Rosebud HospitalBCMA (IHS PSB 3*42) Deployment Site Visit

October 19 – 30, 2015

IHS RPMS EHR Deployment

BCMA Inpatient Deployment

Rosebud Hospital BCMA Team

• Carin Greenhagin, RN, Inpatient Nurse Manager, BCMA Lead• Abby Peterson, PharmD, BCMA Pharmacist• Janette LaBelle, Information Technology

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

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

VA Cross Functional 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 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

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 – 10 EH – (No VA IAA for

implementation)

• Error reduction:• 91% reduction in Category E

• 84% reduction in Category FBCMA Data from 9 IHS/Tribal Hospitals:

Cherokee, NC, Chinle, AZFt. Defiance, AZ Whiteriver, AZGallup, NM Shiprock, NMClaremore, OK Tahlequah, OKTalihina, 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.•MU Stage 3 MU Measure is “Topped Out”

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

BCMA Training & Go Live PlanWeek 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

Rosebud Hospital Training

Rosebud Hospital Training Statistics

Participants

Sunday Pharmacy End User 10/25/15

Pharmacy Specific

2 Sessions(8 Hours)

Monday Super User10/26/15Pharmacy 3 Sessions(12 Hours)

TuesdaySuper User10/27/153 Sessions(12Hours)

WednesdaySuper User10/28/151 Session(4 Hours)

Thursday Go-Live Support

Continues 10/29/15

Friday Go-Live Support

Continues 10/30/15

Total

Rosebud 7 8 10 8 0 0 33Winnebago 2 2 4 2 0 0 10Eagle Butte 0 10 10 3 0 0 23OIT (Onsite & Remote)

3 9 8 3 3 3 29

VHA/VA (Remote)

0 3 2 3 0 3 11

Total 12 32 34 19 3 6 106

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

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)

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

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

Baseline Scanning Statistics

WristbandsCount

Processed via Scanner

%Total Events

95.2%

Scanner By-PassKeyed EntryUnable to ScanOption

1

Total WristbandScan Events

23

MedicationsCount

Processed viaScanner

%Total Events

98%

Scanner By-PassKeyed EntryBCMA Unable to ScanVista Manual MedEntry

1

Total MedicationLabel Scan Events 50

Post Implementation Scanning Statistics

WristbandsCount

Processed via Scanner 60

%Total Event

96.8

Scanner By-PassKeyed EntryUnable to ScanOption 2

3.2

Total WristbandScan Events

62

MedicationsCount

Processed viaScanner 104

%Total Event100

Scanner By-PassKeyed EntryBCMA Unable to ScanVista Manual MedEntry 0

Total MedicationLabel Scan Events 104

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