Professional Documents
Culture Documents
Program
Practice Guide
TABLE OF CONTENTS
Introduction 3
Implementation Timeline 4
Desired Outcomes 8
Self-Assessment 8
Workflow Optimization 11
RFID Tagging 12
Success Plan 34
Appendix 36
Resources 43
Welcome to Kit Check powered by Bluesight and congratulations on adopting an industry leading
inventory management solution! Kit Check powered by Bluesight integrates RFID technology that
prioritizes patient safety and optimizes medication management. Kit Check can help you accomplish your
hospital-specific goals aimed to advance patient safety, improve workflow efficiency, and optimize
inventory.
The intent of this practice guide is to support your hospital in the transition to inventory automation and
ensure you capitalize on all available resources to achieve your goals. This guide works to engage
subject-matter experts and key stakeholders to support a comprehensive program with data analytics,
reporting and auditing, and increased efficiency.
1. The first phase (Pre-Go Live) includes activities to set up and operationalize the Kit Check system.
a. Kit Check provides a scanning station and handheld barcode scanner that seamlessly
integrates with any PC and a printer. The Kit Check hardware is remotely set up by one of our
specialists and does not require an IT personnel on your end.
b. Kit Check is cloud based and can be accessed using any PC with internet access.
c. Kit Check utilizes a ‘single sign-on’ (SSO) login which creates a single set of credentials to
access different apps with the appropriate permissions.
a. The SSO login will be utilized to access the Kit Check system.
b. The SSO login is an optional feature.
d. Upon completion of the remote setup, a 30-minute introductory training session will be
scheduled for initial staff members and a designated group of Super Users.
e. After the training session is complete, new inventory can be tagged and encoded.
● For each tray, the content definition and par levels should be shared with your
Implementation Specialist who will add it to the system. Based on that shared
data, Kit Check will generate and share a recommended order sheet to ensure
a complete stock.
● Pre-existing stock can be utilized in non-Kit Check environments to ensure a
seamless onboarding experience.
2. Our team will suggest several pharmacists and technicians to assist with the second phase (Go-Live)
based on the scope of the project.
a. A clear and open space will be needed to empty and refill trays (ex. Conference room).
b. All untagged items will be removed from trays and replaced with ‘tagged items.’ These trays
are now ready to be scanned and dispatched.
c. All remaining General User and Super User training will be conducted.
d. Kits are ready to be dispatched and assigned to their locations.
3. After going live, the third phase (Advanced KC/Optimize KC/Beyond the Basics) will be initiated
which enhances your workflow beyond the basics through analytic tools that are already built in.
Whether your goals are to improve workflow, inventory management, or patient safety, it all starts with
a strong foundation:
1. Workflow Planning
a. An effective workflow clearly outlines the procedures for each associated task and tray type
and is accessible for team members to reference as needed. Kit Check Standard Operating
Procedures (SOP’s) have been prepared to help facilitate each individual hospital’s policy and
procedure documentation needs for the following:
● Kit to Cart Scanning
● Pharmacist Verification
● Printing tags and tagging items
● RFID seal instructions
● Scanning Trays and Kits
All SOP documents can be found in the Kit Check Application under the ‘HELP’ tab.
Users are given different distinctions based on their role and usage of the application. There are two
types of training sessions available: General User Training and Super User Training.
Maintaining Competencies
Post-implementation, it is important to maintain competency of each employee performing Kit
Check activities. Our recommendation is to evaluate each employee on a quarterly basis, keeping a
record of all continuing education. Please see appendix II for an example of an employee evaluation
for maintaining competency.
Self-Assessment
To ensure all hospital needs are met, let’s first assess your program specifically. Utilize the questions
outlined below to guide your thinking:
▪ What are your desired outcomes?
▪ What are the success criteria of your program?
o SMART: Specific, Measurable, Achievable, Relevant, and Time-bound
▪ What are the identified measures of success for each criterion? Near and long-term?
