Developing a Training Program That is Accessible and Useful for Everyone

Strategies to Consider when Selecting Training Methods for Multiple Groups

Lori J. Strauss
training is to review in detail the code of conduct booklet, which includes the mission statement and values of the institution, eleven commitments related to expected conduct, staff responsibilities, and compliance contact phone numbers. Employees must understand their responsibilities; be able to relate the code of conduct to laws, policies, and procedures; know how to identify and report compliance issues; and know how to access compliance resources. In addition, the code of conduct contains an acknowledgement form that each new employee must sign to indicate he or she received the training. Compliance means to know and follow the rules. Health care is a highly regulated enterprise, and the rules come in many forms. The rules or regulations can be found in federal or state laws, accreditation standards, or internal policies and procedures. In the training program for new employees, everyday examples are provided for each commitment identified in the code of conduct booklet in an attempt to increase the employees understanding of them. For instance, an example of noncompliance with Obey the Law commitment is for an employee to document that they are at work when they are not, or to document that they are present during a procedure when they are not. Examples are used that will drive home the meaning of the commitment. Another example in the new employee compliance program is to connect the accreditation process to financial viability. Often compliance is regarded as a billing problem, and people have difficulty making the connection of compliance to patient care, which is the focus of health care providers. Therefore, at UVA every attempt is made to make this connection by explaining that accreditation by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) allows for participation in federally funded health care programs. Medicare is a federal health care program. The deemed status that the JCAHO has received from the 23

ompliance training provides the foundation of expected behaviors for an organization and provides resources for compliance concerns. At the University of Virginia Health System (UVA), compliance training has been offered for several years. This article provides the reader with content ideas and buy-in strategies for compliance training program development and implementation.

Types of Training
UVA offers compliance training for newly hired employees on both general and specific compliance content. There is also annual compliance training for employees on general and specific content, and there is annual compliance training for physicians and credentialed staff on general and specific content. A fundamental fact of any training program or speaking engagement is to know your audience. At UVA different corporate compliance training programs are available, and training programs using multiple methods are offered. People learn differently and prefer various teaching styles. This was factored into the UVA training programs.

Content Included in All Compliance Training Offerings

All UVA training programsnew hires, annual training for employees, and annual training for physicians and credentialed staffcover content on whom to call regarding a compliance matter, how to reach that person or office, how to report a concern directly to the compliance officer or anonymously through the compliance help line, the consequences of noncompliance both to the individual and the institution, and examples of potential compliance issues relevant to the audience.

Lori J. Strauss, RN, MSA, is the manager for the corporate compliance office at the University of Virginia Health System. She can be reached at 434/ 924-5024 or by email at ljs6n@virginia.edu.

Training for New Employees

All new employees receive compliance training. The focus of the new employee

Journal of Health Care Compliance MarchApril 2003

Developing a Training Program that is Accessible and Useful for Everyone

Centers for Medicare and Medicaid Services allows an organization to continue to receive payments from federal payersindicating compliance with patient safety standards and other key issues. To understand the significance of this connection, by calculating the institutions overall percentage of Medicare patients in the payer mix a determination can be made of the impact to a health care facility of not receiving payment for services provided to Medicare and other federally funded patients. Key policies and procedures based on federal regulations are reviewed during the new employee compliance training. Employees need to understand that many policies and procedures are based either on a law, a regulation, a standard, or some other measure. The policies and procedures provide the employees with the information in an easily understood and accessible format. For example, internal policies and procedures regarding not hiring an ineligible person as listed on the Office of Inspector General Web site and the internal compliance auditing and monitoring program are reviewed.

role in billing. General and specific training sessions are combined for the physicians to eliminate the need for this group to attend two different sessions because everyone in this group needs both types of training. Separate training sessions on general and specific content are provided for all other applicable employees. Separate training sessions recognize, for example, that not all nurses will need the specific training just those involved with the preparation or submission of claims for reimbursements to a federal health care program. For the annual training on the specific content a decision was made to hire a consultant to conduct live sessions geared to pertinent content. One of these sessions is videotaped and is required to be viewed by anyone unable to attend a live session. This videotape is also required viewing of any newly hired staff fulfilling a role identified as needing specific compliance training.

Developing Content for Annual Training

New content is prepared each year for the employees and the physicians and credentialed staff compliance training. Providing new material maintains interest and offers current compliance issues specific to the target audience and the institution. Feedback regarding what compliance issues people would like to know about is provided on evaluation forms, via email, or by calls to the compliance office. Compliance may not be as exciting to some as it is to others involved in the day-to-day operations of the compliance world. Content is more meaningful if it motivates the participants to want to hear, learn, or know more regarding compliance issues important to them. Every attempt is made to determine content ideas by utilizing other resources that deal with compliance issues. For example, in the UVA general training program for employees, there is content regarding OSHA and injured employees to assist with communication of processes to be followed when an employee is injured. The employee injury idea was developed through a discussion at a safety subcommittee. Because OSHA is a regulatory agency to which UVA must comply, it was an appropriate topic to cover in the compliance training. As another content example, the training highlighted the interpreter services available to comply with the civil rights of non-English speaking persons. In addition, employees wanted to know the type of issues handled in the compliance office, so a summary of the type of investigations was provided. Employees asked for an explanation of the difference between Medicare Part A and Medicare Part B insurance, so an overview was provided. Information was included on advanced beneficiary notices due to recent changes in the form by CMS and to reiterate the processes and uses of this form.

