Fort Defiance Indian Health Board, Inc. BCMA (PSB 3*42) Deployment Site Visit

1. December 8 – 20, 2013 Fort Defiance Indian Health Board, Inc. BCMA (PSB 3*42) Deployment Site Visit

2. Background • 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.

3. Bar Code Medication Administration Assistive (BCMA)Technology • BCMA is an Assistive Technology Software Application Developed and Used by the Veterans Health Administration (VHA) Facilities to Document Medication Administration Activities and Reduce Medication Errors • The VHA Bar Code Resource Office (BCRO) has Developed a Structured Process for Performing Usability Assessments of New Features to Assure Successful Adoption by End-Users • BCMA is a Component of the RPMS-EHR Certified Electronic Health Record. PSB*3*42 offers improved functionality.

4. Purpose of BCMA (PSB 3*42) Training • BCMA is an Integral Part of Patient Safety, Nurses Administer Medications, Including IV Piggyback Medications and IV Large-volume Medications, through BCMA • All Information is Documented with a 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

5. Purpose of Training (cont.) • Pharmacy and Nursing Staff Must Collaborate Closely with Information Technology Services Staff if the Medication Administration Arm of the System is to Work Optimally • The Purpose of this Week’s Training is to Provide BCMA Training to the BCMA Super Users, Pharmacy Staff, Respiratory Therapists, and BCMA Coordinators

6. IHS-OIT/FDIHB/Navajo Cohort/CF Teams

7. Fort Defiance Indian Health Board, Inc. BCMA Team • Brenda Benally, DPh, BCMA Project Lead/CAC • Melinda Nez, RN, Lead Informatics Nurse/CAC • Jonathan Boress, PharmD, Pharmacy Resident • Joseph Durand RN, Inpatient Informatics Nurse/CAC, BCMA Coordinator • Nichole Barney, RPMS Site Manager • Kathy Tso, RPMS Site Manager • Lydia Alvarez, FNP Provider Informatics Nurse/CAC

8. VA Remote Cross Functional Team • Cathi Graves, Project Manager, BCRO, OIA, VHA • Kirk Fox, Clinical 1 Support Team, OIT, VA • Barbara Connolly, Clinical 1 Support Team, OIT, VA • Jonathan Bagby, MSN, MBA, RN-BC, Nurse Consultant, BCRO, OIA, VHA • Hugh Scott, MS, RNC, VHA Management & Program Analyst, Washington, DC, IHS/VA Liaison, • Daphen Shum, BSPharm, RPh, Pharmacy Consultant, Perry Point, MD, VAMC • Stephen Corma, BSPharm, RPh, Pharmacist Consultant, VHA Office of Informatics and Analytics,BCRO

9. IHS On Site Cross Functional Team • David Taylor, MHS, RPh, PA-C, RN, BCMA Federal Lead, IHS/OIT • Deborah Burkybile, MSN, RN, CPC, BCMA Nurse Consultant, IHS/OIT • Phil Taylor, BA, RN, BCMA Nurse Consultant, MSC Contractor • Chris Saddler, RN, BCMA Information Technology Consultant, IHS/OIT via Remote Adobe Connect • Kathy Ray, CNM, HIT-PRO CP, CIMTAC Chair, IHS Navajo Area CAC • Northern Navajo Medical Center BCMA Team • Gallup Indian Medical Center BCMA Team • Whiteriver PHS Indian Hospital BCMA Team • Chinle Comprehensive Health Care Center BCMA Team

10. VA IHS BCMA Collaboration Effort • Includes BCMA Software, Hardware, and Medication Administration Process Reviews • FY13 – Implementation at 2 IHS sites • FY14 – Implementation at 8 IHS sites • FY15 – Implementation at 4 IHS sites • 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 • Remote and On-site “Cohort” BCMA Team Participation in the Cherokee Indian Hospital Authority BCMA Implementation/Training, July 14-18, 2013 • Ongoing Remote RPMS Pharmacy Drug File Cleanup • Fort Defiance Indian Hospital Board, Inc. Remote Support: • BCMA Configuration/Test – Dec 8-13, 2013 • BCMA Super User/Pharmacy/Coordinator Training – Dec 15-20, 2013 • Go Live Support – Dec 18-20, 2013

11. Configuration & Test Findings and Recommendations • In order to provide a 12 digit patient ID as the barcode for the patient wristband, it was necessary to switch from using the data flow for the embosser card to the data flow for the wristband routine. This was accomplished with the assistance of AMT Data South. • We edited the %ZISTCP routine to remove mods made for IHS Patient Chart in order to enhance the response time of the BCMA Client GUI. • There should only be one port defined for the VA RPC Broker listener.  It can then be used by more than one application (i.e.. Vista Imaging, Radiology Reports, as well as BCMA) • Taskman Scheduling Issues: Start Up or Start Up Persistent - Edit ‘Special Queuing’ field for tasks that don’t really need this status – Too many items cause a significant delay during reboot. Only listener type tasks should be persistent.

