Q&A with Carol A. Purcell, MSN, RN, CNML
Manager of the Diversion Prevention Program
Following two separate, accidental overdoses from diverted drugs by a nurse and physician in the same 24-hour period in 2014, Michigan Medicine (MM) looked for opportunities to develop an advanced diversion prevention program that integrated data at a higher level. To accomplish this, a need for stricter oversight was identified, as well as development of a formal diversion monitoring program. Through collective efforts, MM has developed a multidisciplinary diversion program focused on prevention, detection, and response.
Pharmacy Purchasing & Products: What was your initial approach to diversion monitoring?
Carol Purcell: Historically, MM had used a standard deviation outlier diversion detection methodology. Reconciliation was done manually and diversion identification required an enormous amount of time and effort. The process was not centralized, so individual leaders were responsible for monitoring and follow up. Once an incident occurred, a group would come together to address the problem. This provided an opportunity to develop a more proactive approach.
Developing a Data Driven, Multidisciplinary Team
PP&P: What were your goals in updating the diversion policies and procedures?
Purcell: As we began updating policies and procedures, our main focus was to ensure regulatory compliance, close any existing gaps, and improve accountability. Creating a dedicated program helped us to enforce and build upon our policy updates. The program was formed in 2015 and initially reported to the chief of pharmacy.
At this time, our team consists of a project manager, who developed and maintains our database and analytics, two analysts with different expertise, and myself as the program manager. Over time, the program shifted to reporting to the director of pharmacy, quality, regulatory, and safety. It now sits with other pharmacy programs such as medication safety, compounding compliance, medication use policy, and pharmacy analytics.
PP&P: What are some challenges innate to building a multidisciplinary program?
Purcell: Leadership support at every level is essential. Hiring or appointing an individual who is a systems thinker, is willing to see things outside of their lens, and who is not afraid to challenge the status quo is key. In many cases, this may require culture change. Leading culture change in any organization is a significant endeavor. To accomplish this, you need the right people doing the right work. Engaging stakeholders who want this program to succeed is important. As a program, it is helpful to establish a common purpose, values, and goals. At the end of the day, relationships are essential as are transparency and consistency. Leaders and staff need to know they can trust the team.
PP&P: How have you used analytics to improve your methods?
Purcell: In 2015, a platform that reconciled automated dispensing cabinet (ADC) activity with the electronic medical record (EMR) did not exist, so this started us on a journey of building our own. Our platform integrates nursing, anesthesia, and pharmacy data but is separate from, and serves as the foundation for, our diversion analytics.
Our reconciliation platform is used in a variety of ways to support regulatory compliance and allows for reporting and monitoring beyond nursing ADC transactions. After each diversion case, we perform a root cause analysis in order to continually refine our analytics and supporting processes. This approach has allowed us to detect diversion earlier and to close gaps in our systems.
Prevention, Detection, and Response
PP&P: What approach have you taken to create a successful program that is proactive rather than reactive?
Purcell: Our team focuses on three key areas: prevention, detection, and response. Prevention efforts are composed of audits, an oversight committee, and educational and awareness campaigns. We generally conduct 100+ in-services a year; these range from small unit-based programs to large grand rounds. The annual e-learning, which is updated to address the issues that have been forefront at MM over the past year, focuses on diversion and drug-free workplace concepts. We also in-service leaders and staff on (deidentified) diversion case examples. We promote staff reporting, whether it be through a manager, via the safety reporting systems, or the anonymous compliance hotline. Due to COVID, we have flexed our approach, but have made a strong commitment to maintain our education efforts.
Accurate data and meaningful analytics are vitally important to a proactive diversion program. Also, how these data are used and responded to is important. While processes may evolve over time, every effort must be made to ensure that there is a consistent response to these events. It is important to engage all our clinical stakeholders–nursing, pharmacy, and anesthesia, as well as human resources, security, union leadership, legal and others in these events. We also work closely with our employee assistance program (EAP).
PP&P: How do you classify a diversion event at your facility?
Purcell: We classify an event as diversion when there is a confession or other hard evidence, such as proof on camera. The content of the diversion interview also must to be considered. Investigatory interview training has made a huge difference for us in terms of securing a confession or resolving concerns. Investigatory interviewing is based on asking questions to elicit an understanding of the interviewee’s motivations and truthfulness. Essentially this training has helped us with three key elements:
With these tools, it is much easier to build rapport with the interviewee and then get to the truth of the matter. There are several types of investigatory interviewing programs available and we do not endorse any one, specifically. Both the lead analyst and I were trained on the core concepts and we then modified our approach to the health care setting.
