1. SEARHC Mt. Edgecumbe Hospital BCMA (IHS PSB 3*42) Deployment Site Visit September 14 – 25, 2015

2. IHS RPMS EHR Deployment

3. BCMA Inpatient Deployment

4. Mt. Edgecumbe Hospital BCMA Team Diane Linn, RN, BCMA Coordinator, Nursing Susan Ward, RN, BCMA Coordinator, Nursing CDR Jill Reid, BSPharm, BCACP, NCPS, Assistant Chief of Pharmacy CDR Eric Skan, PharmD, Pharmacy Clinical Informaticist, IT Rhonda Stiles, Clinical Applications Specialist, IT Darin Gagner, RN, Clinical Applications Specialist, IT Peter Apathy, BSEE, MS Biomedical Engineering, Project Manager, IT

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 via Remote Adobe Connect Mike Allen, MIS, RPh, Pharmacy Informaticist, IHS/OIT - Remote

6. VA On Site/Remote Cross Functional Team Cathi Graves, Project Manager, BCRO, OIA, VHA Kirk Fox, Clinical 1 Support Team, OI&T, VA Jaculyn Bloch, 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 Cross Functional Team

8. ANTHC Team Carlene McIntyre, PharmD, MPH, Pharmacy Consultant Scott DuFour, BSIT, Clinical Applications Trainer

9. 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 4 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

10. 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

11. 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

12. 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

13. 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.

14. BCMA Configuration & Test Week One – 1 Minimal configuration required due to significant prior remote and onsite participation by Pharmacy and IT Nursing should now use BCMA for their patient medication profile CPRS Med Order button Hyphens not allowed in bar code entry field in CPRS Med Order Button - recommend early testing with locally packaged medications Corrected slow performance issue with software developers (resetting PSB Parameter did not fix the issue) Swing bed configuration

15. BCMA Configuration & Test Week One - 2 Preliminary curriculum testing and classroom training on Friday Learned that bedside medication administration processes need to be delineated and refined Reexamined use of RPC broker ports

16. BCMA Training & Go Live Plan Week Two Thursday & Friday –Training Preparation and Practice Session (16 Hours) Sunday – Morning & Afternoon Pharmacy Training (8 Hours) Monday – Morning & Evening Nursing Super User Training, Afternoon BCMA Coordinator Training (12 Hours) Tuesday – Morning, Afternoon, & Evening Nursing Super User Training (12 Hours) Wednesday – Morning BCMA Coordinator Training, Afternoon Nursing Super User Training – *Go Live Wednesday afternoon Thursday & Friday – Go Live Support Continues Friday – Morning Nursing Super User Training (4 hours) A Total of – 40 Training Hours, 103 Training Encounters, of these 51 were Unduplicated Educational Encounters

17. Mt. Edgecumbe Hospital Training

18. Mt. Edgecumbe Training Statistics

19. Go-Live - Wednesday 9/23/15

20. BCMA Training Lessons Learned – 1 Printing vs. Viewing Medication Due List Insulin delivery from Pharmacy has changed Two nurse verification of Insulin Competing priorities & projects, especially for Nursing Administration Defining context of verbal orders Helpful for pharmacy to understand nursing processes BCMA team needs to continue to meet, possibly as part of P&T

21. BCMA Training Lessons Learned - 2 Pharmacy – Incorporate BCMA in workflow (Use BCMA Cover Sheet vs Computer Generated MAR) Nurses should not EHR Verify until medication is either pharmacy finished (daytime) or nurse finished (nighttime) Patch removal to be evaluated to accommodate <24h application, and alternating removal of patches Pharmacy to change process regarding Hospital Supplied Medications vs Self Medications. This includes accessibility of and self-application of medications such as ointments, inhalers etc.

22. BCMA Training Lessons Learned - 3 Medication transport: Evaluate lockable drawers for carts Identify and delineate infection control P&P for mobile med carts Identify training model for new nurses Delineate use of flow sheets vs BCMA documentation Standardization of terminology – policies, standing orders, protocols How to administer and document urgent or emergent postpartum medications New process for documenting PRN effectiveness

23. 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 beginning of shift, after every major med pass, and at end of shift Identify Medications that Require “Comments” Supervisory/Charge Nurse Generating Specified BCMA Reports (Medication Variance, Missed Medications, PRN Effectiveness)

24. Go Live Lessons Learned Nurses to stop using Pyxis as their due list Scenarios covered during training addressed actual situations encountered after go-live

25. Baseline Scanning Statistics Wristbands Count Processed via Scanner %Total Event 92.9% Scanner By-Pass Keyed Entry Unable to Scan Option 0.0% 7.1% Total Wristband Scan Events14 Medications Count Processed via Scanner %Total Events 100% Scanner By-Pass Keyed Entry BCMA Unable to Scan Vista Manual Med Entry 0.0% Total Medication Label Scan Events45%

26. Post Implementation Scanning Statistics Wristbands Count Processed via Scanner %Total Events 95.7% Scanner By-Pass Keyed Entry Unable to Scan Option 4.3% 0.0% Total Wristband Scan Events23 Medications Count Processed via Scanner %Total Events 98.6% Scanner By-Pass Keyed Entry BCMA Unable to Scan Vista Manual Med Entry 0.0% 1.4% 0.0% Total Medication Label Scan Events71

27. Thank You and Good Luck! We want to take the opportunity to recognize the outstanding efforts of the SEARHC Mt. Edgecumbe 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