IU Health University Hospital Group 2: Narcotic Waste Disposal

IU Health University HospitalGroup 2: Narcotic Waste DisposalExecutive Sponsor: Jennifer DunscombTeam Members: Shelly Burns, Amanda Carmack, Ryan Fier, Amy Gravelle, Tyler WysongH-D615 Health Outcomes and Decision MakingFinal PresentationDate: 11/30/16

Today we will be discussing the current issues with the Narcotic Waste Disposal process at IU Health University Hospital, specifically the Medical IUC units.

Executive Sponsor: Jennifer Dunscomb - Director of Professional Nursing Practice and Quality (project champion)Team Members Education Program:Shelly Burns- DNP (Clinical expertise)Amanda Carmack - DNP (Clinical expertise)Ryan Fier - MHA (LEAN SME)Amy Gravelle - MHA (LEAN SME, Clinical unit liaison) Tyler Wysong - MHA (Project Leader, Fresh Eyes, Technical Coordinator, and Presenter)IU Health University HospitalGroup 2: Team Members

Before starting, our team wanted to provide some background our team, academic background, roles played, and links to professional profiles

This presentation is broken into three key sections The BackgroundCurrent State Analysis Solution proposal

Lets get started

IU Health University HospitalNarcotic Waste DisposalBackground

Current narcotic disposal methods are evolving to meet the demands of future compliance and safety regulations DEA has proposed a No flush policy as the industry standardRuling overviewMedical facilities that dispose (waste) of partially administered controlled substances cannot waste in the sink or open waterwaysDEA ruling will adhere to environmental regulations and attempts to further decrease drug diversionDiversion: concept involving the transfer of any legally prescribed controlled substance from the individual for whom it was prescribed to another person for any illicit use (American Society of Health-System Pharmacists, 2016)DEA Ruling Problem Statement: 4.

Our group was consulted because the DEA has proposed a new No Flush Policy around how clinicians waste narcotics.This proposal is quickly becoming the industry standard, so it is key we understand its framework at a high level.

Clinicians will no longer be able to waste narcotics into public waterways, Yes that mean the sink at patient bedsideThis is an attempt to further reduce illegal drug diversion and reduce narcotic exposure into the waste water system.

We also felt it was important to define diversion here. If you would like more information on the Ruling, we have provided a link to the Federal Register (specific information can be found on page 53,548)

Tyler Wysong () - +ajcarmac@iue.edu -- did you say that you would take care of this or do I need to find it?Amanda Carmack () - I will find one. You are just looking for a reference with a definition...correct?Tyler Wysong () - find a reference for diversionTyler Wysong () - Yes, we are just looking for a reference for a similar or exact definition

Sent from my iPadOur team will recommend a dry sink system that is compliant with the DEAs No Flush policy for IU Health University Hospitals Medical ICU in order for the unit to become 100% compliant with this industry standard with a timeline of one calendar year (2016-2017).

Measurable system metrics (realistic, attainable & timely, measureable):System efficiency - limitations Cost effectiveness Safety / Impact on diversion of partially administered narcotics Integration / Sustainability in current workflow

Aim Statement:5.

What now? Our team has worked to create a proposal around which a dry sink system that complies with DEA ruling and works best for IU Health University Medical ICU units.

The goal is to be 100% compliant by the close of one calendar year, yah that is by 2017.

Metrics considered on this project are as follows:

Project Scope:Project Scope: IU Health University ICU (medical); all other units excludedProcess Start: When a controlled narcotic is partially administered Process Stop: When the partially administered narcotic has been witnessed and disposed.6MetricsInitial StateTarget State% compliance to DEA standards for disposing partially administered narcotics 0% compliance 100% compliance% completion of new training on new complaint process N/A 100%

It is important to understand that our team focused on the Medical ICU to provide a tailored solution.

The scope starts when a controlled narcotic is partially administered And Ends When the partially administered narcotic has been witnessed and disposed.

