Our Guest: Dawn Reed, DSL MBA RHIA CHC Compliance Program Manager
In this episode, we’re thrilled to welcome Dawn Reed, Compliance Program Manager at a prominent healthcare system. Dawn, who recently earned her doctorate with a dissertation focused on drug diversion, brings a wealth of knowledge and a unique perspective to our discussion. While her current role does not oversee the drug diversion program, Dawn’s expertise in this area is undeniable.
We’ll explore her background and delve into why she chose drug diversion as the subject of her doctoral research. Dawn will share her insights on some surprising discoveries from her dissertation and discuss the prevalent issue of ambivalence towards drug diversion among front-line staff and management.
We’ll also address strategies for initiating conversations about potential diversion when early data seems off but isn’t yet conclusive. How can we approach these delicate discussions without making staff feel accused?
Finally, we’ll explore which department should ideally oversee drug diversion programs. Dawn will share her thoughts on whether such programs should report to Compliance and how a multidisciplinary committee might impact this perspective.
Join us as Dawn Reed provides valuable insights into drug diversion and compliance in healthcare!
Thanks to our sponsor, MIDAS Healthcare Solutions Learn more about V.I.E.W. Waste and Return System: https://midashs.com/products/ For more information on Drug Diversion mitigation and resources, visit: https://www.rxpert.solutions/
Transcript:
Terri
Welcome back, everybody, to diversion insights. We do have a sponsor for today’s episode, MIDAS Healthcare solutions, taking technology to the next level to help deter and prevent medication diversion. The key features of their product include real time visual proof that the medications were disposed of compliantly with machine learning and AI to identify drug wasting behaviors. Technology integration and reconciliation with your ADC, EMR, and diversion software, which enables you to account for the reconciliation of waste, including outliers, and any time witness technology, which allows the convenience and flexibility when a witness is required in the disposal of unused controlled substances. And RX intercept. Rx Intercept, which is the ability to customize random and targeted sample collection. Secure chain of custody. Quite a robust product. My guest today is Dawn Reed, the compliance program manager with a large healthcare system. Welcome, Dawn.
Dawn
Hello.
Terri
I want to set the stage just a little bit, and then, of course, I want you to fill in the blanks regarding your background. You are, as I mentioned, a compliance program manager, but your department as a whole does not oversee the drug diversion program at your healthcare system. And, you know, because you have recently completed your doctorate degree and your dissertation was related to drug diversion, you certainly would be the perfect person to oversee the diversion program. You wouldn’t need to be convinced that diversion is a thing which sometimes needs to happen and that it needs to be mitigated and monitored. So let’s just kind of start there. What is your background and what is your involvement in the current diversion program?
Dawn
Okay, thank you. So, just a little bit of history back. I’m going to say 15 years ago, I was the physician practice manager for multiple physician clinics that were employed by healthcare system. And early in the days of managing the departments, I became keenly aware of opioid prescribing practices. And I live in a very small town, rural community. And some additional history. We here in Martensville, Virginia, were deemed as having the most millionaires per capita back in the eighties, and that was due to textiles industries. We had the sweatshirt capital of the world. We had the nylon capital, and we also had the furniture capital.
Dawn
Now, of course, all three of those things intertwined with textiles industry workers, factory workers with lots of injuries, lots of repetitive work, a lot of injuries with their backs or their hands, and repetitive techniques that they would have to overcome in the factories. And so that somewhat helped precipitate more prescriptions for opioids was pain. But at that time, the diversion at 15 years ago in my world, was not as prevalent as it is now. And so we recognized some issues, and we started a very robust program of having a contract in place. We were looking at the prescription monitoring program, and it just became very apparent to me that the opioids were a concerning issue. And so, fast forward ten years, in 2017, Martinsville, Virginia was deemed as having the highest prescribed number of opioids per capita in the US.
Dawn
So it did get a lot of negative attention. And I was working with a group through Virginia Tech that were working on strategies on overcoming community actions for opioids. So I’ve been working on that project probably five or six years now. We have made some tremendous strides using a seed method that’s a stakeholder engagement, so that we always are looking at stakeholders in the community to get together information of how we can combat this issue here in Martinsville. And it has since expanded to several of our communities, our joining communities. And so with that in mind, I went and decided to get my doctorate degree. And I thought, you know, with my community dealing with this.
