Our Guest: Kati Shell, PharmD, CpH, Director, Program Integration Ascension
Kati shares ideas for meaningful education. Ascension has done a lot of work surrounding opioid stewardship and diversion prevention education. Creating engaging, applicable content takes work and thought. Kati’s team has demonstrated a thoughtful approach and in this podcast she shares different levels of education they have developed as well as ideas for making content relevant and interesting for their associates.
Transcript:
Terri
Welcome back, everybody, to diversion insights. My guest today is Kati shell. Kati recently changed positions within ascension. She is now the director of program integration, in which she’s doing a lot of work with the drug supply chain security act. But her previous position was pharmacy area manager, and in that role, governance, opioids pain management, and the national diversion prevention steering committee was all under her umbrella. And it was in that capacity that she did a lot of work surrounding education with diversion within her healthcare system. And that education is what we’re going to talk about today. So welcome, Kati, to the podcast.
Kati
Thank you, Terri. Great to be here.
Terri
Yeah, I’m glad you are. We’ve been trying to coordinate this for some time, so I’m glad we made it work. Let’s jump in. I know there is a lot of work that was done at your institution that you are very proud of, and so we want to hear all about those things. So let’s start at the beginning. Do you recall when you originally identified the need for more education? Was there something that happened that made you realize, hey, we need some more education, or did you go looking specifically at what the education was as part of your purview, or was it just kind of one of those things you stumbled upon? It’s like, hey, you know what? We need a little bit more education.
Kati
Yeah. So, Terri, that’s a great question. As it stands, I always find that education is really foundational to any program and strategy, and we developed our original opioid stewardship strategy back in 2020, and then under that came our diversion prevention strategy. So originally we did a lot of education around opioid stewardship for the various disciplines across the health system. And then once we put together the diversion prevention strategy, we recognized immediately that there would be a need for diversion prevention education. At the same time or around that time, we also had the ASHP best practices for diversion prevention come out. And of course, in that there’s a recommendation about including education for your associates.
Kati
And so at that point, we sort of recognized this is a great time to get started with this and make sure that our teams are aware of what is happening out there with diversion and how we can prevent it in our organization.
Terri
Okay. All right, so it started with a general opioid stewardship type of education. It sounds like that’s.
Kati
Exactly.
Terri
Yeah. And did that education, by chance include other options for non opioids treatments and that type of stuff?
Kati
It absolutely did. The original education was focused around an acute pain multimodal management strategy. So, yes, absolutely. Foundational using non opioids acetaminophen and NSAIDs as the foundation, and then only using opioids when it was necessary. So that was a very important first step for us from the opioid stewardship perspective at ascension.
Terri
And was that education given to your bedside nurses as well? Because if they don’t buy into it, obviously the patient’s going to get the other option that is probably on the profile.
Kati
That’s exactly right. And yes, we included that nursing in that education as well as all of our clinicians that we’re prescribing in the hospitals, and in addition to that, our pharmacy staff.
Terri
Okay, I’m just curious, did you do any metrics surrounding that? Did you see change? Did you move the needle on that? Did you see a decrease in prescribing of opioids? And it’s maybe a while ago?
Kati
We did. We absolutely did. In fact, I don’t know the specific numbers, but we did track mme utilization on our inpatient sites of care based on that multimodal pain strategy. Essentially, we built an order set in the EHR for that to happen, and that’s how were able to track all of the metrics behind that. So it was fantastic improvement that we saw, really, since the time that we implemented that order set to now, and now we’re looking at order set utilization more specifically. We’ve now gotten the metrics around that as well. So we’re continuing to track and promote the use of that order set.
Terri
That’s fantastic. Yeah, just yesterday, in fact. So for those of you that aren’t familiar with the ibuprofen and Tylenol using together, they really do work very well together. And there’s studies out there that it’s even better than oxycodone. I think I forget 20 milligrams or I forget exactly the strength. But I had another example of that yesterday. So my daughter’s fiance, that’s a relatively new word in our family, was doing some work in our house, and he ended up cutting his knee on some glass pretty bad, right across his kneecap, and he’s been in a fair amount of pain. And so a couple of days ago, she asked me, hey, mom, do we have anything stronger in the house? Because he’s really in a lot of pain. I’m like, oh, boy.
Terri
And I said, have him take the tylenol along with the ibuprofen, which I had told them a week ago, but he hadn’t done, apparently. But long story short, when I checked in with them again, she said that he said that for the first time in about a week, I think he has been pain free after he took the Tylenol with the ibuprofen.
