Welcome to our latest podcast episode, where we dive deep into the critical world of diversion prevention in healthcare settings. Today, we’re thrilled to bring you a wealth of knowledge and experience from three remarkable guests: A seasoned former diversion prevention specialist who has seen it all Two current diversion prevention specialists who are fresh in their roles, bringing new perspectives and energy to the field Our conversation today is a goldmine of practical advice, innovative ideas, and hard-earned wisdom. We explore the essential steps new diversion specialists should prioritize, discuss game-changing strategies that have significantly improved diversion prevention programs, and share valuable lessons learned along the way. But that’s not all – we also delve into creative education ideas that can help raise awareness and foster a culture of vigilance in healthcare institutions. Whether you’re a seasoned professional in the field, new to diversion prevention, or simply interested in understanding this crucial aspect of healthcare safety, this episode has something for everyone. Get ready for an engaging discussion that bridges experience with fresh perspectives, offering insights that can help shape the future of diversion prevention in healthcare. Let’s dive in!
Transcript:
Terri
Hello, listeners. Today we have a diverse panel of diversion prevention specialists, and we are going to talk about lessons learned, successes and perhaps failures. And I hope it provides some really great ideas and encouragement to those out there that might be new to the diversion prevention space or struggling with some aspect of their program. I am going to ask each of my guests to introduce themselves and tell us a bit about them, but I want to first start by welcoming them. So we have Sheila, I should have asked you, is it saint, how do you say your last name?
Sheila
It’s St. Cyr.
Terri
St. Cyr.
Sheila
Okay.
Terri
Should have asked you that before we got started. Sheila St. Cyr, Shannon Heintze, and Vanessa Cardenas. So welcome to all of you to the Diversion Insight podcast. And Sheila, let’s start with you. Tell us about your background, the time you spend in diversion, and what role you are in now.
Sheila
Okay? Absolutely. Well, as Terri said, I’m Sheila Saint Cyr. I’m not currently working as a diversion prevention specialist. I’m doing work on a volunteer basis with my nursing association, the association for Nursing Professional Development. I just finished being president for that association for two years, and currently I’m the chair for the nominating committee. But I did work as a prevention specialist for eight years at a large academic facility in Oklahoma City. And prior to that, my background, I am a nurse. And prior to being in the diversion role or not diversion, but I wasn’t, I was the prevention person, not the diverter. I did education and training. So I was actually director for the education department at the facility. And I kind of landed into the diversion role.
Sheila
My father was ill, and I kind of needed to take a step back from the 24 hours, day, seven day a week type of setting with the director role so that I could help my mom out a little bit more. And so I moved into this role or the diversion role just kind of happenstance. You know, it was a part time role I was familiar with the role of what was going on in it. And so it was kind of a nash, kind of a natural segue for me. In fact, I really think that being a diversion prevention specialist was kind of a subspecialty or a subset of being a nursing professional development practitioner. So that’s kind of how I landed into that role.
Sheila
And it had its ups and downs because the program only had like a pr in person prior to me stepping into it. And I, so I really had the opportunity to grow the program and work with all the different leaders on our interdisciplinary team, really to make it a really good program so that’s really one of the things that I’m very proud of.
Terri
Okay, great.
Vanessa
Yeah.
Terri
I was going to ask you, was it an established program or was it new?
Sheila
It was kind of established. So, so there wasn’t a lot of structure to it. So I think that’s one of the really important things is you have to establish lots of good structure around the program and flowchart your processes and follow that flowchart, like consistently so that there aren’t any like one offs. And, and you’re doing the same thing with everybody. You know, it’s make it very, very objective and so you take all the subjectivity out of it.
Terri
Yeah. And I think that’s how a lot of programs start. It is kind of a social PRN, and then it’s like, oh, you know what? We need to make this more formal. So. And I liked your diversion specialist. I’ve been in that, too, where I’m, you know, speaking. I am a diversion specialist. Diversion mitigation specialist. All right, Shannon, you’re on. Tell us about you.
Shannon
Hi, Terri. Thank you for having me today. My name is Shannon Hines. I’m also a registered nurse and have been for about 28 years. My background has been mainly floor nursing the majority of my life, except for maybe the last, I would say twelve years of my career. Originally from Canada, so born and raised in Saskatchewan, kind of rural Saskatchewan. Made the transition down here to Billings, Montana, almost nine years ago already. And again, I’ve had a variety of nursing roles, basically all frontline med surg, and then kind of the end of my career was emergency nursing. I was in leadership after I moved to the US because the healthcare systems are very different than Canada, I decided I wanted to do my master’s degree, not only for my personal self, but to learn more about the healthcare system.
Shannon
So once that was done, the diversion role actually happened to come up as a posting. And I am the type of person that I love process improvement as well as investigation and just helping nurses to improve practice and inpatient care. So I applied and after lengthy process, got it. So I’ve actually only been in this role not quite two years. This was an established program. Unfortunately, it came about because we did have a diversion here in 2017. It was actually a significant diversion. Unfortunately, we mean the national news. Anybody can google it. Billings clinic diversion. We had basically an RN diverting in our cath lab, substituting saline for fentanyl. So that just kind of opened up the necessity for a diversion program of sorts.