Dawn
And I was able to work on an audit at my healthcare facility with hospital based departments on regulatory information and making sure that the hospital based departments had the appropriate documentation, their DEA license and DHH license were up to date. I was able to get a little glimpse more into the acute care setting for diversion. And so that’s what made me start to research into more about diversion in the acute care setting. Setting. And so that’s what made me start looking into that.
Terri
Interesting. Yeah, I love to hear about things that are going on at local levels. I think there are a lot of. There’s a lot of things I think we hear in the media about everything, and it seems a little, I don’t know, hopeless, helpless. But you talk to different people and you find that there are several things going on out there trying to make a difference. So that’s. Yeah, that’s interesting to hear about that, and it’s good to hear. So the transition kind of, into the acute care setting, which you’re in healthcare as well. So you’ve. You’ve got that background. And so when you were working on your dissertation, did you discover anything that surprised you? Maybe something you thought you knew, but then you found out? Oh, that’s. Your hypothesis was incorrect.
Dawn
Well, having a fresh eye on this topic in the acute care facility, acute care setting for diversion, I was surprised a bit, maybe not for veterans that have been dealing with this topic for a long time, but just some of the things that I noticed were the actual concealment and sweeping the issue under the rug. I think we all are keenly aware that people fear reporting. They fear, retribution. I was able to interview multiple nurses and to ask them questions. And the first question was your overall awareness. And what was surprising was that either some of the people had didn’t even really know what I was talking about, and these are active nurses working in healthcare, or they had worked with someone that had diverted and were keenly aware of what it was about and had experience, and they shared their stories.
Dawn
I think the overall key focus was lack of time for when I talked to the nursing leadership. It just was not a priority with other pressing issues. And they also discussed how difficult it is to talk to nurses about this topic because it’s almost an automatic defensive nature. So they were really challenged with trying to find ways to speak with nursing just in general conversation or maybe in our huddle group about this topic without people feeling defensive and feeling as though they’re being accused of something or why are you talking to me about this? So the lack of talking about it, I think, has created some of those barriers that you don’t talk about it for a really long time, and now all of a sudden you’re bringing this up to me or to this group. What’s wrong? What did we do wrong?
Dawn
Yeah, just maybe a lack of strategies, you know, to overcome that defensive nature and how to integrate discussions in their team meetings and. Yeah, just. Just competing priorities was very apparent.
Terri
Yeah, I want to unpack some of that. You said a lot in there. I find the same thing when I talk to people in terms of their lack of knowledge about this subject. It’s one or the other. It’s. They don’t really like. No, that’s not a thing. Or, yes, I’ve been involved in it. So I think the tendency is to not probably think that it happens within healthcare unless you’ve experienced it and then you know that it does happen. Did you find that the people that have experienced it then are truly aware of it maybe happening again or maybe even that they feel that was kind of a one off and it just doesn’t really happen that much, although they do have experience with it once. Did you get any sense for that?
Dawn
That’s a great question. I would say that they were hyper focused after that. I think once they got over the initial shock of who diverted because they trusted that person, they may have been a friend. And, you know, again, this is a common thing that we hear is it’s the person you’d least expect and every person that knew someone talked about their work performance, their ethical stance in their. And their quality of work that they were so shocked by what had happened, they just couldn’t believe it was that person that was diverting, always willing to lend a hand, always willing to help when needed. And we, of course, now identify those as red flags. And so now they. They seem to be hyper focused on the topic of this happened.
Dawn
And I don’t want this to happen to me again because some of them were involved in the actual investigation. Investigations. And you could tell that it made a lasting impression on them to experience that.
Terri
Right? Yeah. Well, and in many cases, they maybe inadvertently, not consciously helped conceal it as well. Right. Not doing your waste, due diligence or making excuses or covering for them when they couldn’t complete something without knowing what was going on or without wanting to see what was going on, but they had play to hand it to continue. Yeah. Now when you say that the tendency to kind of sweep things under the rug and just, you know, pretend it’s not happening, were you talking about more on the leadership level that we don’t want to see it, or were you talking about coworkers and direct supervisors as well?
