Phoenix Indian Medical Center BCMA (IHS PSB 3*42) Deployment Site Visit March 9 – March 20, 2015

IHS RPMS EHR Deployment

BCMA Inpatient Deployment

Phoenix Indian Medical Center BCMA Team Karen John, Acting Director Clinical Informatics, PIMC Jeff Walling, PharmD, Pharmacy CAC Dan Diggins, PharmD, Inpt Pharmacy CAC Lynda Von Bibra, RN, CAC/BCMA Lead Tony Millkamp, RN, CAC Sue Barney, RN Clinical Nurse Ernest Jaramillo, RN Clinical Nurse Kira Wilder, RN Specialty Nurse Kris White, RN Clinical Nurse Les Wilkie, RN, ICU Nurse Manager Deborah Ward-Lund, Med/Surg Nurse Manager Erin Ezzell, RN, PP/Couplet Nurse Manager Vina J Dele, IT Director /Site Manager Vernita M Jones, Site Manager Rebecca Shirley, PIMC HIM Dennis Vollin, Systems Administrator Michael Nez, System Administrator Phoenix Area Office Support Elvira Mosely, Phoenix Area CAC Tammy Brewer, Phoenix Area CAC Roberta Joe, System Administrator

“ Team ABQ” Mescalero: Yolanda Adams, RN, DON; Jason Harris, PharmD ACL: Theresa Sanders, RN; Suryem Palanki, PharmD ZSU: Ben Le, PharmD; Terry Kanesta-Brislin, RN, DON; Keith Martinez, IT SFU: Lisa Palucci, RN DON; Kyle Sheffer, PharmD

SEARHC Team Eric Skan, PharmD, Pharmacy/EHR Informaticist Rhonda Stiles, IT System Administrator/EHR informaticist Jill Reid, PharmD, Pharmacy Manager

IHS On Site/Remote Cross Functional Team David Taylor, MHS, RPh, PA-C, RN, BCMA Federal Lead, IHS/OIT Deborah Alcorn, MSN, RN, CPC, BCMA Nurse Consultant, IHS/OIT Chris Saddler, RN, BCMA Information Technology Consultant, IHS/OIT (Remote) Mike Allen, MIS, RPh, Pharmacy Informaticist, IHS/OIT

VA Remote Cross Functional Team Cathi Graves, Project Manager, BCRO, OIA, VHA Kirk Fox, Clinical 1 Support Team, OI&T, VA Jonathan Bagby, MSN, MBA, RN-BC, Nurse Consultant, BCRO, OIA, VHA Stephen Corma, BSPharm, RPh, Pharmacist Consultant, BCRO, OIA, VHA

VA Cross Functional Team

VA IHS BCMA Collaboration Effort Includes BCMA Software, Hardware, and Medication Administration Process Reviews FY13 – Implementation at 2 Indian Health Care facilities FY14 – Implementation at 9 Indian Health Care facilities FY15 – Implementation at 5 Indian Health Care facilities VA IHS BCMA Cross Functional Team Kick-off March 19-21, 2013 Remote Participation for Initial Configuration/Test/End-User Training-April 8-19, 2013, Albuquerque, NM Ongoing Remote RPMS Pharmacy Drug File Cleanup – 6 week series ADT delayed orders/auto DC of orders optimized to align with CMS 2 midnight rule and Interqual® criteria Integrate ADT and BCMA implementation with the Baby Friendly Initiative including rooming-in

Four Essential Components Patient – “Perfect” Admission, Discharge, & Transfer (ADT) Process and Release Events (Delayed Orders and Auto Discontinuation of Orders between “Transitions of Care”) Medication – “Perfect” Orders, Pharmacy Processes, and Drug File Nurse - Nurse Medication Administration Process Equipment – Wristbands, Medication Bar Codes, and Scanners

