- Email: [email protected]
The Service Blueprint as a Tool for Designing Innovative Pharmaceutical Services
TOOLS FOR ADVANCING PHARMACY PRACTICE
The Service Blueprint as a Tool for Designing Innovative Pharmaceutical Services David A. Holdford and Daniel T. Kennedy
Objective: To describe service blueprints, discuss their need and design, and provide examples of their use in advancing pharmaceuncal care. Background: Service blueprints are pictures or maps of service processes that permit the people involved in designing, ~roviding , managing, and using the service to better understand them and deal with them objectively. A service blueprint simultane-
ously depicts the service process and the roles of consumers, service providers, and supporting services. Service blueprints can be useful in pharmacy because many of the obstacles to pharmaceutical care are a result of insufficient planning by service designers and/or poor communication between those designing services and those implementing them. One consequence of this poor design and communication is that many consumers and third party payers are uninformed about pharmacist roles. Service blueprints can be used by pharmaci sts to promote the value of pharmaceutical care to consumers and other decision makers. They can also assist in ~esigning
better pharmaceutical services. Methods: Blueprints are designed by identifying and mapping a process from the con-
sumer's point of view, mapping employee actions and support activities, and adding visible evidence of service at each consumer action step. Key components of service blueprints are consumer actions, "onstage" and "backstage" employee actions, and support ~rocess es.
Discussion: Blueprints can help pharmacy managers identify and correct problems with the service process, provide
pharmacy employees an opportunity to offer feedback in the planning stages of services, and demonstrate the value of pharmaceutical services to consumers. Conclusion: Service blueprints can be a valuable tool for designing, implementing, and evaluating pharmacy services. JAm Pharm Assoc. 1999;39:545-52.
Several authors have described obstacles to the widespread implementation of pharmaceutical care. l -4 Many of these obstacles are associated with inadequate communication between phannacists and decision makers, or they are a result of insufficient planning by those implementing pharmaceutical care services. 1These problems are not unique to pharmacy. umerous services of many types fail because of insufficient planning by designers or poor communication between those designing services and those implementing them. 5 Poor design and planning occurs because most new services are developed
Received August 28, 1998, and in revised form November 10, 1998, and January 7, 1999. Accepted for publication January 12, 1999. David A. Holdford, MS, PhD, is assistant professor of pharmacy administration; Daniel T. Kennedy, PharmD, BCPS, is assistant professor of pharmacy, College of Pharmacy, Virginia Commonwealth University (Mev Campus), Richmond. Correspondence: David A . Holdford, PhD, Virginia Commonwealth UniverSity(MCV Campus), PO Box 980533, Richmond VA 23298-0533. Fax: 004-828-8359. E-mail: [email protected]. Continuing education credits: See page 584 for learning objectives and test qUestions for this article, which is number 202-000-99-130-H04 in APhA's educationa l programs.
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through trial and error instead of through a systematic design process. 6 A trial-and-error approach to service design is analogous to building a house without a blueprint and can greatly increase the potential for failure. 7 The service blueprint is a practical tool that encourages systematic planning for pharmaceutical services and enhances communication between pharmacists and important decision makers, such as patients, physicians, manager , payers, and pharmacy personnel. Service blueprints permit pharmacists to visually depict their services at a level and depth of detail not pos ible with verbal descriptions. This article discus es what service blueprints are, why they are needed, how to design and build them, and provide example of how they can be used in advancing pharmaceutical care.
Background In general, con umer are uninformed about what pharmaci ts do ; hence they have limited expectation of pharmaci t . ,9 Despite the visibility of pharmaci ts in the community rno t prafe sional activitie provided by pharmaci t are not readily
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Editors' Note 'The Service Blueprint as a Tool for Designing Innovative Pharmaceutical Services" is the fourth article in a 12part special issues series titled ''Tools for Advancing Pharmacy Practice" (see page 73 of the January/February 1999 JAPhA for the introduction to this series). Our objective is to publish articles that demonstrate the practical application of various frameworks, measures, methods, and other tools useful to pharmacy practice sites, including practitioners' experiences and impressions of the tools. Each manuscript in the series is peer-reviewed and research-based, but also contains an important educational component. As such, continuing education credit is offered for each article. In this article, Drs. Holdford and Kennedy highlight a managerial tool: the service blueprint. The service blueprint is a map of service processes that can help in the design, implementation, and evaluation of pharmaceutical services. The authors outline the process for developing such a blueprint and discuss how it can be used in pharmacy practice. We trust you will find this article valuable to your research and/or practice area. The editors will appreciate any comments you may have about this series. Jon C. Schommer, PhD Series Editor Associate Professor College of Pharmacy University of Minnesota
David A. Mott, PhD Series Editor Assistant Professor College of Pharmacy University of Wisconsin
apparent to patients and other decision makers. Pharmacists' technical and professional services occur primarily out of view of the consumer. For example, the patient is likely unaware that a pharmacist has checked the patient's profile for allergies, drug interactions, and therapeutic duplication unless the pharmacist takes the time to explain. Physicians and third party payers also have limited exposure to pharmaceutical services. Physician contacts with community pharmacists are mainly by telephone and then often through an intermediary. Third party payer interaction may be through telephone calls, mail, and rare site visits. This restricted level of exposure makes it difficult for physicians and third party payers to gain a true understanding of pharmacist roles. As a result, the pharmacy profession has had difficulties getting patients and third party payers to accept and demand pharmaceutical care. Several factors contribute to these difficulties. Consumers have difficulty evaluating phal1rUlceutical services. The services provided by pharmacists and other health care professionals have unique characteristics that make them difficult to
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evaluate. Some aspects of services are easy to describe (e.g., fasL friendly, inexpensive), whereas others are difficult to evaluate even with extensive experience (e.g., clinical skills). For example. it is unlikely that anyone but a pharmacist would be able to recog. nize when another pharmacist omitted critical drug-related infor· mation to a patient during counseling. Pharmaceutical services are difficult to evaluate in part because they are intangible-they are actions rather than physical objects, It is much easier for consumers to comprehend the purpose of a drug than the pharmaceutical services associated with it. The variability of pharmaceutical services also complicates evaluation. Since services are provided by humans under con· stantly changing circumstances, each service experience is unique. Patients' expectations and responses will vary from encounter to encounter, just as a range of variables can affect each pharmacist's performance at different times during the workday, Services are often invisible to the consumer. Most phannacy services are provided out of view of the consumer. Unless pharo macists inform consumers of the services they have provided, they will get no credit for the value they have contributed. Words can be insufficient to describe services. It is critical that pharmacists be able to explain the concept of pharmaceutical care to others, but there is evidence that pharmacists themselves do not understand the concept. I This misunderstanding may in part be the result of relying on the spoken word to convey the concept of pharmaceutical care. There are a number of risks in relying on words alone to describe services. \0 Verbal explanations often lead listeners to oversimplify or misinterpret an idea. For example, the term "patient counseling" is often used incorrectly to describe a pharo macist's superficial review of a patient's medications, a description that only captures a fragment of what patient counseling real· Iy entails under the paradigm of pharmaceutical care. Words also tend to be incomplete in portraying services. With verbal descriptions, it is easy to omit details that might be critical to a full understanding of a service. For example, patients andI physicians are important participants in the overall pharmacy ser· vice experience. However, verbal descriptions of pharmacy ser· vice often overlook or inadequately detail the roles of nonphann a cy participants in the service process. Another weakness of using words to portray services is their subjectivity. Adjectives such as "responsive," "friendly," "feli- I able," and "competent" mean different things to individual pharo macists, technicians, supervisors, and consumers. For example.'I "pharmacist competence" will inevitably be perceived differently by pharmacists and patients. Patients may define competence in terms of interpersonal aspects of care, or how long they wait for I their prescription, while pharmacists may emphasize technical and clinical components of care. Fin~y, words c~ lead to bi~ inu:rpretation. People base their \ conclUSIOns on thel! own expenence, bIases, and exposure to a ser- I vice. An example is each pharmacist's interpretation of the tef1l1 , "pharmaceutical care." Some pharmacists regard pharmaceutical
.!