▪ What metrics will be used and when will you measure them to gauge progress?
Most commonly, our partners build their goals on three main principles:
1. Prioritizing patient safety
2. Reducing time and manual labor
3. Reducing costs and improved budgeting
Additional Notes:
Example
Desired Outcome: Improve insights on drug utilization
Success Criteria: Understand the usage of 503B compounding syringes over the course of 4 months
Measure of Success: Run the ‘Advanced Segment Optimization’ report every month to determine syringe
turnaround by specific tray type to then quantify average monthly usage to guide future purchasing
Use the outline below to create your own outcomes and measures:
Outcome
Success Criteria
Measure of
Success
Outcome
Success Criteria
Measure of
Success
Outcome
Success Criteria
Measure of
Success
Prior to Kit Check integration within your hospital, tray and kit management was a process that required
multiple manual tasks and an extended amount of time. Technicians are responsible for checking each
kit-pocket for restocking and retrieving the necessary restock items individually from inventory. Between
the manual restocking process and time constraints placed on the team, there was a high risk of human
error, ultimately impacting patient safety. Pulling expired medications is also reliant on human-entered
data and can lead to over-or-under dated medications.
With Kit Check, a quick scan determines which medications are missing, expired, or recalled all in one
screen. Items are removed and replenished as needed and the kit is scanned again averaging a total of 3
minutes per tray. Stocked inventory for replenishment can also effectively be managed to ensure
accurate quantities are available, as well as expiration date tracking.
Outlined in this section is the recommended workflow from our partner hospitals, beginning with the
scanning process to the restocking of various trays and kits.
The workflow can be customized based on your hospital’s policies and procedures.
Note: Kitted Inventory is managed similarly through the restocking process outlined below.
1
For more information on the restocking process reference the Kit Check User Guide found in the program
application
Executing best practices will aid in establishing a successful workflow for crash carts with the Kit Check
solution:
● Establish a procedure for ownership of tray restock when a used tray is returned to the
pharmacy.
o Who is responsible for restocking a used tray?
o When must a tray be restocked after it is returned?
o Where will the restocked tray be stored upon completion?
● When a backup tray is dispatched from the pharmacy, the dispatch location and lock (if
applicable) must be updated in the Kit Check system.
● Leverage bin inventory functionality and reports to ensure all items needed for restock are
tagged and in an accessible location, close to the scanning station.
● In the event of a medication shortage, use shortage management functionality to set
appropriate medication quantity range and acceptable alternative agent(s) to minimize
disruption to workflow.
● Subscribe to expiration reporting to be notified when kit/trays are expiring soon.
o Establish ownership of expired medication verification and response.
o Visibility to expiring soon kits/trays will assist in the planning and allocation of resources
and inventory management, as needed, for tray replenishment.
● If possible, re-allocate expiring soon medications to area of high usage prior to the item
expiration to minimize waste.
● Review kits and trays on a regular (monthly/quarterly) under ‘Inventory’ tab and ‘kits’ to
determine if any kits/trays are not in use (have not been scanned) and can be deleted or edited.
Above is a best practice workflow example. At the end of this section, you will have an opportunity to
create your own workflow. Please work with Solutions Consultants to optimize workflow based on your
specific site needs.
Every hospital has different operational needs to be considered when establishing a workflow. In the
next section, we will provide a step-by-step guide to tracking crash carts using barcoding. This technique
is being used by many hospital teams to streamline their operations. Work with your implementation
team and Solutions Consultants to create a workflow that works for you.
Step 2: Tracking
● Go to Inventory → Kits page in Kit Check
● Any Crash Cart trays that have been sent to Central Sterile will be assigned to “Sent to CS” in the
Location column
Reporting
The Kit Activity report will provide a record of all trays sent to CS, the date and time the tray was sent,
and the staff member who sent them.
● The tray’s cart and location assignment on the Kits Inventory page will show it has been received
by CS, and that the tray is now located in Central Sterile (see below).