Terri
So some people listening have maybe heard me tell the story. It worked with my daughter’s ACL surgery. It worked with my husband’s achilles tendon surgery. And then now we have another example where somebody was finally pain free with that combination. So that’s great. And it seems really kind of like, really? That’s going to work. But if you can get those bedside nurses and your physicians to buy into that and give that a try, then I think they’ll be pretty amazed with what they see, and they can really control a lot of pain there. So that’s great. Okay.
Kati
All right.
Terri
And it sounds like it was a team approach. You guys worked on it, I’m sure, with committees, and that was a lot of work involved with that education content.
Kati
Yes, it was a tremendous amount of work. The original education was put together for our multimodal strategy with a multidisciplinary team that was led by our quality department at that time. And we did assign CES to all of these educational modules. So it was in 1 hour program and were able to do the multidisciplinary Ce for all of those two, which is really always a big win when it comes to education and getting people to complete things. Not only that, but this was also a national assignment and is continued to be assigned to all of our new hires at Ascension so that they are aware of the pain management program and expectations.
Terri
Okay, fantastic. All right, so then it transitioned into we need something for diversion. So was that mostly based on the ASHP recommendations that came out? Did you have an event? What made you realize we really need to do the same thing with diversion education?
Kati
Absolutely. I would say that was definitely multifaceted. At the same time we had those ASHP guidelines come out, we started seeing also diversion cases started popping up in the news, like, every day. And additionally, at that time, I got involved with Natty, and that was really important. Kind of eye opener for me when I started getting involved with that team understanding, like, wow, there is really a big opportunity to provide education and to ensure that our teams know how to prevent diversion and how to identify it. And really, again, foundational. I always feel that education is so foundational.
Terri
Yeah, absolutely. Okay. All right. Yeah, multifaceted. I’m sure there was a lot going on, and you’re right, there seems to be a lot of stories in the news in the last couple of years that it’s just become I don’t know if it’s just we’re more aware people are reporting, so then we become aware. But yeah, there’s a lot going on. All right, so what method of education was it? Mostly modules. You had said that you did CES, which fantastic idea. Everybody out there, nobody likes to do those learning modules, but if you get a Ce and it’s free, then it’s like you kill two birds with 1 stone. Did you do anything in addition to the modules?
Kati
Absolutely. So with our diversion education, we did center it around my learning modules. We utilize a platform at Ascension to track module completion. And so that really helps us in many ways, but primarily it helps us show how many individuals have completed it as we’ve assigned them, and then it also has that assessment portion. So from the Joint Commission perspective, you want to be able to show, yes, my team did this, and yes, they proved they’re competent in this assessment. And that’s really been important too, because the Joint Commission has started looking much more closely at diversion prevention tactics within our hospitals. And what we’re doing so that’s our go to for education is doing the modules.
Kati
However, in some cases we also did separate continuing education programs and didn’t necessarily include those as a module in our my learning system for a number of reasons, but some of them were just live programs that we wanted people to attend live, and those we also assigned ce to using our ACPE accreditation. And sometimes there’s just that really nice thing about having a live program where you can be interactive and ask questions at the same time. We did a little bit of a mix, but really the education was centered around those types of programs in addition to creating resources that our teams could use that were paper resources to follow for diversion investigations and those types of things.
Kati
So while the education was centered really around those live programs or the recorded webinars, we provided resources in a paper format that would help individuals follow the process essentially.
Terri
Okay, and was your education different for the different disciplines or levels of your associates, your management team, did they get something different?
Kati
Absolutely. I’m a huge believer in making sure that you are speaking to your audience and making sure that the content is appropriate for that audience. So for example, for the pharmacy team, the original pharmacy education that we created included the opioid stewardship aspects because we really knew that if we could limit the amount of opioids being used in the hospital, that limits the amount of controlled substances being touched, which then can limit your potential for diversion. So we knew that was a really important foundational effort there. So our original education included that. And we also kind of centered around controlled substance best practices and like those ASHP guidelines, just making sure that were educating our teams to those specifics. But when it came to nursing, they don’t care as much about those types of things.
Kati
We were really talking to nursing about controlled substance handling expectations, timelines, and the importance of them keeping very accurate accountability of those controlled substances. And then when it came to the leadership perspective, absolutely, totally different. They don’t care about all those other things were talking about. What is the implication of diversion at your site? If you have the DEA coming in, what does that mean? And we kind of centered around that and then around really what is the expectation for leadership from our national leadership team, which is really centered around supporting any of the local efforts around diversion prevention, including education, but including support for the investigations and those types of things as well. So absolutely, totally different. Depending on who were talking to. We also made diversion prevention modules for our diversion response teams at each site, which as you know, are multidisciplinary.