Presentation Modalities for New Hires

The corporate compliance training is part of the orientation program that all new employees must attend, and this is generally offered every two weeks. Previously, there was a live presentation of this material by a member of the education department using the content provided by the compliance office. A computer-based learning system with a custom-made training program incorporating the above main content areas is now utilized. A brief post-test follows at the end of the computer module that all employees must successfully complete to receive credit for this module. Additionally, a member of the compliance office meets with all new hires during the orientation program for approximately five minutes. This is done to provide the new hires with a face to connect to a name, to ensure the employees know to give their signed form at the back of their code of conduct booklet to their supervisor, and to show them the 800 compliance help line posters they will see throughout the organization. Newly hired physicians and credentialed staff receive their training individually as part of the credentialing process.

Annual Compliance Training

Annual compliance training is required of all employees, all physicians and credentialed staff, board members, and certain vendors and affiliated staff. The executive leadership at UVA endorsed making compliance training a mandatory training program for all employees; therefore, compliance training is tied to each employees performance review as is fire safety training, confidentiality training, and other key training topics. UVA offers separate training programs for employees and physicians. In addition to general training, specific training is clearly indicated for all physicians due to their 24

Journal of Health Care Compliance MarchApril 2003

Developing a Training Program that is Accessible and Useful for Everyone

Physician and Credentialed Staff Compliance Training

For the physician and credentialed staff annual training, information was obtained from coding services and from health information management about common documentation issues for our institution and key principles of documentation. Documentation was chosen as the main topic for this years physician and credentialed staff compliance training to continue with the focus of the areas of quality improvement in the organization. Coding services and health information management, as well as other content experts, were asked to proof their content areas. Information was included specific to targeted areas for medical staff from the Office of the Inspector Generals Work Plan. Content on recently publicized fraud and abuse cases in the medical community were included in the training program as well. Some of the content from the employee training was duplicated for this program, for example, the case with the interpreter services content. Two staff physicians reviewed the final training program. Meaningful information was the goal of this training program, and honest feedback was needed from the physicians before issuing this mandatory program to the entire medical staff.

Employees could complete the training by any one of the following methods. There were self-learning modules or live lecture sessions with pre-announced dates and times so that anyone could attend. Lecture sessions could be arranged for an entire department if requested. There were two offerings of the compliance training per shift available on the staff education channel, and just recently the material was put online. This year the training can be completed either online or by attendance at a live lecture. It was decided to continue with the lecture offerings for a couple of reasons. First, not everyone likes to complete computerbased modules. Second, the compliance office staff needs to remain visible. Employees need to identify a face with a name and ideally to feel comfortable to call with any concern. The takeaway message is to do the right thing, and the compliance office is here to help.

Tracking Compliance Training

How compliance training will be tracked must be considered. As mentioned, UVA new hires are to sign the form at the back of their code of conduct booklet as an acknowledgement of the training. The signed form goes to the supervisor to be kept as supporting documentation that the initial compliance training has been completed. Annually, thereafter, there are various methods to demonstrate that compliance training has been completed. For example, if a staff member attends a live lecture, they are given a card at the end of the training that they take back to give to their supervisor for their file. For training done online, a computer report can be run to show module completion, or a certificate can be printed for an employees file. Whatever presentation method is chosen, it is recommended to have a method to know whether the employee actually completed the training. At UVA, the mandatory training is documented annually in the performance review, therefore, the managers are checking the employees competency files to ensure their training is complete. We have not come across an employee that does not meet performance standards because of not completing his or her mandatory training requirements. At UVA, any employee not meeting standards in any one category of the performance review is not eligible for any salary increase.

Presentation Modalities for Physicians and Credentialed Staff Annual Training

This past year the medical staff requested that training be available online; in prior years it had been offered only through live training sessions. Therefore, a custom-made online training program was developed for the physicians and credentialed staff. To inform the physicians and credentialed staff about the training, a member from the compliance office attended the clinical chairs meeting to announce the training, to review the training options, live or online, to reiterate how the content was developed, to inform them that their colleagues had reviewed the training for content appropriateness, to communicate the deadline for completion of this years training, and to request feedback for next years content. Additionally, an email message was distributed to all of the medical staff about the training program with instructions as to how to complete it online. As a final step, the president of the clinical staff announced the required training at the clinical staff meeting and emphasized the importance of compliance in the UVA organization.

Summary
In conclusion, UVA offers compliance training (general and specific) for new hires, annual training for employees (general and specific), and annual training for physicians and credentialed staff (combined general and specific). If you would like additional information on any of the content provided in this overview or if you would like a PowerPoint copy of a particular training program, please contact me directly.

Presentation Modalities for Annual Employee Training

The annual training program for the employees was developed in similar format as was done for the physicians and the credentialed staff. Previously, UVA offered the training in a variety of methods so every employee found it easy to complete this mandatory training. The same content is used throughout a given year, but multiple formats are available.

Journal of Health Care Compliance MarchApril 2003

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