This slide, also shows the initial state metrics vs. target state, yes that penny is hard to shine.

IU Health University HospitalNarcotic Waste DisposalCurrent State Analysis

Current State - OverviewEvery time there is a need to waste narcotics the nurse has to find a witness (2nd nurse to watch the process)The unit has two methods of wasting: In the patient room (Virtual Wasting)Witnessed, Wasted in sink, Documented in Pyxis at bedsideIn the Med roomWitnessed, Wasted in sink, Documented in Med Room Pyxis Each room can become an isolation room at any point in time so it is important to have a process that can adapt to the patient room Current wasting procedures at bedside or med room are not compliant with DEA No Flush policy8.

The current Medical ICU process is as follows Nurse has to find a 2nd nurse to witness the process Nurse can choose to waste inside the patient room ORThe nurse can walk to the Med Room to execute the process

Why are there two methods? Each patient room can become an isolation room at any given point That is why it is important to have a system that is flexible to the needs of the medical ICU

Current State- Process MapDescribe the current conditions of this process using text, data, charts, graphs, and photos.9.

This slide represents that process

Current State - Principle Issue Overview ICU is not compliant with DEA proposal due to lack of disposal units Placement of disposal devices in appropriate locationsImplementation of a process that prevents workarounds or breaks in workflow

10.

Some key things our team considered while working on this solution includes

The unites compliance to this proposal System placement for ease of access and use And the overall implementation for sustainability

Current State - Waste Walk

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After multiple visits to the Unit we were able to identify some other areas of waste as seen above.

I would like to draw your attention to the Waiting box. The next few slides will dive into some other issues here that were outside the scope but impact the overall process .

Current State - Collateral Issues Wasting in the Med Room is incentivized because: Computers at patient bedside very slow Computer system timed out when collecting metricsComputer in Med Room is much faster Start to finish took under 60 second start to finishWalking to the Med Room = increased likelihood of finding a witness 12.

Because of the following reasons, wasting narcotics in the Med Room is the preferred method:

First the bedside computing systems are extremely slow I mean slow enough when a unit nurse attempted to show us the process the system timed out on itself

Second the Med room computing system is fast because that computer dedicated to this process

Lastly when you walk to the med room, the likelihood of finding someone to witness the process increases.

These are things we had to consider for the final recommendation but fully understand that they are outside our team scope.

Gap Analysis FishBone SummaryEffect: Non-compliance with DEA standards for disposing partially administered narcoticsPeople: lacking a 2nd nurse; (sometimes unavailable)Policies: lack current policy complying with DEA standardsPhysical plant: lack of appropriate disposal containers; lacking consistent computer systemEnvironment: lack of system / process for compliance 13.

Our team used the Fishbone Diagram to construct the effect on outcomes

These are some of the key components that we pulled for your viewing. Next slide will show the entire diagram.

Gap Analysis - FishBone Visual 14

Our team feels it is important for leadership to have access to our full picture. This graphic indicates other areas explored when constructing the recommendation. Feel free to pause the presentation.

IU Health University HospitalNarcotic Waste DisposalProposed Solutions

16Cactus Smart SinkStericycleRx DestroyerVideo Fact SheetStericycleCompliance solutions video WebsiteWaste instructions for liquidWaste instructions for Pills ProProProMeets the DEAs requirements for controlled substance disposal.One unit can be used for solid and liquid waste.It is mobile and can be installed wherever there are Narcotics being disposed of - ex. At the bedside in patient isolation situations or ICU 1:1 patient care situations. Waste can be thrown out.Meets the DEA requirements for controlled substance disposal.Offers online training center for implementationStericycle offers site specific metrics on training utilization Stericycle offers regulatory updates regarding products and services rendered Membership offers a 10% discount on healthcare products including: sharps containers, mailback disposal, infection control, and safety items.No fine - No Fail OSHA / HIPAA compliance Meets the DEA requirements for controlled substance disposal.Cost $49 per unitMed waste is uncoverable within minutes.Waste is stated to be environmentally safe and can be disposed with traditional trash.Effective for 1,000s of non-hazardous medications and illicit drugs (pills, tablets, Narcotics, creams, capsules, Fentanyl, suppositories

Pros for each System

IU Health was kind enough to provide the three following systems for our team to review.