Shannon
The person that started the program, unfortunately, had left a few months before I started in this role, but did a fantastic job for, I believe, six to eight years in this role and really had a good foundation. So it was easy for me to, you know, kind of slip into this role because there was already a lot of foundation for things. So still learning, you know, every day is different. I would have to say, you know, the biggest thing learning in this role is you have to keep an open mind because there is, first of all, there are no two cases the same. And just when you think that something should it. Is that really possible? Did that really happen? It probably did. And that’s, I think that’s one of the biggest lessons that I learned in this role so far.
Terri
Yeah, good point. And, yes, sorry to hear about the reason why your program needed to come about. That’s something that we try to really impress upon people is don’t wait for that to happen. Right. Get a program in place so that you can mitigate that, hopefully from happening. But, you know, they responded, and. And now you guys are up and going and you’re right about having an open mind. Yeah. That is, you know, at first you’re just, you go into an interview, you’re so sure, and then you walk out with more information and it’s like, oh, okay. So after that happens to you a few times, you just don’t walk in there anymore with any preconceived notions as, you know, what it is. And also your comment about you love process improvement. You know, not all nurses, not all pharmacists, not all pharmacy techs.
Terri
You know, not all quality compliance people lend themselves to this kind of role. And so it does take that process improvement detail, investigative kind of person to do it. So, yeah, not everybody has the traits to really do a good job with it. All right, Vanessa, you are up. Tell us about you.
Vanessa
Thank you. Thanks, Terri, for the invitation. So my name is Vanessa Cardenas, and I am a pharmacy technician by trade. Started my pharmacy journey about 22 years ago, obtaining my pharmacy technician license in the state of California, and I’ve been practicing ever since. Been with my current organization for 15 plus years now. And I started there just as a frontline technician back in that day. When I started with my organization, it didn’t really have a growth ladder or opportunity for pharmacy technicians. Everybody kind of just got hired in as a pharmacy tech, and there was nowhere to grow from there. And over the course of time, the organization builds upon that structure and allowed for pharmacy technicians to kind of move up the ladder from a tech one they restructured their program from a tech one to a tech two to a technician specialist.
Vanessa
So with eager to Juanina move up the ladder and create new opportunities for myself, I continue to take those opportunities and making my way through till a technician specialist became a technician specialist at my organization in 2016. And I oversaw the, it was a narcotic technician specialist for the one hospital that I was at. I did that for about five years. While in the background, they were growing or trying to develop a system wide program for diversion prevention. So two years ago now, this role that I currently in, which is a system wide drug diversion specialist role, became open. It was a brand new position that I took for the very first time.
Vanessa
And it was with that, with the goal, and the main goal intended was to be able to standardize our processes across our entire system, where we did have, I would say, like a pretty robust program, but it was very at a site level, and our program was being developed in the meantime in the background and developing processes and escalation pathways along with policies. And so when that, again, once said opportunity came up and I saw that, I said, you know, this might be an avenue that I want to. I want to take and, you know, take on that challenge. So I did. I landed this role and two years ago in 2022. Okay.
Terri
All right, thank you, Vanessa. All right, so let’s, Shannon, question for you. You’re in the fairly early stages of your time as a diversion specialist. Are there a couple of, like, maybe most important or big bang for the buck that you would recommend that people start with? Now, your program was already in place, so maybe you didn’t really find anything specific with your program, but maybe something you saw needed improvement or updating.
Sheila
Any.
Terri
Of that you would want to share with the listeners.
Shannon
Thank you. Yeah, there’s a couple things. You know, of course, when you go into a role like this, there’s so much. Right. And you have to kind of wrap your head around it that I’m only one person in my role. There is only one person. I am in a full time position for this. So one person can only do so many things. So that was kind of the first thing I had to have, kind of this personal reflection that I’m one person, I’m going to do the best I can, but I have all these resources around me. So just as you indicated, Terri, we do have a very robust senior leadership team that I have as an oversight committee.
Shannon
Yes, I do drive the program, but at any time, I can reach out to our legal person or our vp, our CNO is on is available as well as we actually do have one of our co cmos on our committee as well that is readily available. So that is so important. I’ve actually had some discussions recently with another facility that, for lack of a better term, feels like they’re banging their head, they’re not getting anywhere, they’re spinning their wheels. And one of the comments that I just made to them is you have to get buy in because if you don’t have buy in from your organization, first of all, you need to find the why. Why are we doing this? And then second of all, you need those people, those big advocates that are going to help you through the process improvement.
Shannon
Because if the organization doesn’t have a why or doesn’t feel invested in diversion, why are you having the program? The second thing I can say is I started small and that just like I said, there’s so much to any diversion program. So what I kind of looked at was kind of listened to my peers, started to look at safety nets a little bit and then kind of started looking at the data. We have a portentous AI diversion system that we utilize as one of our tools. And I noticed, like our unreconciled medications were high triple digits. And, you know, again, as one of those people, that why I started asking the questions and got to the point that nobody was really forthcoming with. Yeah, this is the reason why.