Dawn
I think it was a little bit combination of both. Some of the leadership. Again, it’s. It’s a, you know, again, time is a factor. So. And it’s such a small issue in the eyes of most healthcare providers that why do I need to take up this much time to address this issue? And for, you know, the nursing side, I would say that they definitely felt it was important, but didn’t think it was prevalent enough to really take up.
Terri
A lot of time. Sure. Okay. That makes sense. All right. You also touched on the conversations that are hard to have, and I do find that, and it’s frustrating because coming from my perspective, where we’ve done the research and we’ve looked at the data, there’s definitely a conversation that needs to be had. It might not be diversion, but there’s something different. Right. And so we need to ask a few questions because we’re not quite sure where to go next. And I run into put the hand up by HR. It’s like, no, we don’t want to make them feel like they’re being accused. We don’t want to. If nothing is going on, then they have to go back to work and that this makes them uncomfortable and then they don’t trust us, you know, type of thing.
Terri
So did you come to any realization or have, do you have any suggestions on how to make both ends of that?
Dawn
Right.
Terri
You gotta have that conversation, but you’re right, you don’t want to if they’re not doing anything wrong from a diversion perspective and it’s a practice issue, then we want to be able to move forward. So do you have any thoughts on that?
Dawn
Well, I think that, I think having the discussion more will make people feel more comfortable to talk about it. And again, if you go to talk about a topic that you don’t normally talk about, and it’s a very serious topic, people tend to tense up or get defensive. But this has got to be in your everyday, every week discussion. Diversion is important. And I think also that how people respond to questions when they have questions about, well, what if I were to suspect someone? What would happen if the managers and the HR personnel are not prepared for those conversations and respond appropriately, that will cause a defensive nature. For example, if you were to say, well, you know, if an employee were to come to a manager and say, well, what happens if someone is diverted?
Dawn
And the manager just says, you know, I really am not sure. I’ve never had that happen before, then there might increase fear in reporting. And if the manager says, you know, this is our program here at whatever institution you’re working at, these are the steps that we take and that, you know, there would be an investigation. But there also is, you know, programs for those that are suffering with substance use disorders and, you know, really embrace the overall topic in a way that they make the person who may be struggling with substance use or a person that is observing this to be less defensive. And some employees may feel as though they’re doing that person a favor by reporting them rather than just sweeping that under the rug and just letting this behavior continue.
Terri
Yeah, I agree with that. I like the idea of not only talking about it from an education perspective, you got to know what it is. You got to know that it happens, but making it more of a quote unquote, normal conversation. And I think that might actually even go along with holding people more accountable from a practice perspective, too. And again, I think that comes down to time. Right. It’s, you know, you’ve probably been in positions, well, I’m sure you are right now, of supervising employees. Right. And that’s a lot of work to keep track of things. If you really do have to give them some sort of performance improvement to stay on it, to see what consistently they’re doing that they need assistance and help with. And it takes a lot of time.
Terri
But when we talk about nurses from a practice accountability perspective, maybe you come across something where, oh, they did, let’s say, barcode scan or they wasted late or whatever the situation is. It’s easy just to like, eh, I’m sure that was just a one time thing that hardly ever happens, rather than to look a little bit closer and like, oh, this person is always not doing that and falling into the policies and procedures. And so if you increase those conversations as well, then the whole practice, which may or may not be diversion, but that whole thing, it becomes a conversation that is just a normal thing. You know, I’m gonna talk to you. I’m gonna talk to you. I’m gonna talk to you. I mean, if I see it happening, it’s not just you that has the problem, right?
Dawn
That’s right.
Terri
And then culture. You’re right. I mean, I don’t think any of us would say that none of us will ever experience some sort of emotional trauma in the years that we work together, right? Whether it be a death or an illness or a divorce or injury or something. And so that’s just. You wouldn’t be surprised if somebody came to you and said, I’m, you know, I’m going through this right now. And so why should we be surprised if somebody’s struggling with a substance. Substance use disorder? It’s just one more thing that in the course of life. Right? And so if you change that culture to this life, and so let us talk you through it and help you stay healthy.
Dawn
That’s right.
Terri
That’s right.