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something they have always done, while others see it as a
~ taJjcaI change in practice. In fact, examination of the original defi-
· !lion of phannaceutical care-"the responsible provision of drug i1trapy for the purpose of achieving definite outcomes that · iJ¥Ove a patient's quality of life"ll-<:an describe both the level ~dispensing mandated by OBRA '90 and much higher levels of · ~aceutical services. In summary, words are often inadequate to depict a concept as romplex as pharmaceutical care. Visual representations of ser\?;e$ may be more helpful.
The Service Blueprint Defined The purpose of the service blueprint is to design a service prores&'system that can be visualized and that minimizes subjective interpretations. The service blueprint is a picture or map of a service process that permits the people involved in providing and managing the service to better understand it and deal with it objectively.12 A service blueprint simultaneously depicts the process of service delivery and the roles of consumers, service JlllViders, and supporting services. It breaks down the service into Iromponents and arranges them according to their purpose. Exam~es of service blueprints are shown in Figures I and 2. Service blueprints are based on process design theory from mdustrial engineering, computer programming, decision theory, and operations management. 13 They are similar to flow, operalion, and activity charts, which visually delineate each step in a ~ision, activity, or design process. Flow charts illustrate the octivities involved in an entire process, showing their interrela~nship and the sequence. Operation charts focus on specific ~rations within flow charts. Activity charts show the interactions of members of a group in performing a task. One key feature unique to service blueprinting when compared with other process Itsign methods is the inclusion of consumers and their view of the process. The premise of the service blueprint is that if consumers contribute to the service process, they should be recognized explicitly in its design and management. This means that the consumer's "job" must be clearly defined in the blueprint. 12 The primary benefit of the service blueprint is that it forces a careful analysis of each step in the service process and helps communicate that information to the people (e.g., front-line employees) Who influence its success. Blueprints can be used for a variety of other purposes (see Table 1).7.13
Methods Components of a Service Blueprint Although there are no concrete rules for drawing up a service blueprint-which permits considerable flexibility in their design-there are some key components of the service blueprint: 12 consumer actions, "onstage" contact employee
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Table 1_ Uses for Service Blueprints Developing service strategies Integrating services Assessing the quality of services Allocating resources Managing service image Managing personnel
actions, "backstage" contact employee actions, and support processes, as demonstrated in the blueprints in Figures I and 2. Examples of consumer actions in pharmacy include the faceto-face counseling encounter, telephone calls for prescription refills, and written refill reminders mailed to the patient's residence. This "consumer" is not only the patient but any recipient of the service (e.g., physician, nurse), depending on the process of interest. Consumer actions are matched by onstage and backstage employee actions. Onstage employee actions are contact employee acts that are visible to the consumer, such as obtaining medication-related information and counseling. Anything that the pharmacist or technician does for the patient that is not visible is a backstage employee action. Backstage actions include many professional decisions made by pharmacists, such as checking the patient profile for drug allergies, interactions, and duplicate medications or consulting with the physician on therapy. Support processes identify system actions that support contact employees in the delivery of services. For pharmacists, these processes include computer support services, billing, development of patient education inserts, and inventory control. In Figures I and 2 the four service blueprint components are separated by three horizontal lines: the line of interaction, the line of visibility, and the line of internal interaction. • The line of interaction characterizes interactions between consumers and providers. In this schematic, service encounters occur whenever a vertical line crosses the line of interaction. • The line of visibility separates on stage contact employee actions and backstage employee actions. Provider actions conducted below this line are invisible to the consumer. This line is critical, because a pharmacist's image in the mind of the consumer is determined to a great extent by what they see the pharmacist do. If the only view is of the pharmacist "counting and pouring," then the image of pharmacists will be consistent with that view. • The line of internal interaction separates contact employees from supporting individuals. Any vertical line that crosses this line illustrates a process that supports the front-line employee. An optional component found in some service blueprints is the physical evidence provided by the service. An example is demonstrated in Figure I. Services are intangible; therefore, consumers
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often rely on tangible cues or physical evidence to evaluate services. 14 This physical evidence can include all features of the organization's physical structure and tangible communications. This can encompass signs, parking, landscaping, lighting, cleanliness, decor, layout, and other visual cues. It is important that pharmacies control these aspects of the service experience, because they communicate a message to the consumer. That message should be one that the pharmacy wants to send.
Building a Blueprint Before designing a blueprint, a service process must be selected. The service process to be blueprinted may consist of an entire service process (e.g., dispensing) or a specific component of the process (e.g., patient counseling). A macro view of the entire service process is called a concept blueprint. 7 The concept blueprint demonstrates how each job or department functions in relationship to the service process as a whole. Some detail may be sacrificed in order to provide a thorough overview. Figure 1 is an example of a concept blueprint for
dispensing. It describes the entire dispensing process, including multiple subprocesses such as drug use review (DUR), counseling, and disease management activities. Micro-level blueprints called detailed blueprints can map subprocesses in greater detail.? Figure 2, an example of a detailed i blueprint of a pharmacy smoking cessation program, elaborates on those elements of the concept blueprint used to identify prospective clients: greeting the patient, filling out the patient profile, and counseling. A pharmaceutical service that entails a series of visits, with. each visit focusing on a different service component, may require i mUltiple blueprints. For example, the smoking cessation visit illustrated in Figure 2 concludes with an appointment for a follow-up visit, which could be blueprinted also. Sequential blueprints can be placed in an easily accessible notebook to be referred to during the planning process or as a reminder for the practitioner of what needs to be done for each type of visit. I One of the primary benefits of the service blueprint is the insight and understanding gained through the process of its development. 12 In the experience of the authors, the action of building aI
I
Figure 1. Example of a "Concept Blueprint" of a Typical Dispensing Process for a New Prescription
Pharmacy exterior Parking Appearance of non pharmacy areas
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-----------------------------------------------------548
Journal of the American Pbannaceutical Association
July/August 1999 VoL39,NO'~
The Service Blueprint
A;ure 2. EXBlTlpie of a •"
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Arrive at pharmacy
1
TOOLS FOR ADVANCING PHARMACY PRACTICE
"Detailed Blueprint" of a Pharmacist-Conducted Smoking Cessation ProgralTl
Give history Medical Medication Smoking
Diagnostic tests Fagerstrom test Blood pressure/pulse
Receive instruction Make follow-up NRT/"Cold Turkey" appointment within Lifestyle/environment 1 week modifications Alternatives to smoking Personalized smoking cessation plan
Line of Interaction - - - W - - - - - - - - - l F - - - - - - - - - - - - - - - - - - I I L . . - - - - - - - - - - I - - - - - - Greet patient
Record history
Administer diagnostic tests
Instruct patient Make follow-up NRT/"Cold Turkey"~ appointment within Lifestyle/environment 1 week modifications Alternatives to smoking Personalized smoking cessation plan
Line of Visibility SOAP Note ..... Stage - - . Check for drug ..... Select therapy - - . . NCPA/HCFA Claim Form the interactions with smoker smoking cessation
Line of Internal Interaction - - - - - - - - - - - - - - - - - - - - - - - - 1 - - - - - - - - - - - - - - - -
-
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HCFA = Health Care Financing Administration; NCPA = National Community Pharmacists Association; NRT = nicotine replacement therapy; SOAP = Subjective, Objective, Assessment, Plan.