Shannon
So I actually went to one of our governing council meetings and talked to some leadership and just said, hey, would anybody be interested in doing a trial with me? We use omnicell. Could we do this trial and start this? And I did have a team, actually a fairly new leadership team in a fairly new unit in our organization, and it was my win. And basically we saw them go from double digits to single digits with their unreconciled medications. We rolled that out to all our med surg units as well as a couple of our critical care areas. And we’ve seen significant changes with that. Unfortunately, when I looked at the data yesterday, it wasn’t so I was a little bit upset with that. But you also in this have to understand, again, the why.
Shannon
The why is we have a lot of new grants starting. We have some travelers that are, you know, coming in and out. So, you know, I think that’s part of it. We kind of talked a little bit before we started this that you have to roll with it because no two days are the same.
Terri
Right? Can you share with us what that program was? I was just talking to somebody else that was saying, oh, my goodness, the amount of, you know, unaccounted for us that we have that are missing. And it’s like, yeah, this is what you discover when you turn on your software. I mean, it’s there, but when you turn on that software, you start to see it. So can you share with us what it was that you did to bring those?
Shannon
So it was actually fairly simple. So we have omnicell. So I talked with our Omnicell rep here, who’s one of our pharmacy analysts or it people, and we looked because we can get reports printed out kind of daily. So what we did was with this unit we started, they picked the time, so they wanted the report printed at 05:00 a.m. And 05:00 p.m. So it basically pulls all the data for any unreconciled medication the 12 hours before. So if I’m working days and I have, say, a medication that I miss giving, it’s going to show up on that sheet. So initially, we had the charge nurses basically say, hey, Bob or Jane or whoever, you’re missing a medication. But pretty soon people started going to that printer because they didn’t want their peers to know they made a mistake.
Shannon
And I can honestly tell you that was a significant change in our organization for the culture and that understanding that it’s not about blame, it’s understanding processes. Maybe we have glitches somewhere, but now I have nurses, like, emailing me daily. Hey, I just wanted to let you know this is what happened. This is what I did. And that, so it was a huge, significant change in our organization.
Terri
So I’m curious. I have mixed feelings about a report like that, or I think it’s fixes that can tell you know, you go, you see it on the screen that if you didn’t for something, how I’d like to hear from Vanessa and Sheila, what are your thoughts on that? Yes, it makes people aware and so they take care of business. But I don’t know, I kind of have mixed feelings because it’s, now we’ve just told them and I don’t, I can’t collate the data of somebody that is continuously not doing it timely, unless maybe you are keeping track of that. Shannon, I’m not sure what youre, what the process is, but let’s talk about that a little bit. Sheila, how do you feel about, like, letting people know that they forgot?
Sheila
Yeah. Yeah. And we did something similar when I was in the diversion prevention role at my facility as well. And it printed off very similarly. It printed off at certain times of the day, but it was the managers that were. They were the ones to review the information. It wasn’t out for the staff to be able to look at it. And we started looking for more, you know, not. Not somebody that, oh, I got busy and I forgot to document the medication that I gave. But we started. We wanted to look for those trends, because really, it’s the trends where the questions and issues come up, or at least for me, that was always the case, but it always printed into the manager’s office, and so. And they could go back, you know, and, you know, document the medication that they missed.
Sheila
But we also. It also let us find other issues as well. They might have documented the medication, but they documented it on the wrong paper. So then we would have to go back to our billing department and say, okay, you need to remove the charge, this charge from this patient, and we need to move it over to this patient. So we also found other issues that were able to correct along the way. I understand where Terri’s coming from because you don’t want to skew your data by allowing someone to cover their tracks. I guess that’s probably what you’re trying to get at. And that’s why I. That’s why we had it printed to the manager’s office instead of having nurses have access to it. But we encourage nurses, especially those nurses that may have missed a documentation of a medication.
Sheila
Maybe they even missed a couple of times. We made sure that they had tools that they could use to kind of double check themselves at the end of the shift to make sure that they had completed everything accurately and timely.
Terri
Right. Okay. Yeah. Shannon, are they doing any tracking and trending to see if the same person is.
Shannon
So what happens is with our protanis AI system, that also tracks in the background, so I get cases sent to me. You can decide how many cases a week, and that. So that tracks that piece of it. So if it’s somebody that’s continually, even though they’re fixing it’ll pop up. As, you know, back. Charting is outside of the parameters or whatever, so there’s other ways to pick it up as well as, you know, just the same name will keep popping up. Sure, if that makes sense. And that if it’s somebody that is, I usually know if it’s in your grad or maybe it’s somebody that has never, like, in my entire time here, you know, made an error, and then it’s like, okay, something happened with that shift and that.
Shannon
So I think, you know, the diversion program itself is more than just that document that’s printed off. There’s so many other tools we have to use.
