BCMA Implementation checklist and lessons learned

First off let me start by saying that I think BCMA is a worthwhile endeavor. It can have a positive impact on a healthcare system, not only in terms of safety, but with inventory management and billing . The other nice benefit is the ability to see the medication administration in “real-time”. Pharmacists can look at vancomycin and aminoglycoside administration times online now instead of going to the paper chart, for example. And isn’t that the whole idea behind electronic documentation? I think so.

Our facility went live with out first BCMA unit last week. It’s still early, but my initial take is that things went fairly well. We had a few minor issues, but nothing that couldn’t be handled easily and quickly. No matter how well you plan for something there will always be some bumps in the road, and that is important to note.

Below are some things that I picked up along the road to implementation. Some of these things we did well and some we didn’t do at all. This list is my opinion and not the gospel on BCMA implementation by any stretch of the imagination. Please remember that as you read through it.

And now, on to my list of recommendations for BCMA implementation:

• Pick a strong person to lead your implementation team. They’ll have to shoulder quite a bit and they need to be able to make decisions, stick to them, and hold others accountable.
• Create an empowered multi-disciplinary team to work on the project.
• Create an empowered multi-disciplinary team to work through issues following implementation.
• Only meet when you have to. I hate meeting to decide when you’re going to meet.
• Involve nursing early and often.
• Make sure you have enough resources assigned to the project. I believe this is one of the most common mistakes that leads to project failure. If you don’t assign the proper resources to a project people will get spread too thin and things will get missed.
• Remember: you’ve added something to your healthcare system and it will require maintenance and optimization. You need to have resources assigned and available to handle these two things. Don’t short change the BCMA system.
• Identify key people to take ownership of the system once things start flying. In other words figure out who can help troubleshoot something once you go live.
• Assign someone to analyze data coming from the BCMA system. If you chose not to have the data analyzed don’t even bother collecting it.
• Only speak positively about the system in public. If you have to complain about something do it behind closed doors. People believe what they hear and a positive attitude goes a long way.
• Be aggressive with your implementation timeline. Don’t sit on a project too long; it costs money and people get bored.
• Don’t “over plan”. You can’t plan for every possibility. Some people think you can, but I don’t think that’s realistic. Do what you can and implement. You’ll learn more during the first 3 months after implementation then you could ever learn by sitting around a table talking about what could go wrong. We agonized over our pharmacy automation much longer than we should have. A few months after implementation we ended up scrapping our original workflow in favor of a better one. Two years later and we’re still tweaking things. Be diligent in your preparation, but don’t go overboard. All you’ll do is make everyone uptight and drive yourself crazy.
• Don’t be afraid to scrap something and start over. Not every idea translates well from paper to practice.
• Don’t marry yourself to an idea. Just because someone else is doing something a certain way, doesn’t mean you have to. It’s always a good idea to get opinions from other facilities, but don’t force it into your system if it doesn’t makes sense for you.
• Train nurses and pharmacists together prior to go-live, but not too far in advance. People tend to forget things soon after being taught when the lessons aren’t reinforced; out-of-sight, out-of-mind. I think it’s important for the pharmacists to see how the system works from the nurses point of view; it helps when barcode issues come up.
• Create a list of FAQ for end users. These are typical questions that come up during training. It’s basically a list of “what ifs”.
• Have lots and lots of “super users” available to help nursing during the initial implementation phase. This prevents people from getting frustrated with the system before they’ve had the change to use it correctly and efficiently.
• Have a good downtime plan including a way to generate a paper MAR that isn’t too far out of date. We print a MAR to a holding queue every 60 minutes. Each time the MAR is generated it overwrites the previously stored version. If the system goes down we can print the MARs from the holding queue and the oldest they can be is 60 minutes.
• Decide how to best use clinical prompting in the BCMA system, if available. There’s no need to give nurses alert fatigue with a new system. If you currently use a system to define sound-alike-look-alike meds, black box warnings, etc then consider not forcing the nurse to deal with it again in the BCMA system. For example: we use our ADCs to alert nurses of drugs with black box warning. When the nurse removes a black box med from an ADC they receive a pop-up window alerting them of what to look for. They acknowledge the alert and chose to remove the drug or not based on the information presented. It makes no sense to add the same pop-up message to the BCMA system. All you’ve accomplished by duplicating the waring is ensure that nurses will start ignoring the warnings.