I blueprint requires those involved to explicitly evaluate each step in !he service process. While fostering a shared vision among all involved, this analysis can help service planners identify obstacles !hat may not have been apparent initially. It can also help them delineate the roles and responsibilities of each participant in the . service process, even those who are not traditionally envisioned as participants (e.g., consumers, supporting staff). All of these groups should be consulted as the blueprint is developed. However, most critical to the service blueprint is an understanding of how conSUmers view the service in question. A consumer focus permits · I designers to highlight processes that accentuate the value to the consumer. I Qualitative research methods such as focus groups can be useful , in identifying which processes add value in the consumer's . mind. IS Consumers can be asked to describe their perceptions about a service process in order to understand which service ele\ ments are clearly remembered (either positively or negatively) and · \' Which are not even noticed. If consumer perceptions are inconsistent with the image that the pharmacy wants to portray, the service . process can be altered. The process can be modified to highlight those elements consistent with the desired service image and I downplay negative elements. For example, if consumers do not recognize the clinical expertise of pharmacists, then the process
I
I
I
· i. '" be redesigned to e~ dinicru activities 1hat are typically
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t
Vol. 39, No.4 July!August 1999
conducted behind the scenes, such as drug therapy monitoring. The service blueprint could be changed to add steps that highlight the pharmacist's drug monitoring role, such as having the phannacist verify some item on the patient profile during each visit. There are five steps to building a service blueprint. 12 Step 1: Identify the service process to be blueprinted. This step depends on the service problem present. If the problem is unclear or the result of multiple interrelated processes, a concept blueprint might be designed to establish a basic understanding of an overall process. Once specific, identifiable problem areas are identified within a service process, a detailed blueprint can be developed to focus on the problems in greater detail. Step 2: Map the service process from the consumer's point of view. This step requires that each action and choice of the consumer be charted. This includes not only those steps conducted when purchasing a service but also when using and evaluating it. The purpose of mapping the process from the consumer's point of view is to focus on those processes that have an impact on the consumer. Understanding the viewpoint of the consumer may require some research to determine how the consumer actually perceives the service. If the blueprint does nothing beyond exposing a deficiency in consumer understanding alone, then its worth is justified. If consumers experience the service in different ways, then different blueprints should be developed for each significant
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The Service Blueprint
consumer group; for example, refill consumers may require a different blueprint than consumers with new prescriptions. Step 3: Map contact employee actions. Both onstage and backstage employee actions should be mapped. This is an opportunity for service employees and managers to communicate. Care must be taken to ensure that each term in the service blueprint has the same meaning for all of those involved, especially if different interpretations are possible. For example, it may be wise to define "patient counseling" in any blueprint. A line of interaction and a line of visibility should be drawn separating consumer/employee actions and onstagelbackstage employee actions, respectively. Step 4: Map internal support activities. The line of internal interaction should be drawn and linkages between contact and support employees diagrammed.
Step 5: Add evidence of service at each consumer action step. The physical evidence of service can be mapped at this point to illustrate what the consumer sees and experiences at each contact with the pharmacy.
National Retail Chain Example A national retail pharmacy chain working in collaboration with the Virginia Commonwealth University (VCU) School of Pharmacy set the goal of implementing disease-state management in all of its pharmacy sites nationwide. This example followed the steps described in the previous section on building a blueprint. Step I: Identify the service to be blueprinted. It was determined that before implementing disease-state management, a template for patient counseling would need to be in place to ensure that all patients had access to an advanced level of counseling, regardless of their involvement in a disease-state management program. It was then realized that in order for the pharmacist to counsel a patient on every prescription, the workflow for the typical dispensing process needed to be standardized. Therefore, the national retail chain developed standards of practice for the dispensing process for new prescriptions, which would be consistent for each pharmacy site nationwide. Figure I, which shows a concept blueprint for dispensing a new prescription, incorporates these standards. Consistency in the dispensing process was essential to ensure that the blueprint could be incorporated into all of the pharmacy sites, regardless of any differences in pharmacy setup.
Step 2: Map the process from the consumer's point of view. After identifying the dispensing process for blueprinting, the next step was to create the dispensing blueprint from the consumer's point of view. The goal here was to dispense medications in a timely manner and ensure that each patient receives counseling sufficient to his or her needs. The blueprint called for pharmacy personnel to invite patients waiting for their prescriptions to examine materials about health-related topics and other services offered by the pharmacy. This information had two purposes: to occupy the patients while they waited for their prescriptions and, more important, to stimulate consumer questions about health needs that might
550
Journal or the American Pharmaceutical Association
be met by pharmacy programs (e.g., smoking cessation programs).
Steps 3 and 4: Map employee actions and internal suppon activities. To optimize workflow and create time for patient C0Unseling, pharmacy managers and staff pharmacists mapped out each person's responsibilities. Once responsibilities were established, system-related problems were identified. One issue of particular importance was breakdowns in the dispensing system. A number of questions were identified by examining the blueprint. Is each member of the team fulfilling his/her responsibilities? Is the technician taking primary responsibility for data entry? Is the phanna· cist reviewing drug profiles and DUR notifications to assess appropriateness of therapy? Is the physician office returning calls in a timely manner? The blueprint permitted a systematic analysis of the process and minimized the chance of overlooking any details. Once problems in the process were identified, solutions could be generated.
Step 5: Add evidence of service at each consumer action step. Finally, in creating this blueprint for dispensing, the retail chain wished to communicate to consumers the value provided by each consumer action step. For example, the purpose of filling out the patient profile was explained to the consumer as an important step in ensuring patient health. Instead of patients asking why they had to fill out the profile sheet, patients were more likely to ask, "Is there anything else you needT Other evidence of service value in the dispensing process included the quality and accuracy of the labeling process, the drug information insert, and the counseling the patient receives with each prescription. Feedback from patients on this process, obtained verbally in informal conversa· tions and via telephone surveys, is being incorporated to continuo ally improve the service.
