Zuni Comprehensive Health Center BCMA (IHS PSB 3 Zuni Comprehensive Health Center BCMA (IHS PSB 3*42) Deployment Site Visit June 1 – June 6, 2015

IHS RPMS EHR Deployment

BCMA Inpatient Deployment

Zuni Comprehensive Health Center BCMA Team Rebecca Grizzle, RD, Project Manager Erica Harker, PharmD, Director of Pharmacy Benjamin Le, PharmD, Pharmacy CAC Terry Kanesta-Brislin, BSN, RN, DON, BCMA Coordinator Melanie Romancito, CAC Roxanne Salvador, IT Keith Martinez, IT Wil Darwin, PharmD, (A) CEO, Albuquerque Area CAC

IHS On Site 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 On Site 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 (Remote) Stephen Corma, BSPharm, RPh, Pharmacist Consultant, BCRO, OIA, VHA

VA/IHS BCMA CFT 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

Bar Code Medication Administration (BCMA) IHS-VA Interagency Agreement & Collaborative MU Stage 2 Criteria for EHs and CAHs FY 2013 – 2 beta test sites FY 2014 – 9 EH FY 2015 – 9 EH FY 2016 – 3 EH – (No VA IAA for implementation) Error reduction: 91% reduction in Category E 84% reduction in Category F BCMA Data from 9 IHS/Tribal Hospitals: Cherokee, NC, Chinle, AZ Ft. Defiance, AZ Whiteriver, AZ Gallup, NM Shiprock, NM Claremore, OK Tahlequah, OK Talihina, OK

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.

BCMA Configuration & Test Printer Naming Convention Transfer and Release Events From L&D  Obstetrics  GMS Allowed an Interward Transfer to follow an Interward Transfer (Previously could only move patient once) Pharmacy “Auto Verify” Activated for All Pharmacists CPRS Medication Order Button was Tasked BCMA Parameter Default Answer List was Incomplete

BCMA Training & Go Live Plan Monday – Configuration and Test (8 Hours) Tuesday – Training Preparation and Practice Session (9 Hours) Wednesday – Morning Pharmacy Training (4 Hours), Afternoon Nursing Super User Session (4 Hours), Evening Nursing Super User Session (4 Hours) Thursday – Morning BCMA Coordinator Session (4 Hours), Afternoon Nursing Super User Training Session (4 Hours), Evening Nursing Super User Session (4 Hours) Go Live Thursday Morning at 11:30 AM Go Live Support and Troubleshooting Continued Simultaneous to Training and Over to Nursing Night Shift Friday – Morning Nursing Super User Session (4 hours), Afternoon Nursing Super User Training Session (4 hours) Troubleshooting Throughout Evening Saturday – Debriefing, Go Live and Troubleshooting Continues Throughout Saturday Major Medication Passes (0900 and 2100, as well as other medication med passes scattered throughout the day) ~12 hours on Friday and ~12 hours on Saturday A Total of – 32 Training Hours, 120 Training Encounters, of these 53 were Unduplicated Educational Encounters

Zuni Comprehensive Health Center Training

Zuni Comprehensive Health Center Training Statistics

BCMA Training Lessons Learned Documentation of IVs Needs to be Standardized for Both Nursing and Coders Start Time, Stop Time, and End Time Documentation for IV infusions needs to be Clarified for Both Nursing and Coders POC Blood Glucose Values are Not Entered into EHR via POC Button At a Minimum Enter Blood Glucose Values into EHR via the POC Button for SS Insulin Doses

BCMA Training Lessons Learned Both Sliding Scale and PRN Insulins are Confusing for Nurses Standardizing ALL insulin sliding scales via P&T committee The “Scanner Barcode Fix” was Added to the BCMA “Tools” Menu Inpatient Birth Control – Nexplanon Process to be delineated and Pharmacy will scan the Contraceptive into BCMA and Add Comment: “Dispensed to (Provider)” Medical Provider Education needs to be provided so Nexplanons removed from the pharmacy are scanned into BCMA by a pharmacist to ensure adequate Medication documentation.