Dawn
Because they’re watching how we respond to these investigations, and if they see someone just, you know, abruptly leave and no regard to their future or their well being, they will take note of this. And so having a positive discussion about substance use disorders and diversion, and also for those nurses that are putting themselves at risk by saying they witnessed a waste when they didn’t, that’s another educational component we really need to look at to reemphasize to all clinical staff that you are participating in this when you are stating in a legal document that you witnessed. And I think sometimes that we forget that risk on the other side.
Terri
Right? Yeah. Well, and there might be, again, it comes back probably to culture if the culture on your unit is to log into the automated dispensing machine and walk away because it’s busy and you trust your coworkers, and then all of a sudden, you have a new employee, right, that knows, oh, that’s not cool. And so they stand there and they stare at you and they watch you, and it’s like, what? What’s your problem? It’s like, well, I’m supposed to witness. Don’t worry about it. And then you give into that peer pressure of, well, nobody else does it. So that makes me stand out, even though I’m trying to follow the rules. So again, we come back to what is the culture on that unit for everything, really, for the full practice lineup of best practices. So let’s talk about the compliance department.
Terri
So, overseeing, what is the compliance department’s role at your institution with your diversion program?
Dawn
So the executive director and the director level, they will attend some meetings with the controlled substance assessment teams at the individual entities, and. But we also, for compliance, we audit controlled substance documentation. We go to the hospital based departments, which we have many that have controlled substances, and we will look at their documentation to make sure that they are meeting the required regulation, making sure their DEA license is up to date, their DHHS license. And so that is part of our audit work plan. And so that’s how I became involved in the. The audit process, and it again made me more aware of the regulatory expectations, the requirements. And just then, it just sparked even more interest into the diversion space for me.
Terri
Okay. All right. So the compliance department then doesn’t oversee the diversion program. It participates more from a. An audit gap assessment type of perspective. And then they get involved, potentially with investigations, if they have.
Dawn
Correct.
Terri
Do you, after your dissertation work and your experiences, do you have an opinion on what? Because sometimes it falls under pharmacy, sometimes it’s compliance. I’ve heard of legal, maybe nursing, although I haven’t really heard that as much, but the program falls under one of these entities. Do you have any thoughts about where you think it should fall?
Dawn
I do, and I’ve talked to several colleagues about this as well, and attending seminars, and I think compliance is an excellent space for a system wide diversion department to be, and I think it allows for an unbiased, cohesive approach to bridge nursing and pharmacy. And there’s so many other departments that are involved. I think sometimes we even forget we have human resources. We have security and safety, nursing, pharmacy, central supply. And I think compliance is an excellent opportunity department to bring together a system wide diversion program. I do.
Terri
Okay. The main reason you feel that way is the bridge between nursing and pharmacy, or what do you think? What do you think can be gained by having compliance do it versus all of those multidisciplinary people involved? But having it underneath pharmacy is often where it goes.
Dawn
Yeah. I think there are several great points. One is aiding entities with understanding regulatory requirements. I think most hospitals have a very good diversion plan or program throughout, but we need to remember physician practices, skilled nursing facilities, hospital based departments, and, you know, those may not have the capacity to learn about the regulatory requirements as much as they should or could, and so compliance would oversee all of those areas. As far as the diversion perspective, centralizing efforts and minimizing, you know, work efforts that are overlapping, increasing effectiveness by utilizing experience from all of the departments, for example, policies, resources, and, you know, we talked about education, I think, and this seems very minor, but I think that larger hospital systems should have one place for employees to go and look for information about diversion. So you may have different intranet sites for each entity.
Dawn
And just having an overall encompassing approach and appearance about diversion, I think, will increase awareness. Tailoring disciplinary programs for reentry. Again, I think that it is so important that we do not come across as a Gotchu program, but more of we understand that clinicians are having. Are experiencing substance use disorder, and what can we do to assist with this while also keeping our patients safe, our employees safe, our organizational safe, and so tailoring this reentry program for clinicians that may have experienced substance use disorders, to allow people to understand that this is not the end of the line, I think, is very important. And having that approach from a system wide perspective, I think, would speak volumes to the overall encompassing organization.
Dawn
Integrating physician compliance to ensure that you don’t have any physicians that are inappropriately prescribing, we can fix the problem as much as we want to in the acute care setting, but if we have physicians that are constantly prescribing these medications, our efforts are futile. So we need to make sure that the entire aspect of diversion is encompassed in this diversion program. Creating a surveillance program where some entities may be small and may not have many investigations and may not have that experience with that. So if you have someone at the system level that can either assist with investigations or help train others, I think that would help, but also leveraging knowledge and expertise from the managing entities.