Discussion Despite the potential value of service blueprints, there is as yet little empirical evidence substantiating their use. Therefore, this discussion is based on the authors' professional experience with service blueprints. One limitation of this discussion is that service blueprints were not used in the initial development of the smoking cessation program, but, rather, in the evaluation stage. Therefore, the blueprint was used primarily as a tool to help the clinical pharmacist in charge of implementing the program to identify potential problem areas in the service process and to troubleshoot problems. For example, not all pharmacies were equally successful at providing smoking cessation services. For those pharmacies that experi· enced difficulties, the clinical pharmacist checked the concept blueprint in Figure I to identify bottlenecks. Although problems could have been identified without a service blueprint, the blueprint permitted a more systematic analysis. Some staff pharmacists had difficulty balancing their dispens· ing duties with the smoking cessation program. Thus the clinical pharmacist questioned staff pharmacists at each stage of the dis'
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~Illing process to look for inefficiencies and make suggestions.
bsome cases, the staff phannacist was performing all computer &Ja entry on each new prescription rather than delegating this talk to the technician, leaving inadequate time for counseling. In ~ instances, pharmacists were spending significant time clari~g new prescriptions or responding to unimportant computer OUR notifications. As a result, time that could have been devoted ro professional activities was spent on telephone calls to physicians' offices. Regardless of the situation, the blueprint permitted ~ pharmacist to see a visual representation of each step in the ~s, probe for difficulties, and identify the problem. Resolu00n of the problem was dependent on each specific pharmacy, fl!arJnacy staff, and pharmacist. Because service blueprints were being used for the fust time, !bey were used on a limited basis. As experience was gained, oowever, the authors began to identify desirable future uses for M ueprints. One potential future use would be in the analysis of rust·benefit trade-offs associated with the level of consumer conta:t when designing services. In general, it stands to reason that !be more consumer contact a pharmacist has, the less efficient he ~ she will be in dispensing prescriptions. Therefore, a pharmacy mat stresses efficiency in services may want to limit patient-pharmacist interaction, because pharmacists can complete much more work when they are not interrupted by phone calls and patient ~uestions. On the other hand, because the level of ~acist-consumer contact is critical to the development of a ~aceutical care relationship, a consumer-driven pharmacy may fmd that increased interaction between patient and pharmacist fosters opportunities to develop these relationships and ~monstrate the value of pharmaceutical services. The blueprint could provide an opportunity to identify points of patient contact mat can influence desirable service outcomes, such as repeat conlumers, patient satisfaction, and positive therapeutic outcomes. It would also have been desirable to use the blueprint to help pharmacy employees visualize the entire service process. Blueprints can help each employee to fully understand his or her role in the process, how this role affects others in the process, and exactly what everyone on the team is trying to achieve. Including phannacists in the blueprinting process might have increased their buY·in to the new services. In addition, blueprinting might have ittotified problems unique to individual pharmacies and pennitted feedback in the planning stages instead of after implementation. One potential idea for blueprints that has never been discussed in the literature would be to help promote the value of pharmaceutical services to consumers and third party payers. One reason for the limited success of pharmacists in obtaining reimbursement for cognitive services is that third party payers and patients have difficulty understanding what pharmaceutical services are. Blueprints can be used to pinpoint opportunities for demonItrating to the consumer how pharmaceutical care services differ from basic dispensing services. For example, a quick examination of the typical dispensing process blueprint (Figure I) and that of a disease-state management program such as smoking cessation
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(Figure 2) can show those who receive and/or pay for the services how these processes differ. The average amount of time spent in each step can also be included to help in establishing prices. In addition, as mentioned previously, patients and third party payers do not understand how to evaluate these services once they have been received. I•S This is not surprising, since pharmaceutical services are often provided backstage. Moreover, as mentioned earlier, the benefits are often intangible-for example, self-monitoring skills, the ability to recognize changes in health, an understanding of therapy, and/or improvements in perceptions of control over the disease would become evident to the consumer only over time. The service blueprint can help the phannacist explain the service process to patients and third party payers and train them what to look for in good pharmaceutical services. Since service blueprints can illustrate essential characteristics of pharmaceutical services at a glance, they can be used as supportive materials in marketing advanced pharmaceutical services in oneon-one interactions with third party payers. Well-designed, succinct visual aids can communicate ideas immediately, with minimal verbal explanation. Components of the service process that provide extra value, such as the elements of patient counseling in smoking cessation or other disease states, can be highlighted to demonstrate benefits not offered in a basic dispensing contract. In addition, the blueprint can assure third party payers that intangible services, such as patient counseling, have been standardized. Further empirical work will be needed in this area to understand how service blueprints can be used in promotional activities.
Conclusion This article has presented an overview of the service blueprint and a discussion of its use in a chain pharmacy setting. Each individual pharmacy environment and pharmacy service will likely require unique blueprints to meet specific needs. The service blueprint is a valuable tool for designing, implementing, and evaluating pharmacy services. A useful, effective blueprint will require input from both the onstage and backstage players who work together to provide the service. Most importantly, consumer-perceived value and satisfaction are the basis for the design and success of any individual blueprint. The authors declare no conflicts of interest or financial interests in any product or service mentioned in the manuscript, including grants, employment, gifts, and honoraria.
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Kingman -Brundage J. The ABC's of service blueprinting. In: Bitner MJ, Crosby LA, eds. Designing Winning Service Strategies. Chicago, III: American Marketing Association; 1989:30- 3.
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William Procter Jr. (1817-1874}-Father of American Pharmacy The word "father" brings to mind a person of authority who commands respect and reverence. In Webster 'sl the word also refers to an originator, founder, or inventor. In 1874 William Procter Jr. was named the "Father of American Pharmacy" for his outstanding contributions to his profession. 2 (p.l75) Procter lived during a period of transition for pharmacy, when practitioners were mostly uneducated and preceptor-trained. Just a few years after Procter's birth, the Philadelphia College of Pharmacy (PCP) was founded (1821) in response to pressure exerted by physicians regarding the adulterated drugs being dispensed by many uneducated practitioners and apprentices. 3 PCP offered evening lectures for interested practitioners, but it was obvious that more had to be done. Procter graduated from PCP in 1837, and in 1846 was appointed as the first professor of pharmacy, a title he held for 30 years. Together with others, Procter introduced the formal lecture and the printed word as a method of educating practitioners and blending the practical with the science of pharmacy. For 34 years he served as a contributor to or editor of PCP's scientific and practical publication, the American Journal of Pharmacy. During much of this time Procter also managed his own community pharmacy. 4 Greatly influenced by the European pharmacists he met in Philadelphia, who were trained in the scientific aspects of compounding and dispensing, Procter pursued his own research program and eventually published some 550 research papers.4.In 1849 he also became editor and contributor of a textbook on practical pharmacy (originally written by Mohr and Redwood) that for many years was used as a primary reference by pharmacy students and practitioners. 4 In 1851 the New York College of Pharmacy invited pharmacy organizations to meet and discuss the problem of adulterated drugs entering the country because of unqualified drug inspectors at each port. It was during this meeting that Procter suggested the formation of a national profession wide pharmacy organization. Delegates from each pharmacy organization met in Philadelphia in October 1852 to form this national pharmaceutical organization. Procter prepared well for this meeting, and through his efforts the American Pharmaceutical Association was founded. 2(p.l75) The new organization's constitution reflected the best interests of the pharmaceutical community and focused on solving the problems facing the profession. Present-day pharmacy is also undergoing a transition, from a product-oriented profession to a patient-oriented one. The professional pride, integrity, scientific creativity, and political skills of the Father of American Pharmacy can serve as an inspiration to all pharmacists attempting to elevate the profession during our own critical period of transition. Patrick F. Belcastro, PhD, Professor Emeritus of Pharmaceutics, Purdue University, School of Pharmacy and Pharmacal Sciences, W. Lafayette, Ind.
References 1. Neufeldt V. Webster's New World Dictionary. New York: Simon and Schuster; 1988. 2. Higby GJ. In Service to American Pharmacy. Tuscaloosa: The University of Alabama Press; 1992. 3. Sonnedecker G. Kremers and Urdang 's History of Pharmacy. Philadelphia: J. B. Lippincott; 1976:190. 4.
552 ~
Bender GH. Great Moments in Pharmacy. Detroit: Northwood Institute Press; 1966.
