Frequently Asked Questions (FAQs)

1. What is the ASHP Controlled Substance Diversion Prevention Program (CSDPP) Assessment Tool?

CS diversion in health systems can lead to serious patient safety issues, harm to the diverter, and significant liability risk to the organization. In addition to patient harm, there are regulatory and legal risks to the organization, including fraudulent billing and liability for resulting damages, and decreased community confidence in the healthcare system. The ASHP Guidelines on Preventing Diversion of Controlled Substances provide a detailed and comprehensive framework to support organizations in developing their CSDPP. Ultimately, each organization is responsible for developing a CSDPP that complies with applicable federal and state laws and regulations, but also one that applies technology and diligent surveillance to routinely review process compliance and effectiveness, strengthen controls, and seek to proactively prevent or detect diversion. This Tool is designed to help organizations see how their CSDPP aligns with ASHP's Guidelines. It serves as a complement to other tools and resources organizations can use in their efforts to design, implement, and manage the best CSDPP possible. The Tool consists of questions that assess the adoption of the ASHP Guidelines on Preventing Diversion of Controlled Substances that can be customized to several scenarios and provides recommendations that apply to an organization, a specific work site, pharmacy only location, or a community pharmacy. Upon completing the questions, the Tool will allow the user to develop an “Action List” of priorities individualized to their own situation. Organizations can also generate reports comparing their data with aggregated data collected from other similar practice settings.

2. How were the CSDPP Assessment Tool questions selected?

The CSDPP Assessment Tool questions were based on recommendations and examples of implementation described in the ASHP Guidelines on Preventing Diversion of Controlled Substances. A steering committee helped to prioritize and categorize items selected for inclusion in the tool.

3. Does the CSDPP Assessment Tool assess legal and regulatory compliance with CS management?

The CSDPP Assessment Tool aligns with the best practice recommendations in the ASHP Guidelines on Preventing Diversion of Controlled Substances and do not specifically address legal and regulatory requirements. The contents of the Tool address topics of interest to pharmacy practitioners and other audiences, and are offered on a blind basis, without any knowledge as to specific circumstances. The application and impact of relevant laws will vary from jurisdiction to jurisdiction. The Tool does not include all relevant legal requirements or incorporate all current applicable laws. The Tool is intended solely to enhance diversion prevention controls in the healthcare settings and should only be used to complement policies and procedures required by state, federal, and local authorities as well as those required by accreditation agencies. [See Disclaimer]

4. What devices are compatible with the CSDPP Assessment Tool?

The CSDPP Assessment Tool is designed to work with desktop devices (e.g., laptop, desktop computer). For the best experience we recommend a screen resolution of 1280 pixels wide.

5. What’s required to create an account?

You will need an active email address to create an account.

6. How do I recover a lost password?

Select “Login,” from the home page of the CSDPP Assessment Tool, and then click on the “recover lost password” link located under the “LOGIN” button. Provide the email associated with your existing account and the system will send you an email with instructions on how to reset your password. The email will be sent from noreply@ashp.org with the subject of “Reset Password Notification.”

7. Is entered data saved automatically as I move from screen to screen OR do I need to click the “Save & Exit” button each time?

You can work on completing the assessment in multiple sessions; your data will automatically be saved. You can move on to the next section to answer questions, however, you cannot “mark an Assessment as complete” until all the questions are answered.

8. If I cannot complete the Assessment in one sitting, will I lose the data I entered?

You can work on completing the Assessment in multiple sessions; your data will automatically be saved.

9. May I create a different Assessment for each hospital in our system under one account?

Yes, when completing an “Official Assessment” you will have two options: to complete Option 1 for a single assessment or Option 2 for multiple assessments. If you wish to complete a different assessment for each hospital within your system, select “Official Assessment,” then Option 2.

10. How do I share an Assessment with someone so they can also see results?

From the Dashboard, select details, and select “Create invite.” The collaborator will be able to see the Action Plan or overall results for the Assessment from their Dashboard under “Shared with me.”

