Education and Training Tips for Your Compliance Program

“Providing appropriate education and training is a vital component of an effective compliance program.”  

So begins the U.S. Department of Health and Human Services Office of Inspector General (OIG) General’s Compliance Program Guidance (GCPG) document for element #3 –Training and Education. 

This is such an important program element that many healthcare organizations will either have a full-time equivalent (FTE) employee(s) or assign a compliance professional as the point person for compliance education. 

There are many important aspects to a compliance program’s education and training efforts. However, the four described below have also been highlighted by the OIG in their GCPG document.  

These include: 

1. Education and training on the entity’s compliance program 
2. Education and training on Federal and State standards applicable to the entity 
3. Education and training on board governance and oversight of a health care entity 
4. Development of an annual training plan

1. Education and Training on the Entity’s Compliance Program

When an organization is committed to doing the right thing and establishes a compliance program, it is essential for its workforce and partners to know about it! It is critical that a compliance training and education program offers awareness training about the existence of the program, the organization’s commitment to compliance, the program’s purposes, and the channels for effectively communicating with the compliance program. 

For example, dedicating time and resources to a compliance hotline can be a waste if individuals in the organization are not aware of the hotline or how to use it. Also, if they are not encouraged to use it and made aware of the organization’s commitment to non-retaliation for raising issues in good faith, few, if any, will use the hotline. 

It is also important that employees know there is a compliance officer and who that individual might be. Depending on the size and geographic locations of the organization, this might mean they know who their local compliance contact is for their region.  

General awareness training is usually provided upon initial hire of the employee and is repeated at a regular interval thereafter. Many organizations do this kind of formal compliance program awareness training at least once a year, but their efforts shouldn’t stop there. Regular reminders or awareness campaigns are also a part of this training, even if those activities are not formal training sessions. 

Providing training about the organization’s compliance program is the foundational education that should be provided. 

2. Education and Training on Federal and State Standards Applicable to the Entity

After providing awareness training about an organization’s compliance program, training should be provided that specifically addresses the laws and standards applicable to the organization. This training is best suited for the key personnel involved in those activities. This is often referred to as job-specific training because not everyone in the organization necessarily needs the same detailed compliance training on job-specific activities. 

For example, assume you are developing compliance training for an organization that consists of multiple hospitals. Most employees in this type of organization will likely need training on HIPAA and patient privacy standards. Some will need more training than others. Will those food service workers in the cafeteria need that same level of HIPAA training as someone who accesses the medical record all day, every day? And, what additional HIPAA training will be required for those who regularly process requests for release of records? 

In this example of a hospital organization, even the type and extent of coding and billing training can vary. The detailed, job-specific coding and billing training for those working exclusively in an inpatient psychiatric hospital is likely to differ from those working in an inpatient rehabilitation facility (IRF), an academic medical center or a broad-based community hospital. Certainly, some of the coding and billing regulations will be the same, but because of the unique clinical services each different facility type might be providing, training on compliant billing for those unique types of services is likely to vary from hospital type to hospital type. 

Just think of how the detailed regulatory training will vary from hospitals to physician practices, ambulance companies, skilled nursing facilities or pharmaceutical and device manufacturers. Though all of these organizational types will need to understand the basics of many of the same standards, each will also be more involved than others in different standards and requirements that are unique to their organization. 

This detailed training is usually best developed after a thorough risk assessment has been performed. After identifying the most significant risks for an organization, a compliance program can plan and create training to address the unique requirements of the organization. 

3. Education and Training on Board Governance and Oversight of a Health Care Entity

Compliance officers manage the day-to-day activities of an organization’s compliance program. But the board of directors or similar body is ultimately responsible for ensuring the compliance program's overall effectiveness. This is not to say they get involved in management of the program. However, they should exercise proper oversight of the compliance program. 

The OIG states, “Targeted training also should be developed for board members. New board members should receive training on their governance and compliance oversight roles promptly after joining the board. The initial board training should address the specific responsibilities of health care board members, including the risks, oversight areas, and approaches to conducting effective oversight of a health care entity. The compliance officer should consider arranging additional, periodic training to update the board on the entity’s compliance risks, including changes to applicable Federal and State health care requirements.”  

You should not have to reinvent the wheel when it comes to developing compliance oversight training for your board. Over the years, the OIG has issued a number of resources for boards of healthcare organizations (see: https://oig.hhs.gov/compliance/compliance-resource-material/).  

One particularly useful document when first starting board compliance training is the OIG’s “Practical Guidance for Health Care Boards on Compliance Oversight.” (see: https://oig.hhs.gov/documents/root/162/Practical-Guidance-for-Health-Care-Boards-on-Compliance-Oversight.pdf). This document can help board members understand their compliance program oversight responsibilities and offers suggestions for actions they can take to begin fulfilling these responsibilities. 

4. Development of an Annual Training Plan

None of the first three training and education activities occurs on its own. Commitment, effort, and planning are required. An effective compliance training and education program really begins with an annual training plan. 

The OIG writes, “The compliance officer should develop an annual training plan that includes the training topics to be delivered and the target audience for each topic. The annual training plan should incorporate material addressing any concerns identified in audits and investigations.” 

The Compliance Committee can be an invaluable resource to the compliance officer in implementing the training plan. They should review the training plan at least annually to ensure that compliance training topics and materials address current needs, including any issues identified through monitoring and auditing and changes to Federal and State health care requirements.  

Because a compliance committee is often composed of key operational and management leaders outside of the compliance department, they can lend practical insights and perspectives on implementation of the training plan. They should ensure that the training materials, whether developed internally or purchased externally, appropriately address the entity’s compliance program and specific compliance risks.  

The OIG explains that “the Compliance Committee should also ensure that the training materials are accessible to all members of the designated audience. For example, if an entity has a culturally diverse staff, training materials may need to be available in several languages.”  

An annual training plan can also include details about the training formats that will be used, such as live (in-person or via videoconference), computer-based training, or through watching a pre-recorded video. Not all compliance training is likely to be offered through the same format. 

The plan should also consider requirements for completing the training and appropriate discipline for not completing it. The OIG expects that participation in required compliance training programs should be made a condition of continued employment or engagement by the entity. Failure to comply with training requirements should result in consequences, up to and including possible termination of employment or engagement when warranted by the circumstances. Completion of mandatory training should be a basic requirement of each employee’s annual performance evaluation.  

Conclusion

Compliance training and education is such an important part of compliance programs that it has been established as one of the seven elements of an effective compliance program. 

Though there are many important aspects to compliance training and education, this paper has highlighted the following four key considerations: 

1. Education and training on the entity’s compliance program 
2. Education and training on Federal and State standards applicable to the entity 
3. Education and training on board governance and oversight of a health care entity 
4. Development of an annual training plan 

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