Dawn
I think it’s important, again, to really emphasize that our priority is our patients and our employees, and we just want to make sure that the program is helping to assist with both of those needs. Now, some people think that, you know, a nurse that diverts has done an egregious thing and they shouldn’t have a license ever. But I think that there are different cases where nurses may have the opportunity to reenter into the healthcare system and maybe work in an area that they don’t have access to controlled substances. That’s an important mission for me, is for people to understand that, you know, the employee is as important as is the patient.
Terri
Okay, go ahead. Was there something else you wanted to say?
Dawn
Well, I was just going to say that, you know, I think it’s important, too, that, like, there are no benchmark. There are no benchmark data points right now for diversion when reporting up to a one diversion team at a system wide level, I think it would give leadership an opportunity to be able to compare entities as to where they are with inventory. There may be some issues with inventory or how many waste they’re having per month, how many eras.
Dawn
And I think by creating silos, having it at each individual entity, you’re able to mask problems a little easier, rather than creating a system where everyone is working together, and then the information is shifting up to that compliance department where the regulations are looked at, and we are seeing an increase in, say, for example, if you see an increase in waste at one of the entities, is it a problem with that specific entity? Is it a problem with a specific area where maybe it will help us to identify across the system that we need additional education in the, or whatever the department might be? I think that leverage of creating system wide reporting and key performance indicators would help us to identify more areas of where we can strategically combat this issue and have actions in place to do that.
Terri
Okay. Again, there’s a lot there to unpack. I want to not really challenge you, because I don’t know that, I don’t necessarily disagree when it comes to pharmacy. I think that most certainly pharmacy directors and those that would be involved in a diversion program are very well aware of the regulations and everything surrounding it, because that’s very personal for them. Right. And pharmacy is extremely heavily regulated when it comes to controlled substance purity. They definitely hold the ownership for that in their hand. So I could see, you know, having a different group like compliance holding the program to bridge those gaps. But do you think that, and some will say, you know, it’s the fox watching the henhouse, because you need to pay attention to your pharmacy employees as well.
Terri
So there could be some bikes there, just like you would have in nursing, with nursing leadership. So I definitely get all of that. But I’m curious on your thoughts of some of what you said as a benefit for holding it in compliance. I feel that pharmacy could do, too, at a system level. They know who the registrants are. They know where everything is. But do you, in your experience, does compliance hold more authority? I guess you could say, because I know, I mean, I’ve been institutions where when it becomes a regulatory issue, there’s no question the money flows, things get done you know, it becomes a priority. So do you think that compliance kind of sits in that same spot where it’s maybe to the benefit for the institution and the program because they’re going to get more support because it’s a compliance issue?
Dawn
I do, after talking with some of my colleagues that have, you know, some as recently moved under compliance, they felt that they had more responsiveness just from, like you say, the regulatory aspect and just the overall realization that, okay, this is serious as far as, from a regulatory standpoint, compliant, because I don’t want to say we have more authority. I just would like to say we have, you know, subject matter experts that can help with the regulations. But I agree with you on what you were saying about pharmacists. They take this very seriously, but they’re also dealing with nursing, working with nursing where, and this was my comment in one of the conferences I attended. You know, pharmacists think nursing doesn’t take it serious enough, and nursing thinks that pharmacists take it too seriously.
Dawn
And so you have that little bit of clash that, you know, the pharmacists are responsible for this, and they do take it very serious. They are the ones that has the contact, the DEA and the reporting. And so nursing may not understand just the weight that they do have on them. So they do take that regulatory aspect very seriously. And I think that the reason for putting it under compliance is not so much to pull it from pharmacy because, you know, this is not to replace their diversion programs. It is only to complement this system wide for more consistent reporting. And there’s still a need for those experts at the entity level, and you may have some entities that may not understand that regulation as much.
Dawn
And so centralizing and under compliance, I think, can just aid with that and help with them to expand again out to skilled nursing, physician practices, hospital based departments, which are at risk just as much as the acute care setting.