Sheila
And that’s one of the things, like talking about so many other tools. I think it’s like, for me, I was the only person that served in that role for probably for seven years, I guess. So I kind of had to, like, pick and choose, but it was, I tried to make really good choices of the things that I monitored. That way I could look at incident reports and I could look at, and we used RX auditor was the software that we utilized. So I would look at that, but then I would also just, I had good contacts with my HR people. So if somebody was popping up here and they were popping up there, then I would also call an HR and I’d say, hey, you know, I’ve got this person, you know, are there any other issues? Are they having any absentee issues?
Sheila
Are they being, do they have tardis? Are there any other performance things going on? So it’s kind of like being able to look at all the data to really give a good picture of what was going on. And if I, you know, started having inklings of problems, I took it one or two or three steps further where I would check their, check them on the Oklahoma court records, look to see if there were any issues going on there. I would look at their nursing license to see in the past had they had issues or concerns, know, that were against their license. I would look at their social media accounts to see if I could find out information there because I learned from, he was a director of pharmacy in, I believe it was Arkansas.
Sheila
And he and I were having a conversation one time and he said, yeah, he said, you know, I caught one of my, I think it was a pharmacy tech that was stealing medications from the pharmacy. And he was like, I went out and I looked at his social media account and he was basically selling them on Facebook. So that’s how he kind of, you know, if you’re going to do something, don’t broadcast it, you know, out there where everybody can see it. But that’s how he got caught, you know, because he was putting it out on his social media. And I’m like, aha, there’s an epiphany. I should be looking at people’s social media just in case, because you never know what people will put out there.
Sheila
So, you know, but having that big view of multiple things because if you start seeing things in all those areas, it’s like that’s a pretty big red flag.
Terri
Yeah, absolutely. And, you know, certainly from a pharmacist in charge regulatory perspective, you want all of your medication accounted for. So giving them the opportunity to clean it up before they leave their shift is important from that perspective. Definitely. So I can see that. And, yeah, Shannon, you’re right. With your new grads coming out, you know, right about now, remember very clearly working at a teaching institution years ago that we would all like, oh, the new residents are here. In terms of the, you know, physician residents, it’s like, all right, everybody up your game because the pharmacists now are that final stop and we’re going to be stopping a lot. And so we have to get through those first, you know, two, three months so that we could start to semi relaxed again because the mistakes were just, you know, crazy. Yeah.
Terri
All right, Vanessa, how about you? Anything that you discovered when you were new in your role, that was a big bang for your buck to take care of right away.
Vanessa
Yeah, but let me touch on that last topic. I wanted to share my insight on putting out reports that, you know, kind of let individuals clean up their or cover their trail before they leave. We don’t do it at our organization, and we have mixed feelings about it as well as we do realize that it would clean up a lot of poor practice and allow our AI system to not fire a lot of, or as much missing met alerts or, you know, high risk alerts. And that would minimize the level of work that we do. We don’t, we kind of don’t really give them a lot of information on what it is that we’re looking for.
Vanessa
We do a lot of the work on the back and we feel that if we put out those reports that, you know, says, hey, you know, you didn’t document this waste or, hey, you have this unaccounted for. Take care of it then. Yes, we’ll see it in other buckets, you know, the delayed action or the, you know, the back charting, and we’ll see it in other actions. But I feel, and members on my team kind of feel that if we allow them to, when diversion is occurring, it’s going to occur and it’s going to occur in one fashion or the other. And if you show your hand and let them know what you’re monitoring for, sometimes they’re just going to deviate or switch to a different method and then you’re chasing yourself for that. So the unaccounted or lack thereof.
Vanessa
Documentation is the low hanging fruit. So we don’t preview them to letting them know what they have unaccounted for before the end of the shift. Our artificial intelligence software flags that triggered that. And we do have a process in place where we follow up on it and say, hey, you know, but it’s on a manager level or leadership level to say, hey, this nurse has this transaction that’s unaccounted for. Can you let us know what happened? And then we have a process where after a handful of them, three of them, we’ll take that into a, you know, more of a serious look. And we’ll want to do what you guys already mentioned, you know, certainly looking at other things, looking at the whole picture, trying to summarize what’s really going on with this individual from a trending perspective.
Vanessa
So kind of wanted to share my thoughts on that.
Terri
Yeah, it’s interesting. I mean, there are different ways to look at it, that is for sure. So it’s good.
Vanessa
We do get questions. People will ask us, you know, hey, can you set us up with a report? And I really do explain. I really do say, you know, that the report is an option. The software we use, Omniso, you know, does have the capability of doing it, but I don’t think that it’s the best thing. So we do teach them that, you know, hey, if they’re concerned that their waste transaction didn’t go through, they can print, look for a receipt transaction, you know, at the omni. So we teach to that. We teach, you know, we have the closed loop process in omnicell to say that, you know, hey, if they have something outstanding, they withdrew a partial dose. Every time they log on, they get that little banner at the top of the screen in omnicell.
Vanessa
So we do have some processes in place that allow nurses, we know it’s hectic. We know they’re, you know, they’re often rushing. We know they’re busy. But there is a lot of opportunity that if they just take the time to slow down, read their screen, that they can fix these more in real time. We also try to promote the wasting right at the time of removal so that you don’t have to forget about that undocumented waste. So we try to push more on those things than an end of shift report to say, oh, you lacked doing all of these tasks throughout the day, go back and fix them.
