Evidencing Effectiveness In Compliance Training

Richard P. Kusserow | May 2014

The compliance officer’s primary responsibilities include developing, coordinating, and participating in a multifaceted educational and training program that focuses on the elements of the compliance program. The objective of this responsibility to ensure that all appropriate employees and management are knowledgeable of, and comply with, pertinent federal and state standards. The OIG in their compliance guidance documents use the term effectiveness twenty- seven (27) times. They make it abundantly clear that for any organization to gain credit for the compliance efforts, they must be able to evidence all aspects of their program as being effective. One of the critical elements of an effective compliance program is compliance education and training. Therefore, it is essential that an organization be able to evidence these programs as effective. This chapter focuses on this challenge.

An effective compliance program should incorporate periodic (at least annual) reviews of whether the program’s compliance elements have been satisfied. This includes compliance education and training. The Compliance Officer should ensure an annual of audit compliance training, including checking the sign-in sheets for compliance training against the payroll records of the organization. Any employees who missed training should be scheduled immediately.

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An ongoing evaluation process is critical to a successful compliance program. The OIG believes that an effective program should incorporate thorough monitoring of its implementation and regular reporting to senior hospital or corporate officers. An effective compliance program engages in periodic (at least annual) reviews of whether the program’s compliance elements have been satisfied. This includes whether there has been appropriate dissemination of the program’s standards, training, and ongoing educational programs. This process will verify actual training has take place and those appropriate records have been created and maintained to document the process

Corporate Compliance Training is critical to the implementation of an effective Compliance Program. The compliance training surveys can be used to documents the effectiveness of the compliance training and education programs. At the end of the training session, the trainer should encourage the employees to complete a provided training survey form. Everyone must be assured that the survey is anonymous. The survey should include questions that relate to the quality of instruction, course content, delivery, and overall receptiveness. To provide convincing results, the forms should be standardized and used over a period of time to establish a benchmark, against which individual trainers and classes can be compared. For best and most convincing results, using a standardized survey that is anchored to a national database should be used.

An effective compliance program must include the development and implementation of regular, effective education and training programs for all affected employees. The proper education and training of corporate officers, managers, employees, physicians and other health care professionals, and the continual retraining of current personnel at all levels, are significant elements of an effective compliance program. Organizations must ensure their people attend specific training on a periodic basis. This should include appropriate training in federal and state statutes, regulations and guidelines, and the policies of private payors, and training in corporate ethics that the organization’s commitment to compliance with these legal requirements and policies.

Compliance training programs should include sessions highlighting the organization’s compliance program, summarizing fraud and abuse laws, coding requirements, claim development and submission processes and marketing practices that reflect current legal and program standards. The organization must take steps to communicate effectively its standards and procedures to all affected employees, physicians, independent contractors and other significant agents, e.g., by requiring participation in training programs and disseminating publications that explain in a practical manner specific requirements.1 Managers of specific departments or groups can assist in identifying areas that require training and in carrying out such training. Training instructors may come from outside or inside the organization.  New employees should be targeted for training early in their employment.

The OIG in their compliance guidance notes that the compliance officer should document any formal training undertaken as part of the compliance program. It is important to be able to evidence that training has taken place. This can be done with sign-in sheets and documentation as what was included in that training session. Compliance officers should keep copies of all training programs for possible review and inspection by the government, or anyone else who is interested in evaluating the compliance education program. However, this kind of process documentation relates to output, how many trained and what kind of training was given. It does not address outcome, how effective the training was. Ideally, the training should reduce the likelihood of wrongful behavior from occurring, particularly as it relates to federal laws and regulations. As such, it is important to be able to evidence the effectiveness of this training in properly communicating the compliance program messages.  Compliance officers should be prepared at any time to produce this evidence.

The OIG recommends that attendance and participation in training programs be made a condition of continued employment and that failure to comply with training requirements should result in disciplinary action, including possible termination, when such failure is serious. They also expect that managers and supervisors will be held accountable for making their employees available for compliance training. Any failure to do this should also be actionable against the offending manager or supervisor. The OIG also believes the adherence to the provisions of the compliance program, such as training requirements, should be a factor in the annual evaluation of each employee. The organization should retain adequate records of its training of employees, including attendance logs and material distributed at training sessions.

Adherence to all the points noted above would contribute to evidencing effectiveness of the compliance education effort.

About the Author

Richard P. Kusserow established Strategic Management Services, LLC, after retiring from being the DHHS Inspector General, and has assisted over 3,000 health care organizations and entities in developing, implementing and assessing compliance programs.