In the example below, there are two trays that have been received by Central Sterile, and one tray that
still has yet to be marked as received.
Step 4: Tracking
● Pharmacy can easily track how many trays are stored in Central Sterile at any given moment
using the Manage Carts page.
o Go to Inventory → Carts
o Select the cart “Received by Central Sterile”
o All kits currently in Central Sterile will be listed
Step 5: Assigning trays to Crash Carts & Dispatching to a location in the hospital
● When a tray is ready to be put into a Crash Cart, and dispatched from Central Sterile to
somewhere in the hospital, CS Staff will perform the following steps:
3. Immediately following Step 2, scan the QR code for the location the Crash Cart is being
dispatched to. The tray will now have been assigned to a crash cart, and the crash cart to a
location.
The date, time, and staff member who dispatched each Crash Cart out of Central Sterile to a location in
the hospital Manage Cart page.
Kit Check creates many benefits in the OR and Procedural areas. These benefits can be seen with
non-automated cabinets as well as with automated dispensing cabinets with open matrix drawers.
Current State:
▪ Labor intensive with a heavy FTE burden for appropriate and thorough restocking.
▪ Lack of consistent performance and difficulties with cross-training employees leads to potential
safety issues.
▪ Absence of NDC/lot data leads to increased difficulty in managing recalls.
▪ Expiration date tracking is a manual process leading to the risk of human error as well as
workflow inefficiencies.
▪ No usage reports or analytics to assist in inventory management.
▪ Results in under-dated medications, over-dated medications, potential for over and understocks.
Pharmacy
▪ More visibility and control
▪ Eliminate extra inventory and waste
▪ Ensure accuracy and compliance
▪ More efficient recall handling
OR/Anesthesia:
▪ Fewer stock outs
▪ Reduce time spent handling medications: daily restocking, expiration checks, recalls
To capitalize on these areas for improvement, you need to implement a solution that increases visibility,
maximizes efficiency for both pharmacy and anesthesia, all while improving patient safety. The good
news is that Kit Check has helped over 500 hospitals improve medication management in the OR and
other areas of the hospital by increasing visibility, efficiency, and safety:
There are two workflow options that can be customized based on your specific needs: Centralized
Workflow Model and De-centralized Workflow Model. The next section highlights the specific benefits of
each workflow.
The Centralized workflow is also referred to as a Tray Exchange. Set up and workflow are similar to that
of crash carts but can be utilized for Anesthesia Workstations by removing the liner of the open matrix
drawer and replacing it with a tray. By shifting the restock of the open matrix drawer to a tray restock,
you bring the process into the main pharmacy versus when the technician is out on delivery. Not only
will you achieve all the benefits the RFID solution offers, but you will improve operational efficiency and
restock time.
▪ Decrease in delivery/restock time
▪ Improves patient safety
o Captures all expiration dates by unit
o Provides consumption data to aid in eliminating stock outs
o Creates consistency amongst staff
▪ Access to data and analytics on drug turnover in hospital ORs
▪ Allows for reallocation of resources
o The same technician/shift does not need to complete all restocking activities
▪ Resources can be reallocated to accommodate the demands of the entire hospital
There are many ways to leverage Kit Checks RFID solution to improve OR Workflow. Please see Appendix
IV and V for a best practice example of an OR Workflow. Use the space provided on the next page and
work with your Solutions Consultant to establish a process that meets your specific site needs.
With Kit Check, tracking and reporting is simplified. Pharmacies can quickly and easily view data pertaining to kits and medication usage, which
enables decisions that can improve patient safety, lower costs, improve accountability, and streamline processes.