Journal of the American Pharmaceutical Association
July/August 1999
Vol. 39, No.4
The Service Blueprint as a Tool for Designing Innovative Pharmaceutical Services David A. Holdford and Daniel T. Kennedy
Objective: To describe service blueprints, discuss their need and design, and provide examples of their use in advancing pharmaceuncal care. Background: Service blueprints are pictures or maps of service processes that permit the people involved in designing, ~roviding , managing, and using the service to better understand them and deal with them objectively. A service blueprint simultane-
ously depicts the service process and the roles of consumers, service providers, and supporting services. Service blueprints can be useful in pharmacy because many of the obstacles to pharmaceutical care are a result of insufficient planning by service designers and/or poor communication between those designing services and those implementing them. One consequence of this poor design and communication is that many consumers and third party payers are uninformed about pharmacist roles. Service blueprints can be used by pharmaci sts to promote the value of pharmaceutical care to consumers and other decision makers. They can also assist in ~esigning
better pharmaceutical services. Methods: Blueprints are designed by identifying and mapping a process from the con-
sumer's point of view, mapping employee actions and support activities, and adding visible evidence of service at each consumer action step. Key components of service blueprints are consumer actions, "onstage" and "backstage" employee actions, and support ~rocess es.
Discussion: Blueprints can help pharmacy managers identify and correct problems with the service process, provide
pharmacy employees an opportunity to offer feedback in the planning stages of services, and demonstrate the value of pharmaceutical services to consumers. Conclusion: Service blueprints can be a valuable tool for designing, implementing, and evaluating pharmacy services. JAm Pharm Assoc. 1999;39:545-52.
Several authors have described obstacles to the widespread implementation of pharmaceutical care. l -4 Many of these obstacles are associated with inadequate communication between phannacists and decision makers, or they are a result of insufficient planning by those implementing pharmaceutical care services. 1These problems are not unique to pharmacy. umerous services of many types fail because of insufficient planning by designers or poor communication between those designing services and those implementing them. 5 Poor design and planning occurs because most new services are developed
Received August 28, 1998, and in revised form November 10, 1998, and January 7, 1999. Accepted for publication January 12, 1999. David A. Holdford, MS, PhD, is assistant professor of pharmacy administration; Daniel T. Kennedy, PharmD, BCPS, is assistant professor of pharmacy, College of Pharmacy, Virginia Commonwealth University (Mev Campus), Richmond. Correspondence: David A . Holdford, PhD, Virginia Commonwealth UniverSity(MCV Campus), PO Box 980533, Richmond VA 23298-0533. Fax: 004-828-8359. E-mail: [email protected]. Continuing education credits: See page 584 for learning objectives and test qUestions for this article, which is number 202-000-99-130-H04 in APhA's educationa l programs.
V01. 39,No.4
July/August 1999
through trial and error instead of through a systematic design process. 6 A trial-and-error approach to service design is analogous to building a house without a blueprint and can greatly increase the potential for failure. 7 The service blueprint is a practical tool that encourages systematic planning for pharmaceutical services and enhances communication between pharmacists and important decision makers, such as patients, physicians, manager , payers, and pharmacy personnel. Service blueprints permit pharmacists to visually depict their services at a level and depth of detail not pos ible with verbal descriptions. This article discus es what service blueprints are, why they are needed, how to design and build them, and provide example of how they can be used in advancing pharmaceutical care.
Background In general, con umer are uninformed about what pharmaci ts do ; hence they have limited expectation of pharmaci t . ,9 Despite the visibility of pharmaci ts in the community rno t prafe sional activitie provided by pharmaci t are not readily
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TOOLS FOR ADVANCING PHARMACY PRACTICE
The Service Blueprint
Editors' Note 'The Service Blueprint as a Tool for Designing Innovative Pharmaceutical Services" is the fourth article in a 12part special issues series titled ''Tools for Advancing Pharmacy Practice" (see page 73 of the January/February 1999 JAPhA for the introduction to this series). Our objective is to publish articles that demonstrate the practical application of various frameworks, measures, methods, and other tools useful to pharmacy practice sites, including practitioners' experiences and impressions of the tools. Each manuscript in the series is peer-reviewed and research-based, but also contains an important educational component. As such, continuing education credit is offered for each article. In this article, Drs. Holdford and Kennedy highlight a managerial tool: the service blueprint. The service blueprint is a map of service processes that can help in the design, implementation, and evaluation of pharmaceutical services. The authors outline the process for developing such a blueprint and discuss how it can be used in pharmacy practice. We trust you will find this article valuable to your research and/or practice area. The editors will appreciate any comments you may have about this series. Jon C. Schommer, PhD Series Editor Associate Professor College of Pharmacy University of Minnesota
David A. Mott, PhD Series Editor Assistant Professor College of Pharmacy University of Wisconsin
apparent to patients and other decision makers. Pharmacists' technical and professional services occur primarily out of view of the consumer. For example, the patient is likely unaware that a pharmacist has checked the patient's profile for allergies, drug interactions, and therapeutic duplication unless the pharmacist takes the time to explain. Physicians and third party payers also have limited exposure to pharmaceutical services. Physician contacts with community pharmacists are mainly by telephone and then often through an intermediary. Third party payer interaction may be through telephone calls, mail, and rare site visits. This restricted level of exposure makes it difficult for physicians and third party payers to gain a true understanding of pharmacist roles. As a result, the pharmacy profession has had difficulties getting patients and third party payers to accept and demand pharmaceutical care. Several factors contribute to these difficulties. Consumers have difficulty evaluating phal1rUlceutical services. The services provided by pharmacists and other health care professionals have unique characteristics that make them difficult to
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JoumaJ 01 the Amerbn Pbarmaceutlcal Association
evaluate. Some aspects of services are easy to describe (e.g., fasL friendly, inexpensive), whereas others are difficult to evaluate even with extensive experience (e.g., clinical skills). For example. it is unlikely that anyone but a pharmacist would be able to recog. nize when another pharmacist omitted critical drug-related infor· mation to a patient during counseling. Pharmaceutical services are difficult to evaluate in part because they are intangible-they are actions rather than physical objects, It is much easier for consumers to comprehend the purpose of a drug than the pharmaceutical services associated with it. The variability of pharmaceutical services also complicates evaluation. Since services are provided by humans under con· stantly changing circumstances, each service experience is unique. Patients' expectations and responses will vary from encounter to encounter, just as a range of variables can affect each pharmacist's performance at different times during the workday, Services are often invisible to the consumer. Most phannacy services are provided out of view of the consumer. Unless pharo macists inform consumers of the services they have provided, they will get no credit for the value they have contributed. Words can be insufficient to describe services. It is critical that pharmacists be able to explain the concept of pharmaceutical care to others, but there is evidence that pharmacists themselves do not understand the concept. I This misunderstanding may in part be the result of relying on the spoken word to convey the concept of pharmaceutical care. There are a number of risks in relying on words alone to describe services. \0 Verbal explanations often lead listeners to oversimplify or misinterpret an idea. For example, the term "patient counseling" is often used incorrectly to describe a pharo macist's superficial review of a patient's medications, a description that only captures a fragment of what patient counseling real· Iy entails under the paradigm of pharmaceutical care. Words also tend to be incomplete in portraying services. With verbal descriptions, it is easy to omit details that might be critical to a full understanding of a service. For example, patients andI physicians are important participants in the overall pharmacy ser· vice experience. However, verbal descriptions of pharmacy ser· vice often overlook or inadequately detail the roles of nonphann a cy participants in the service process. Another weakness of using words to portray services is their subjectivity. Adjectives such as "responsive," "friendly," "feli- I able," and "competent" mean different things to individual pharo macists, technicians, supervisors, and consumers. For example.'I "pharmacist competence" will inevitably be perceived differently by pharmacists and patients. Patients may define competence in terms of interpersonal aspects of care, or how long they wait for I their prescription, while pharmacists may emphasize technical and clinical components of care. Fin~y, words c~ lead to bi~ inu:rpretation. People base their \ conclUSIOns on thel! own expenence, bIases, and exposure to a ser- I vice. An example is each pharmacist's interpretation of the tef1l1 , "pharmaceutical care." Some pharmacists regard pharmaceutical
.!