Terri
Makes sense. Okay.
Vanessa
Yeah.
Terri
Any big bang for your buck?
Vanessa
Yes. What came to mind when you asked that question. I had mentioned that when I kind of stepped into this role, it was already developed for me on paper. And when I came into this role, I felt like I had a decent number of years of experience and thought I knew what I was doing and was like, okay, this is going to be a nice transition. And I really quickly learned that there’s so much outside of hospital, right. So now I oversee the program for the entire system, and I wish that I would have taken the time to kind of learn the entire system. I felt very confident with what I knew from a hospital setting and the processes from a hospital setting. But when I stepped into this corporate role, it was like, things vary so much in different settings, right?
Vanessa
And urgent care space and clinic spaces and surgery centers and outpatient pharmacies. And yes, our standards are the same and the, you know, de requirements are the same, but the way we practice within our organization is completely different. And I’m still finding that I learn on a day to day basis, somebody will come with me and I’m like, I didn’t even know you guys had meds there, like an infusion center. Wait, what? And, you know, and then I have to, like, jump on it and have this sense of urgency. So I really feel like that was a big, that would have been a big bang for my buck if I had taken the time to out the gate, learn more in detail about the way my organization is structured and being there.
Vanessa
You know, at that point, I had been there, you know, eleven, 1112 years, and I was like, oh, I got this. Like, I know what I’m doing.
Terri
I’m the expert on my organization. No, just on my facility.
Vanessa
Yes.
Terri
Yeah.
Sheila
When you look at, you know, who touches medications the most, you know, you automatically think about, you know, nurses for the most part. And, you know, with nurses, they can, you know, be, have a role in so many different areas. And you’re absolutely right. They all function a little bit differently. And even though I’m a nurse by trade, I never worked post op. And you know how they function and how they titrate doses. So having to learn all of that and learn what’s acceptable in that area while yet still maintaining the security of the medication and the integrity of it and all of that, and clinics are completely different. And surgery, you know, in the or is completely different with the anesthesiologist. So you’re right.
Sheila
Kind of learning the do’s and the don’ts and what is standard of care and standard of practice in those areas. I think it’s important because then when you’re looking at the data, you know, that’s okay because of this particular setting, but it might not be okay in an acute care setting or in a critical care setting, right?
Terri
Yeah. And it’s kind of the difference between just the workflow versus maybe best practice. I mean, that might be your workflow, it might not best practice, but okay, maybe this is what happens in this kind of, you know, arena. So, Vanessa, you’ve kind of launched us on lessons learned. So I will take that as a lessons learned. And Shannon, you have a breadth of experience with lots of different nursing units, shall we say, different types. So I’m sure that was a big advantage for you. And from that perspective, do you have any lessons learned that you can share?
Shannon
Yeah, I think, you know, one of the biggest lessons learned probably in the last bit is we’ve had a change in our anesthesia practice here at billings clinic. So when I had started here, there wasn’t a lot of focus on anesthesia, mainly because we didn’t have all the parts in place. So we have a surgery center that had AWS in all of their or, but not in our main hospital. So fortunately, and I was so excited. And that to get AWS is in our, all of our main hospital bars, plus the cameras over top, which makes our lives so much easier because if you’re trying to find a, you know, a medication issue or whatever, it’s lots of times you don’t know what happened because you can’t see in the, or in that.
Shannon
But along with that anesthesia process change, we also had a change with leadership and that, so we now have a dedicated anesthesia lead. Initially we had a contracted individual start, and now we do have a Billings clinic anesthesia lead, which makes my life so much easier. We have a great communication. I do monitor anesthesia, unrecognized stuff as well. And I know, like, even yesterday when I was reviewing something, I was like, gosh, you know, that really seems like a lot of medication that individual gave. So I have a great rapport with this end with the lead and just said, hey, could you have a look at this chart for me? And that, because this seems like a lot. And it was great. It was like, no, this is right. And, you know, whatnot.
Shannon
But I think understanding, like, I’m not the expert, you know, I’m still learning every day. But you need to find those experts in your program to help you identify, like, is this truly an issue? Because I call it going down the rabbit hole in that, like Alice in Wonderland, because that can happen very easily, and then it’s. There’s truly not an issue. But you spent all this time on this that wasn’t an issue when you could be missing something else.
Terri
Absolutely, yeah. Collaboration with the different departments, that was one of my first lessons learned. When I first started. Nobody trained me. There was a semi program in place at the hospital where I started my work in diversion, but it was really just, okay, here’s the stuff, you know, okay, start watching. And so I had to learn that investigative piece, what I’m looking for, what’s important, all by myself. And there was a particular nurse that were using, the Picsis proactive diversion reports there, and a particular nurse that just had that plus two standard deviation, which, you know, is not high. Most programs don’t even look at that. But she had it consistently for months. And so she would pop up on the list of, you know, this is what you’re supposed to look at her. I look, everything seems fine.
