1. Acoma-Canoncito-Laguna Service Unit (ACL) BCMA (IHS PSB 3*42) Deployment Site Visit June 8 – June 11, 2015

2. IHS RPMS EHR Deployment

3. BCMA Inpatient Deployment

4. ACL Service Unit BCMA Team Teresa Sanders, BSN, RN, BCMA Coordinator Melvina Murphy, (A) DON, RN, Albuquerque Area Nurse Consultant Kimberly Phillips, BSN, RN, (A) Inpatient Nurse Supervisor CDR Dan Fletcher, BSN, RN (A) Outpatient Nursing Supervisor CAPT Suryam Palanki, PharmD, Pharmacist Informaticist LT Jeremy Peacock, BSN, RN, BCMA Coordinator CAPT Wil Darwin, PharmD, (A) ACL CEO, Albuquerque Area CAC & Pharmacy Consultant Merlin Lucero, IT Specialist

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

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 9 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. 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, AZWhiteriver, AZ Gallup, NMShiprock, NM Claremore, OKTahlequah, OK Talihina, OK

11. 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.

12. BCMA Configuration & Test Removed Medications from Nursing Text Orders Reviewed all Order Sets Realigned Sliding Scale Insulin Order Sets Cleaned up Nursing Location File Configured and Realigned IV Labels and Patient Wristbands Resolved User Configuration and Permissions

13. BCMA Configuration and Test

14. BCMA Training & Go Live Plan Monday – Configuration and Test (8 Hours) Tuesday – Training Preparation and Practice Session (6 Hours), Evening Nursing Super User Session (4 Hours) Wednesday – Morning BCMA Coordinator Session (4 Hours), Afternoon Nursing Super User Session (4 Hours), Evening Nursing Super User Session (4 Hours) – Go Live Wednesday Morning with 8:00 AM Medication Pass – Troubleshooting Throughout Evening Thursday – Morning Pharmacy Training Session (4 Hours) – Debriefing, Go Live and Troubleshooting Continues Throughout Thursday Major Medication Passes ( 8 AM, 9 PM) on Wednesday and Thursday A Total of – 16 Training Hours, 38 Training Encounters, of these 24 were Unduplicated Educational Encounters

15. ACL Service Unit BCMA Training

17. ACL Service Unit Training Statistics

18. BCMA Training Lessons Learned Not all Nurses and Pharmacists had Necessary Keys Add “Clinical Key © ”, “Micromedex © ”, and “Do Not Crush Tablet List” to the BCMA Tool Menu Many Users with Multiple RPMS Accounts

19. 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)

20. Go Live June 10, 2015

21. Go Live Findings No Local Technical Support for Mobile Workstations – Mobile Workstations Lack Capability of Powering Laptops, PCs, Monitors, etc. on Battery Power No Network Ports for the Mobile Workstations in the Patient Rooms Current Setup Presents both Safety and Infection Control Concerns No Ability to Securely Store Patient Medications in Patient Rooms (eg. Creams) Use of Outpatient Prepacks in Pyxis with Non- Scannable Barcodes

22. Go Live Recommendations Configure Network Ports for the Mobile Workstation Carts in the Patient Rooms Until Wireless Connectivity is Available Mobile Workstations to have Capability of Powering Laptops, PCs, Monitors, on Battery Power Lockable Bedside Medication Drawer for Self Administered Ointments, Creams, Inhalers Re-examine Administration Times Scrutinize Drug File, Quick Orders, and Bar Coding of Medications

23. Baseline Statistics 06/10/2015 @ 0700 to 06/10/2015 @ 1400 Wristbands Medications Count Processed via Scanner 9 %Total Events 100% Scanner By-Pass Keyed Entry (0) Unable to Scan Option (0) 0.0% Total Wristband Scan Events 9 Count Processed via Scanner 22 % Total Events 78.6% Scanner By-Pass 6 Keyed Entry (1) BCMA Unable to Scan (4) Vista Manual Med Entry (1) 21.4 Total Medication Label Scan Events 28

24. Post Implementation Statistics 06/10/2015@1400 to 06/11/2015@0900 Wristbands Medications Count Processed via Scanner 14 %Total Events 93.3 % Scanner By-Pass 1 Keyed Entry (1) Unable to Scan Option (0) 6.7% 6.7 0 Total Wristband Scan Events 15 Count Processed via Scanner 97 % Total Events 94.2 % Scanner By-Pass 6 Keyed Entry (0) BCMA Unable to Scan (6) Vista Manual Med Entry (0) 5.8 0 5.8 0 Total Medication Label Scan Events 103

25. Thank You Hospital Leadership! We want to take the opportunity to recognize the outstanding efforts of Teresa Sanders and Suryam Palanki for their BCMA Team leadership. We also thank the Acoma- Canoncito-Laguna Service Unit Leadership for providing financial and human resources, which helped contribute to a highly successful BCMA Training and Implementation