July/August 1999 VoJ.39, No,J
The Service Blueprint · (It as
something they have always done, while others see it as a
~ taJjcaI change in practice. In fact, examination of the original defi-
· !lion of phannaceutical care-"the responsible provision of drug i1trapy for the purpose of achieving definite outcomes that · iJ¥Ove a patient's quality of life"ll-<:an describe both the level ~dispensing mandated by OBRA '90 and much higher levels of · ~aceutical services. In summary, words are often inadequate to depict a concept as romplex as pharmaceutical care. Visual representations of ser\?;e$ may be more helpful.
The Service Blueprint Defined The purpose of the service blueprint is to design a service prores&'system that can be visualized and that minimizes subjective interpretations. The service blueprint is a picture or map of a service process that permits the people involved in providing and managing the service to better understand it and deal with it objectively.12 A service blueprint simultaneously depicts the process of service delivery and the roles of consumers, service JlllViders, and supporting services. It breaks down the service into Iromponents and arranges them according to their purpose. Exam~es of service blueprints are shown in Figures I and 2. Service blueprints are based on process design theory from mdustrial engineering, computer programming, decision theory, and operations management. 13 They are similar to flow, operalion, and activity charts, which visually delineate each step in a ~ision, activity, or design process. Flow charts illustrate the octivities involved in an entire process, showing their interrela~nship and the sequence. Operation charts focus on specific ~rations within flow charts. Activity charts show the interactions of members of a group in performing a task. One key feature unique to service blueprinting when compared with other process Itsign methods is the inclusion of consumers and their view of the process. The premise of the service blueprint is that if consumers contribute to the service process, they should be recognized explicitly in its design and management. This means that the consumer's "job" must be clearly defined in the blueprint. 12 The primary benefit of the service blueprint is that it forces a careful analysis of each step in the service process and helps communicate that information to the people (e.g., front-line employees) Who influence its success. Blueprints can be used for a variety of other purposes (see Table 1).7.13
Methods Components of a Service Blueprint Although there are no concrete rules for drawing up a service blueprint-which permits considerable flexibility in their design-there are some key components of the service blueprint: 12 consumer actions, "onstage" contact employee
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TOOLS FOR ADVANCING PHARMACY PRACTICE
Table 1_ Uses for Service Blueprints Developing service strategies Integrating services Assessing the quality of services Allocating resources Managing service image Managing personnel
actions, "backstage" contact employee actions, and support processes, as demonstrated in the blueprints in Figures I and 2. Examples of consumer actions in pharmacy include the faceto-face counseling encounter, telephone calls for prescription refills, and written refill reminders mailed to the patient's residence. This "consumer" is not only the patient but any recipient of the service (e.g., physician, nurse), depending on the process of interest. Consumer actions are matched by onstage and backstage employee actions. Onstage employee actions are contact employee acts that are visible to the consumer, such as obtaining medication-related information and counseling. Anything that the pharmacist or technician does for the patient that is not visible is a backstage employee action. Backstage actions include many professional decisions made by pharmacists, such as checking the patient profile for drug allergies, interactions, and duplicate medications or consulting with the physician on therapy. Support processes identify system actions that support contact employees in the delivery of services. For pharmacists, these processes include computer support services, billing, development of patient education inserts, and inventory control. In Figures I and 2 the four service blueprint components are separated by three horizontal lines: the line of interaction, the line of visibility, and the line of internal interaction. • The line of interaction characterizes interactions between consumers and providers. In this schematic, service encounters occur whenever a vertical line crosses the line of interaction. • The line of visibility separates on stage contact employee actions and backstage employee actions. Provider actions conducted below this line are invisible to the consumer. This line is critical, because a pharmacist's image in the mind of the consumer is determined to a great extent by what they see the pharmacist do. If the only view is of the pharmacist "counting and pouring," then the image of pharmacists will be consistent with that view. • The line of internal interaction separates contact employees from supporting individuals. Any vertical line that crosses this line illustrates a process that supports the front-line employee. An optional component found in some service blueprints is the physical evidence provided by the service. An example is demonstrated in Figure I. Services are intangible; therefore, consumers
Journal of the American Pharmaceutical Association
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TOOLS FOR ADVANCING PHARMACY PRACTICE
The Service Blueprint
often rely on tangible cues or physical evidence to evaluate services. 14 This physical evidence can include all features of the organization's physical structure and tangible communications. This can encompass signs, parking, landscaping, lighting, cleanliness, decor, layout, and other visual cues. It is important that pharmacies control these aspects of the service experience, because they communicate a message to the consumer. That message should be one that the pharmacy wants to send.
Building a Blueprint Before designing a blueprint, a service process must be selected. The service process to be blueprinted may consist of an entire service process (e.g., dispensing) or a specific component of the process (e.g., patient counseling). A macro view of the entire service process is called a concept blueprint. 7 The concept blueprint demonstrates how each job or department functions in relationship to the service process as a whole. Some detail may be sacrificed in order to provide a thorough overview. Figure 1 is an example of a concept blueprint for
dispensing. It describes the entire dispensing process, including multiple subprocesses such as drug use review (DUR), counseling, and disease management activities. Micro-level blueprints called detailed blueprints can map subprocesses in greater detail.? Figure 2, an example of a detailed i blueprint of a pharmacy smoking cessation program, elaborates on those elements of the concept blueprint used to identify prospective clients: greeting the patient, filling out the patient profile, and counseling. A pharmaceutical service that entails a series of visits, with. each visit focusing on a different service component, may require i mUltiple blueprints. For example, the smoking cessation visit illustrated in Figure 2 concludes with an appointment for a follow-up visit, which could be blueprinted also. Sequential blueprints can be placed in an easily accessible notebook to be referred to during the planning process or as a reminder for the practitioner of what needs to be done for each type of visit. I One of the primary benefits of the service blueprint is the insight and understanding gained through the process of its development. 12 In the experience of the authors, the action of building aI
I
Figure 1. Example of a "Concept Blueprint" of a Typical Dispensing Process for a New Prescription
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-----------------------------------------------------548
Journal of the American Pbannaceutical Association
July/August 1999 VoL39,NO'~
The Service Blueprint
A;ure 2. EXBlTlpie of a •"
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Arrive at pharmacy
1
TOOLS FOR ADVANCING PHARMACY PRACTICE
"Detailed Blueprint" of a Pharmacist-Conducted Smoking Cessation ProgralTl
Give history Medical Medication Smoking
Diagnostic tests Fagerstrom test Blood pressure/pulse
Receive instruction Make follow-up NRT/"Cold Turkey" appointment within Lifestyle/environment 1 week modifications Alternatives to smoking Personalized smoking cessation plan
Line of Interaction - - - W - - - - - - - - - l F - - - - - - - - - - - - - - - - - - I I L . . - - - - - - - - - - I - - - - - - Greet patient
Record history
Administer diagnostic tests
Instruct patient Make follow-up NRT/"Cold Turkey"~ appointment within Lifestyle/environment 1 week modifications Alternatives to smoking Personalized smoking cessation plan
Line of Visibility SOAP Note ..... Stage - - . Check for drug ..... Select therapy - - . . NCPA/HCFA Claim Form the interactions with smoker smoking cessation
Line of Internal Interaction - - - - - - - - - - - - - - - - - - - - - - - - 1 - - - - - - - - - - - - - - - -
-
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HCFA = Health Care Financing Administration; NCPA = National Community Pharmacists Association; NRT = nicotine replacement therapy; SOAP = Subjective, Objective, Assessment, Plan.