The Kit Check solution includes customizable analytics and reports so you can easily view the data that is most important. Reports can be
subscribed to by individual users or can be accessed as needed
Evening Tech/Intern Process used trays (OR and/or GI) using 5pm-6pm
Kit Check
Evening Resident/Evening RPh Check that all trays are wrapped and 6pm-9pm
dispatched
Evening Resident/Evening RPh Notify night tech that filled anesthesia 6pm-9pm
trays are ready for dispatch
Night Tech Deliver filled anesthesia trays to OR 9pm-12am
and Tower. Final #s after delivery
should be 20 OR Trays in OR and 3 trays
in Tower
Night Tech Return late used trays to pharmacy 9pm-12am
2. This Anesthesia Tray is currently in A1 - Trauma. How do you update the kit cart/location information
if it were to change?
3. When associating tags to products, what identifiers need to be consistent when batch tagging?
Select all that apply.
a. Label color
b. Lot number
c. Expiration date
5. This crash cart is going to expire. How do you find out if a cart is expiring?
a. Inventory 🡪 Kits 🡪 Kit Expiration
b. Look through all the carts
c. Inventory 🡪 Manage Kit Masters
d. Inventory 🡪 Manage Items
6. How do you know how many items need to be tagged per day?
a. Ask the PIC
b. Look at the bins and tag anything that looks low
c. Review bin inventory report and display bins below “low” alert level, tag just above “low
alert”
d. Leave it for someone else
e. Review bin inventory report and display bins below “low” alert level, tag fill packages of
items up to designated “par”
Step 1: Get the QR code generator add on for Google Excel Sheets in Drive.
▪ Open a new Google Sheets Documents
▪ Select Add-ons from the toolbar. Select “get add-ons” from the drop-down menu.
▪ Type “QR Code generator” into the search field. Get the app that looks like the below:
Step 2: Once you have the add on, simply open any Google Sheet in Drive and paste the list of locations
or Crash Cart numbers you wish to generate QR codes for. See picture below.
▪ Make two identical columns of the list of items you want to generate QR codes for. One column will
be used to generate the QR code, and the other will be used to label the QR code. Very important.
Success Plan
Account- ABC Medicine Prepared By- Dedicated Solution Consultant Date/ Version- April 14, 2021
Key Challenges Key Benefits Milestones, Actions & Dates Success Criteria Measures of Success
1. System standardization 1. Reduce Expired Items 1. Quarterly check-ins 1. Maintain 0 expired items and 0 1. Dashboard landing
2. Drug shortages 2. Reduce Recalled Items 2. Quarterly check-ins recalled items in kits in 2021 page
3. Staff Turnover 3. Increased Inventory 3. Q1 2022 check-in 2. Maintain a kit processing time 2. Kit Activity Report
4. Potential Budget Reduction Visibility 4. Q1 2022 check-in under 5 minutes (mean w/ 20% 3. Reduction in Spend
5. Rising drug prices 5. Quarterly check-ins limits) 4. Items Consumed or
6. Potential for new pharmacy 6. Target = September 1st 3. Increase use of pre-tagged options Removed Report
construction delays kickoff, September 30th in 2021 - to 20% of formulary 5. Trays being scanned
go-live items, daily & tagged
7. Target = October 31st 4. 5% reduction in tag spend based inventory area setup
completion on utilization of Sandoz Items in complete (w/ Bins)
2021 6. Kit Check
5. Reduce system implementation
expiration-to-consumption ratio records
below 2.5% by implementing 7. Kits section of Kit
expiring soon rotation programs Check application
6. Successful Implementation of Kit
Check in the newly constructed
pharmacy in Fall 2021
7. Implementation of Code Bags by
the end of 2021
Engineering Lead
Sales Lead
Solutions Consultant
There are many resources available within the application that can be accessed by clicking on the ‘?’
button, located on the top right hand of any Kit Check Screen or by clicking the ‘Help’ button, located on
the top center hand of any Kit Check screen (See Figure 1). Some of these include, but may not be
limited to:
- E-learning modules
- User Guide
- Contact Us
- Submit a Ticket
- Release Notes
Figure 1
Kit Check Support is available 24/7, 365 days a year. If you have any questions or need technical
assistance, contact us at any time: