This was a semester-long journey to discover and recommend best practices and disposal methods for the Medical Intensive Care Units at IU Health.

1. IU Health University Hospital
Group 2: Narcotic Waste Disposal
Executive Sponsor: Jennifer Dunscomb
Team Members: Shelly Burns, Amanda Carmack, Ryan Fier, Amy
Gravelle, Tyler Wysong
H-D615 Health Outcomes and Decision Making
Final Presentation
Date: 11/30/16

2. 1. Executive Sponsor:
a. Jennifer Dunscomb - Director of Professional Nursing Practice and Quality
(project champion)
1. Team Members Education Program:
a. Shelly Burns- DNP (Clinical expertise)
b. Amanda Carmack - DNP (Clinical expertise)
c. Ryan Fier - MHA (LEAN SME)
d. Amy Gravelle - MHA (LEAN SME, Clinical unit liaison)
e. Tyler Wysong - MHA (Project Leader, Fresh Eyes, Technical Coordinator,
and Presenter)
IU Health University Hospital
Group 2: Team Members

3. IU Health University Hospital
Narcotic Waste Disposal
Background

4. ● Current narcotic disposal methods are evolving to meet the demands of future
compliance and safety regulations
● DEA has proposed a “No flush” policy as the industry standard
○ Ruling overview
■ Medical facilities that dispose (waste) of partially administered controlled
substances cannot waste in the sink or open waterways
■ DEA ruling will adhere to environmental regulations and attempts to further
decrease drug diversion
● Diversion: concept involving the transfer of any legally prescribed
controlled substance from the individual for whom it was prescribed to
another person for any illicit use (American Society of Health-System
Pharmacists, 2016)
■ DEA Ruling
Problem Statement:
4.

5. Our team will recommend a dry sink system that is compliant with the DEA’s
“No Flush” policy for IU Health University Hospital’s Medical ICU in order for
the unit to become 100% compliant with this industry standard with a timeline of
one calendar year (2016-2017).
○ Measurable system metrics (realistic, attainable & timely, measureable):
■ System efficiency - limitations
■ Cost effectiveness
■ Safety / Impact on diversion of partially administered narcotics
■ Integration / Sustainability in current workflow
Aim Statement:
5.

6. Project Scope:
• Project Scope: IU Health University ICU (medical); all other units excluded
• Process Start: When a controlled narcotic is partially administered
• Process Stop: When the partially administered narcotic has been witnessed
and disposed.
6
Metrics Initial State Target State
% compliance to DEA standards
for disposing partially
administered narcotics
0% compliance 100% compliance
% completion of new training on
new complaint process
N/A 100%

7. IU Health University Hospital
Narcotic Waste Disposal
Current State Analysis

8. Current State - Overview
● Every time there is a need to waste narcotics the nurse has to find a
witness (2nd nurse to watch the process)
● The unit has two methods of wasting:
1. In the patient room (Virtual Wasting)
a. Witnessed, Wasted in sink, Documented in Pyxis at bedside
2. In the Med room
a. Witnessed, Wasted in sink, Documented in Med Room Pyxis
● Each room can become an isolation room at any point in time so it is
important to have a process that can adapt to the patient room
● Current wasting procedures at bedside or med room are not compliant
with DEA “No Flush” policy 8.

9. Current State- Process Map
• Describe the current conditions of this process using
text, data, charts, graphs, and photos.
9.

10. Current State - Principle Issue Overview
• ICU is not compliant with DEA proposal due to lack of
disposal units
• Placement of disposal devices in appropriate locations
• Implementation of a process that prevents workarounds or
breaks in workflow
10.

11. Current State - Waste Walk
11.

12. Current State - Collateral Issues
• Wasting in the Med Room is incentivized because:
a. Computers at patient bedside very slow
i. Computer system timed out when collecting metrics
b. Computer in Med Room is much faster
i. Start to finish took under 60 second start to finish
c. Walking to the Med Room = increased likelihood of
finding a witness
12.

13. Gap Analysis – FishBone Summary
1. Effect: Non-compliance with DEA standards for disposing
partially administered narcotics
2. People: lacking a 2nd nurse; (sometimes unavailable)
3. Policies: lack current policy complying with DEA standards
4. Physical plant: lack of appropriate disposal containers;
lacking consistent computer system
5. Environment: lack of system / process for compliance
13.