Terri
I’d pass it off to the nurse manager. She would hand it back to me, signed off, she reviewed it, and finally, after, you know, like, three months, and I knew she’d been on there prior to me starting over, I’m like, you know, this is just weird. I mean, nobody comes up this much, and, you know, are you not finding anything? And that was when the manager admitted to me, oh, I’m not really looking that hard. I’m like, okay, you need to look. And so when she did, right now, this month, she’s looking. She’s like, why is she removing pcas? We don’t do pcas in our unit. Like, we wait till the floor. Like, okay, well, I didn’t know that. I mean, that’s normal in a Pacu. This is Pacu, like, some places do. So it was information. I didn’t know everything was accounted for.
Terri
But as soon as the manager actually took the job seriously, immediately it was like, that’s not normal. Well, that’s what she was taking, and she’d been doing it for quite some time. So that was when I realized, you know, I’m telling the managers, here’s your audit. You know, see what you see. But it required a deeper conversation and a deeper relationship with those people, and that is pure collaboration. Like, I cannot do this myself. You are the expert here. You need to tell me if you see something that is going on, and that’s where you’re either your diversion response team with your experts or the manager in that area to, like, you know, look it over. But that was my lesson learned. So, Sheila, do you have any lessons.
Sheila
Learned that you can recall? I have a few lessons learned. There were a couple of quotes that always stuck with me. It’s, it’s never personal. Like, when you’re having a conversation with somebody that you think might be diverting or you’re having that conversation with a manager about one of their staff that you think there’s an issue with, it is not personal. So that’s one, that was one thing that I always had to remind myself, and don’t make it personal, you know, because I think the managers, they do take it personal. And so I always, I would, you know, I always. How many times did I hear there’s such a good nurse, you know, I heard that so many times, you know, so I would even start the conversation with, this is not personal. Against, against your nurse. I don’t know the nurse.
Sheila
I’m only looking at the data, and I’m telling you what the data is telling me. Okay. The other, the other thing that I kind of went by was, we trust everyone, but we also validate everything as well. So those were kind of two things. Two things that I always kind of went by. The other one is, and it kind of stems from my education background, was that education and training is extremely important at all levels. It doesn’t matter if you were the CFO, you need to understand our system and our program, because you don’t want the DOJ coming in and, you know, or the DEA coming in and doing a great big, you know, investigation. And then we have to write a nice big check, you know, which, you know, we know that has happened in a lot of institutions.
Sheila
So I would do education and training, and I would make it specific for the crowd that I was doing training with. And so our CFO, I made sure to point out some things specifically for him. But, you know, you were talking about, like, new nurses, like, oh, we’ve got all these new nurses coming on board, so we’re seeing more things.
Sheila
So I made sure that I got in front of our new nurse residents or our new nurse hires to make sure that they understood what our program was, why we had it, what my role is, and even what their role is as a new nurse, because they also need to be kind of keeping their eye out for different things, you know, if they always have that nurse that comes up to them because they know that they’re new to the unit and saying, hey, you know, I forgot to have somebody watch me waste that, you know, two milligrams of morphine. Could I, could I just get you to sign off on that, you know, real quick?
Sheila
And, and so I always talk to them about, once you establish your bar, you never lower it for anybody, your professional bar, you always keep it up here and you just, and it’s okay to say no to somebody. And even if it’s your manager or a supervisor that’s asking you to do that, you don’t lower your bar for them as well. You say, you know, I feel really uncomfortable doing that. I just don’t think that. I don’t think that I can do that, I said, and they’ll quickly learn who not to come to to help cover their tracks. So education and training, I think, is extremely important. And I didn’t only educate about the diversion prevention. I also did education and training about substance use disorder in general. What does it look like? How do people get there?
Sheila
What are the things that you should be? You know, if you’re seeing things with a person, you know, maybe you need to report it on up your chain of command. So I made sure to cover both aspects when I did the education and training as well.
Terri
Yeah, that’s great. Yeah. So let’s talk about education. Did you or do any of you have any programs that are different than your standard education module? Go ahead and read this and sign off and say that you did it. Did you find anything outside of that box that worked?
Sheila
Gosh, I’m trying to think. We did the online modules, but I also tried to do as many, like, face to face as I could. So I would, you know, because I think that makes more impact. And once the staff got to know who I was and what my role was and that I’m really not a bad person at all because I’m doing this is that they actually, I would get calls from staff members or I would get emails from staff members going, you know, this is going on. What do you think about it? You know, or they would just, because maybe they didn’t feel comfortable going to their supervisor or their manager for whatever reason, but they always knew that they could count on me to, like, you know, look at their questions and answer them. So, so I think that was really valid.
Sheila
So I think getting as much face to face. So I know with some of the units that I would go do training with, they would actually videotape it because they would have their own unit Facebook page or Instagram page, and they would actually put the video out for staff that weren’t able to attend. So I think doing those types of things made it a little bit better for me in the long run because I actually got help from those staff nurses and identifying people that might be diverting.
Terri
Right, right. Shannon and Vanessa, anything on the education front that has worked for you?
