The compliance officer’s responsibilities include developing, coordinating and participating in a multifaceted training program that focuses on the elements of the compliance program. In its Compliance Guidance for Hospitals, the OIG used the term “effectiveness” and its synonyms twenty-seven (27) times; underscoring the importance of being able to evidence all elements of the compliance program. The OIG recommends that healthcare organizations make attendance and participation in training programs mandatory. The OIG also recommends that training program attendance and participation should serve as a factor in the annual evaluation of each employee where failure to comply with requirements results in disciplinary action. Further, the OIG expects healthcare organizations to hold managers and supervisors accountable for making their employees available for compliance training. Training should address:
- Organization and operation of the Compliance Program;
- Applicable federal and state statutes, regulations and guidelines;
- Code of Conduct, policies and procedures;
- How to report suspected wrongdoing anonymously or in confidence (hotline);
- Non-retaliation policy for reporting wrongdoing; and
- Claims submission processes and marketing practices.
The OIG compliance guidance notes that the compliance officer should maintain documentation of all compliance training programs and the dates trainings were presented. As part of ongoing auditing and monitoring, compliance officers should review all evidence supporting compliance training. Compliance officers should:
- Verify maintenance of sign-in sheets to evidence training participation;
- Compare sign-in sheets against payroll records of the organization;
- Ensure employees who missed training are scheduled for training immediately; and
- Keep copies of all training programs for possible review by outside parties.
The above process relates to output – meaning the number of employees trained and the kind of training given. However, it does not address outcome – that is, the effectiveness of the training lessons and overall program. There are two commonly employed techniques to evidence effectiveness of compliance training:
- Web-based training programs often contain quizzes and/or tests based on course content at the end of the session to evidence understanding of the lessons provided. This would provide direct evidence of training effectiveness.
- Objective and independently administered Compliance Knowledge Surveys query employees about key issues related to the compliance program, applicable laws, compliance polices, and the Code of Conduct. A survey of this type can go a long way to validate effectiveness of not only compliance training but the entire program. The OIG encourages using this method in their compliance guidance and even notes what employees should know about compliance. In many ways, conducting this type of knowledge survey may be the most efficient and cost effective method to evidence compliance training effectiveness and the overall effectiveness of the compliance program. For the best and most convincing results, using standardized and validated survey instruments that are anchored to a national database is vital. Further, if healthcare organizations employ knowledge surveys over a period of time, results can establish benchmarks for compliance improvement.