Underscoring the fact that diversion is an ongoing and widespread problem, it is estimated that one in every 100 healthcare workers divert medications.1 In 2022, ASHP published revisions to their Guidelines on Preventing Diversion of Controlled Substances describing a comprehensive controlled substances diversion prevention program that includes organizational oversight and accountability as a core element as well as system level controls (eg, monitoring, surveillance, investigation, and reporting).2 Additionally, ASHP has long encouraged pharmacy technicians to serve in leadership roles.3

Because pharmacy technicians are well suited to play vital roles in auditing and diversion prevention, our facility created a centralized, multi-hospital statewide controlled substances diversion prevention program founded on the unique utilization of remote pharmacy technicians leading interdisciplinary compliance.

Build a Centralized Team

AdventHealth comprises over 50 facilities split into 8 regions, and a centralized, remote, technician-led diversion prevention program services 3 regions of the system. The program has undergone 9 years (see FIGURE 1) of growth from an original coverage model of 16 facilities (3407 total beds) to the current coverage model of 47 facilities (7024 total beds).

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Diversion Prevention Analysts

The diversion prevention team comprises 10 certified pharmacy technicians dedicated solely to diversion prevention analysis, detection, investigation, escalation, interdisciplinary communication, and event coordination across the organization. These technicians act as diversion prevention analysts (DPAs) led by a pharmacy technician manager in a centralized system cost center. The team provides data, information, and support including monthly reports and virtual meetings to review metrics and compliance with the pharmacy directors who have the ultimate authority for each facility’s diversion compliance program and results. The DPAs also provide perpetual surveillance of suspected diversion cases, and, at the time of discovery, actionable findings are escalated to the pharmacy director and campus leadership.

Diversion Response Team Structure

The pharmacy directors oversee the physical controlled substance medication inventory and manage any issues falling outside of the DPAs’ daily tasks. The DPAs coordinate virtually with hospital campus stakeholders for direct compliance questions or requests.

Each facility has an on-campus designated diversion response team to review escalated cases. The diversion response teams consist of hospital leaders in pharmacy, nursing, human resources, security, and other disciplines as necessary as well as staff leaders from impacted areas. This multidisciplinary group reviews notable cases, determines any additional investigative steps, and interfaces directly with the impacted staff. This ensures decisions are not made in silos, allowing a uniform approach to treat all cases equitably and in a standard fashion.  

While the pharmacy director is the ultimate lead for each hospital’s diversion response team, the facility DPAs guide these meetings following a standard algorithm (see FIGURE 2 for our standard process). For case escalations that do not result in a positive finding, each diversion response team follows the guidelines described in FIGURE 3.

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Nearly a Decade of Advancements

Overhauling a facility-based diversion prevention program in favor of a centralized multi-site structure may seem daunting. However, it is important to remember our current program is the product of several years of dedicated effort, leadership support, and execution. Our 9 year journey of enhancing diversion prevention offers valuable lessons to other organizations undertaking similar optimization efforts.

Individualized Hospital Approach

In early 2015, the region one leadership team sought to strengthen our diversion prevention efforts. Beginning at the largest facility in region one, an internal diversion assessment was undertaken to understand baseline risks and opportunities for improvement. In this initial phase, a single technician DPA position was piloted to monitor controlled substance medication processes and define workload metrics. Experienced in pharmacy automation and technology, the technician DPA was assigned to review automated dispensing cabinet (ADC) inventory movement, ADC inventory discrepancies, and standard deviation dispensing reports, as well as conducting chart reviews of clinician documentation and patient response to treatment.

Our organization enlisted external consultants with legal and healthcare experience who recommended expanding the diversion prevention team and increasing the visibility of the program across the organization. Historically, each of the sites operated independently with individual compliance models. Centralized guidance on diversion prevention could help prevent individual weak points and the lack of cross-hospital tracking or accountability.

Expanding Analyst Support

The initial pilot expanded from one technician analyst to three in July 2016 at our flagship campus. An interdisciplinary diversion oversight committee (DOC) was developed to guide the implementation of consultant recommendations and included leaders from pharmacy, nursing, informatics, anesthesia, security, human resources (HR), risk management, physician leadership, and compliance. The DOC developed an improvement plan which included creating region-wide standardization through new policies, procedures, and education applicable to and required by all sites. It also established interdisciplinary expectations of controlled substances management across the organization and prioritized the shared accountability of diversion prevention across a variety of departments outside of pharmacy.

While progress was achieved across the region, additional improvements were needed to address variances in labor allocations, engagement, and staff skill levels with the available applications and software. True standardization called for a centralized, team-driven approach where pharmacy technician DPAs were coordinated centrally through standard oversight of training, workflow management, analyst productivity, and outcome metrics for all campuses. To achieve this goal, in 2019 the existing group was expanded to four technician DPAs in a shared location to ensure the daily work resulted in standardized monitoring across 16 facilities in region one. The DPAs performed site visits as needed.

