1. Pine Ridge IHS Hospital BCMA (PSB 3*42) Deployment Site Visit September 8 – September 19, 2014

2. IHS RPMS EHR Deployment

3. BCMA Inpatient Deployment

4. Pine Ridge IHS Hospital BCMA Team Latona Austin, PharmD, BCMA Pharmacy Coordinator/ BCMA Lead Rodney Sahr, BSN, RN, Clinical Applications Coordinator Angela Nelson, PharmD, Inpatient Pharmacy Supervisor Maxine American Horse, RN, Acute Care Nursing Supervisor Linda Dixon, RN, Acute Care Staff Development, BCMA Nursing Coordinator Tasheena Schreiner, RN, BCMA Nursing Coordinator Ed Stover, IT Supervisor Teresa Blacksmith, RN, OB Nursing Supervisor Leslye Rauth, MPH, RD, Great Plains Area Clinical Applications Coordinator, Sioux Falls Martin Hall, Great Plains Area IT Specialist, Sioux Falls

5. Pine Ridge IHS Hospital BCMA Team

6. 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

7. IHS OIT EHR/BCMA Team

8. VA On Site/Remote Cross Functional Team Cathi Graves, Project Manager, BCRO, OIA, VHA Kirk Fox, Clinical 1 Support Team, OI&T, VA Jaculyn Bloch, Clinical 1 Support Team, OI&T, VA Jonathan Bagby, MSN, MBA, RN-BC, Nurse Consultant, BCRO, OIA, VHA Jan Zeller, MBA, BSN, RN, Education Project Manager, VHA EES Stephen Corma, BSPharm, RPh, Pharmacist Consultant, BCRO, OIA, VHA Daphen Shum, PharmD, Pharmacist SME, VA Maryland HCS Clayton Curtis, MD, VHA/IHS Interagency Liaison Barbara Connolly, Clinical 1 Support, OI&T, VA

9. VA Cross Functional Team

10. 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

11. 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

12. 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.

13. BCMA Configuration & Test Week One Cohort Activities DataRay™ on site for Printer Configurations Drug Product and Wristband Samples Verified by BCRO with Recommended Modifications Labor & Delivery, Obstetrics/Postpartum, Day Surgery and Inpatient Surgical Suite Configurations and Test BCMA Pharmacy Configuration Activities CPRS Med Order Button Troubleshooting CNM and OB orientation to EHR/RPMS process of admitting and transferring OB patients Surgeon and OR Nurse Supervisor orientation to EHR/RPMS process for inpatient surgery patients

14. BCMA Week Two Training & Go Live Plan Friday – Training Preparation and Practice Session (8 Hours) Sunday – Morning, Afternoon, Evening Nursing Super User Training Sessions (12 hours) Monday – Morning, Afternoon, Evening Nursing Super User Training Sessions (12 hours) Tuesday – Morning Nursing Super User Training Session (4 hours), Pharmacy Afternoon Training Session (4 hours) – OB Go Live Tuesday 4:00 PM – Troubleshooting Wednesday – Morning BCMA Coordinator (4 hours), Afternoon Pharmacy Session (4 hours) – Acute Care Go Live Wednesday 2:00 PM – Troubleshooting Thursday – Debriefing, Go Live and Troubleshooting Continues Throughout Thursday and Friday Major Medication Passes (1000,1400,2200) 14 hours on Wednesday and 14 hours on Thursday A Total of – 40 Training Hours, 232 Training Encounters, of these 94 were Unduplicated Educational Encounters

15. Pine Ridge IHS Hospital Training

16. Pine Ridge Training Statistics

17. Pine Ridge IHS Hospital Training

18. BCMA Training Lessons Learned Define and Develop Policies/Procedures for Hospital Supplied Medications and Patients Supplied Medications Delineate Nursing Notification to the Contract Remote Pharmacist and Communicate the Acceptable Response Time for Contract 24 hour Pharmacy Support Timely A/D/T Admission/Discharge/Transfer Processes CPOE within Labor & Delivery and OB (Hybrid System) Auto Discontinue Pharmacy and Nursing Orders on transfer from Inpatient Ward to Surgery Consider a process of reviewing Admission orders and defining orphan orders (Nursing, Lab and Radiology) to clean up obsolete orders

19. BCMA Training Lessons 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)

20. Go Live Lessons Learned Equipment Placement and Ergonomics Keyboard Orientation and Challenges Computer Workstation in Medication Room Refine & Implement the Policy for Multiple Dose Containers at Patient Bedside Pharmacy Finishing Process Impacts End-Users Provide Patient Education on BCMA Wristband and Medication Scanning Ongoing Communication between Pharmacy and Nursing

21. Baseline Statistics Wristbands Medications Count Processed via Scanner 30 %Total Events 96.8% Scanner By-Pass 1 Keyed Entry (0) Unable to Scan Option (5) 3.2% Total Wristband Scan Events 31 Count Processed via Scanner 72 % Total Events 93.5% Scanner By-Pass 5 Keyed Entry (0) BCMA Unable to Scan (3) Vista Manual Med Entry (2) 6.5% Total Medication Label Scan Events 77

22. Post Implementation Statistics Wristbands Medications Count Processed via Scanner %Total Events Scanner By-Pass Keyed Entry Unable to Scan Option Total Wristband Scan Events Count Processed via Scanner % Total Events Scanner By-Pass Keyed Entry BCMA Unable to Scan Vista Manual Med Entry Total Medication Label Scan Events

23. Thank You Hospital Leadership! We want to take the opportunity to thank the Pine Ridge IHS Hospital Leadership for providing financial and human resources, as well as limiting inpatient census which helped contribute to a highly successful BCMA Training and Implementation

24. Thank You & Good Luck! “Patient Safety First, Because Second is Too Late”