Phoenix Indian Medical CenterBCMA (IHS PSB 3*42) Deployment Site Visit

March 9 – March 20, 2015

IHS RPMS EHR Deployment

BCMA Inpatient Deployment

Phoenix Indian Medical Center BCMA Team

• Karen John, Acting Director Clinical Informatics, PIMC

• Jeff Walling, PharmD, Pharmacy CAC• Dan Diggins, PharmD, Inpt Pharmacy

CAC• Lynda Von Bibra, RN, CAC/BCMA Lead• Tony Millkamp, RN, CAC• Sue Barney, RN Clinical Nurse• Ernest Jaramillo, RN Clinical Nurse• Kira Wilder, RN Specialty Nurse• Kris White, RN Clinical Nurse• Les Wilkie, RN, ICU Nurse Manager

• Deborah Ward-Lund, Med/Surg Nurse Manager

• Erin Ezzell, RN, PP/Couplet Nurse Manager

• Vina J Dele, IT Director /Site Manager• Vernita M Jones, Site Manager• Rebecca Shirley, PIMC HIM• Dennis Vollin, Systems Administrator • Michael Nez, System AdministratorPhoenix Area Office Support• Elvira Mosely, Phoenix Area CAC• Tammy Brewer, Phoenix Area CAC• Roberta Joe, System Administrator

“ Team ABQ”

• Mescalero: Yolanda Adams, RN, DON; Jason Harris, PharmD

• ACL: Theresa Sanders, RN; Suryem Palanki, PharmD

• ZSU: Ben Le, PharmD; Terry Kanesta-Brislin, RN, DON; Keith Martinez, IT

• SFU: Lisa Palucci, RN DON; Kyle Sheffer, PharmD

SEARHC Team

• Eric Skan, PharmD, Pharmacy/EHR Informaticist

• Rhonda Stiles, IT System Administrator/EHR informaticist

• Jill Reid, PharmD, Pharmacy Manager

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 (Remote)

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

VA Remote 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 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 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.

PIMC BCMA Equipment Costs

BCMA Medication Cart **

Wireless Scanner

Thermal Wrist

Printers

Wristband stock (adult and baby)

for 3 months

Wall mounts

(Enovate)

Keyboard (antimicrobial

& waterproof)

Mouse (antimicrobial

& waterproof)

Dell Wyse Thin Client's

- BCMA Carts & Wall

Mounts24" Dell

Monitors

Wireless Equipment for 2, 3, 4

floors Comments

ICU (11 beds) 5 7 1 5 5

3 East Med/Surg 7 9 1 7 7

4 West Nursery 2 2 1 2 2

4 - L&D 1 11 1 1 1

4 - Postpartum 4 9 1 8 12 12

Pharmacy 6

Emergency Department 1

Spare 2 1

Totals 19 46 7 8 27 27 27 27

Cost Each$

6,909.00 $

750.00 $

1,437.66 $ 2,700.00 $

39.00 $

30.00 $ 653.70

Overnight Shipping 1437.66$ 300.00

Total Cost$

131,271.00 $

34,500.00 $

29,756.31 $

2,210.72 $ 21,600.00 $

1,053.00 $ 810.00

$ 17,950.00

$ 6,209.73 $ 11,859.92 $ 257,220.68

** BCMA Medication Cart

- 8 drawers, IV pole, Electric height adjustment

BCMA Configuration & Test Activities

• Installed the Correct BCMA GUI on all Workstations• Older Versions of BCMA Installed on Some Workstations• Equipment (Carts, PCs, Scanners) Needs to be

Purchased for PACU, Same Day Surgery, and OR• PIMC ADT – Observation & Treating Specialties, Day

Surgery, Inpatient Surgical Suite, Release Events• Assigning Security Keys, Menu Options and System

Access Permissions• Assemble carts and configure cart management

software• Configuration and setup of Wristband printers• Pharmacy Drug File cleanup

BCMA Implementation Barriers• Nurse Informaticist/Nurse BCMA Coordinator(s)– Nursing leadership involvement with workflow process

• Wireless– Equipment– Bridge Solution; Piggyback onto Phoenix Area Office– On going support

• Carts– Arrived One Week Ago– Acquisitions Process

• RPMS Configuration & BCMA Access– Delineation of Responsibilities– Large Number of Users (Options & Keys)

BCMA Week TwoTraining & Go Live Plan

• Friday – Training Preparation and Practice Session (96 Person Hours)• Saturday Evening – Nursing Super User Training (4 Hours)• Sunday – Morning Pharmacy BCMA Training (4 Hours), Afternoon BCMA Coordinator

Training (4 Hours), Evening Nursing Super User Training (4 Hours)• Monday – Morning Nursing Super User Training (4 Hours), Afternoon BCMA

Coordinator Training (4 Hours), Evening Nursing Super User Training (4 Hours)• Tuesday – Morning Nursing Super User Training (4 Hours), Afternoon Nursing Super

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

User Training Session (4 hours)– Go Live Wednesday 2:oo PM– Troubleshooting Wednesday Afternoon, Evening, Night Shifts

• Thursday – Debriefing, Go Live and Troubleshooting Continues Throughout Thursday and Friday Major Medication Passes (9:00 AM, 2:00 PM, 9:00 PM) 16 hours on Wednesday and 18hours on Thursday