PP&P: What steps do you take once an individual admits to diversion?
Purcell: We always report diversion to the DEA, the state licensing board (if applicable) and the police. Generally speaking, if an employee is compliant with the investigation and expresses an interest in getting help, they are connected with treatment, with the goal of rehabilitation and a return to work. It is important to state here that substance use disorder (SUD) is a disease. More egregious cases, such as large quantity theft or tampering, would go before an internal board for review and recommendations for final disposition per our controlled substance progressive discipline policy, but these types of cases are rare at MM.
I strongly believe this approach is the safest way forward, and that it is in the best interest of public health. We have hired people from other hospitals who were caught diverting there and were allowed to resign or were fired but not reported, and then we caught them diverting in our system. All too often, health care workers who are caught diverting and not connected with treatment simply get another job and repeat their behaviors at their next place of employment. With each subsequent position, the risk of damage and harm, including patient harm, increases.
In my experience, the most common diversion scheme involves a clinical staff member who is diverting for personal use and falsifying the record in some way. Typically, they are ashamed, do not understand how they became addicted and why they cannot stop. Although about 10% of us, over our lifetime, may struggle in some way with a substance use disorder, diversion manifests in just a small fraction of this number.1 The most commonly abused drug is alcohol, and we see this reflected in our community too. In my experience, health care staff have different risks or challenges because we are educated about medications, and with that knowledge sometimes comes a false belief that we know just how much to take to keep our use under control. Often, this illusion falls apart with the progression of SUD.
Following initial denials and a difficult interview, I may be the first person to whom these staff confess. The interviews can be very challenging and emotional, requiring a balanced amount of firm and direct engagement, fact-finding, and compassion. Along with the shame and sadness, staff may also feel relief and be eager to get help because they recognize that, despite their efforts, they cannot solve this problem alone.
PP&P: What specific support do you offer to employees?
Purcell: As I mentioned earlier, we work closely with our EAP. Before we conduct an interview, we ensure EAP has a counselor trained to work with health professionals with a SUD waiting on standby for intervention and connection to treatment, if needed.
They serve as the gateway to the state of Michigan’s Health Professionals Recovery Program (HPRP), which aims to protect the public and support health professionals’ recovery. Participants in this highly effective program are monitored for compliance with treatment, drug testing, and ongoing monitoring. We believe HPRP is the safest place for our licensed staff with substance use disorders to land.
PP&P: What are your future plans for the program?
Purcell: I have a smart, highly motivated team that cares deeply about these issues and is committed to improvement and innovation. I cannot overstate how important they are to our success, as together, we have done great things. We want to continuously improve all facets of our program, especially our analytics. We need to continuously work to create safer, more reliable systems. Diversion is a very difficult problem to solve; each case is different and teaches us something new. Embracing these challenges is part of what makes our work engaging, meaningful, and fun! We are currently learning what worked well over the past year, in terms of COVID-related changes, and embedding those changes into our program.
PP&P: What advice would you give other institutions looking to revamp their drug diversion programs?
Purcell: Consider a focused effort to help staff speak up as they are often closest to the issue. Many people hesitate to speak up for two reasons: they are afraid of being wrong, and they do not know what happens after a report is made. To address this, we have designed targeted educational efforts because even with effective analytics in place, we rely on our staff to identify when something is not right. Helping educate staff to recognize that when they speak up, they may actually save a life is central to a successful program. “Speak up; save a life” is a central piece of the message that we try to help people understand. We are always happy when staff reach out to us for any reason and regardless of the outcome, my team always follows up with positive reinforcement. We set the tone when people reach out about small things, so they are less likely to hesitate when the stakes are much higher.
Diversion is a challenging and difficult problem to solve, which is why it requires a team effort. Take an honest look at your culture. Bring people onboard who will challenge you, the status quo, and your biases. I am very fortunate to have a diverse team who tries to do this. And it requires all of us looking through different lenses at this extremely complex problem to try to move the needle, to try to advance the art and the science of diversion detection.
Carol A. Purcell, MSN, RN, CNML, has held the role of manager of the Diversion Prevention Program at Michigan Medicine since 2015. Carol has nearly 20 years’ experience in health care and has presented locally and nationally on the topic of drug diversion and program development. Her program was also featured by the Advisory Board as a best practice, specifically regarding interviewing techniques and Michigan Medicine’s rehabilitative support for staff with substance use disorders.
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