconstruction, and if the pharmacy activities were a continuation of existing activities or a completely new start-up. The sample included two best practices, two responses to an invitation in the ‘Pharmaceutisch Weekblad’ (PW), and four randomly selected pharmacies. At the time of the interview, six out of eight pharmacies were completed, one was in the middle of a construction process, and one in the design process. Six out of eight pharmacies were constructed on a new location, the remaining two were reconstructed. At five pharmacies the construction was a continuation of existing activities and at three the construction coincided with a start-up. In addition, it can be mentioned that four of the designed community pharmacies were completed in 2002, three were completed 2003, and one pharmacy started it’s new construction in the autumn of 2003. The studied group comprised of three female pharmacists and five male. The pharmacies were located in the Dutch provinces Gelderland, Groningen, Limburg, NoordBrabant, Noord-Holland, Overijssel (2), and ZuidHolland. Four of these pharmacies were located in urban areas and four in rural areas. Only one

Table 1 Properties of the studied cases Case

1 2 3 4 5 6 7 8

Properties Selection

Stage in construction process

(Re)construction

Nature of activities

Researcher: best practices

Completed Completed Completed Construction Completed Design Completed Completed

Construction Reconstruction Construction Reconstruction Construction Construction Construction Construction

Existing Existing Existing Existing Start-up Existing Start-up Start-up

Pharmacist: response to PW Researcher: random selection

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pharmacy (case 1) hired a consultancy firm to assess the weaknesses in the old working system and reported proposed changes that were used in the requirements list for the new building. The other pharmacists prepared the design process themselves. The first research question concerning the leading concepts is elaborated in Tables 2 and 3. Table 2 shows the soft systems key words that were mentioned in connection with the concept for the construction process. Some pharmacists seem to agree on the use of the terms professional (n = 4), accessible (n = 3), and transparent ( n =2). All other key words were different. Table 3 shows the pharmacist’s commentary on the soft systems key words. They were asked to explain

what the soft systems key words like rest, professional, and cooperation in case 1 meant. Some of commentaries agree in their relation with the provision of information (n = 5) and the cooperation with other disciplines (n = 5). The second research question with respect to the transformation in building and organization is elaborated in Table 4. This table shows the transformation of the key words from Table 2 in building and organization per case. The table also points at some recent trends in the Dutch community pharmacy sector. The main observed trends were the separate consultation room (n = 8), the multi-disciplinary health centre (n = 7), and robotization (n = 3). The interviews with the architects have confirmed these trends. The table

Table 2 Observed soft systems key words guiding the construction process Case

Observed soft systems key words

1 2 3 4 5 6 7 8

Rest, professional, cooperation Transparent, difference between regular and natural medicine Technical, kind Professional, beautiful, accessible, progress Professional, solid but not boring, transparent Questions-wise finding answers, pleasant Accessible, unity, warm and open Accessible, open, provision of information, professional, privacy

Table 3 Observed pharmacist’s commentary on soft systems key words Case

Soft systems key words

Pharmacist’s commentary

1

Rest Professional

–we have time for you –professional handling, but not overloading the patient with professionalism –we share knowledge with other health-care experts –improve transparency between pharmacy and society –decrease tension between natural and regular medicine –natural medicine can supplement regular medicine –relation between medicine and nature –pharmacy is a technical profession –interior should invite customer to ask questions –we work efficient and in one building with other health-care professionals, we respect privacy –nice to look at and to visit –not distant, but common –you are a patient, but I can be a patient too –open communication –we keep up with the times, we innovate –we are professionals in medication and information –it should look organized, not cluttered –the pharmacy work may be seen –increase of perceived size at small pharmacies –pharmacy as a tourists information office –patient has to feel at home –we cooperate with other disciplines –we cooperate with other disciplines –not the atmosphere of a hospital or institution –we cooperate with other disciplines –the pharmacy work is visible from the waiting room –we have brochures available –we show what we do, we do not work behind screens –there is space for a private conversation

2

3 4

Cooperation Transparent Difference between regular and natural medicine Technical Kind Professional Beautiful Accessible

5

6 7

8

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Progress Professional Solid, but not boring Transparent Question-wise finding answers Pleasant Accessible Unity Warm and open Accessible Open Provision of information Professional Privacy

Table 4 Pharmacist’s transformation of soft systems key words into hard systems properties Soft systems key words 1.a. Rest