Kati
So those were also different because diversion response teams expectations and responsibilities are very different from that of a frontline technician or pharmacist. So in those we really centered the education around, what is the expectation of you on that team and what is the team’s responsibility in that investigation process? So, like I said, lots of different educational opportunities. A lot of those we’ve actually made available to really all of our teams in case there’s a desire for people to share that with a new individual that’s coming on or go back and watch something if they’ve forgotten. So we’ve tried to make that available again, either within our my learning system or we also have access to a Ce portal, if you will, that allows individuals to go in and view CES outside of the My learning system.
Terri
Okay, all right, well, that sounds great. Sounds very comprehensive. How do they repeat these modules? I know you said they have access to it if they want to go look at it, but is this an ongoing thing?
Kati
So that’s a great question as well, Terri. What we focused on is creating, again, that foundational first education, like I said, for pharmacy. We did our first national education in 2022. So last spring we finished that up. And that was really foundational from the perspective of, again, providing that opioid stewardship background, providing those controlled substance best practices, and just, again, kind of high level. Here’s the overview of what we’re going to do for diversion prevention. But this last year, so in 2023, we just completed a second round of pharmacy education, which was instead of an hour, it was a half hour Ce program. And instead of focusing on all the things we focused on last year, we really centered ourselves around the diversion prevention strategy at Ascension. And then we also really took a huge focus this year on substance use disorder awareness.
Kati
How can you tell if someone in your site, your colleague, your friend, is suffering from substance use disorder? What are the resources available in our institutions for those individuals, and how can you get help and how can you report? We centered around all of those things. I’m especially really grateful we had an individual within our organization that had previously suffered from substance use disorder and received help by his manager identifying that there was a challenge. And were able to include a brief video of him to really drive the point home and really help individuals identify with these challenges. And that was a huge win from the perspective of associates. Really appreciated that deep insight from that individual and that informational sharing. So that was this year.
Kati
So, again, like I said, we included different aspects to these educations, but that recording of the individual sharing his story was included in all of our education for this year. So leadership, nursing, pharmacy, everybody, because that applied everywhere. And realistically, I’d really love to share that with every single associate at Ascension, too, because as you guys know, it’s not always maybe that frontline nurse that’s diverting, it could be someone else. And by putting the information out there and that substance use disorder awareness out there to everyone, just helps kind of open the door for having those discussions, having people think about who’s suffering potentially from substance use disorder, because that is really such an important part of our diversion prevention strategy as well.
Terri
Yeah, absolutely. And I think you did a couple of things there. By doing that, you really made it personal. You probably engaged your audience more because they could hear a personal story. But in addition to that, I think what you did is you went a long way in working to establish a culture of self reporting and you’ve now said, hey, ascension is a place where you can come to us and you can get help, rather than continuing to hide it for fear of what is going to be done with you. Because we’ve done this with one of our associates in the past, so I think that’s fantastic. So between your ce offering and a personal sharing story, you’ve done something that maybe a lot of places haven’t done. And both of those, I think, are fantastic.
Terri
Just for pharmacy, you did the 1 hour overview and then now it’s a 30 minutes completely different content. Do you require all new hires to do the 1 hour overview and then whatever the current offering is for that year?
Kati
That’s exactly right, Terri. We felt like there was not overlap in the content, really. So we felt it was important to continue that foundational education module, including, as I went, going back to our Opioid stewardship module that’s also assigned to all new hires. So really they’re getting the full story when they’re coming into Ascension to understand, okay, so I need to focus on Opioid stewardship and I need to focus on diversion prevention. Oh, and now I need to focus on substance use disorder awareness. So absolutely. We have continued to assign those original modules and then, yes, all new hires will get the 30 minutes module that we assigned this year as well, again, because we really want to make sure everyone gets all of that content, right?
Terri
Yeah. So five years from now, they might have all the original all the years, their year, if you keep changing your content. That is excellent.
