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Wednesday 23 January 2019
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Implementing the Smart Store system: a case study

PHARMACY PRACTICE
Medicine Smart Store cabinets are fully automated solutions to providing instant access to stock supplies 24 hours a day, seven days a week. The process of implementing such a system from trial to installation is detailed

William Pulman
Deputy Pharmacy System Manager,
Ward Automation 
Guy's & St Thomas' Foundation Trust Hospital, London, UK
Email: William.Pulman@gstt.nhs.uk
A medicine Smart Store cabinet is a fully automated cabinet that provides end users with instant information and access to stock medication 24 hours a day, seven days a week. Orders are automated and delivered by pharmacy staff to cater for the individual ward requirements and needs. Stock is checked weekly to monitor levels and usage.
The vision
The vision held by the Guy's and St Thomas's Trust was to enable:
  • End users spending less time preparing and dispensing medicines, enabling them to spend more time at the patient’s bedside
  • A more efficient and safety-controlled system that protects and aids users along with our patients
  • Better control of inventory stock delivered and unpacked by pharmacy staff
  • Reports available to identify key information
  • A clear, clean environment to hold stock and administer medications
  • Availability of financial reporting 
  • Improvement of the preparation of discharge medicine on the ward
  • Reduced costs of unused, waste and overstocked medicine
  • Ability to quality review areas and assess performance
  • A flexible, robust system 
  • Decrease in the need for ad hoc deliveries.
Trialling
A number of trial cabinets were installed in A&E Majors, and some of the wards where it would be used. These included a surgical admissions ward and an elderly care ward. A cabinet with fridge lock was also installed on Esther Ward at Guy’s to provide a medium of passing knowledge and a reference so that staff could see what the future held. 
The trial period lasted six months and, following this, the Omnicell system was chosen. Avantec provided their knowledge and assistance for the installation and maintenance. 
Installation
The installation began in 2009, piggy-backed onto the installation of Medical Supplies, and resulted in Europe’s largest installation of automated cabinets, providing for 30 wards and areas including A&E, ICU and Surgical and Elderly Care. We process and provide more than 70 orders each week, and these are delivered and put away by our Pharmacy Assistant Technical Officers. Many hours of hard work and thought have gone into the set up of the system, and no more than for the interface. 
The system
The Omnicell system is a hardware solution that comprises a network of cabinets linked through the hospital intranet that facilitates the supply and dispensing of medical supplies and pharmacy products. The cabinets are linked to the central server, which runs the software, stores, manages and analyses the data it receives from the network. The software solution is a data management system that delivers information to users throughout the hospital, as well as controlling and reordering stock at point of use.
The system is designed to interface with many different pharmacy systems and the JAC program is no exception. Despite a small setback, we were able to move forward with the help of Omnicell engineers. We have used the BWPROF program (designed to be used with a PDA) and, although not widely used, it provides the means to upload and process data from the cabinets through the central server to a pharmacy terminal. To create the specific interface required, this being the first in the UK, we required some specific information and data. We obtained sample output files from the Royal Liverpool Hospital. The datafiles, which were written in hexidecimal, were reverse-engineered by an Omnicell program developer, and, using the Medicator stock list, an interface was then created.
The information for the restocking data file is created from the daily usage each time a user exits the cabinet and the information is uploaded to the central server. On a set day and time, the data file is created and passed through the Trust IT network and ‘parked’ in a specific folder on one of the drives of the system. This is accessed via BWPROF and, when the file is uploaded, the JAC program books out available stock, and when completed prints out the picking paperwork and asks operators if they want to delete the file. 
The system provides a full audit trail on all transactions. These provide key information and financial reporting. The data can be used to obtain payment for services rendered by the hospital to patients as requested by the Commissioners. Through the use of patient hospital numbers, this is something that will ensure correct payment to the hospital from November 2013. 
Every three months, Par vs Usage reports are extracted to ascertain whether the present stock levels are correct or whether a change of stock level is required. I extract monthly usage to create information to pass to the chief pharmacist, ward managers, sisters and matrons. The reports include wastage and expired stock and poor usage, allowing guidance and targeting of stock no longer required, which can be removed or the stock level reduced.
Users are able to spend more time at the bedside instead of looking for stock, dispensing or preparing medications. It is used as an efficient, timely and safe system to protect and aid the users. Safety features include dispensing alerts to remind users of requirements prior to removing medications, and use of the scanner for restocking, removal and returning of heparins and potassium products.
Special considerations
In preparing to install the cabinets, certain special considerations were required to enable a successful programme. Some of these were pharmacy tasks, the remainder being dealt with by contractors and other trust staff. These included:
  • Confirm works department completed any prep work required (tests and certificates)
  • Configured cabinet for quantity, size, location