1.b. Professional 1.c. Cooperation 2.a. Transparent

2.b. Difference between regular and natural medicine

3.a. Technical

3.b. Kind

4.a. Professional

4.b. Beautiful 4.c. Accessible

4.d. Progress 5.a. Professional

5.b. Solid, but not boring

5.c. Transparent

6.a. Question-wise finding answers

6.b. Pleasant

7.a. Accessible

7.b. Unity

7.c. Warm and open

8.a. Accessible

8.b. Open

8.c. Provision of information

8.d. Professional

8.e. Privacy

Perceived hard systems properties at building and organization Building

–natural materials in wood and metal, mahogany and silver –curved counters –efficient logistics with robot –tight design –shift of assistant’s work from logistics to pharmaceutical care –one building for various disciplines –most materials in glass and Plexi –look throughs –privacy at separate consultation room through positioning Organization –patient’s sight at assistant’s work Building –periodic table and blister packs in shop front design –green coloured Plexi and leaflet pattern on the floor –real tree trunk in counter –racks with brochures of both medicine forms Building –materials in metal, silver coloured –efficient lay-out with small walking distances –two separate consultation rooms –separate room for group information Organization –efficient logistics with robot –decreased coordination need with robot Building –materials in wood, beech coloured Organization –shift of assistant’s work from logistics to pharmaceutical care –two consultation rooms avoid queue Building –efficient lay-out with small walking distances –separate consultation room –one building for various disciplines with one entrance –user-friendly elevator –table to read –illuminated news trailer Organization –efficient logistics with robot –shift of assistant’s work from logistics to pharmaceutical care –pharmacy and other health care professionals work together –ticket systems to queue creates rest in waiting room and time to read available information Building –materials in aluminium and glass with anthracite paving tile, white stucco, and grey colours –tight design Building –lay-out and glass allows look-throughs –variation with glass and frosted glass for privacy –transparent shop front Organization –patient’s sight at assistant’s work from waiting room and outside –visible contact with patients during work Building –a new building Building –tight design –conceal cables –no standing counter frame to avoid clutter ness –separate consultation room –integrated drawer block for brochures –filled brochure racks Organization –logic of working and walking to avoid crossing lines –separation in counters of medicine ready to take-a-way or OTC versus medicine to be filled and waited for Building –grey Formica interior with yellow accents –tight design Organization –bright work light and attractive atmospheric light behind and before the counter respectively Building –look throughs –windows panes in counter closet Organization –patient’s sight at assistant’s work Building-OTC closet in the –separate consultation room waiting room –extra office space for project preparations Organization –computer work at the counter Building –natural materials in wood and metal added with yellow and red –coffee machine –children’s play area –respecting patient’s privacy: increased distance between waiting area and counter and separate consultation room –noticeable entrance (24 h) Building –natural materials stone, metal and wood added with purple/blue –separate consultation room –separation of counter units –different contact heights (ordinary, wheelchairs users) –table to read Organization –computer work at the counter –same assistant for each patient –clear order in the queue Building –one building for various disciplines –same materials and colours throughout the building Organization –central reception for all disciplines –shared coffee room for employees of all disciplines Building –warm materials and colours –attractive atmospheric light –children’s play area –variation in look-throughs Organization –variation in open areas (patient’s sight at assistant’s work) and concentration areas (no sight at assistant’s work) Building –materials in wood and metal added with red colours –large waiting room with OTC –one building for various disciplines Building –look-throughs –the filling area is right at angles to the waiting room Organization –patient’s sight at assistant’s work –patient’s sight at pharmacist’s office Building –separate consultation room –separate room for group information –brochure rack Building –look-throughs and positioning of the filling –computer work at the counter Organization –patient’s sight at assistant’s work –internet on working floor Building –separate consultation room Organization Building Organization Building Building

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also shows a large variety of different hard properties at building and organization, reflecting different (but still related) pharmacy concepts. It is a patchwork rather than a homogeneous mass. In its current presentation its coherence with pharmaceutical care remains hard to assess. Therefore, in the fourth research question this connection is made more explicit. The third research question concerning the performed hard measurements to prove relevant progress is elaborated in Table 5. The table shows the evidence provided by the pharmacists to prove the progress after completion of the building. Only cases 1 and 3 provided some hard evidence of the changes through time, whereas in the other cases the evidence was yet incomplete (only pre-test in cases 3 and 6) or remains absent due to missing pre-test results (cases 2, 4, 5, 7, and 8). The fourth and final research question focussed on possible derivations from Tables 2, 3, and 4. The results of key words, commentaries, and properties of building and organization were used to make a classification into two elements of pharmaceutical care: atmospheres and activities. The derived atmospheres were based upon the key words and the pharmacist’s commentaries in Tables 2 and 3. The derived activities were based upon the selected properties of the building and the organization in Table 4. Firstly, following Tables 2 and 3, a derived classification of five atmospheres around pharmaceutical care was made based upon the mentioned concepts and commentaries. The derived classes of atmospheres are (with the key words in brackets): (a) please do come in (accessible, kind, transparent, beautiful, warm and pleasant), (b) we like to inform you (question-wise finding answers, provision of information, accessible, kind, rest), (c) we are experts in our field (professional, technical, solid, progress), (d) our work may be seen (transparent, open), and (e) we work together with other health-care professionals (cooperation, unity, professional). Secondly, following Table 4, a derived classification of pharmaceutical care related activities was made based upon the selected properties of the building and the organization. Table 6 summarizes this classification. The derived classes of activities are: written information, oral information, conversation setting,