Kati
Absolutely. And I think everything is evolving so much. The other thing that we always try to include in the education is focusing on a diversion case. And a lot of times I actually focus on something that I’ve seen in the news that is just so egregious or so unbelievable that you’re like, how could this happen? I think that always also pulls the individual in. It doesn’t matter who that is. Pharmacists, nurses, providers, leaders, everyone cares about hearing about, oh my gosh, how did that diversion case happen? So that’s something I always like to include one or more actual diversion cases and again, usually I’m pulling those from something that’s happened out there in the United States that I just could not believe. Some of the cases we heard at Natty, for example. Also I’d like to share those.
Kati
So I think that’s really important too, as we talk about the cases. And of course, as time goes on, we will have to probably refine those CES. As you know, CES have to be renewed every three years or so. So we’ll have to go back and review the content, make sure still everything is up to date and that we haven’t changed anything. And then, yes, as we move forward, they may retire some of those and modify depending on what the strategy looks like at that time, but certainly could actually have all of those things in place and great opportunities for our new associates to get a bunch of CES as they’re onboarding.
Terri
Yeah, no, I think that’s great. I think it’s wonderful how you take the time to personalize the content. I think at a lot of institutions it’s just the same thing year after year. And so the tendency is, oh, I did this last year, you just jump straight to the answers and you have them all and that’s that. And there’s really not a lot of absorbing and a lot of learning. So I was going to ask you, do you do anything to make sure that they’re really paying attention? But it seems to me that your content is interesting enough that people probably are actually doing the whole module so that they can hear these different types of information and stories. Because stories do draw people in, for sure.
Kati
Yes, we do have some pieces that require them to for example, for the ones that are videos, they have to watch the video. It literally will not allow them to complete it until they’ve watched the whole video. But another strategy is in the nursing program. It’s interactive, where they’re actually having to select certain things with their mouth during the program, which also just encourages that interactivity. And then throughout that module, there are little questions that come up that they have to get right. So I do think it’s kind of a force factor, but at the same time, that is one way we can make sure that they’re really picking up on it. But the other piece of that is when there are challenges identified, like if a nurse is not following policy or what have you, they completed the module.
Kati
So really the expectations were set forth in that, they were set forth in the policy. So you have all of that background to say like, well, you have completed that and you have shown competence when you completed it. So from that perspective, I think that’s also very important.
Terri
That’s a good point. It’s another tool that you can use to show we gave you the baseline, the standards, and so you signed off on it. And that’s just kind of another checkbox to say, well, you’ve heard it.
Kati
That’s right.
Terri
Yeah, that’s a good point because we always want to in every case, it’s like, well, what’s your understanding of this policy? So this proves that they’ve at least done it. Okay, so you talked about the pharmacy nursing is handled the same way, and then you’ve got your individual diversion teams that do it. Do they do that annually as well? Do you modify that or that’s probably more consistent as to what their expectations and as long as the process stays the same, I would suspect.
Kati
Yeah. The Medication Diversion Response Team program has really only been created once, so we haven’t provided an update in that one yet. That one will probably not change too much because it’s centered around the use of our national policy template for diversion investigations and the process there, which really spells out exactly how at Ascension we expect for diversion investigations to occur. So from that perspective, probably not a huge amount of change for that. But as we identify things that our diversion investigation teams need, we do center education around that. For example, one of the things that was specifically requested was that interviewing was a challenge. And I know that you know this, but not everyone has ever participated in an actual interview and an investigation. So really honing in on those skills is extremely important.
Kati
So I was fortunate that were able to collaborate with one of our I’m in a hospital system, it’s a health system, but work with a lot of hospitals. And one of our hospital individuals that’s a security leader is a former detective and investigator with our local sheriff’s office. So I was able to collaborate with him to provide a ce program on interviewing and investigation skills. And this again, so we just hear from our teams, what is it that you need and what can we help provide? So we’re trying to meet those individual needs as they come up. And what we’re hearing is kind of the same thing around the country. Interviewing and investigation skills was a challenge. A lot of pharmacists and nurses don’t have that. Your security folks might, but not everyone else will.
Kati
So that was an important and it was really excited to be able to offer that one. And that one was another one that was really interesting because you don’t often have a police officer security lead talking to a bunch of pharmacists. But that’s essentially and nurses. But that’s essentially what we had there, which that one was really unique too, and really engaging.
Terri
Yeah, absolutely.
Kati
For sure.
Terri
Because that’s a different side and not everybody has the skill set for it. It’s a difficult position that you’re put in to ask the hard questions and interview somebody. So you certainly found the person who had the expertise. I think that’s great. And CES again, which is fantastic.
Kati
Absolutely.