I blueprint requires those involved to explicitly evaluate each step in !he service process. While fostering a shared vision among all involved, this analysis can help service planners identify obstacles !hat may not have been apparent initially. It can also help them delineate the roles and responsibilities of each participant in the . service process, even those who are not traditionally envisioned as participants (e.g., consumers, supporting staff). All of these groups should be consulted as the blueprint is developed. However, most critical to the service blueprint is an understanding of how conSUmers view the service in question. A consumer focus permits · I designers to highlight processes that accentuate the value to the consumer. I Qualitative research methods such as focus groups can be useful , in identifying which processes add value in the consumer's . mind. IS Consumers can be asked to describe their perceptions about a service process in order to understand which service ele\ ments are clearly remembered (either positively or negatively) and · \' Which are not even noticed. If consumer perceptions are inconsistent with the image that the pharmacy wants to portray, the service . process can be altered. The process can be modified to highlight those elements consistent with the desired service image and I downplay negative elements. For example, if consumers do not recognize the clinical expertise of pharmacists, then the process
I
I
I
· i. '" be redesigned to e~ dinicru activities 1hat are typically
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Vol. 39, No.4 July!August 1999
conducted behind the scenes, such as drug therapy monitoring. The service blueprint could be changed to add steps that highlight the pharmacist's drug monitoring role, such as having the phannacist verify some item on the patient profile during each visit. There are five steps to building a service blueprint. 12 Step 1: Identify the service process to be blueprinted. This step depends on the service problem present. If the problem is unclear or the result of multiple interrelated processes, a concept blueprint might be designed to establish a basic understanding of an overall process. Once specific, identifiable problem areas are identified within a service process, a detailed blueprint can be developed to focus on the problems in greater detail. Step 2: Map the service process from the consumer's point of view. This step requires that each action and choice of the consumer be charted. This includes not only those steps conducted when purchasing a service but also when using and evaluating it. The purpose of mapping the process from the consumer's point of view is to focus on those processes that have an impact on the consumer. Understanding the viewpoint of the consumer may require some research to determine how the consumer actually perceives the service. If the blueprint does nothing beyond exposing a deficiency in consumer understanding alone, then its worth is justified. If consumers experience the service in different ways, then different blueprints should be developed for each significant
Joumal of the American Phannaceutiall Association
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TOOLS FOR ADVANCING PHARMACY PRACTICE
The Service Blueprint
consumer group; for example, refill consumers may require a different blueprint than consumers with new prescriptions. Step 3: Map contact employee actions. Both onstage and backstage employee actions should be mapped. This is an opportunity for service employees and managers to communicate. Care must be taken to ensure that each term in the service blueprint has the same meaning for all of those involved, especially if different interpretations are possible. For example, it may be wise to define "patient counseling" in any blueprint. A line of interaction and a line of visibility should be drawn separating consumer/employee actions and onstagelbackstage employee actions, respectively. Step 4: Map internal support activities. The line of internal interaction should be drawn and linkages between contact and support employees diagrammed.
Step 5: Add evidence of service at each consumer action step. The physical evidence of service can be mapped at this point to illustrate what the consumer sees and experiences at each contact with the pharmacy.
National Retail Chain Example A national retail pharmacy chain working in collaboration with the Virginia Commonwealth University (VCU) School of Pharmacy set the goal of implementing disease-state management in all of its pharmacy sites nationwide. This example followed the steps described in the previous section on building a blueprint. Step I: Identify the service to be blueprinted. It was determined that before implementing disease-state management, a template for patient counseling would need to be in place to ensure that all patients had access to an advanced level of counseling, regardless of their involvement in a disease-state management program. It was then realized that in order for the pharmacist to counsel a patient on every prescription, the workflow for the typical dispensing process needed to be standardized. Therefore, the national retail chain developed standards of practice for the dispensing process for new prescriptions, which would be consistent for each pharmacy site nationwide. Figure I, which shows a concept blueprint for dispensing a new prescription, incorporates these standards. Consistency in the dispensing process was essential to ensure that the blueprint could be incorporated into all of the pharmacy sites, regardless of any differences in pharmacy setup.
Step 2: Map the process from the consumer's point of view. After identifying the dispensing process for blueprinting, the next step was to create the dispensing blueprint from the consumer's point of view. The goal here was to dispense medications in a timely manner and ensure that each patient receives counseling sufficient to his or her needs. The blueprint called for pharmacy personnel to invite patients waiting for their prescriptions to examine materials about health-related topics and other services offered by the pharmacy. This information had two purposes: to occupy the patients while they waited for their prescriptions and, more important, to stimulate consumer questions about health needs that might
550
Journal or the American Pharmaceutical Association
be met by pharmacy programs (e.g., smoking cessation programs).
Steps 3 and 4: Map employee actions and internal suppon activities. To optimize workflow and create time for patient C0Unseling, pharmacy managers and staff pharmacists mapped out each person's responsibilities. Once responsibilities were established, system-related problems were identified. One issue of particular importance was breakdowns in the dispensing system. A number of questions were identified by examining the blueprint. Is each member of the team fulfilling his/her responsibilities? Is the technician taking primary responsibility for data entry? Is the phanna· cist reviewing drug profiles and DUR notifications to assess appropriateness of therapy? Is the physician office returning calls in a timely manner? The blueprint permitted a systematic analysis of the process and minimized the chance of overlooking any details. Once problems in the process were identified, solutions could be generated.
Step 5: Add evidence of service at each consumer action step. Finally, in creating this blueprint for dispensing, the retail chain wished to communicate to consumers the value provided by each consumer action step. For example, the purpose of filling out the patient profile was explained to the consumer as an important step in ensuring patient health. Instead of patients asking why they had to fill out the profile sheet, patients were more likely to ask, "Is there anything else you needT Other evidence of service value in the dispensing process included the quality and accuracy of the labeling process, the drug information insert, and the counseling the patient receives with each prescription. Feedback from patients on this process, obtained verbally in informal conversa· tions and via telephone surveys, is being incorporated to continuo ally improve the service.