BCMA Training Lessons Learned Pharmacy Issues Hospital Supplied Meds (HSM) Functionality to be Examined and Clarified by Policy (i.e. lanolin in breastfeeding moms, clotrimazole cream, hydrocerin lotion, etc) Standardize a Multidisciplinary Policy & Procedure for Patient Supplied Medications to be Examined by Pharmacy and Packaged for Medication Cart and Scanning Numerous Old Pending Orders in ^OTHER Queue Cleanup Task Queued to Run Daily List was Reduced from over 50 obsolete medication orders to 12 Pharmacy will review Remaining Obsolete Medication Orders and Discontinue as Appropriate

BCMA Training Pharmacy Issues Define: NOW dose time frame ONCE (ONE TIME) dose frame Self administered Insulin must be re-educated with Nursing Staff that stock supply insulins cannot be shared Re-Orient Staff on Pharmacy Call-Back Policy Re-educate Standard Time Schedules (i.e. meal times, dialysis, weekly meds, etc)

BCMA Training Pharmacy Issues Education: Delayed orders do not include NOW doses Separate order will be required for a NOW dose Refer back to education on Standard Times After hour medications need to be removed from the Inpatient Night Cabinet Stock bottles removed from outpatient pharmacy will not scan in BCMA Overall Clinical Education: NO PAPER MARs Find info on Med Admin History (EHR)

BCMA Training Pharmacy Issues After hour use Folder Insulin labels, common cream labels, etc Will be located on top of the Med Cart in a Cardex Needed Items Move IV infusion label Aztec Bar Scan to upper right hand corner to prevent smearing and unreadable bar codes Utilizing MAR label printer as an alternate to the WASP system

BCMA Training Lessons Learned Update Policies & Procedures to Align with New BCMA Processes: Each Ward needs to Designate a BCMA NURSING CHAMPION(S) for ongoing BCMA support & orientation Each Nurse to View Missed Med & 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 BCMA GUI Not Installed On All Nurse Workstations Lack of Standard Medication Administration Schedule Times – Medication Administration Time was Scattered Throughout all Shifts Workstations On Wheels (WOWS) will be used in some Patient Rooms since Wall Cabinets have not arrived WOWs do not all have Scanners Attached, one WOW had a Scanner but it was not Ported

Go Live Lessons Learned Equipment – West Side Rooms have Work Stations in Rooms but No Place for Scanner Limited work space in the West Rooms along with infection control concerns Printed Virtual Due Lists need to be SHREDDED After Each Med Pass Practice what we were taught this week

Baseline Statistics 6/4/15@1200 to 6/5/15@0900 Wristbands Medications Count Processed via Scanner 14 %Total Events 100% Scanner By-Pass 0 Keyed Entry (0) Unable to Scan Option (0) % Total Wristband Scan Events 14 Count Processed via Scanner 27 % Total Events 90.0% Scanner By-Pass 3 Keyed Entry (0) BCMA Unable to Scan (0) Vista Manual Med Entry (3) 10% Total Med Label Scan Events 30 100%

Post Implementation Statistics 6/5/15 @ 2000 to 6/6/15 @ 2100 Wristbands Medications Count Processed via Scanner 44 %Total Events 97.8% Scanner By-Pass Keyed Entry (0) Unable to Scan Option (1) 2.2% Total Wristband Scan Events 45 Count Processed via Scanner 76 % Total Events 98.7% Scanner By-Pass Keyed Entry (0) BCMA Unable to Scan (1) Vista Manual Med Entry (0) 1.3% Total Medication Label Scan Events 77

Thank You Hospital Leadership We want to take the opportunity to recognize the outstanding efforts of the Zuni BCMA Team and their Executive Leadership for committing financial and human resources to contribute to a highly successful BCMA Training and Implementation to assure Patient Medication Administration Safety.