Zuni Comprehensive Health Center BCMA (IHS PSB 3*42) Deployment Site Visit June 1 – June 6, 2015.

Zuni Comprehensive Health CenterBCMA (IHS PSB 3*42) Deployment Site Visit

June 1 – June 6, 2015

IHS RPMS EHR Deployment

BCMA Inpatient Deployment

Zuni Comprehensive Health Center BCMA Team

• Rebecca Grizzle, RD, Project Manager• Erica Harker, PharmD, Director of Pharmacy• Benjamin Le, PharmD, Pharmacy CAC• Terry Kanesta-Brislin, BSN, RN, DON, BCMA

Coordinator• Melanie Romancito, CAC• Roxanne Salvador, IT• Keith Martinez, IT• Wil Darwin, PharmD, (A) CEO, Albuquerque Area CAC

IHS On Site 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 (Remote)

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

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 (Remote)• Stephen Corma, BSPharm, RPh, Pharmacist

Consultant, BCRO, OIA, VHA

VA/IHS BCMA CFT 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 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

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 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.

BCMA Configuration & Test • Printer Naming Convention• Transfer and Release Events– From L&D Obstetrics GMS – Allowed an Interward Transfer to follow an

Interward Transfer (Previously could only move patient once)

• Pharmacy “Auto Verify” Activated for All Pharmacists

• CPRS Medication Order Button was Tasked• BCMA Parameter Default Answer List was

Incomplete

BCMA Training & Go Live Plan

• Monday – Configuration and Test (8 Hours)• Tuesday – Training Preparation and Practice Session (9 Hours)• Wednesday – Morning Pharmacy Training (4 Hours), Afternoon Nursing Super User

Session (4 Hours), Evening Nursing Super User Session (4 Hours)• Thursday – Morning BCMA Coordinator Session (4 Hours), Afternoon Nursing Super

User Training Session (4 Hours), Evening Nursing Super User Session (4 Hours)– Go Live Thursday Morning at 11:30 AM– Go Live Support and Troubleshooting Continued Simultaneous to Training and

Over to Nursing Night Shift• Friday – Morning Nursing Super User Session (4 hours), Afternoon Nursing Super User

Training Session (4 hours)– Troubleshooting Throughout Evening

• Saturday – Debriefing, Go Live and Troubleshooting Continues Throughout Saturday Major Medication Passes (0900 and 2100, as well as other medication med passes scattered throughout the day) ~12 hours on Friday and ~12 hours on Saturday

• A Total of – 32 Training Hours, 120 Training Encounters, of these 53 were Unduplicated Educational Encounters

Zuni Comprehensive Health Center Training

Zuni Comprehensive Health Center Training Statistics

Participants

Wednesday 6/3/15 Pharmacy 1 Session (4 Hours)

Super User 2 Sessions(8 Hours)

Thursday 6/4/15

Super User2 Sessions(8 Hours)

BCMACoordinator (4 Hours)

Go-Live 11:30 AM

Friday 6/5/15 Super User2 Sessions(8 Hours)

Go-Live and Troubleshoot-ing Issues

Saturday 6/6/15 Go-Live Support

Continues Through Saturday (8 Hours)

Total

Zuni 20 31 4 55Bristol Bay On Site 6 2 8OIT On Site 7 7 8 3 25OIT Remote 1 1 2VHA/VA 9 5 6 3 23VHA/VA Remote 1 0 1ABQ Remote 5 1 6Total 49 47 18 6 120

BCMA TrainingLessons Learned

• Documentation of IVs Needs to be Standardized for Both Nursing and Coders

• Start Time, Stop Time, and End Time Documentation for IV infusions needs to be Clarified for Both Nursing and Coders

• POC Blood Glucose Values are Not Entered into EHR via POC Button– At a Minimum Enter Blood Glucose Values into

EHR via the POC Button for SS Insulin Doses

BCMA TrainingLessons Learned

• Both Sliding Scale and PRN Insulins are Confusing for Nurses– Standardizing ALL insulin sliding scales via P&T committee

• The “Scanner Barcode Fix” was Added to the BCMA “Tools” Menu

• Inpatient Birth Control – Nexplanon Process to be delineated and Pharmacy will scan the Contraceptive into BCMA and Add Comment: “Dispensed to (Provider)”– Medical Provider Education needs to be provided so Nexplanons

removed from the pharmacy are scanned into BCMA by a pharmacist to ensure adequate Medication documentation.