12. Training Activities • Saturday – Training Preparation and Practice Session (12 Hours) • Sunday - Morning and Afternoon Super User Training Sessions (4 hours each) • Monday – Morning and Afternoon Super User Training Sessions (4 hours each), Evening BCMA Pharmacy Training Session (4 hours) • Tuesday – Morning and Evening Super User Training Sessions (4 hours each), Afternoon Pharmacy Training Session (4 Hours) • Wednesday – Morning BCMA Pharmacy Training (4 hours), Afternoon BCMA Coordinator Training (2 hours) • Go Live Wednesday afternoon • Troubleshooting • Thursday – Debriefing, Go Live and Troubleshooting Continues Throughout Thursday and Friday Major Medication Passes (9:00 AM & 9:00 PM) 14 hours on Wednesday and 14 hours on Thursday • A Total of 105 Navajo Cohort Nursing, Pharmacy, Respiratory, and Physical Therapy Staff Attended Training that Included Remote Attendees • Close to One-Third of Students Attended all Three Classes • Students were trained as BCMA Coordinator’s will continue Troubleshooting and Continued Monitoring

13. BCMA Training

14. BCMA TrainingFindings & Recommendations • Install the BCMA GUI client on 10 MSU Nursing workstation, 5 Carts, Inpatient Pharmacy 4, Pharmacy downstairs 2, Respiratory workstation 1, ICU 5 • A Scanner does not have to accompany each BCMA GUI Client; only those that will be used in Point of Care requires a scanner • Involvement of HIM BCMA Team Member for guidance to document “High Acuity” situations i.e. “Comments” for late medication • Provide Access to the VA BCMA Training Module in preparation for on-site BCMA Training and for Refresher and New Hire Training • Plan to Continue to Train all Inpatient Nurses, Inpatient Pharmacists, and Respiratory Therapists

15. BCMA TrainingFindings & Recommendations • Consider Placing the “Comment” Bar Code Sheet on the Medication Cart for Convenient Access • Consider Refresher/Reinforcement Training for “New Functionality”: • CPRS Med Order Button • Scanning Failure Processes • Create Policies and Procedures to Align with New BCMA Processes: • Each Nurse to View Missed Med & PRN Effectiveness Reports Often • BCMA Competency Evaluation periodically (annual, bi-annual, etc.) • Documentation for All PRN Effectiveness • Consider Realistic PRN Documentation Time Frame • Independent Nurse Verification for 5 Rights Medication Administration when Over-riding Scanning Process

16. BCMA TrainingNursing, Pharmacy, Respiratory Therapists

17. Go LiveFindings & Recommendations • Identify BCMA Competency Forms & Perform for Nursing, Pharmacy, Respiratory Post Go Live • Incorporate BCMA Reports in Medication Error Review Committee and Root Cause Analysis Meetings • FDIHB BCMA Team to Meet Weekly to Discuss Scanning Failures/Troubleshooting and Provide Feedback to All Clinical Staff • Pharmacists to Shadow Nurse Medication Administration Periodically and Nurse shadow Pharmacists

18. Post-Implementation Statistics • Medications • Wednesday 1700 to Friday 0900 - 92% • Thursday 1700 to Friday 0900 – 96.3% • Friday 0700 to 0900 – 97.7% • Wristbands • Wednesday 1700 to Friday 0900 - 47% • Friday 0700 to 0900 – 76%

19. Go LiveFindings & Recommendations • RN’s View Assigned Patient’s PRN Effectiveness Report Several Times Per Shift • Respiratorywill Document PRN Effectiveness Through BCMA GUI • Each RN & RT View Missed Med Report Beginning Shift, After Every Major Pass, and End of Each Shift • Prior to Discharge, Complete or Stop all IV Infusions, if Ordered Remove Patient Med Patches and Document as Removed in BCMA • Monitor the Observation to Full Admit Process for both ADT and Pharmacy • Medical Staff to Review the 2-Midnight Rule requirements

20. Thank You