Blackfeet Community HospitalBCMA (IHS PSB 3*42) Deployment Site Visit

October 27 – November 7, 2014

IHS RPMS EHR Deployment

BCMA Inpatient Deployment

Blackfeet Community Hospital BCMA Team

• Jamie Ladd, PharmD, Inpatient Pharmacy CAC/ BCMA Lead• Purnee Brandvold, CAC• James Farr, BSN, RN, Night Nursing Supervisor/BCMA Coordinator• Charlene Ramirez, BSN, RN, Day Nursing Supervisor/BCMA Coordinator• Shirley St. Goddard, IT/RPMS Specialist• Stacey Thompson, PharmD, Pharmacy Supervisor• Jody Sabo, BSN, RN, Surgery Nurse Supervisor• Lisa Racine, HIM• Eric Chosa, RPh, Billings Area Pharmacy/CAC• Margaret Cooper, Area Billings Area CAC• Verna Kuka, Billings Area IT/RPMS Specialist

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

• Mike Allen, MIS, RPh, Pharmacy Informaticist, IHS/OIT - Remote

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

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 5 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

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.

BCMA Configuration & Test Equipment Barriers

• Scanners were Requested, but Less Expensive Scanners were Purchased that Did Not Include BCMA Default Settings

• Facility CAC Expedited a Purchase Order for Required BCMA Default Cards, thus Increased Costs were Incurred ($400)

• VHA BCRO Team Member Fortunately was Prepared to Intervene (Luck!)

BCMA Configuration and TestMiscellaneous “IT” Barriers

• Inconsistent Connectivity to Mobile Workstations

• Inconsistent Connectivity and Performance of Thin Clients

• EHR Does Not Display Correctly on Old Monitors• Lack of Data Ports• Lack of Patch Cables• Lack of Human Resources for IT Support

BCMA Configuration & Test Week One Cohort Activities

• ADT – Delineating, Fine-Tune Admission, Discharge, Transfer Processes and Delayed Orders

• Day Surgery – Identify and Communicate Selected Processes– “BCMA vs Admit to PACU Note with Medication and IV

Sections”– Communication of Handoff of Medication Administration

Responsibilities from CRNA to RN– Concern for Short BCMA Timeout Interval– Post Op Discharge Rx appear on EHR Medication Tab, Staff will

Need Training to Locate and Provide Hard Copy for CII medications

BCMA Configuration & Test Week One Cohort Activities

• Pharmacy Issues– IV Fluids Must Match Orders– No Consistency in Available Surgery IV Fluid Stock– Pharmacy Scheduling for Day Surgery Medications

Must be Finished Prior to 7:30• Scanning Failures– Delineate and Implement a Process for Receiving IV

Solutions and Scanning into the Drug File– Problem Solving Medication Scanning Failures begins

with Pharmacy Tech (i.e. synonym file)

BCMA Week TwoTraining & Go Live Plan

• Friday – Training Preparation and Practice Session (8 Hours)• Sunday – Afternoon Nursing Super User Training Session (4 Hours)• Monday – Morning Nursing Super User Training (4 Hours), Afternoon BCMA

Coordinator Sessions (4 Hours)• Tuesday – Morning Pharmacy Training Session (4 Hours), Afternoon Nursing Super User

Training Session (4 Hours)• Wednesday – Morning Pharmacy Training Session (4 hours), Afternoon Nursing Super

User Training Session (4 hours)– Go Live Wednesday 3:30 PM– Troubleshooting

• Thursday – Debriefing, Go Live and Troubleshooting Continues Throughout Thursday and Friday Major Medication Passes (6:00 AM, 10:00 AM, 10:00 PM) 16 hours on Wednesday and 18hours on Thursday

• A Total of – 28 Training Hours, 111 Training Encounters, of these 56 were Unduplicated Educational Encounters

Blackfeet Community Hospital Training

Blackfeet Community Hospital Training

Blackfeet Training Statistics

Participants

Sunday 11/2/14

Super User 1 Session(4 Hours)

Monday 11/3/14

Super User1 Session(4 Hours)BCMA

Coordinator1 Session(4 Hours)

Tuesday11/4/14

Pharmacy1 Session(4 Hours)

Super User1 Session(4 Hours)

Wednesday11/5/14

Pharmacy1 Session(4 Hours)

Super User (4 Hours)

Total

Blackfeet 10 17 11 15 53OIT 2 4 4 4 14VHA/VA 4 8 8 8 28I/T/U Remote 7 3 6 16Total 16 36 26 33 111

BCMA TrainingLessons Learned

• Consider HSM Configuration for Bedside Creams, Topicals, etc.

• Recommend Leaving Inhalers, Ointments Used by Patients in a Locked Bedside Drawer

• Clearly Delineate and Communicate Insulin Administration Policies and Procedures

• Formalize and Communicate PRN Effectiveness Documentation Policy (BCMA vs DAR)

BCMA TrainingLessons Learned

• PCA Documentation Between Transitions of Care

• IV Fluid Documentation Between Transitions of Care

• Nursing and HIM Need to Define and Approve Bar Coded Comments for Use with CPRS Med Order Button

BCMA TrainingLessons 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)

Go LiveLessons Learned

• Patient Supplied Medications• Wristbands MUST be Attached to Patients• All Medications MUST be Bar Coded• Two Nurse Verification Process for Insulin and

other “High Alert” Medications• Standard Administration Times• Removed “128 Bar Code” from the Wristband to

Minimize Confusion• Infection Control Practices and Techniques for

Medication Administration

Baseline Statistics

Wristbands MedicationsCount

Processed via Scanner 21

%Total Events

80.8%

Scanner By-Pass 5 Keyed Entry (2 )Unable to Scan Option (3)

19.2%

Total Wristband Scan Events

26

Count

Processed via Scanner 60

% Total Events

93.8%

Scanner By-Pass Keyed Entry (0)BCMA Unable to Scan (4)Vista Manual Med Entry (0)

6.3%

Total Medication Label Scan Events

64

Post Implementation Statistics

Wristbands MedicationsCount

Processed via Scanner 27

%Total Events

87.1%

Scanner By-Pass 4 Keyed Entry (1)Unable to Scan Option (3)

12.9%

Total Wristband Scan Events

31

Count

Processed via Scanner 49

% Total Events

100%

Scanner By-Pass Keyed Entry (0)BCMA Unable to Scan (0)Vista Manual Med Entry (0)

Total Medication Label Scan Events

49

Thank You Hospital Leadership!

We want to take the opportunity to recognize the outstanding efforts of Purnee Brandvold and Jamie Ladd for their BCMA Team leadership. We

also thank the Blackfeet Community Hospital Leadership for providing financial and human resources, which helped contribute to a highly successful BCMA Training and Implementation