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Accountability, the second pillar for 340B Program compliance

By Craig Frost

Craig Frost, President Sectyr®
Craig P. Frost, RPh, MBA, FACHE
President & COO, Sectyr

Accountability is doing what you say you’ll do when you say you’ll do it. It’s keeping score (in a good way), reaching a goal, and getting stuff done on time. Accomplishing things takes a plan, of course. But even with the best laid plans, managers won’t achieve the outcome they want if there’s no accountability.

Accountability with a 340B Program also means following policies and procedures. Despite well-crafted policies and hardworking staff, a 340B Program manager can struggle to keep tabs on who owns each task and reach outcomes. Most covered entities are sufficiently complex and busy to make attaining certain 340B Program results a steep climb. That complexity and pace of activity can undercut attempts to promote accountability. A cynic might chalk up a lack of accountability to either people slacking off or not wanting someone holding them to task. That’s misreading the situation.

Back to the Future

Most compliance work in a 340B Program is, by its nature, retrospective. As part of their job, 340B Program managers and teams review and fact-check what’s been done. Competing with that work are the priorities a 340B Program manager and team know they need to tackle in the hours, days, and weeks ahead. Team members want to do what they’ve signed up to accomplish (e.g., conduct a self-audit). But a pressing issue related to, say, patient care causes a person to delay a self-audit. Things like a self-audit, or contract review, then fall off a person’s radar. It’s human nature. When program managers are constrained by time and resources–which nearly every person is–they need help staying accountable.

The good news is that if a 340B Program has sufficient resources, a covered entity can expect compliance. But if a covered entity has a scarcity of resources, then a compliance software system is one way to stretch those resources. For example, SectyrHub® 340B is a software platform that creates one source of truth for analyzing and tracking the 340B Program data required by auditors from HRSA. Managers can tap into SectyrHub’s logic-based, 340B-specific workflows to meet eligibility requirements by prompting team members to review critical documents and tasks like:

  • the Disproportionate Share Hospital percentages for DSH entities in the Medicare cost report, and
  • pharmacy services agreements.

SectyrHub 340B also automatically ensures OPAIS is accurate by synchronizing a covered entity’s records with any changes to the information about its contract pharmacies. Program managers will know each day that their contract pharmacy information is accurate, which stops errors arising from someone forgetting to double-check records against OPAIS. Compliance software systems like SectyrHub 340B also enable a program team to schedule reviews of Medicare cost reports, findings from self-audits, and policies and procedures.

Without compliance software, a manager would rely on manual methods to stay compliant. The manager could call a team meeting and document with a spreadsheet or whiteboard how the group will conduct audits and parcel out work to each member. But the only way the manager will know if workers are following the process and finishing tasks is by asking for an update via seemingly endless emails. With multiple stakeholders, 340B Program managers often struggle to identify who owns tasks and outcomes. Manual processes can also lead program managers to inadvertently analyze outdated or incorrect information because there are no real-time updates to rely on.

By automating the management of documents with compliance software, a director can assign tasks to each responsible party and verify the owner completes the job. Accountability is further improved when each team member can see their tasks, what’s expected, and when it’s due. Visibility is equally important for compliance. And in my next post, I’ll explore the role visibility plays for compliance.

Craig Frost, RPh, MBA, FACHE, is the president and COO of Sectyr, LLC where he manages operations and facilitates an innovative team to develop and market tools that enable best practices for continuous compliance

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