This slide and the next provide an overview of our pros and cos list for the products

On this slide I would like to point out two things:the Cactus Smart is so user friendly that the system requires minimal training and even tell the practice when it needs replaced through a display The Stericycle system offers online training models, and a No-Fine No Fail Osha/Hipaa compliance assurance (if the unit gets a fine because of the systems and they were being used properly, stericycle absorbs the cost). They also provide a 10% discount on other health products when you have their product. The RX destroyer is by far the most cost effective

17Cons for each System Cactus Smart SinkStericycleRx Destroyer

Video Fact SheetStericycleWebsiteWaste instructions for liquidWaste instructions for Pills ConConConCost $500 per unit Cost $99-$170 per unitTakes 7-10 days for FedEx delivery.Cost is listed in Pros section

Cannot handle hazardous materials Must have multiple containers (one for solid, one for liquid)

Looking at the downside of these products

Cactus smart sinks are by far the most expensive Stericycle has to use FedEx for waste disposal RX destroyer is limited to what it can handle and uses multiple containers

Proposed Solutions - 1Cactus dry sink in Med Room (2)Stericycle in each patient room to ensure consistent compliance with DEA standards Reasoning:Voice of the Customer feedbackSystem expense Cost efficency Platform / Design for Success 18.

After considering the options our Team proposes: That a cactus dry sink is placed in each med room because of the systems reputation for user friendliness and that this location has the highest flow for wasting partially administered narcotics. We also propose Stericycle units be placed at patient bedside for three reasons:Voice of the customer the clinical team said on numerous accounts that having a waste system in each room is imperative to care. After looking at the cost difference between these two systems and their capabilities, Stericycle is a clear choice for bedside use. We understand that having multiple systems can introduce multiple points of failure however the Stericycle product offers the pre build training and a no fine no fail policy.Lastly having a dry sink system existing in each patient room builds a platform for success. This is our way of referencing the IT system improvements that should happen in the future around wasting narcotics at bedside.

Future State Process Map

Now it is important for us to consider the impact on workflow, here is the process map showing our recommendations and the impact they would have.

Please note that our teams recommendation does not impact the current workflow process.

Please feel free to pause here for a moment.

Action Plan

20.ITEM #ACTION ITEMWHO TIMESTATUS1Create new standard work procedure/document about wasting narcotics at patient bedside/MedRoomProcess Owner*TBD2Update policy to reflect new procedure and expectationsProcess Owner*TBD3Create training program on new processProcess Owner*/ ICUunit managerTBD4Implement training programICU Unit Manager/Charge NursesTBD5Implement control plan to sustain new processProcess Owner* TBD6Designate champions for new process (super users) Charge NursesTBD

*Process Owner is the individual who is responsible for managing a process on a daily basis.

Its one thing to recommend a solution but we also considered the next steps.

This slide outlines our action plan for the IU Health Medical ICU team.

As you can see the who and time have been left with ambiguous terms because we would need your help identifying who would own these processes and what timeline they need to be on.

Please note that step three will be minimal since one system only has a few steps and the second vendor provides that training as a part of the product suite

Communication Plan

21.TYPE OF INFORMATION & PURPOSEPREPARED BYDUE DATEDISTRIBUTION LISTSTATUSNew standard work proceduresProcess OwnerTBDUnit managers and Staff nurses of medical ICUInformation of maintenance of new containers Process OwnerTBDTBD (environmental services, nurses, housekeeping)Information of ordering new supplies for containersProcess Owner TBDTBD (inventory, administration, nurses) Project timeline rollout of systemsClinical Project LeaderTBDTBD (inventory, administration, nurses)Training education scheduleClinical Project LeaderTBDTBD (inventory, administration, nurses)

*Process Owner is the individual who is responsible for managing a process on a daily basis.