14. Gap Analysis - FishBone Visual
14

15. IU Health University Hospital
Narcotic Waste Disposal
Proposed Solutions

16. 16
Cactus Smart Sink Stericycle Rx Destroyer
Video
Fact Sheet
Stericycle
Compliance solutions video
Website
Waste instructions for liquid
Waste instructions for Pills
Pro Pro Pro
● Meets the DEA’s requirements for
controlled substance disposal.
● One unit can be used for solid and
liquid waste.
● It is mobile and can be installed
wherever there are Narcotics being
disposed of - ex. At the bedside in
patient isolation situations or ICU
1:1 patient care situations.
● Waste can be thrown out.
● Meets the DEA requirements for controlled
substance disposal.
● Offers online training center for
implementation
● Stericycle offers site specific metrics on
training utilization
● Stericycle offers regulatory updates
regarding products and services rendered
● Membership offers a 10% discount on
healthcare products including:
○ sharps containers, mailback disposal,
infection control, and safety items.
● No fine - No Fail OSHA / HIPAA
compliance
● Meets the DEA requirements for controlled
substance disposal.
● Cost $49 per unit
● Med waste is uncoverable within minutes.
● Waste is stated to be environmentally safe and
can be disposed with traditional trash.
● Effective for 1,000’s of non-hazardous
medications and illicit drugs (pills, tablets,
Narcotics, creams, capsules, Fentanyl,
suppositories
Pros for each System

17. 17
Cons for each System
Cactus Smart Sink Stericycle Rx Destroyer
Video
Fact Sheet
Stericycle Website
Waste instructions for liquid
Waste instructions for Pills
Con Con Con
● Cost $500 per unit ● Cost $99-$170 per unit
● Takes 7-10 days for FedEx
delivery.
● Cost is listed in Pros section
● Cannot handle hazardous materials
● Must have multiple containers (one for
solid, one for liquid)

18. Proposed Solutions - 1
• Cactus dry sink in Med Room (2)
• Stericycle in each patient room to ensure consistent
compliance with DEA standards
Reasoning:
Voice of the Customer feedback
System expense – Cost efficency
Platform / Design for Success
18.

19. Future State Process Map

20. Action Plan
20.
ITEM # ACTION ITEM WHO TIME STATUS
1 Create new standard work procedure/document
about wasting narcotics at patient bedside/MedRoom
Process Owner* TBD
2 Update policy to reflect new procedure and
expectations
Process Owner* TBD
3 Create training program on new process Process Owner*/
ICUunit manager
TBD
4 Implement training program ICU Unit
Manager/Charge
Nurses
TBD
5 Implement control plan to sustain new process Process Owner* TBD
6 Designate champions for new process (super users) Charge Nurses TBD
*Process Owner is the individual who is responsible for managing a process on a daily basis.

21. Communication Plan
21.
TYPE OF INFORMATION & PURPOSE PREPARED BY DUE DATE DISTRIBUTION LIST STATUS
New standard work procedures Process
Owner
TBD Unit managers and Staff
nurses of medical ICU
Information of maintenance of
new containers
Process
Owner
TBD TBD (environmental
services, nurses,
housekeeping)
Information of ordering new
supplies for containers
Process
Owner
TBD TBD (inventory,
administration, nurses)
Project timeline rollout of systems Clinical
Project Leader
TBD TBD (inventory,
administration, nurses)
Training education schedule Clinical
Project Leader
TBD TBD (inventory,
administration, nurses)
*Process Owner is the individual who is responsible for managing a process on a daily basis.

22. Control Plan
22.
PROCESS NAME: Narcotic Disposal System PROCESS OWNER: Jennifer Dunscomb
PROCESS STEP MEASUREMENT FREQ WHO MEASURES CORRECTIVE ACTION
1. Dispose of narcotic
in new container
Frequency of
container capacity
becoming full
Bi-Weekly Charge
nurse/unit
manager/design
ee
Voice of Customer target
audience of nurses who
use the process -- Root
Cause Analysis (discover
barriers and reasons for
non compliance) (5 whys)
2. Document disposal
in electronic system
Alignment between #
of narcotics used and
# of narcotics
documented as
disposed
Weekly Automated
report
(pharmacy)
Drill down on what drugs
were not wasted properly
to understand barriers and
trends
3. Continue education /
training for new staff
Completion rate of
training modules
Quarterly Integration to
ELMS modules
Follow up with new care
providers to ensure
training occurs

23. Barriers & Roadblocks
•Nurse workflow current preferences
•Resistance to change
•Risk of drug diversion
•Slow computer system in patient rooms
23.

24. Team Insights
• Helped: (1)Going to the Gemba, (2)Talking with stakeholders (nurses),
(3)Witnessing the current processes
• Hindered: (1)Online meetings, (2)team members schedules (minimal
impact)
• What worked well: (1)Interdisciplinary team (nursing/MHA students)
• Lessons learned: (1)Students need to understand how to better
engage with the IU Health team
24.

25. 25.
Thank You!
Any Questions?

26. References
American Society of Health-System Pharmacists. (2016) ASHP guidelines on preventing diversion
of controlled substances. Retrieved from ww.ashp.org/DocLibrary/BestPractices/
MgmtGdlCSDiversion.aspxf
Catt, E. (2014). Lean Six Sigma & A3 Thinking Workbook. TTAC Consulting, LLC.
Institute for Healthcare Improvement (2016). XX. Retrieved from http://www.ihi.org
Plsek, P. (2014). Accelerating health care transformation with Lean and innovation: The Virginia
Mason experience. Boca Raton, FL: CRC Press.
US Department of Justice. (2012). Rules - 2012. Retrieved
from https://www.deadiversion.usdoj.gov/fed_regs/rules/2012/fr1221_8.htm
26.