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 () - [email protected] -- 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
11.
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
26.
Amanda Carmack () - What is this reference for?