Vanessa
Yeah, we are in a pilot phase at our organization where we also do the online, you know, required annual or new hire. But, you know, some people learn different. Right. So some people just kind of go through the motions and, you know, they’re eager to start. And then we know that, you know, as a new hire, you get so many things thrown in your direction, so only a few of that sticks. Most recently, I learned that at one of our larger hospitals, they’re doing there’s a like a 30 minutes segment for the pharmacy department to come speak to a group of new hire nurses during their new hire orientation.
Vanessa
And they touch out of those 30 minutes, you know, they touch on a lot of things medication wise, but they do touch on, you know, diversion and the fact that, you know, we’re monitoring and we’re looking and kind of just briefly touch on the expectations, you know, that most nurses should know, but we kind of re emphasis, you know, to, you know, and what diversion looks like and who to reach out to. So I feel like it’s another touch point, aside from their online modules is another touch point.
Vanessa
And then I was beginning of this year, was invited to come and speak to our supervisors amongst all, not just nursing supervisors, but on all supervisors in the organization to kind of come and do like a, you know, show and tell, you know, who I am, what I do, what our program is designed to do, what to look for, what diversion looks for. And I found that to be very valuable. So we’re doing, you know, a little road show amongst all of the organ sites that are at our organization to talk to the supervisors. And then I haven’t done it yet, but I was invited to come and talk to managers and above and kind of we do the same presentation just so that we can touch everybody, right.
Vanessa
And everybody can see what our program does because we’ve learned that what they think we can do and sometimes what we have the ability to do are two completely things. And we learned from a case that they were like, oh, I thought that you guys could see that, you know, so I didn’t think to tell you. And so really just, you know, have a casual conversation with them to say, you know, diversion occurs. This is kind of the signs, you know, and symptoms to look for, but, you know, we rely on you guys, you know, that are in, you know, on the front line to report to us anything that you have concerns for. And there’s no such thing as over reporting. Right.
Vanessa
If you have a concern for something and you let us know and you bring it to our attention, we can look within our resources and determine if we think that’s a problem. Maybe it’s, maybe it isn’t. If it’s nothing, then nothing’s going to turn of it. And really just being able to have that dialogue back and forth. When I did my presentation, I was supported by the director of HR. That led into her having a conversation about substance use disorders and more of what to do in the here and the now.
Vanessa
If a supervisor finds somebody that’s under the influence at work, not just from a diversion piece, but you also have individuals that will use while on the job, and it was important for them to kind of get some resources on, you know, who to report it to and what, you know, actions need to be taken place. So I felt that was a very good collaboration, the way that took place.
Terri
Yeah. So again, getting in front of people, I like that, too. And tweaking how you present and what you present, depending on who you’re presenting to, because that makes a difference. Shannon, anything you want to add on the education piece that you have found?
Shannon
I don’t think anything hugely different with billings. You know, Montana is kind of a vast state, so we have a lot of regional sites that are kind of out there, you know, small, critical access hospitals. So I have done one presentation so far, you know, for them, just as you both have indicated, kind of like what to look for, basically. Like, I’m available. Not all people I can do the same depth of investigation with, but, you know, like you both have said, just, hey, there’s somebody out here, you know, that can help you and that with it, but definitely similar things that you all are doing.
Terri
Yeah, yeah. All right, go ahead.
Sheila
I was just going to add one thing with the, some of the education and training that I did. It was I’d been in the role for probably four years or so, and we had a lot of new leaders, so they were doing a new leader orientation. And I actually had two of the directors that I had worked with to identify diversions that were taking place in their units. And one of them was one of those that she always told me that they’re such a good nurse. They’re such a good nurse. So I actually invited those two directors to present with me and tell their story. So that they could. So that other managers could, and directors could get it from their perspective, not just my perspective.
Sheila
And I think that made a huge difference with the new managers, and it was all the managers, actually, I think, that attended that so that they would know that if I was calling, I really had something that was important that I needed to talk to them about. It wasn’t me just picking on somebody. So I think having those two directors present with me, I think that was a big win.
Terri
Excellent idea. Excellent. Yeah, I like that idea.
Shannon
All right.
Terri
Anything that this would be specifically, I guess, for Shannon and Vanessa, anything that you’re working on at your facility, in your system that you’re excited about, it’s something new, maybe that you just got permission to pursue or some new workflow process or anything that you think will be helpful for diversion, mitigation or monitoring.
Vanessa
Yeah, I can share. At our organization, it’s been a long time coming, but we’re really working on implementation of monitoring of controlled substances electronically in some of our smaller spaces. And they do have a process in place, but it’s very much, you know, a locked cabinet with a paper log. And yes, we do have access. We can reach out and they can send step over, but there’s nothing like just the visibility of it being electronic. So we. I’m really excited once that, you know, comes, gets completely implemented at all of our smaller clinics where, you know, it’s nowhere near the volume of, you know, a large hospital, urgent care surgery centers. But, you know, we can’t forget about the clinics where, you know, diversion does occur.
