1. Rosebud Hospital BCMA (IHS PSB 3*42) Deployment Site Visit October 19 – 30, 2015

2. IHS RPMS EHR Deployment

3. BCMA Inpatient Deployment

4. Rosebud Hospital BCMA Team Carin Greenhagin, RN, Inpatient Nurse Manager, BCMA Lead Abby Peterson, PharmD, BCMA Pharmacist Janette LaBelle, Information Technology

5. IHS On Site/Remote Cross Functional Team David Taylor, MHS, RPh, PA-C, RN, BCMA Federal Lead, IHS Office of Information Technology Deborah Alcorn, MSN, RN, CPC, BCMA Nurse Consultant, IHS Office of Information Technology Chris Saddler, RN, BCMA Information Technology Consultant, IHS Office of Information Technology via Remote Adobe Connect Mike Allen, MIS, RPh, Pharmacy Informaticist, IHS Office of Information Technology

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

7. VA Cross Functional Team

8. 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 FY 16 – Implementation at 10 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

9. 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

10. 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

11. 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 – 10 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

12. 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. MU Stage 3 MU Measure is “Topped Out”

13. BCMA Configuration & Test Week One Lessons Learned Not Participating at Another Site was Disadventagious Continued Drug File Clean-up BCMA Equipment Installation Safety Keyboards are Difficult to Use Placement of Scanners are Precarious Classroom BCMA Training Books (Admitting Demo Patients, Entering Orders, Preparing Demo Patient Wristbands, Preparing and Copying Medication Barcode Copies and Labels for Training Books) Identifying and Delineating Medication Administration Processes Pharmacy and BCMA Preparation for Winnebago and Eagle Butte

14. BCMA Training & Go Live Plan Week Two Sunday – Pharmacy Focus Staff, End User (Nursing Content) 8-12, 1-5 Pharmacy Specific Curriculum Monday – End User (Nursing Content) 8-12, BCMA Coordinator 1-5, Pharmacy 6-10 Tuesday – End User (Nursing Content) 8-12, End User (Nursing Content) 1-5, End User (Nursing Content) 6-10 Wednesday – End User (Nursing Content) 8-12 A Total of – 36 Training Hours, 100 Training Encounters, of these 48 were Unduplicated Educational Encounters

15. Rosebud Hospital Training

16. Rosebud Hospital Training Statistics

17. BCMA Training Lessons Learned Pharmacy Staffing is Dangerously Stretched Inpatient Pharmacy Support is Necessary Consider Remote Pharmacy Support BCMA Coordinator Resource to be Available at All Times BCMA Contingency Plan Delineate “Self-Med” versus “Hospital Supplied Med” Delineate “Patient’s Own Med” After-hours Storage of Reconstitutable Antibiotics Procedure for Scanning Medications into Drug File and Pyxis Policy for “First Dose Now” Order Many Possible Failure Modes for Medication Errors (ADT, CPOE, Verbal Orders, Medication Administration) Continue to Examine Optimal Inpatient Medication Administration Times

18. BCMA Training Lessons Learned Update Policies & Procedures to Align with New BCMA Processes: Each Ward needs to Designate a BCMA NURSING SUPERUSERS 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)

19. Go Live Lessons Learned Admission, Discharge, and Transfer Process is Paramount for Patient Safety, Medication Safety and Reimbursement Multiple Points of Failure for Accessing Server(s) in Thin Client Environment Do Not Turn Off Terminals in Patient Rooms Inpatient Pharmacy Support is Erratic Realign Medication Administration Times to Align with Physician, Pharmacy, and Nursing Patient Care Optimization

20. Recommendations Scan ALL Medications into Drug File and Assign a Synonym Pharmacy Staff is Dangerously Stretched Full Time Pharmacy Informaticist Necessary (Drug File, Quick Orders, Automated Dispensing Cabinets, BCMA, CMOP, ePrescribing) Full Time Clinical Application Coordinator Necessary for (a) EHR, (b) BCMA, (c) Other GUI Applications, and (d) RPMS Clinical & Administrative Applications Seek TDY Pharmacy Informaticist to Assist with Drug File Clean-up and Broken Quick Orders Providers to Use Medication Tab to Manage Medications Providers MUST Use Quick Orders to Avoid Medication Errors Acquire Necessary Equipment & Supplies (Amber Syringes, Unit Dose, Pyxis Tower, Pyxis Refrigerator) Inpatient Pharmacy Support is Necessary Pharmacy Training is Necessary to Avoid Crisis Mode (RPMS, CMS, DNV) Continue BCMA Implementation for L&D, Post-Partum, Day Surgery, Inpatient Surgical Suite to Maintain a Complete Medication Administration Record throughout All Transitions of Care

21. Baseline Scanning Statistics Wristbands Count Processed via Scanner %Total Events 95.2% Scanner By-Pass Keyed Entry Unable to Scan Option 1 Total Wristband Scan Events 23 Medications Count Processed via Scanner %Total Events 98% Scanner By-Pass Keyed Entry BCMA Unable to Scan Vista Manual Med Entry 1 Total Medication Label Scan Events50

22. Post Implementation Scanning Statistics Wristbands Count Processed via Scanner 60 %Total Event 96.8 Scanner By-Pass Keyed Entry Unable to Scan Option 2 3.2 Total Wristband Scan Events 62 Medications Count Processed via Scanner 104 %Total Event 100 Scanner By-Pass Keyed Entry BCMA Unable to Scan Vista Manual Med Entry 0 Total Medication Label Scan Events 104

23. Thank You and Good Luck! We want to take the opportunity to recognize the outstanding efforts of the Rosebud 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