11. How do I invite someone to complete a section of an Assessment?

When you add a section to an Assessment you can invite a colleague to complete that section of the Assessment. Once you add their email address, they’ll receive an email inviting them to create an account. They will not be able to see the Action Plan or overall results for the Assessment.

12. How do I remove someone from having access to an Assessment?

From your dashboard, select details, manage collaborators, then select “Remove Collaborator.” Note, there will not be an email notification when you remove a collaborator.

13. How is the data collected?

Data is collected through the web-based CSDPP Assessment Tool and is accessible to anyone who is interested in completing an Assessment. The Tool is designed to prepare reports and create individualized Action Plans. The Account Owner will name the entities they wish to assess and can invite colleagues to complete sections of the Assessment. Only data in “Official Assessments” is available for comparison reports.

14. What happens to the data I submit? Is it kept confidential?

All data will be kept confidential and only aggregated data will be reported. The reports that result from use of the CSDPP Assessment Tool are for internal, peer-review purposes only. All those who register for an Account to use the CSDPP Assessment Tool have to agree to the Data Consent: ASHP may access and use user data (the “User Data”) and user hereby authorizes ASHP: (1) to Anonymize (as defined below) User Data (the “Anonymized User Data”) and to combine it with data from other users into a new aggregate dataset; and (2) to use such Anonymized User Data as a component of such new aggregate dataset for any legal business purpose, including without limitation for distribution to third parties. Without limiting the generality of the requirements for Anonymized data below, ASHP shall: (a) implement technical safeguards that prohibit reversal of Anonymization of User Data; (b) implement business processes that specifically prohibit such reversal or recreation; (c) make no attempt to achieve such reversal; and (d) implement reasonable business processes to prevent inadvertent release of Anonymized User Data. (“Anonymize” refers to removal of personal information and any information reasonably likely to identify individuals, a company or other business entity; provided such revised data does not include and is not subject to any key, code, or other mechanism that may be used to restore such information).

15. How often should a user or organization complete an Assessment?

The CSDPP Assessment Tool can be completed at any time, but it is recommended that it be completed at least annually depending on the degree of change in practice in order to measure progress. For “reassessments,” it is recommended to assign a different name to the updated assessment, then you can run a report to compare the two assessments.

16. I created a “Personal” Assessment [p] and I want it to be an “Official” Assessment [o]. How do I change it?

Personal Assessments, if desired, can be used to familiarize yourself with the Tool or to help inform a collective response for an Official Assessment, which is the official response from an organization or institution. A Personal Assessment is not counted as an official submission from your practice setting. However, if you create a Personal Assessment and would later like it to be considered an Official Assessment, you can convert it to an Official Assessment . Once you convert a Personal Assessment to an Official Assessment, you cannot change it back to Personal. So, you must be sure the change is appropriate. Once you're sure you want to make the change, log into your account and locate the Assessment on the Dashboard, click the "Details” button, click the radio button next to "Official," and then click the "Apply Changes" button.

17. How do I change or share ownership of an Assessment?

You cannot change the owner of an Assessment or transfer the Assessment to another Account holder. However, you can share the results of the Assessment with other Account holders. Find the Assessment you want to share on your Dashboard and click on the “Details” button. On the Assessment Settings page, click on the “create invite” button to share the results of the assessment with other Account holders. The system will send an invite notice to the email address(es) you enter. Those with whom you share the results can use your data in their Comparison Reports.

18. What types of reports are available to me?

Once an Assessment is marked complete, we recommend completing the Action Plan by clicking the “Work on Action Plan” button on the Dashboard. Once the Action Plan is complete you can download the results as a PDF or CSV file. You can also view the Assessment Results page. Once an Assessment is marked complete, you can create Comparison Reports. To do so, click on the “Reports” button in the navigation on the left side of the screen. Define Data Set #1 and then define Data Set #2. Data Set #2 can be data from your library or compiled data from Assessments outside your library. Only data from Official Assessments are included in the compiled data. There are filters so that you can create a Data Set #2 that best matches Data Set #1.

19. Who should I contact if I have questions about the CSDPP Assessment Tool?

If you have any questions or comments about this Tool, please send an email to practiceadvancement@ashp.org.