How Self-Auditing Can Build a Stronger 340B Program

Episode Description

Self-auditing is a critical part of maintaining 340B compliance, but it also can be an important tool for improving the efficiency and effectiveness of hospital 340B operations. Kevin Forbush, 340B program director at Intermountain Health based in Utah, discusses how a self-auditing structure isn’t just about compliance, it’s an opportunity to improve workflows across the board and attach a “why” to everyday tasks.

Match cadence of reviews to actual risk

First and foremost, Forbush says every task should map to a specific compliance or operational risk. That means not every activity requires the same attention. The right cadence “balances risk, workload, and available resources” to keep compliance team members engaged and avoid busy work.

Look for hotspots

Forbush emphasizes looking for trends rather than individual or isolated findings. Intermountain team members usually look for sudden changes in purchasing or dispensing volumes or unexpected shifts in how claims are accumulating. These can be symptoms of larger data submission or interface issues. This is all part of an effort to find and fix root causes instead of having team members fix the same problem multiple times.

Track it, standardize it, assign ownership

Forbush says that in self-auditing, all tasks should be tracked, standardized, and assigned to a specific owner. Failing to do so will lead to failures in managing, scaling, and completing key tasks. Succeeding will enable teams to spend less time on those tasks and more time improving 340B programs and processes.

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