Along side the Action plan we have also constructed a suggested communication plan

Again the prepared by, dates, and distribution are left ambiguous so that the clinical and administrative team can identify key team player that are appropriate for product roll out.

Control Plan

22.PROCESS NAME: Narcotic Disposal SystemPROCESS OWNER: Jennifer DunscombPROCESS STEPMEASUREMENTFREQWHO MEASURESCORRECTIVE ACTION1. Dispose of narcotic in new container Frequency of container capacity becoming fullBi-WeeklyCharge nurse/unit manager/designeeVoice of Customer target audience of nurses who use the process -- Root Cause Analysis (discover barriers and reasons for non compliance) (5 whys)2. Document disposal in electronic system Alignment between # of narcotics used and # of narcotics documented as disposedWeeklyAutomated report (pharmacy) Drill down on what drugs were not wasted properly to understand barriers and trends3. Continue education / training for new staffCompletion rate of training modules Quarterly Integration to ELMS modules Follow up with new care providers to ensure training occurs

This control plan was our teams way of providing guide rails for your team while implementing this system, if chosen.

Three key areas to watch include: If the systems are being used (watching the frequency of container capacity vs. pharmacy reports on narcotics administered) How well these systems integrate with the workflow (pulling report as to wasting at bedside or in med room) Discussing barriers with the customer (clinicians) about the training, how effective the training is for travelling nurses, and the current workflow.

We made this process owner Jennifer however this process can be shared by charge nurses, and IT team members.

Barriers & RoadblocksNurse workflow current preferences Resistance to change Risk of drug diversion Slow computer system in patient rooms 23.

These were some of the barriers identified in the process

This first one identifies that each clinician has a preference on the process, and from what we gathered there is not a set standard process since the unit is so fluid in patient needs Second we just recognize the human nature to resist change Compliance is key here This statement is just saying that the system chosen needs to be integrated and easy access for team members to use Lastly the IT system at patient bedside reduces the effectiveness of clinical team members to document and execute the process in a timely manner.

Team InsightsHelped: (1)Going to the Gemba, (2)Talking with stakeholders (nurses), (3)Witnessing the current processesHindered: (1)Online meetings, (2)team members schedules (minimal impact)What worked well: (1)Interdisciplinary team (nursing/MHA students)Lessons learned: (1)Students need to understand how to better engage with the IU Health team24.

As a team we really enjoyed going to Gemba, Talking with the clinical staff, and actually viewing the process

Since we are an interdisciplinary team out meetings and work happened completely online. Some members time schedules also varied making it hard to have inclusive conversations but that was far and few.

We all agreed that the diverse backgrounds and strong work ethics provided the best team work and outcome we have experienced

Lastly we received mixed signals around the best method to contact stakeholders at the beginning of the semester. This made it hard to construct the deliverable but with guidance we were able to connect and construct this proposal.

25.

Thank You!Any Questions?

We would like to thank you and your team for working with us this semester. Now that you have heard our perspective, what are your thoughts?

ReferencesAmerican Society of Health-System Pharmacists. (2016) ASHP guidelines on preventing diversion of controlled substances. Retrieved from ww.ashp.org/DocLibrary/BestPractices/MgmtGdlCSDiversion.aspxf

Catt, E. (2014). Lean Six Sigma & A3 Thinking Workbook. TTAC Consulting, LLC.

Institute for Healthcare Improvement (2016). XX. Retrieved from http://www.ihi.org

Plsek, P. (2014). Accelerating health care transformation with Lean and innovation: The Virginia Mason experience. Boca Raton, FL: CRC Press.

US Department of Justice. (2012). Rules - 2012. Retrieved from https://www.deadiversion.usdoj.gov/fed_regs/rules/2012/fr1221_8.htm

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Amanda Carmack () - What is this reference for?