Terri
Yeah. So let’s talk about the national the approval. I know when you and I spoke you were really excited about that. So what does that mean? What is involved in getting it? How many facilities is this distributed through to?
Kati
Overall, yes, I was extremely excited. Essentially the process that we use at Ascension for the approval of our modules, typically the content begins in one place or another, often for these programs. Often it was something I put together and then we would review it with our Regulatory and Compliance subcommittee. It’s a pharmacy group that contains members from each of our states. And that way we could just make sure if there were any state driven regulations or anything like that, we could just make sure that weren’t overstepping on any of that. So that team would review it and then we have a national diversion prevention Steering committee and that team would ultimately, finally review it and sign off for us to be able to move forward and share that. So that’s sort of the approval process.
Kati
But the process to actually get something assigned to all associates is a little different. So from the pharmacy perspective, I work on the pharmacy national team, so that one was a little bit more easy to navigate because I’m part of that team, but with nursing, and this one was the one I was so excited about recently. This one we have to get approval by our nursing executives. And part of that was just ensuring that our executive sponsor, which is actually a nurse, was able to share information with the team and everyone kind of got on the same page with being able to assign that to all of our nurses nationally. So frontline nurses. And again, this is really centered around controlled substance handling expectations. So how many minutes should I be holding that med before I’m giving it?
Kati
How many minutes should it before I put that back in the ADC? Those types of things. So again, we kept that program fairly short for nursing. It was not a ce program because it’s about 20 minutes. And the content from this one was actually pulled from a previously used module in one of our states that was really good and we just pulled in the national perspective to move that one forward. But overall, that’s sort of the challenge. The easy part is creating the modules, the hard part is getting them approved and then ultimately getting them assigned. But were able to achieve that for the Pharmacists, for all of the pharmacists, both programs last year and this year, and for our nursing team this year. So very excited about that.
Terri
Yeah, that’s great. And anybody that’s involved in this stuff knows how hard it is. I mean, they’re very protective and rightly so of their nurses time. And we don’t want to give them stuff that they don’t need to listen to and especially across the board, but that’s great. And then everybody is getting the same information. And if you’ve got anybody transferring between sites that they know exactly what the process is. And again, in the case with the nurses in that module, those are all the baseline things, I’m sure, that you’re going to look for when you do a diversion audit. Where did they fall short? And if everybody has done that module, then you’ve kind of got that first box check. Like, you should know this because we did educate you on this. So that’s great. Congratulations on that.
Terri
I know how long that can take. And patience, the patience it requires. How long did it take? Do you know?
Kati
So we put that module together last year. Okay. I’m thinking towards the end of last year, I think it’s been almost a year, probably like eight to twelve months to move that one forward. But I do think, Terri, that one of the things that really helped us move forward with the nursing module assignments was the inclusion of the substance use disorder awareness video with our associates sharing experience, because you can’t replace that type of information to be shared with every single person. So I think that was one thing that really helped us move the entire program through.
Terri
Okay. Yeah, good to know. Interesting. Okay, well, this is fantastic. Is there anything else you want to share with the listeners? Were there any lessons learned along the way that you feel you would do different if you had to do it over again or top one or two things that you want to emphasize that if this is a direction, they want to know how to get the buy in or something that you would recommend that they.
Kati
Great? That’s a great question, Terri. I think probably ultimately, again, I would say educational is foundational to all of our diversion prevention work. And I know that it can be very time consuming to do this process, but I do feel it is extremely valuable and has been extremely valuable to our program and our team members to be able to share the information that we’ve shared and really just engage these individuals in diversion prevention by sharing stories, by sharing associate experiences. This is a great way to engage individuals and have people being on the lookout for diversion in your sites of care. In our sites of care.
Kati
I think if anything, I would just say to your point, use your patience in this process, pack it and be ready that sometimes things are going to be hard to move forward, but once everyone is on board, it is absolutely phenomenal to see the success that it can be brought forward.
Terri
Perfect. Kati, I couldn’t have said it any better. I think all of those are really good points. And congratulations to that national module and thank you for all the work that you’ve done because that just improves patient care and patient safety as well as employee safety and for working to create that. Culture that’s an open, hopefully more of a self reporting culture within your organization. So I think it’s great what your organization has done. So thank you for sharing and all of that.
Kati
Awesome. Thank you. Thank you for having me.
Terri
Absolutely. All right, I’ll probably see you soon at NADDI right?
Kati
That’s right.
Terri
All right, thank you. You have a great rest of your week.
Kati
Thanks, Terri.