Adjusting for COVID-19

The COVID-19 pandemic forced non-patient-facing roles in our health system to shift to a remote model, which included our DPA technicians. At the same time, the redeployment of several technician analysts to other conventional roles occurred to address the challenges presented by the pandemic. Despite this shift, basic functions for diversion prevention and controlled substances compliance were maintained under a smaller group with temporarily restructured priorities. As the health system transitioned back to offices, our leadership team opted to leverage the benefit of remote work to expand the DPAs’ reach to other locations within our corporate structure but outside of our region.

Leveraging Software

In 2021, the organization implemented a company-wide auditing software to enhance surveillance capabilities by automatically reconciling EHR administration data to ADC transactions. The decreased audit time allowed the DPAs to refocus efforts on the validation of software results and review of trends, while expanding the number of records a single analyst could review per shift. The standard deployment of the software established interconnected access allowing the DPAs to expand services to any hospital in the system; shortly thereafter, 8 hospitals in a neighboring region within the health system adopted the program’s services.

Before expanding services, a needs assessment was completed determining two additional DPAs would be required to cover the compliance work at the 8 additional facilities. Because of the geographical distance of the new facilities and to maintain consistency in both regions, the DPA team leveraged telepharmacy techniques by moving to virtual touchpoints with campus leadership. In addition, processes for campuses to electronically submit all required information to their assigned DPA were implemented, eliminating the need for physical site visits. This move repurposed roughly 16 hours per month per DPA and allowed the existing group to oversee more facilities, further increasing their value and coverage capacity. The new approach allows each DPA to provide coverage for approximately 800 beds, versus the previous 500 beds. Each DPA owns all processes for assigned hospitals within the new region and they deliver the same standardized services. This approach provides a scalable model delivering standard coverage for compliance across the health system.

Measuring Success

The success of the expanded, centralized DPA technician model was evident during a company-wide internal assessment of controlled substance compliance conducted by our corporate leadership team. As these results were shared, leadership in the next region requested assistance developing their program, and our model was expanded to include four additional technician DPAs to oversee 20 additional hospital facilities in March 2023. As of August 2024, the DPAs oversee all controlled substance inventory movement and clinical documentation for each of our 47 hospital facilities across the state of Florida, which includes 7024 patient beds and a line of sight to 6.3 million medication doses per year.

This program also delivers significant labor cost savings. The median weekly salaries in 2023 for nurses, pharmacists, and pharmacy technicians were $1442, $2208, and $903 respectively.4 Dedicating a pharmacy technician to this work in place of a pharmacist has a conservative annual salary savings of $67,860 per technician. In addition, the centralized efficiencies are associated with a significant improvement in local nursing unit and pharmacist compliance work, saving an average of 1 hour of nurse and nursing leader time per day per care area and 2 hours of pharmacist leader time per week. Based on 659 care areas, this translates to 240,535 hours of nursing time. For pharmacy, this model has resulted in 4472 hours annually of pharmacist time saved or redirected to direct patient care activities across all 47 facilities.

Conclusion

A centralized, technician-led diversion prevention model is a novel concept with the potential to revolutionize the historic practice of pharmacy-led diversion prevention. This program has improved unresolved discrepancies, demonstrated tangible cost savings, reduced medication error risk, and has the potential to be expanded to other administrative functions. Other program outcomes include quantifiable regulatory and quality improvements in inventory control, medication related documentation and reconciliation, accountability for controlled substance medication safety, and clinical workflow processes. Our model demonstrates that pharmacy technicians can positively impact organizational compliance and enable nursing and pharmacy leaders to dedicate time to higher level tasks, making this a practical application for health systems of any size.

References

1. 2024 Diversion Digest. The Future of Drug Diversion: 2024 Diversion Digest. Accessed December 20, 2024. www.protenus.com/diversion-digest.
2. Clark J, Fera T, Fortier C, et al. ASHP Guidelines on Preventing Diversion of Controlled Substances. Am J Health-Syst Pharm. 2022;79(24):2279-2306.
3. American Society of Health-System Pharmacists. ASHP statement on the roles of pharmacy technicians. Am J Health-Syst Pharm. 2016; 73:928–30.
4. Median weekly earnings of full‐time wage and salary workers by detailed occupation and sex. U.S. Bureau of Labor Statistics. January 26, 2024. www.bls.gov/cps/cpsaat39.htm.

Amanda Wollitz, PharmD, BCPS, BCSCP, FISMP, is the executive director of pharmacy quality and regulatory affairs at AdventHealth Central Florida Division South.

Heath Jennings, PharmD, MBA, BCPS, FASHP, FACHE, is the executive director of business, operations, and strategy at AdventHealth Central Florida Division. 

Austin Kucher, CPhT, manages AdventHealth’s centralized diversion prevention program consisting of ten pharmacy technician analysts monitoring 47 facilities across Florida.