Vanessa
And this kind of stemmed from a diversion case that we did have at one of our clinics, you know, where, you know, it’s going to be everywhere. So it really, you know, to be able to have that focus and have that oversight. So I am excited.
Terri
That’s great expanding. Shannon, anything that you have that you want to. I saw you thinking hard.
Shannon
I know. You know, I just.
Terri
I mean, the reality of it is sometimes there isn’t anything big going on. It’s the day to day, you know, consistency and doing what you’re doing. And you may know that there’s things that could be improved, but either the money’s not there, the buy in isn’t there, the time isn’t there. You’re one person, and so you just, you continue on with what you’re doing. Well, so there isn’t always something big going on.
Shannon
Absolutely. Terri, as you guys can’t see this, but I have a whiteboard, you know, full of things, you know, I would just say, you know, continuing and not to look again, you know, I’m fairly new in the process, but I truly enjoy, you know, being with the IHFDA and just having people reach out, you know, I know this is, we’re speaking to various people in various levels of diversion programs, but something may work for your program that doesn’t work for mine. You know, don’t take whatever I’m doing as gospel for your program, you know, and I think it’s so nice to collaborate with the peers that we have to say, hey, what are you doing with lockboxes? Or what are you doing with this? Or, you know, because we are kind of our own entity and that we’re kind of different than everybody.
Shannon
But I think, you know, just as you said, Terri, there’s so many things. Like right now, my biggest thing is trying to figure out anesthesia, you know, and going down that road. And then, you know, looking at right now, I’m very data driven. Is like the why, you know, why are we doing this? What are we missing? That type of thing. But the other stuff just comes up on the whiteboard and that, and eventually I’ll get to it and that. But it’s one day at a time, and that’s truly all you can do.
Terri
Yeah, it is one day at a time. And sometimes we can get overwhelmed because we. I know there’s something out there. I know there’s a safety issue out there. We’ve got to get to it. But you can only do what you can do, and that varies with, you know, it sounds like you’ve all had good support from your leadership, and that’s fantastic. But some people don’t. As Shannon, you had mentioned, and I talked to a colleague the other day, she does not. And that’s frustrating because, you know, you feel it and you want to do it, but if you don’t have the support, then you don’t. So you do what you can. And I. Whatever it is that you are doing is better than not doing anything at all.
Terri
So you are making a difference and you just keep, you keep going and you keep plugging away and finding people that you can network with is an excellent resource. So, yes, definitely encourage everybody to do that.
Shannon
All right, I was just going to add that, you know, just when you think you have everything down path, you know, to allude to what Vanessa’s saying is the non controlled substances are now just as much. Something that we need to watch is the controls and that. So that’s the added twist in the game of diversion.
Terri
Yeah. Yeah. Well, there, you know, people with a substance use disorder will. They’re constantly evolving and constantly looking for new ways. Just because you have a program doesn’t mean that people aren’t going to divert at your institution. And so, yeah, just when you think you got it nailed, you talk to somebody who tells you what happened at their place and you’re like, oh, my gosh, you know, never thought of that. So we have to constantly be thinking big picture and open to that. And you’re right, the non controls, I mean, that is just a black hole. I mean, you know, at first it was just, okay, those that have a CN’s depressive effect, well, now it’s. Oh, it looks like it. Like, how many, you know, little white pills are there that look like another white pill? So, yeah, it’s constantly evolving.
Terri
All right, well, this is a good conversation. Go ahead.
Sheila
I just. You said something about how, you know, diverters, they will change, you know, their modus operandi and do things differently. There was a saying that I heard, and I can’t remember if it was at an IHFDA convention or if it was somewhere else, but they said, diverters are smart. We are smart. You know, as a diversion prevention specialist, we are smart. Diverters have a need we don’t. Therefore, they will outsmart us every single time. And I just always thought that was, you know, when you have that need, you can, you can figure it all out in some way, shape, fashion or form.
Terri
Right? Well, and a good friend of mine, who is it, been in recovery for years, he always reminds me, twenty four seven, the person with substance use disorder, is thinking about the reasons that they can give you as a single diversion specialist. You spend a few hours maybe looking at their case and thinking about it amongst the rest of your duties that you’re doing 24/7 they are ready to come at you. So they’re constantly thinking of what they’re going to say to give you that excuse. And so that goes right with their need that they have. It is crucial that they come up with some logical explanation. And many buy it because you don’t want to see it. You do take it personally if you’re their manager.
Terri
So there’s lots of reasons why it can just like, go past you and say, yeah, let’s just reeducate. Had one of those conversations. Listen to people have that conversation yesterday, and I’m like, oh, my gosh. Okay, there’s more here, but they’re going to coach and educate. Okay. I can’t do anything about that. But.
Sheila
That’S where having a good relationship with their supervisor comes in really handy. Like having. Sometimes you have to go step up in order to get something done, so.
Terri
Yeah. All right, ladies, thank you. This was a great conversation. Hope it was encouraging or at least informational for everyone listening. And I do appreciate the time from all three of you. Thank you.
Sheila
And, well, thank you, Terri.
Shannon
Thank you, Terri.
Vanessa
Thank you.
