Combatting drug diversion and managing prevention efforts can be challenging at a large health system or on a company-wide level. The responsibility for oversight and accountability of controlled substances falls to each hospital’s DEA registrant, which may be a member of the chief executive suite or the pharmacist lead. Health system pharmacy teams are perfectly positioned to lead drug diversion prevention programs by working collaboratively through interdisciplinary teams on behalf of the organization. Prioritizing standardization and leveraging innovative technology are two ways for health system pharmacies to manage robust auditing and facilitate a large-scale diversion prevention program across multiple facilities.

AdventHealth, a large health system of over 50 facilities split into eight regions, successfully implemented a centralized, pharmacy technician-led team to provide diversion prevention services to 47 different hospital facilities across the state of Florida. To learn how we developed this team, see the article Technician-Led Centralized Diversion Program published by Pharmacy Purchasing & Products in January 2025.

Diversion Team Structure

Our diversion prevention team comprises 10 certified pharmacy technicians as diversion prevention analysts (DPAs) dedicated to diversion prevention analysis, detection, investigation, escalations, interdisciplinary communication, and event coordination. These technicians are led by a pharmacy technician manager in a centralized system cost center. The team provides data, information, and support to the pharmacy directors who manage each facility’s diversion compliance program. The DPAs also provide perpetual surveillance of suspected diversion cases and escalate actionable findings to the appropriate pharmacy director and campus leadership. Each facility has an on-campus multidisciplinary diversion response team to review escalated cases.

Evolving Diversion Audits

In 2019 our diversion prevention team comprised four technician DPAs centralized in a shared location, performing campus site visits as needed to 16 facilities to ensure standardized compliance monitoring services. At this time, DPAs would travel across the system to conduct site audits following a standard structure (see FIGURE 1) and would complete each visit according to a set of standard activities (see FIGURE 2).

Financially, the organization shared the labor cost of the analyst team among all facilities based on bed count, which established a reliable model of diversion surveillance for each hospital with minimum operational expenses incurred by campus leaders. Advantages of this model included reduced variability in work and consistent handling of diversion cases across campuses. Despite the regulatory benefits, this model presented challenges: travel time limited the team’s available working hours, and workspace constraints or lack of office space during the site visit hindered the analyst’s work.

In 2020, the COVID-19 pandemic forced non-patient-facing roles in our health system to shift to a remote model, this included the DPA technicians. While the pandemic forced our model to adapt to a remote monitoring approach quickly, it served as proof of concept for a centralized telepharmacy model for this team. As the health system transitioned back to offices, our leadership team opted to leverage the benefit of remote work to expand the reach of our team to other locations within our corporate structure outside of our region, which required our audit structure to change again.

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Expanding Technology

In 2021, the organization implemented a new company-wide auditing software that enhanced surveillance capabilities through automatic reconciliation of the EHR administration data to automated dispensing cabinet (ADC) transactions. This decreased audit time for the DPAs, allowed the refocus of work to the validation of software results and the reviewing of trends, and expanded the number of records a single analyst could review per shift. The standard deployment of the software across the entire system established interconnected access allowing expanded diversion services to be provided by the centralized team to any hospital in the company. This set the stage for the adoption of our standardized program services by a neighboring region within the health system consisting of eight additional hospital locations without adding FTEs for the centralized diversion prevention team.

As of August 2024, our centralized team of 10 DPAs oversees the controlled substance inventory movement and clinical documentation for each of our 47 hospital facilities across the state of Florida, which includes 7,024 patient beds and line of sight to 6.3 million medication doses per year.

Realized Benefits

At each stage of our program’s growth, notable improvements were achieved in key areas related to controlled substances compliance and safety. Since discrepancies in ADCs pose a risk for diversion if not immediately addressed, the rate of unresolved ADC discrepancies was one of the first areas of focus as the diversion prevention model was implemented for each region. Region 1, seen in FIGURE 3, was the first region to embrace the centralized diversion prevention process in 2015 and has since tracked an 88.1% decrease in unresolved discrepancies. This compliance metric requires ongoing monitoring and escalations to local leadership from the centralized team. The DPA intervenes when the metrics trend upward and proactively engages with local leadership to work through any anomalous data or spikes in unresolved discrepancy numbers.

By utilizing the integrated software, our DPAs provide proactive surveillance to highlight key areas of risk and anomalous staff activity at each facility. DPAs review a rolling sample of healthcare workers, nurses, and anesthesia physicians, with access to controlled substances equivalent to 5% of the bed count at the assigned facility monthly. FIGURE 4 shows the total number of audits since implementing the technician-led diversion prevention model in 2016, with the auditing software resulting in a significant increase in completed audits.

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Audits have increased from an average of 22 per month to approximately 400 per month and continue to increase with the improvement of auditing software and DPA technician experience. Key points to note in each audit graph are the impact of COVID-19 and subsequent technician analyst redeployment, new software implementation, and the addition of new DPA technicians over time. Overall, this proactive health system-wide surveillance provides an ongoing accountability infrastructure that improves awareness, mitigates potential product loss or misuse, and allows for early intervention by the local clinical leadership team.

Conclusion

Controlled substance diversion places patients, staff, and organizations at significant risk. Fortunately, proactive monitoring processes and structured teams are proven methods for detecting and preventing diversion within healthcare systems. Leveraging technology and innovative technician roles can reinforce organizational goals with the support of leadership buy-in. When initiating a new program such as a centralized diversion prevention team, plan to track performance metrics including year-to-year rates of discrepancy resolutions and audits completed to tangibly demonstrate the program’s success.

Amanda Wollitz, PharmD, BCPS, BCSCP, FISMP, is executive director of pharmacy quality and regulatory affairs AdventHealth Central Florida Division South. She holds a PharmD from Mercer University, completed her residency training at UF Health Jacksonville, and completed a fellowship in 2013 with the ISMP. She is responsible for P&T coordination, policy creation, review, and implementation and oversees the pharmacy quality program for 10 hospitals and associated free standing emergency departments and infusion centers. Today, her reach expands to corporate services for AdventHealth through the creation and oversight of the company-wide compounding

Heath Jennings, PharmD, MBA, BCPS, FASHP, FACHE, is the executive director of business, operations, and strategy at AdventHealth Central Florida Division.  Dr. Jennings has been recognized nationally and internationally for clinical program development, pharmacy residency program expansion, and integrated clinical practice, including four ASHP Best Practice Awards with three different healthcare companies.

Austin Kucher, CPhT, became AdventHealth Orlando’s sole diversion prevention analyst in January 2015. Ten years later, Austin manages AdventHealth’s centralized diversion prevention program consisting of ten pharmacy technician analysts monitoring 47 facilities across Florida.