  • Liase with ward staff, in particular the sister, matron and senior nursing practitioner
  • Agree re-stocking schedule with pharmacy stores and the ward
  • Train ward staff (minimum of 80% before go-live)
  • Deploy cabinets to ward areas and transfer stock
  • Carry out 100% stock check
  • Remove over-stock and any expired stock found
  • Handover system to ward staff
  • Trainers present to assist during shift change and problems encountered.
The installation of the cabinets has created a cleaner, safer working environment in which to hold and administer medications (and supplies) and improves the preparation of medication for discharge when used with pharmacy access (JAC) and label printers on the wards. It has removed the time previously spent searching for locker keys to access medications to treat patients, thereby speeding up the complete process and freeing-up time to be spent at the bedside. 
We have been able to reduce the volume of unused, wasted and over-stocked medications on wards. The cabinets are configured with eight days’ stock, which is sufficient to carry out a full week’s work. The extra day is to absorb any user problems, late delivery of stock or a short-term rise in usage of any line product. Any changes requested by the ward pharmacist are usually completed within three days. This is a flexible yet robust system that has delivered to the Trust and will continue to do so.
Rationale for installation
Part of the reason for installing the Omnicell Cabinet system was to generate savings for the Trust. The vision from the beginning was to reduce stock holdings of all wards by 20%. This has been achieved, with some being higher or lower than the general requirement. Overall, 22% was saved on stock inventory over the first year from going live. 
Benefits
There are a number of benefits of the system, which include:
  • Releasing many hours of nursing time to care
  • A 22% stock inventory saving in first year of go-live
  • A safer system for patients and nursing staff
  • A clean, tidy environment for medicine storage
  • TTO medicines dispensed from cabinets traditionally done in dispensary
  • Reduced ad hoc deliveries
  • More frequent deliveries to all 30 wards. This has been achieved with no additional staff.
  • Better financial and inventory stock control
  • Less stock, better use of staff time, full cost control
  • Lower consumption - security and accountability stops waste 
  • Minimum but safe stock levels based on real usage data 
  • Provides audit records
  • Automated reordering and link to e-procurement 
  • Usage is costed directly to patient/procedure/consultant 
  • Fast, easy restocking – huge savings in materials management 
  • Reduced data entry
  • Tidy, space efficient flexible, hygienic storage 
  • Reduced dispensing errors and better patient safety: uses Omnicell ‘guiding light’ technology to guide the user to the appropriate location.
Training
Training in the correct and efficient use of the cabinets is important. Dan Mandeman, the System Manager, devised a 40-minute teaching package to be delivered to the nursing staff through the use of Trust Trainers, and we delivered it to the pharmacy staff. Good training is essential. In the three years I have worked for the Trust, I have trained many of our pharmacists, technicians, ATOs, and pre-reg pharmacists from the UK, Spain, Italy and America. 
The training is comprehensive and all new changes or additions to the system are included. I have created abridged versions of the standard operating procedures written by Dan, to pinpoint the specific information required by the users to enable them fast and efficient access. Since going live, a number of different applications have been added to our system. These applications are:
  • Barcode scanning for heparins and potassiums for restock, removal and returning to the cabinet
  • Dispensing alerts for paracetamol IV, gentamicin injection, all penicillins including changing cardiac wards to flucloxacillin 1g injection, amikacin injection and zopiclone tablets.
Troubleshooting
With any system, new or old, problems will be encountered. We have experienced problems when setting up the system and they have ranged from the ability or knowledge of users; failure of electronic and internet systems; to jammed drawers and broken equipment. We have a contract with Avantec to provide on-site repair and information assistance, including out-of-hours help. 
Roll-out
At present, we have gone live on 30 wards. The original plan was to install cabinets on both sites (Guy’s at London Bridge) and Evelina Children’s Hospital. The last two have unfortunately not been implemented because of changes in funding, although Evelina is now looking at its own installation project for early 2013.
Conclusions
The project has now changed to become a user and maintenance system. I continue to train pharmacy staff (we lose about 30% of staff each year due to placements), updating the interface part number listings, and changing both pack sizes and drug changes. We have hosted many NHS Trusts interested in the knowledge and possibility of using the same systems at their Trust. We have also hosted a number of international clients on behalf of Avantec, including delegates from Germany, Japan, Hungary, Australia and Denmark. 
Key points
  • A medicine Smart Store cabinet is a fully automated cabinet that provides end users with instant information and access to stock medication 24 hours a day, seven days a week. 
  • SmartStore cabinets provide a clean, tidy, flexible and hygenic safe environment, thereby reducing danger to patients and staff; all medications are secure but available 24/7. 
  • Part of the reason for installing the Omnicell Cabinet system was to generate  savings for the Trust.
  • Financial benefits of installation include a reduction in inventory holdings, better control and costings to correct patient procedure/ consultant. 
  • Implementation has resulted in increased audit records, better visualisation of staff usage  and training requirements, resulting in reduced drug errors and better patient safety. 

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