and cooperation. The argued coherence with pharmaceutical care is here put in brackets. In the context of the building the following properties were argued to be in support of pharmaceutical care: one or two separate consultation rooms (privacy for oral information), separation of counter units (privacy for oral information), larger distance from counter to chairs in the patient waiting room (privacy for oral information), low sit/sit counter for wheelchairs users (pleasant setting for wheelchairs users, approachable contact for oral information), separate meeting room (group information), Internet connections behind the counter (printable written information), laptop with Internet in the patient waiting room (readable information), illuminated news trailer (readable information), brochure rack for general information (readable information visible available), table to read and with information on it (readable information visibly available), mini library (readable information visibly available), integrated drawer block for medication and illness specific brochures behind the counter (written information available in prescription handling), and one building for various disciplines (collective involvement with patients). In the context of the organization the following properties were in support of pharmaceutical care: the purchase of a robot (more time for oral information), one building for various disciplines (improved handling of transdisciplinary problems), intake and dispense by the same assistant (approachable contact for oral information), ICT at the counter (approachable contact for oral information), ticket systems to queue (clearness in queue, more rest in the patient waiting room to read written information), and a working systems aimed at a quick intake (avoiding queuing, more rest in the patient waiting room to read written information), and a children’s play area (more rest to absorb oral and written information). Three general developments were identified by all architects: the separate consultation room, the multidisciplinary health centre, and robotization. The separate consultation room was regarded as a bottom line. New buildings without this room are very rare. The development is mature. The multi-disciplinary health centre is very often used for new buildings, although it’s application is not self-evident. In some cases these connections remain absent. Robotization

Table 5 Longitudinal comparative hard systems evidence of changes Case

Evidence

1

–time interval studies: increased counter time (robot) –customer satisfaction: improved –error analysis: decreased –none: no pre-test available –personnel perception: increased counter time (robot), decreased waiting time –customer satisfaction: only pre-test yet –none: no pre-test available –none: no pre-test available, complete new outlet –customer satisfaction: only pre-test yet –‘mystery guests’: only pre-test yet –none: no pre-test available, complete new outlet –no pre-test available, complete new outlet –only post-test at light intensity: was sufficient for assistant’s work

2 3 4 5 6 7 8 334

Table 6 Derived activities of pharmaceutical care from properties in building and organization Derived activities of pharmaceutical care

Building

Organization

Written information

Integrated drawer block for brochures, brochure racks, table to read, mini library, illuminated news trailer, Internet before and behind the counter Separate room(s) for group information, separate consultation room, distance between counter and chairs in waiting room Separate consultation room, separation of counter units, sit/sit counter for wheelchairs users One building for various disciplines

Ticket systems to queue or quick intake after entrance of patient for rest in waiting room, children’s play area

Oral information

Conversation setting

Cooperation

Robot for improved efficiency

ICT at the counter, intake and dispense by the same assistant Informal and formal cooperation in operational work and projects

Table 7 Trends identified by the architects Pharmacy properties

Observed at pharmacy (n)

Trend identified by architect (n)

Separate consultation room Multi-disciplinary health centre Robotization

case 1–8 (8) case 2–8 (7) case 2–4 (3)

yes (4) yes (4) yes (4)