BCMA Training Lessons Learned Pharmacy Issues

• Hospital Supplied Meds (HSM) Functionality to be Examined and Clarified by Policy (i.e. lanolin in breastfeeding moms, clotrimazole cream, hydrocerin lotion, etc)

• Standardize a Multidisciplinary Policy & Procedure for Patient Supplied Medications to be Examined by Pharmacy and Packaged for Medication Cart and Scanning

• Numerous Old Pending Orders in ^OTHER Queue– Cleanup Task Queued to Run Daily – List was Reduced from over 50 obsolete medication orders to 12– Pharmacy will review Remaining Obsolete Medication Orders and

Discontinue as Appropriate

BCMA TrainingPharmacy Issues

• Define: – NOW dose time frame– ONCE (ONE TIME) dose frame

• Self administered Insulin must be re-educated with Nursing Staff that stock supply insulins cannot be shared

• Re-Orient Staff on Pharmacy Call-Back Policy• Re-educate Standard Time Schedules (i.e. meal

times, dialysis, weekly meds, etc)

BCMA TrainingPharmacy Issues

• Education:– Delayed orders do not include NOW doses– Separate order will be required for a NOW dose– Refer back to education on Standard Times

• After hour medications need to be removed from the Inpatient Night Cabinet– Stock bottles removed from outpatient pharmacy will

not scan in BCMA• Overall Clinical Education: NO PAPER MARs– Find info on Med Admin History (EHR)

BCMA TrainingPharmacy Issues

• After hour use Folder– Insulin labels, common cream labels, etc– Will be located on top of the Med Cart in a Cardex

• Needed Items– Move IV infusion label Aztec Bar Scan to upper

right hand corner to prevent smearing and unreadable bar codes

– Utilizing MAR label printer as an alternate to the WASP system

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

• BCMA GUI Not Installed On All Nurse Workstations

• Lack of Standard Medication Administration Schedule Times – Medication Administration Time was Scattered Throughout all Shifts

• Workstations On Wheels (WOWS) will be used in some Patient Rooms since Wall Cabinets have not arrived

• WOWs do not all have Scanners Attached, one WOW had a Scanner but it was not Ported

Go LiveLessons Learned

• Equipment – West Side Rooms have Work Stations in Rooms but No Place for Scanner

• Limited work space in the West Rooms along with infection control concerns

• Printed Virtual Due Lists need to be SHREDDED After Each Med Pass

• Practice what we were taught this week

Baseline Statistics6/4/15@1200 to 6/5/15@0900

Wristbands MedicationsCount

Processed via Scanner 14

%Total Events

100%

Scanner By-Pass 0 Keyed Entry (0)Unable to Scan Option (0)

%

Total Wristband Scan Events 14

100%

Count

Processed via Scanner 27

% Total Events

90.0%

Scanner By-Pass 3 Keyed Entry (0)BCMA Unable to Scan (0)Vista Manual Med Entry (3)

10%

Total Med Label Scan Events 30

100%

Post Implementation Statistics6/5/15 @ 2000 to 6/6/15 @ 2100

Wristbands MedicationsCount

Processed via Scanner 44

%Total Events

97.8%

Scanner By-Pass Keyed Entry (0)Unable to Scan Option (1)

2.2%

Total Wristband Scan Events 45

Count

Processed via Scanner 76

% Total Events

98.7%

Scanner By-Pass Keyed Entry (0)BCMA Unable to Scan (1)Vista Manual Med Entry (0)

1.3%

Total Medication Label Scan Events

77

Thank You Hospital Leadership

• We want to take the opportunity to recognize the outstanding efforts of the Zuni 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.