Terri
Right. Yeah. Well, I definitely agree with a system wide program, for sure, not just your individual entities, because, you know, you want to be consistent and you’re also redoing work that could just be done once and then rolled out and implemented and the expertise. Right. I mean, you can kind of hone in on who your experts are that can then train if it needs to be trained, but you know who your experts are for the whole system. So I think that’s good. And then also I think it’s nice if you have it with pharmacy, there’s things that we don’t know that are going on that we’re not necessarily supposed to know and not privy to. Right. So I would always tell people, make friends with your risk department because they know what is happening.
Terri
You may see somebody that looks suspicious, but they know if there’s been other things going on with that person.
Dawn
Right.
Terri
And it kind of holds true for HR as well, because they know if somebody’s been disciplined for something. So it really, no matter who it sits under, there definitely needs to be that elimination of those silos. And it is a cohesive group that is in the know and has the information. I think some departments, such as Hrtaine, you know, tend to hold things very closely. Now, I can’t tell you that’s a breach of, you know, whatever, so we can’t share that with you. But it’s like, yeah, but I need to, over here, I need to know what, you know, because, you know, I kind of think there might be something. And the leadership, the nurse leader has told me it’s not, it’s okay. I’m not concerned. But I didn’t know this part over here, HR, and that would have been really important to me.
Terri
Put that together, and I think that’s where a lot of things fall apart.
Dawn
Yep. Well, and I think also that, I think that pharmacy is definitely a great place to have the diversion program and even system wide. I think the main point, I would like to point out, is to remove the silos, but to also have a reporting structure to one entity, one area, especially with travel nursing. You know, we have nurses that are skipping from hospital to hospital, and we may have a nurse that’s skipping around to different hospitals in our own organization that we’re not even aware that there’s issues at another hospital. And so it’s things like that can just really help with increasing the awareness and increasing the effectiveness of the program by not, I don’t want to say the word comparing, but, you know, looking at, do you need assistance with the education? What are the needs?
Dawn
But to report all of that up? And so also senior leadership in the organization can have an overall encompassing glimpse of what’s happening with the version in the entire organization. Otherwise, they’re getting reports from different entities that are not just coming together cohesively.
Terri
Yeah. And they need that. Yeah. You talk about jumping around within an institution. I remember very distinctly, I was pretty knee deep in an investigation and having conversations with a nurse supervisor on a particular person. And then I find out, oh, they left. I’m like, where’d they go? And they went to another entity within the same system. It’s like what you transferred. And then when I reached out to them, they had no idea that this had been going on. And then it’s like, you guys, this is the same system. You’re all under the same umbrella, and nobody knew, you know, what was going on. So that’s something that we do need to work toward breaking those silos. I agree, and I don’t know whether it was partly sweeping under the. She’s not my problem. She’s moving on.
Terri
I can’t tell you anything because that would be. I can’t reach that privacy hr piece of it. So, you know, where are those lines? But that’ll be a conversation for another time.
Dawn
Well, and that’s a great point. You know, when the DEA comes in and sees a problem at one hospital and sees the person went to another hospital, what defense do we have as a system wide organization of not knowing this has happened?
Terri
It’s one thing to not tell when somebody calls you to get a reference and they’re outside of the system, but within your own system, you know, that communication. What can you have? What can you not have? What should you have from a safety perspective? Your patient safety perspective.
Dawn
Exactly.
Terri
Yeah. A lot to it. Okay. All right. Any final thoughts that you would like to give the listeners?
Dawn
Well, you know, thank you for the opportunity to let me give some of my thoughts about, you know, just minimizing the silos through larger organizations. It’s so important to communicate and just educate I those around us about diversion to keep our patients safe and our organization safe. I think it’s, again, regardless of where a system wide diversion program is, I think it’s a great opportunity just to increase the overall effectiveness of a diversion team.
Terri
So 100% agree? Yep, agree. All right, thank you, dawn.
Dawn
Thank you.
Terri
I also want to thank our sponsor, Midas Healthcare Solutions. Learn more about their technology integration, real time visual proof of medication disposal anytime witness feature and customizing sample collection with secure chain of custody. You can visit them at IHFdA in Denver, where you can see a live demonstration of their product, which applies to med surg areas and procedure suites and pharmacy. Thank you again, Dawn. You have a great rest of your day.
Dawn
Thank you, Terri.