appears to be in an introduction phase, but is growing sionalism or transparency. For instance, one of the very fast. Many pharmacists show interest in this new studied pharmacies did argue to have warm and technological development (Table 7). pleasant purple and blue colours incorporated in a solid look of smooth and natural materials throughout a health centre in combination with an inviting Discussion transparent shop front, internal openness with lookThe transformation of soft systems pharmacy con- throughs and transparent materials at eye level, and cepts into hard systems in building and organization different contact heights at the counter, and, by shows the intense relationship between the three doing so, combined many of these different soft scientific disciplines: pharmaceutical, architectural principles. In fact, similar combinations of such and organizational sciences. In practice architectural activities, atmospheres and concepts can expected to and organizational designs appear to be clearly be found at most modern pharmacies in the linked with pharmaceutical care. However, the evi- Netherlands, although they will differ in their final dence about possible and supposed improvements is appearance. Combinations seem to do more justice to very poor and needs further attention. Below the the fact that pharmaceutical care is a vast and observations of activities and atmospheres will be comprehensive concept with a large variety of interdiscussed in relation with pharmaceutical care, just pretations in practice: none of the studied pharmacies as three trends in Dutch community pharmacy incorporated all observed properties exhaustively. practice: the consultation room, the health centre, Although Tables 4 and 6 show very different and robotization. possibilities in the transformation of pharmaceutical care into hard systems, it also reveals a possible Activities and atmospheres for pharmaceutical care classification on the higher level. Almost all pharmacy At all studied pharmacies different concepts, activities, designs supported a combination of activities around and atmospheres were observed. A pharmacist aiming the provision written and oral information, the conat pharmaceutical care incorporates different activities versation setting, and cooperation. Regardless of the and atmospheres. The sole provision of oral informa- different interpretations, the results suggest that the tion will not be enough to perform pharmaceutical elaboration of activities and atmospheres, being care, just as only written information, an attention for consistent with the pharmacist’ interpretation of the conversation setting or cooperation. Moreover, pharmaceutical care, were taken very seriously at sole accessibility will not be enough to promote construction and reconstruction processes in compharmaceutical care, just as only kindness, profes- munity-based pharmacy practice in the Netherlands.

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Trends in resources for pharmaceutical care Although many differences were obviously present in the studied pharmacy designs, some interesting similarities were observed also. For instance, a separate consultation room and brochure rack were observed at all pharmacies. Most of the observed designs are rather common properties of a pharmacy. In contrast, the design decisions to have a separate consultation room, to be part of a multi-disciplinary health centre, and robotization may be regarded as very important developments that at least have the potential to support pharmaceutical care intensively. The separate consultation room supports the private conversation, the health centre intensifies the relations with other professionals, and the robot improves efficiency, and, by doing so, creates time for a conversation with the patient. Due to their potential relevance for pharmaceutical care these hard systems properties are discussed below. Separate consultation room The separate consultation room is key in the supportive design for pharmaceutical care although not mentioned by all pharmacists in the interview; it was present at all new pharmacies and confirmed with a simple observation after the interview. A pharmacist argued: ‘In the context of pharmaceutical care the separate consultation room is the core of the change.’ For architects the separate room is even a bottom line. It is regarded as a precondition for a professional conversation in the case of sensitive problems. In comparison with earlier coffee room and office of the pharmacist the separate room is an evident improvement. Two pharmacists decided to have two separate consultation rooms in order to avoid congestion. This argumentation seems flawed: it was not based on facts, but rather on a personal impression. Facts about room occupation or any hindrance to have a conversation due to room occupation were absent. Just as arguments that an extra room would be necessary for any future cooperation with other medical or paramedical disciplines. A decision for two rooms may as well justify a decision for three or four rooms. But, the decisions to reduce privacy problems with the separate consultation room does not only illustrate that the need for privacy at patient and staff is being taken seriously, but also the potentially supportive function of architectural design. The separate consultation room may therefore be regarded as an important development and a facilitator for pharmaceutical care. It will not make pharmaceutical care work, that is after all the responsibility of the team, but it does seriously meet the basic needs for implementation. Although the argumentation seems sensible, be reminded that no hard evidence of these supposed improvements was yet present at the pharmacies.

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Multi-disciplinary health centre The multi-disciplinary health centre is another important development that has the potential to support pharmaceutical care intensively: the coherence within primary healthcare. It was observed at seven out of eight pharmacies. The development illustrates the increasing coherence between the pharmacy and other healthcare providers. The observed cooperating disciplines were pharmacy, general practitioner, physiotherapy, speech therapy,