What Is BCMA? “Patient Safety First… Because Second is too Late!” BCMA is an Integral Part of Patient Safety, Nurses Administer Medications Including IV Medications through BCMA All Medication Information is Documented with Date/Time Stamp for Improved Accuracy of Clinical Information The Documented Information is Available Throughout the Facility to Any Clinician as Part of the Patient’s Health Record Pharmacy and Nursing Staff must collaborate closely with Information Technology Staff if the Medication Administration Arm of the System is to Work Optimally

Meaningful Use Criteria Meaningful Use Stage 2 Criteria for Eligible Hospitals (EHs), and Critical Access Hospitals (CAHs): – Objective: Automatically track medications from order to administration using assistive technologies in conjunction with an electronic medication administration record (eMAR). – Measure: More than 10% of medication orders created by authorized providers of the EH or CAHs inpatient or emergency department during the EHR reporting period for which all doses are tracked using eMAR.

PIMC BCMA Equipment Costs BCMA Medication Cart ** Wireless Scanner Thermal Wrist Printers Wristband stock (adult and baby) for 3 months Wall mounts (Enovate) Keyboard (antimicrobial & waterproof) Mouse (antimicrobial & waterproof) Dell Wyse Thin Client's - BCMA Carts & Wall Mounts 24" Dell Monitors Wireless Equipment for 2, 3, 4 floorsComments ICU (11 beds) East Med/Surg West Nursery L&D Postpartum Pharmacy6 Emergency Department1 Spare21 Totals Cost Each $ 6, $ $ 1, $ 2, $ $ $ Overnight Shipping $ Total Cost $ 131, $ 34, $ 29, $ 2, $ 21, $ 1, $ $ 17, $ 6, $ 11, $ 257, ** BCMA Medication Cart - 8 drawers, IV pole, Electric height adjustment

BCMA Configuration & Test Activities Installed the Correct BCMA GUI on all Workstations Older Versions of BCMA Installed on Some Workstations Equipment (Carts, PCs, Scanners) Needs to be Purchased for PACU, Same Day Surgery, and OR PIMC ADT – Observation & Treating Specialties, Day Surgery, Inpatient Surgical Suite, Release Events Assigning Security Keys, Menu Options and System Access Permissions Assemble carts and configure cart management software Configuration and setup of Wristband printers Pharmacy Drug File cleanup

BCMA Implementation Barriers Nurse Informaticist/Nurse BCMA Coordinator(s) – Nursing leadership involvement with workflow process Wireless – Equipment – Bridge Solution; Piggyback onto Phoenix Area Office – On going support Carts – Arrived One Week Ago – Acquisitions Process RPMS Configuration & BCMA Access – Delineation of Responsibilities – Large Number of Users (Options & Keys)

BCMA Week Two Training & Go Live Plan Friday – Training Preparation and Practice Session (96 Person Hours) Saturday Evening – Nursing Super User Training (4 Hours) Sunday – Morning Pharmacy BCMA Training (4 Hours), Afternoon BCMA Coordinator Training (4 Hours), Evening Nursing Super User Training (4 Hours) Monday – Morning Nursing Super User Training (4 Hours), Afternoon BCMA Coordinator Training (4 Hours), Evening Nursing Super User Training (4 Hours) Tuesday – Morning Nursing Super User Training (4 Hours), Afternoon Nursing Super User Training Session (4 Hours), Tuesday Evening Pharmacy BCMA Training (4 Hours) Wednesday – Morning Nursing Super User Training (4 hours), Afternoon Nursing Super User Training Session (4 hours) – Go Live Wednesday 2:oo PM – Troubleshooting Wednesday Afternoon, Evening, Night Shifts Thursday – Debriefing, Go Live and Troubleshooting Continues Throughout Thursday and Friday Major Medication Passes (9:00 AM, 2:00 PM, 9:00 PM) 16 hours on Wednesday and 18hours on Thursday A Total of – 48 Training Hours, 324 Training Encounters, of these 121 were Unduplicated Educational Encounters

