1. Blackfeet Community Hospital BCMA (IHS PSB 3*42) Deployment Site Visit October 27 – November 7, 2014

2. IHS RPMS EHR Deployment

3. BCMA Inpatient Deployment

4. Blackfeet Community Hospital BCMA Team Jamie Ladd, PharmD, Inpatient Pharmacy CAC/ BCMA Lead Purnee Brandvold, CAC James Farr, BSN, RN, Night Nursing Supervisor/BCMA Coordinator Charlene Ramirez, BSN, RN, Day Nursing Supervisor/BCMA Coordinator Shirley St. Goddard, IT/RPMS Specialist Stacey Thompson, PharmD, Pharmacy Supervisor Jody Sabo, BSN, RN, Surgery Nurse Supervisor Lisa Racine, HIM Eric Chosa, RPh, Billings Area Pharmacy/CAC Margaret Cooper, Area Billings Area CAC Verna Kuka, Billings Area IT/RPMS Specialist

5. 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 Mike Allen, MIS, RPh, Pharmacy Informaticist, IHS/OIT - Remote

6. 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 Stephen Corma, BSPharm, RPh, Pharmacist Consultant, BCRO, OIA, VHA

7. 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

8. 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

9. 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

10. 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.

11. BCMA Configuration & Test Equipment Barriers Scanners were Requested, but Less Expensive Scanners were Purchased that Did Not Include BCMA Default Settings Facility CAC Expedited a Purchase Order for Required BCMA Default Cards, thus Increased Costs were Incurred ($400) VHA BCRO Team Member Fortunately was Prepared to Intervene (Luck!)

12. BCMA Configuration and Test Miscellaneous “IT” Barriers Inconsistent Connectivity to Mobile Workstations Inconsistent Connectivity and Performance of Thin Clients EHR Does Not Display Correctly on Old Monitors Lack of Data Ports Lack of Patch Cables Lack of Human Resources for IT Support

13. BCMA Configuration & Test Week One Cohort Activities ADT – Delineating, Fine-Tune Admission, Discharge, Transfer Processes and Delayed Orders Day Surgery – Identify and Communicate Selected Processes – “BCMA vs Admit to PACU Note with Medication and IV Sections” – Communication of Handoff of Medication Administration Responsibilities from CRNA to RN – Concern for Short BCMA Timeout Interval – Post Op Discharge Rx appear on EHR Medication Tab, Staff will Need Training to Locate and Provide Hard Copy for CII medications

14. BCMA Configuration & Test Week One Cohort Activities Pharmacy Issues – IV Fluids Must Match Orders – No Consistency in Available Surgery IV Fluid Stock – Pharmacy Scheduling for Day Surgery Medications Must be Finished Prior to 7:30 Scanning Failures – Delineate and Implement a Process for Receiving IV Solutions and Scanning into the Drug File – Problem Solving Medication Scanning Failures begins with Pharmacy Tech (i.e. synonym file)

15. BCMA Week Two Training & Go Live Plan Friday – Training Preparation and Practice Session (8 Hours) Sunday – Afternoon Nursing Super User Training Session (4 Hours) Monday – Morning Nursing Super User Training (4 Hours), Afternoon BCMA Coordinator Sessions (4 Hours) Tuesday – Morning Pharmacy Training Session (4 Hours), Afternoon Nursing Super User Training Session (4 Hours) Wednesday – Morning Pharmacy Training Session (4 hours), Afternoon Nursing Super User Training Session (4 hours) – Go Live Wednesday 3:30 PM – Troubleshooting Thursday – Debriefing, Go Live and Troubleshooting Continues Throughout Thursday and Friday Major Medication Passes (6:00 AM, 10:00 AM, 10:00 PM) 16 hours on Wednesday and 18hours on Thursday A Total of – 28 Training Hours, 111 Training Encounters, of these 56 were Unduplicated Educational Encounters

16. Blackfeet Community Hospital Training

18. Blackfeet Training Statistics

19. BCMA Training Lessons Learned Consider HSM Configuration for Bedside Creams, Topicals, etc. Recommend Leaving Inhalers, Ointments Used by Patients in a Locked Bedside Drawer Clearly Delineate and Communicate Insulin Administration Policies and Procedures Formalize and Communicate PRN Effectiveness Documentation Policy (BCMA vs DAR)

20. BCMA Training Lessons Learned PCA Documentation Between Transitions of Care IV Fluid Documentation Between Transitions of Care Nursing and HIM Need to Define and Approve Bar Coded Comments for Use with CPRS Med Order Button

21. 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)

22. Go Live Lessons Learned Patient Supplied Medications Wristbands MUST be Attached to Patients All Medications MUST be Bar Coded Two Nurse Verification Process for Insulin and other “High Alert” Medications Standard Administration Times Removed “128 Bar Code” from the Wristband to Minimize Confusion Infection Control Practices and Techniques for Medication Administration

23. Baseline Statistics Wristbands Medications Count Processed via Scanner 21 %Total Events 80.8% Scanner By-Pass 5 Keyed Entry (2 ) Unable to Scan Option (3) 19.2% Total Wristband Scan Events 26 Count Processed via Scanner 60 % Total Events 93.8% Scanner By-Pass Keyed Entry (0) BCMA Unable to Scan (4) Vista Manual Med Entry (0) 6.3% Total Medication Label Scan Events 64

24. Post Implementation Statistics Wristbands Medications Count Processed via Scanner 27 %Total Events 87.1% Scanner By-Pass 4 Keyed Entry (1) Unable to Scan Option (3) 12.9% Total Wristband Scan Events 31 Count Processed via Scanner 49 % Total Events 100% Scanner By-Pass Keyed Entry (0) BCMA Unable to Scan (0) Vista Manual Med Entry (0) Total Medication Label Scan Events 49

25. Thank You Hospital Leadership! We want to take the opportunity to recognize the outstanding efforts of Purnee Brandvold and Jamie Ladd for their BCMA Team leadership. We also thank the Blackfeet Community Hospital Leadership for providing financial and human resources, which helped contribute to a highly successful BCMA Training and Implementation