dentist, Caesar therapy, veterinary surgeon, Mensendieck therapy, and service institution. The most frequently observed disciplines were pharmacy, general practitioner, physiotherapy, and speech therapy. The most important arguments for this architectural merger are rooted in professionalism. It is expected to stimulate the informal and formal contacts with other professionals, and, by doing so, expected to improve transdisciplinary medical problems and simplify the organization of common projects. Although the argumentation seems sensible again, hard evidence of the supposed improvements was absent. Robotization The robot is another important development that also has the potential to support pharmaceutical care; it was observed at three out of eight pharmacies. The architects argued that the robot is considered as a serious option and an increasing number of pharmacists would actually purchase the robot and incorporate it in their working system. This development is an illustration of the strong coherence between working systems and pharmaceutical care. In The Netherlands robotization of the logistic parts of the dispensing process is relatively new, but from pharmaceutical and organizational perspectives very promising. Consequently, for decision makers in the design process the fit between the robot, the architectural design, and the working systems is also new. The organization principle of robotization is very simple: logistic tasks are transferred to a robot (filling) and to personnel with a low education (refilling stock). The efficiency is two-fold: the machine works faster than humans and the refill is much simpler and can therefore be staffed cheaper. This shift of work increases the available time for pharmaceutical care at the educated staff, for instance, for a conversation at the counter or continuing education. In this perspective the increased time of the educated staff is used for pharmaceutical care. Two out of the three pharmacies with a robot performed longitudinal comparative analyses to prove these advantages in favour of work at the counter. The studies comprised time interval studies and staff perceptions. It showed an increase of the time spent at the counter and a decrease of the time for logistics. However, this positive inference only holds under the condition ceteris paribus. On a national or worldwide scale there is no guarantee that the time advantage really is a change for the better for pharmaceutical care. Robotization can also be used easily for cost-reduction of staff expenses, for instance, at times of financial setback or staff shortage in the labour market. In this view cheaper low educated staff may actually replace parts of the educated staff. In addition, the robot is a substantial investment made in combination with an expensive (re)construction, in which the recovery of the cost has an important role. Although robotization has some potential drawbacks for the general development of pharmaceutical care, it may also be regarded as an important facilitator for pharmaceutical care. The influences are more indirect than the separate consultation room: it improves efficiency substantially and, by doing so, creates time for pharmaceutical care. This principle is vulnerable as the advantages of improved efficiency may be used for other purposes, not in any way being related to pharmaceutical care. However, the earliest experiences in the Netherlands show that

the advantages of robotization are indeed used for the care should consider using the architectural and the strengthening of the implementation of pharmaceuti- organizational perspectives. cal care and which is even supported with some hard evidence.

Acknowledgements Generalization? This study has explored the transformation of a pharmacy concept, with a special focus on pharmaceutical care, into architectural and organizational design in community-based pharmacy practice. The study was not designed for generalization purposes: the sample size is far too small. This first current stage may be regarded as an explorative quest for relevant ingredients in interdisciplinary design: qualitative research in the context of discovery. As such, this study has provided relevant insights in this new interdisciplinary design area. It should also be mentioned that the available data sources at the architects nuanced this modest conclusion. All architects were specialized in the design of pharmacies; indirect but very solid background evidence. It therefore provided the researcher with a rich overview of design experiences at many more pharmacies than the current sample size. In this perspective the study exceeds the mere exploration of the design practices mentioned. The data triangulation26 in this study comprised interviews, document analyses and photographic material, and observation. Most respondents were very open and supportive in all aspects of the data collection. It allowed an up-close, deep, and credible understanding of complex real-world contexts27. In that sense the study had substantial rigour. However, be reminded that this current study primarily serves as a preparation for stage two and three: the development of support for pharmacists in a quasi-experiment. In a small sample a large variety of quantitative and qualitative analyses will be performed in a longitudinal comparative case study design26.

Conclusion This study has revealed some of the interdisciplinary relations between pharmaceutical, architectural, and organizational designs at Dutch community pharmacies. From this study we can conclude that interventions in building and organization are actually used in the support of pharmacy concepts, specifically of pharmaceutical care. Supported pharmaceutical care activities were the provision of written and oral information, the setting of the conversation, and the cooperation with other healthcare professionals. The support was elaborated broadly: from the evident brochure rack, to a separate consultation room, a table to read, a multi-disciplinary health centre, a children’s play area, and robotization of the dispensing process, but even support in colours, light, forms, and materials. Although most observed transformations appear sensible, hard evidence provided by the pharmacist was very poor and mostly absent. The full impact on pharmaceutical care or other concepts remains a mystery. Further research is needed to assess the hard impact of architectural and organizational design on the performance of pharmaceutical care and will be addressed in the next stages of this project. Future studies evaluating interventions in pharmaceutical

I thank Prof. Dr C.J. de Blaey of the Scientific Institute for Dutch Pharmacists (WINAp) and the governing board of the Royal Dutch Association for the Advancement of Pharmacy (KNMP) for their scientific and financial support in this project. Moreover, I thank the involved community pharmacists and architects for their open responses. It had allowed me to develop new insights for the (re)construction of community pharmacies aimed at pharmaceutical care. Finally, I thank the referees for their valuable comments.

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