Discussion Despite the potential value of service blueprints, there is as yet little empirical evidence substantiating their use. Therefore, this discussion is based on the authors' professional experience with service blueprints. One limitation of this discussion is that service blueprints were not used in the initial development of the smoking cessation program, but, rather, in the evaluation stage. Therefore, the blueprint was used primarily as a tool to help the clinical pharmacist in charge of implementing the program to identify potential problem areas in the service process and to troubleshoot problems. For example, not all pharmacies were equally successful at providing smoking cessation services. For those pharmacies that experi· enced difficulties, the clinical pharmacist checked the concept blueprint in Figure I to identify bottlenecks. Although problems could have been identified without a service blueprint, the blueprint permitted a more systematic analysis. Some staff pharmacists had difficulty balancing their dispens· ing duties with the smoking cessation program. Thus the clinical pharmacist questioned staff pharmacists at each stage of the dis'
July/August 1999
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The Service Blueprint
~Illing process to look for inefficiencies and make suggestions.
bsome cases, the staff phannacist was performing all computer &Ja entry on each new prescription rather than delegating this talk to the technician, leaving inadequate time for counseling. In ~ instances, pharmacists were spending significant time clari~g new prescriptions or responding to unimportant computer OUR notifications. As a result, time that could have been devoted ro professional activities was spent on telephone calls to physicians' offices. Regardless of the situation, the blueprint permitted ~ pharmacist to see a visual representation of each step in the ~s, probe for difficulties, and identify the problem. Resolu00n of the problem was dependent on each specific pharmacy, fl!arJnacy staff, and pharmacist. Because service blueprints were being used for the fust time, !bey were used on a limited basis. As experience was gained, oowever, the authors began to identify desirable future uses for M ueprints. One potential future use would be in the analysis of rust·benefit trade-offs associated with the level of consumer conta:t when designing services. In general, it stands to reason that !be more consumer contact a pharmacist has, the less efficient he ~ she will be in dispensing prescriptions. Therefore, a pharmacy mat stresses efficiency in services may want to limit patient-pharmacist interaction, because pharmacists can complete much more work when they are not interrupted by phone calls and patient ~uestions. On the other hand, because the level of ~acist-consumer contact is critical to the development of a ~aceutical care relationship, a consumer-driven pharmacy may fmd that increased interaction between patient and pharmacist fosters opportunities to develop these relationships and ~monstrate the value of pharmaceutical services. The blueprint could provide an opportunity to identify points of patient contact mat can influence desirable service outcomes, such as repeat conlumers, patient satisfaction, and positive therapeutic outcomes. It would also have been desirable to use the blueprint to help pharmacy employees visualize the entire service process. Blueprints can help each employee to fully understand his or her role in the process, how this role affects others in the process, and exactly what everyone on the team is trying to achieve. Including phannacists in the blueprinting process might have increased their buY·in to the new services. In addition, blueprinting might have ittotified problems unique to individual pharmacies and pennitted feedback in the planning stages instead of after implementation. One potential idea for blueprints that has never been discussed in the literature would be to help promote the value of pharmaceutical services to consumers and third party payers. One reason for the limited success of pharmacists in obtaining reimbursement for cognitive services is that third party payers and patients have difficulty understanding what pharmaceutical services are. Blueprints can be used to pinpoint opportunities for demonItrating to the consumer how pharmaceutical care services differ from basic dispensing services. For example, a quick examination of the typical dispensing process blueprint (Figure I) and that of a disease-state management program such as smoking cessation
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TOOLS FOR ADVANCING PHARMACY PRACTICE
(Figure 2) can show those who receive and/or pay for the services how these processes differ. The average amount of time spent in each step can also be included to help in establishing prices. In addition, as mentioned previously, patients and third party payers do not understand how to evaluate these services once they have been received. I•S This is not surprising, since pharmaceutical services are often provided backstage. Moreover, as mentioned earlier, the benefits are often intangible-for example, self-monitoring skills, the ability to recognize changes in health, an understanding of therapy, and/or improvements in perceptions of control over the disease would become evident to the consumer only over time. The service blueprint can help the phannacist explain the service process to patients and third party payers and train them what to look for in good pharmaceutical services. Since service blueprints can illustrate essential characteristics of pharmaceutical services at a glance, they can be used as supportive materials in marketing advanced pharmaceutical services in oneon-one interactions with third party payers. Well-designed, succinct visual aids can communicate ideas immediately, with minimal verbal explanation. Components of the service process that provide extra value, such as the elements of patient counseling in smoking cessation or other disease states, can be highlighted to demonstrate benefits not offered in a basic dispensing contract. In addition, the blueprint can assure third party payers that intangible services, such as patient counseling, have been standardized. Further empirical work will be needed in this area to understand how service blueprints can be used in promotional activities.
Conclusion This article has presented an overview of the service blueprint and a discussion of its use in a chain pharmacy setting. Each individual pharmacy environment and pharmacy service will likely require unique blueprints to meet specific needs. The service blueprint is a valuable tool for designing, implementing, and evaluating pharmacy services. A useful, effective blueprint will require input from both the onstage and backstage players who work together to provide the service. Most importantly, consumer-perceived value and satisfaction are the basis for the design and success of any individual blueprint. The authors declare no conflicts of interest or financial interests in any product or service mentioned in the manuscript, including grants, employment, gifts, and honoraria.
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William Procter Jr. (1817-1874}-Father of American Pharmacy The word "father" brings to mind a person of authority who commands respect and reverence. In Webster 'sl the word also refers to an originator, founder, or inventor. In 1874 William Procter Jr. was named the "Father of American Pharmacy" for his outstanding contributions to his profession. 2 (p.l75) Procter lived during a period of transition for pharmacy, when practitioners were mostly uneducated and preceptor-trained. Just a few years after Procter's birth, the Philadelphia College of Pharmacy (PCP) was founded (1821) in response to pressure exerted by physicians regarding the adulterated drugs being dispensed by many uneducated practitioners and apprentices. 3 PCP offered evening lectures for interested practitioners, but it was obvious that more had to be done. Procter graduated from PCP in 1837, and in 1846 was appointed as the first professor of pharmacy, a title he held for 30 years. Together with others, Procter introduced the formal lecture and the printed word as a method of educating practitioners and blending the practical with the science of pharmacy. For 34 years he served as a contributor to or editor of PCP's scientific and practical publication, the American Journal of Pharmacy. During much of this time Procter also managed his own community pharmacy. 4 Greatly influenced by the European pharmacists he met in Philadelphia, who were trained in the scientific aspects of compounding and dispensing, Procter pursued his own research program and eventually published some 550 research papers.4.In 1849 he also became editor and contributor of a textbook on practical pharmacy (originally written by Mohr and Redwood) that for many years was used as a primary reference by pharmacy students and practitioners. 4 In 1851 the New York College of Pharmacy invited pharmacy organizations to meet and discuss the problem of adulterated drugs entering the country because of unqualified drug inspectors at each port. It was during this meeting that Procter suggested the formation of a national profession wide pharmacy organization. Delegates from each pharmacy organization met in Philadelphia in October 1852 to form this national pharmaceutical organization. Procter prepared well for this meeting, and through his efforts the American Pharmaceutical Association was founded. 2(p.l75) The new organization's constitution reflected the best interests of the pharmaceutical community and focused on solving the problems facing the profession. Present-day pharmacy is also undergoing a transition, from a product-oriented profession to a patient-oriented one. The professional pride, integrity, scientific creativity, and political skills of the Father of American Pharmacy can serve as an inspiration to all pharmacists attempting to elevate the profession during our own critical period of transition. Patrick F. Belcastro, PhD, Professor Emeritus of Pharmaceutics, Purdue University, School of Pharmacy and Pharmacal Sciences, W. Lafayette, Ind.
References 1. Neufeldt V. Webster's New World Dictionary. New York: Simon and Schuster; 1988. 2. Higby GJ. In Service to American Pharmacy. Tuscaloosa: The University of Alabama Press; 1992. 3. Sonnedecker G. Kremers and Urdang 's History of Pharmacy. Philadelphia: J. B. Lippincott; 1976:190. 4.
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