• Decide if you will chart in the BCMA system or elsewhere, not both. I’m talking about blood pressures, HR, finger sticks, etc. If your nurses already use a separate system to chart vitals don’t force duplicate documentation somewhere else. For example: our blood glucose monitors synch to our clinical nursing system. It makes no sense to have nurses enter the same blood sugar value in the BCMA system prior to administering insulin.
• Don’t let just anyone re-print patient wristbands. If anyone can re-print a wristbands, then you’ll find them attached to clipboards, IV polls, guardrails on the beds, etc. Make it hard to do the wrong thing.
• BCMA Hardware for nursing
• I’m not a big fan of “hardware fairs”. Put a thousand nurses in an area with 20 different vendors and you’ll get 500 opinions on what hardware configurations should be used. On the other hand, use a small group of nurses to select a few vendors to evaluate and you’ve got something to work with.
• Look at various solutions, i.e. in room devices mounted on the wall, laptops, tablets, computers on wheels (COWs), etc.
• If you decide to go with COWs or tablet PCs consider: 1) your storage needs for the devices, 2) battery life and replacement, 3) your protocol for cleaning the devices that go from one room to another, and how to handle patients in isolation
• Evaluate several types of barcode scanners, i.e. wireless, bluetooth, tethered. Look at different manufacturers. I’m a fan of Code Corp scanners myself, but would also recommend Honeywell.
• Don’t skimp on the barcode scanners; this is the center piece of the barcode scanning workflow after all.
• I still believe that the scanner you chose should be the same as the one used in pharmacy. I’ve received some negative feedback regarding this opinion, but I’m sticking with the recommendation. A single vendor means one support system to deal with, one set of hardware configurations, fewer questions trying to decide if it’s the hardware or the barcode and the ability to instantly pick up a scanner and use it anywhere in the hospital.
• Evaluate your wireless coverage throughout the hospital if you chose to go with wireless devices. Nothing is worse than pushing a wireless COW into a patient care area only to find out you can’t connect to the hospital network. I don’t care how great the system is, at that point the COW becomes a doorstop.
• Make sure you have enough electrical outlets and network access points.
• Take the opportunity to clean up your pharmacy formulary
• Standardize the nomenclature in your pharmacy system, i.e. tablet, capsule, etc
• Take a long hard look at your latin sig file. Pharmacists tend to use a lot of unnecessary latin sigs. Create a standard list along with standardized administration times. You should already have standardized sigs and administration times, but if you don’t get it done now.
• Get rid of as many non-formulary items as you can.
• Consider how you’re going to handle the following:
• pediatric syringes. are you going to use dose specific barcoding or drug identification only.
• insulin. patient specific vials or pens or a third option
• premixed IVs. Are you going to have nursing scan the product barcode or the pharmacy generated barcode
• chemotherapy
• Get everything in the pharmacy barcoded. This is key. You may have to use a combination of systems. You will need a way to barcode everything from bulk tablets to injectable vials to pediatric syringes. We use a complete automated packaging and labeling solution from Talyst, but there are others out there that offer similar services. Medical Packaging Inc offers a simple label solution; m:Print bar code label software from PearsonMedical is another. Even with all of our high-tech labeling equipment we ended up using Microsoft Word, a bunch of Avery return address labels and a free on-line linear barcode image creator at IDAutomation.com, Inc for certain items. That simple solution actually worked better than our multi-thousand dollar system in a couple of situations where we needed a barcode image without the lot and expiration data on the label. Go figure.
• Think about oddball medication in the pharmacy that may require a unique solution like unit dosed respiratory therapy drugs, levalbuterol, budesonide, etc, ampules, bulk tablets, etc.
• Scan everything in the pharmacy to make sure they are in your system. In fact, I recommend you do it twice.
• Scan everything in the automated dispensing cabinets on the pilot unit a few days before you go live. I thought we had everything well in hand until I scanned the items in our ADCs and found a couple of meds by manufacturers we hadn’t purchased in several months. The meds were still in date, but not in the system.
• Develop a system to deal with medications that have no barcode, won’t scan or scan as the wrong drug. No matter how diligent you are items will slip through the cracks; better to have a system in place than to be caught with your pants down.
• Cross train everyone in the pharmacy to troubleshoot barcoding issues. Trust me, you’ll regret it if you don’t.

I won’t tell you where I think we failed in our implementation because that just wouldn’t be right, but needless to say we didn’t do everything perfect which is how I got the idea for some of the items on the list. If you’d like to talk about my experience with implementation in more detail feel free to contact me and we can chat about it one on one. I would like this list to become a living document and I encourage you to leave comments, good or bad, about the list above or about items you think should be added that could help others. There’s always someone out there smarter with better ideas and I’d like to hear about them.