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Strategies for Drug Diversion Prevention in Multi-Facility Enterprises: Key Takeaways 

Drug diversion poses safety and reputation risks to all hospitals, but those risks are amplified for multi-facility enterprises and large integrated delivery networks (IDN’s.) In order to prevent diversion across a large, intricate system, an effective, holistic strategy must be in place.

Aimée Posivak, PharmD, MBA, BCSC is the Director of Controlled Substance Utilization and Diversion Prevention at Tenet Health, a multi-national healthcare enterprise operating more than 500 surgical centers and hospitals, 52 acute care hospitals and approximately 160 additional outpatient centers and sites of care that leverages Bluesight’s drug diversion software, ControlCheck as a key component of its diversion prevention strategy. She recently joined Bluesight to discuss how she measured the unique diversion risks and challenges at her organization, and what strategies she deployed to make sure the organization was compliant and minimizing the risk for diversion. Below is a summary of the key takeaways from Aimée’s presentation.

Assessing Unique Challenges and Risks

It’s crucial to identify challenges and risks associated with drug diversion within multiple hospitals and various healthcare types in different states when creating a drug diversion monitoring strategy. Here are some key challenges to consider:

  • Variations in Regulation and Enforcement – regulations and enforcement may differ state-to-state and jurisdiction-to-jurisdiction.
  • Different Healthcare Settings – Different facility sizes and types not only face varying challenges and regulatory obligations, but also have different tools at their disposal.
  • Complex Supply Chains – Drugs can be diverted at many points in the supply chain, including delivery, dispensing and waste disposal. Additionally, low-volume facilities may encounter challenges in maintaining consistent inventories of controlled substances when utilizing multiple vendors.
  • Technological Disparities – While some facilities might use advanced technologies like drug diversion software and automated dispensing cabinets, others may still rely on manual systems, which are more susceptible to manipulation and error. Similarly, camera surveillance technology may not be an option for every institution regardless of size.
  • Monitoring & Detection Challenges – Regular audits are essential but can be resource-intensive. 
  • Staffing – Factors such as authorized personnel, staffing variability, and organizational structure can vary from site-to-site and impact diversion efforts

Identify key risks and challenges of your current drug diversion monitoring program by filling out our Drug Diversion Surveillance Program Internal Assessment.

Strategies for Compliance

The regulatory landscape for drug diversion monitoring is as diverse as the healthcare systems it monitors. Between the DEA, state health care boards, federal and state laws, and accreditation standards from The Joint Commission, The Accreditation for Ambulatory Health Care (AAAHC), The Commission on Accreditation of Rehabilitation Facilities (CARF), The Community Health Accreditations Partner (CHAP), and others, health systems have many compliance standards to adhere to. 

Here are four steps healthcare enterprises can take to ensure compliance with regulatory standards across their entire system:

  1. Policy Development and Implementation – Develop comprehensive policies and procedures that cover all elements of controlled substances. 
  2. Monitoring and Auditing – Determine each facility type’s capabilities and limitations, then establish effective monitoring and auditing techniques to ensure policies and procedures are followed.
  3. Reporting and Response Protocols – Establish a centralized reporting and response team to support individual sites with suspected diversion, confirmed diversion, and significant loss.
  4. Training and Education – Create an initial training program to educate staff on the new policies and procedures. 

To learn more about regulatory compliance, watch our webinar featuring a former DEA agent here.

Practical Tools and Resources

When implementing comprehensive diversion prevention programs tailored to the specific needs of diverse healthcare settings, it’s important to consider what tools are available and realistic for each site based on its resources. Below are recommended tools for certain types of care settings:

  • Large Hospitals – Automated Dispensing Machines, Centralized inventory management systems, Fisheye and multiple angle camera surveillance systems, Drug diversion software, Dedicated multidisciplinary diversion staff and response team, 24/7 pharmacy coverage, Diverse staff: security, infection prevention, compliance, patient safety 

Small Hospitals – Automated Dispensing Machines, Cameras in the medication room and some hallways, Multidisciplinary diversion team, Pharmacy department, Diverse staff: security, compliance, human resources 

  • Surgery Centers – Cabinets to for controlled substance storage, Manual audits- standardized audit forms and check list, Standardized Controlled Substance Binder and Playbook , Standardized order sets and basic procedures
  • Physician’s Offices – Order history and vendor reports, EHR data, PDMP, Internal audits, Controlled Substance Binder


Education & Accountability

Recognizing the role of ongoing education, training, and accountability in fostering a culture of vigilance and accountability in combating drug diversion within a multi-facility enterprise is a key component to establishing a strong diversion prevention program. Some key aspects to consider are:

  • Staff Awareness – Regular training sessions to keep staff updated on new drug diversion monitoring tactics and prevention technologies.
  • Skill Development – Focus on developing skills necessary for identifying and reporting potential diversion activities. 
  • Diverse Education – Tactics, such as interactive workshops, e-learning modules (like those provided in the Diversion Collective), and case-based discussions are crucial for staff to effectively learn and retain information necessary for recognizing signs of drug diversion and substance use disorder signs. 
  • Responsibility at All Levels – Ensuring that each member of the organization understands their roles in diversion prevention. 
  • Transparent Reporting System – Encouraging open communication about potential issues without fear of retribution. 


Monitoring at the System vs. Facility Level

Monitoring diversion at the system level versus the facility level comes with unique challenges. Here is a breakout of what to consider at each level 

System Level:

  • Alignment with corporate goals
  • Strategic decision making and resource allocation
  • Benchmarking against industry standards, competitors, and overarching goals
  • Risk management and compliance system-wide
  • Aggregating data and reporting from multiple facilities to achieve a consolidated view of the enterprise
  • Standardization and consistent measurement across all facilities
  • Scale and scope enterprise-wide


Facility Level:

  • Tailored goals for site-specific challenges
  • Decision making based on individual site resources and operations
  • Peer-to-peer benchmarking that relies less on industry standards
  • Risk management and compliance with local laws
  • Aggregating and reporting data consistently at a localized level
  • Flexible measurement goals as program expands
  • Scale and scope specific to single location performance indicators 



By harnessing the expertise of leaders throughout an organization, hospitals can develop a comprehensive and effective diversion prevention program to safeguard patients, staff, and the community. Consider the following titles when developing a diversion task force: Chief Medical Officer (CMO), Chief Nursing Officer (CNO), Pharmacy Director, Risk Management Officer, Security Director, Legal Counsel, Quality Improvement Director, Compliance Officer, IT Director, Clinical Department Heads, Education and Training Coordinator, Patient Safety Officer, and Human Resources Manager

More Resources

As you evaluate your current drug diversion monitoring program, here are some other resources to help you measure your risks and challenges and develop strategies to address them.