• A Total of – 48 Training Hours, 324 Training Encounters, of these 121 were Unduplicated Educational Encounters

Phoenix Indian Medical Center Training

Phoenix Indian Medical Center Training

PIMC Training Statistics

Participants

Saturday 3/14/15

Super User 1 Session (4 Hours)

Sunday 3/15/15

Super User 1 Session(4 Hours) Pharmacy 1 Session (4 Hours)

BCMA Coord (4 Hours)

Monday 3/16/15

Super User 1 Session(4 Hours)Pharmacy1 Session(4 Hours)

BCMA Coord (4 Hours)

Tuesday3/17/15

Super User 1 Session(4 Hours)Pharmacy1 Session(4 Hours)

BCMA Coord (4 Hours)

Wednesday3/18/15

Super User 2 Sessions(8 Hours)

Go-Live Begins

Wednesday 2:00 PM throughFriday

3/20/15Total

PIMC 17 64 74 77 21 0 253Incl: Santa Fe 0

Mescalero 0Zuni 0ACL 0SEARHC 0

OIT 3 9 8 4 6 0 30VHA/VA 10 5 4 0 19I/T/U Remote 9 9 4 0 22

Total 20 73 101 95 35 0 324

BCMA TrainingLessons Learned

• Respiratory Therapists- do not enter EHR orders and Do Not Have Access to the CPRS Med Order Button – A Process will be Developed

• Place a Laptop in Each Medication Room for Easy Access to BCMA while Accessing Pyxis

• Often could not Access BCMA through Thin Client Workstations

• RPMS & BCMA Access

BCMA TrainingLessons Learned

• Layers & Silos• On-going Training & Support Needs• Training Preparation• Overextension of Staff• Adaptability of Nursing Staff and Impressive

Competency with “First Use” • Successful Preparation of Pharmacy Package • Area CAC Staff Participation• Training Equipment

BCMA TrainingLessons Learned

• Update Policies & Procedures to Align with New BCMA Processes:– Each Ward needs to Designate a BCMA NURSING

COORDINATOR(S) for ongoing BCMA support & orientation– Each Nurse to View Missed Med, IV bag status report & 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

• Printing Wristbands via PPW• Workstations “Lock Up” During Medication

Pass• Workstations “Drop Connection” on Third

Floor• Fourth Floor (L&D and Couplet Care) is

“Different”• Due List and Missed Medication Reports will

Prevent Errors

Baseline Statistics

Wristbands MedicationsCount

Processed via Scanner 40

%Total Events

81.6%

Scanner By-Pass 9 Keyed Entry (0)Unable to Scan Option (9)

18.4%

Total Wristband Scan Events 49

Count

Processed via Scanner 309

% Total Events

71.5%

Scanner By-Pass 123Keyed Entry (2)BCMA Unable to Scan (19)Vista Manual Med Entry (102)

28.5%

Total Medication Label Scan Events 432

Post Implementation Statistics

Wristbands MedicationsCount

Processed via Scanner 68

%Total Events

84%

Scanner By-Pass (13) Keyed Entry (8)Unable to Scan Option (5)

16%

Total Wristband Scan Events

81

Count

Processed via Scanner 117

% Total Events

62.6%

Scanner By-Pass Keyed Entry (70)BCMA Unable to Scan (9)Vista Manual Med Entry (59)

37.4%

Total Medication Label Scan Events 187

Recommendations for BCMA-Nurse Management Team

• Managing Scanning Failures (MSF)– Wrist Bands and Medications– Workstation & Wireless Issues

• Medication Errors– Medication Due Lists– Missed Medication Reports

• Realign BCMA Documentation with EHR• Root Cause Analysis Medication Errors• Medication Variances and Medication Schedules• Infection Prevention• Managing Urgent Doses• Review and Revise Medication Administration Policies • Future training of current and new employees• Contingency Plan Development

Recommendations for BCMA-Nurse Management Team

• BCMA and EHR Documentation– Pain– Insulin– Heparin– PRN Effectiveness– IV Bag Status– Tubing Change– Patch Medications – Canned Scanned Comments

• Nursing Competencies and Training– At-the-Elbow– Classroom

• Monitoring “Work Arounds”• CPRS Med Order Button

Special Thanks• IHS Office of Information Technology

– Mike Allen, OIT Pharmacy Informaticist– Chris Saddler, OIT Information Technology Specialist

• VA BCRO– Kirk Fox, VA CLIN 1 Team

• Phoenix Area Office– Elvira Mosely, Area CAC– Tammy Brewer, Area CAC– Roberta Joe, Area Systems Administrator– Dan Wood, Area Systems Administrator

• “Team ABQ”– ACL, Santa Fe, Zuni, Mescalero

• SEARHC• Clint Krestel, PharmD, NNMC

Thank You Hospital Leadership!

We want to take the opportunity to recognize the outstanding efforts of Lynda Von Bibra,

Jeff Walling, Dan Diggins, and Tony Millkamp for their BCMA Team leadership. We

also thank the Phoenix Indian Medical Center Leadership for providing financial and human resources, which helped contribute to a highly successful BCMA Training and Implementation

Good Luck!