Phoenix Indian Medical Center Training

PIMC Training Statistics

BCMA Training Lessons Learned Respiratory Therapists- do not enter EHR orders and Do Not Have Access to the CPRS Med Order Button – A Process will be Developed Place a Laptop in Each Medication Room for Easy Access to BCMA while Accessing Pyxis Often could not Access BCMA through Thin Client Workstations RPMS & BCMA Access

BCMA Training Lessons Learned Layers & Silos On-going Training & Support Needs Training Preparation Overextension of Staff Adaptability of Nursing Staff and Impressive Competency with “First Use” Successful Preparation of Pharmacy Package Area CAC Staff Participation Training Equipment

BCMA Training Lessons Learned Update Policies & Procedures to Align with New BCMA Processes: – Each Ward needs to Designate a BCMA NURSING COORDINATOR(S) for ongoing BCMA support & orientation – Each Nurse to View Missed Med, IV bag status report & PRN Effectiveness Reports at Specified Shift Intervals – Identify Medications that Require “Comments” – Supervisory/Charge Nurse Generating Specified BCMA Reports (Medication Variance, Missed Medications, PRN Effectiveness)

Go Live Lessons Learned Printing Wristbands via PPW Workstations “Lock Up” During Medication Pass Workstations “Drop Connection” on Third Floor Fourth Floor (L&D and Couplet Care) is “Different” Due List and Missed Medication Reports will Prevent Errors

Baseline Statistics Wristbands Medications Count Processed via Scanner 40 %Total Events 81.6% Scanner By-Pass 9 Keyed Entry (0) Unable to Scan Option (9) 18.4% Total Wristband Scan Events 49 Count Processed via Scanner 309 % Total Events 71.5% Scanner By-Pass 123 Keyed Entry (2) BCMA Unable to Scan (19) Vista Manual Med Entry (102) 28.5% Total Medication Label Scan Events 432

Post Implementation Statistics Wristbands Medications Count Processed via Scanner 68 %Total Events 84% Scanner By-Pass (13) Keyed Entry (8) Unable to Scan Option (5) 16% Total Wristband Scan Events 81 Count Processed via Scanner 117 % Total Events 62.6% Scanner By-Pass Keyed Entry (70) BCMA Unable to Scan (9) Vista Manual Med Entry (59) 37.4% Total Medication Label Scan Events187

Recommendations for BCMA-Nurse Management Team Managing Scanning Failures (MSF) – Wrist Bands and Medications – Workstation & Wireless Issues Medication Errors – Medication Due Lists – Missed Medication Reports Realign BCMA Documentation with EHR Root Cause Analysis Medication Errors Medication Variances and Medication Schedules Infection Prevention Managing Urgent Doses Review and Revise Medication Administration Policies Future training of current and new employees Contingency Plan Development

Recommendations for BCMA-Nurse Management Team BCMA and EHR Documentation – Pain – Insulin – Heparin – PRN Effectiveness – IV Bag Status – Tubing Change – Patch Medications – Canned Scanned Comments Nursing Competencies and Training – At-the-Elbow – Classroom Monitoring “Work Arounds” CPRS Med Order Button

Special Thanks IHS Office of Information Technology – Mike Allen, OIT Pharmacy Informaticist – Chris Saddler, OIT Information Technology Specialist VA BCRO – Kirk Fox, VA CLIN 1 Team Phoenix Area Office – Elvira Mosely, Area CAC – Tammy Brewer, Area CAC – Roberta Joe, Area Systems Administrator – Dan Wood, Area Systems Administrator “Team ABQ” – ACL, Santa Fe, Zuni, Mescalero SEARHC Clint Krestel, PharmD, NNMC

Thank You Hospital Leadership! We want to take the opportunity to recognize the outstanding efforts of Lynda Von Bibra, Jeff Walling, Dan Diggins, and Tony Millkamp for their BCMA Team leadership. We also thank the Phoenix Indian Medical Center Leadership for providing financial and human resources, which helped contribute to a highly successful BCMA Training and Implementation

Good Luck!