Many healthcare organizations consider compliance to be a major headache and ask themselves why they spend so much time and energy on this function. That’s why it is important to remember that compliance programs are mandatory; Section 6401 of the Affordable Care Act (ACA) states that every “Provider of medical or other items or services… shall establish a compliance program as a condition for enrollment in Medicare, Medicaid, or the Children’s Health Insurance Program” (CHIP). Training and education makes up one of the seven essential elements of an effective program, as stated in the U.S. Sentencing Guidelines, with additional guidance available from the Office of Inspector General (OIG). Also, training is typically a key requirement in an integrity agreement or corporate integrity agreement that results from the government settlement of an organizational healthcare compliance violation. Importantly, organizations should always track their employees’ completion of compliance training, in order to have proof in case of audit.
This blog post, the second in a series of four, is based on our webinar, “4 Necessities to Building an Indestructible Compliance Training Program,” in which compliance training experts from HCCS, A HealthStream Company, shared their insights and wisdom about using compliance education to strengthen the organizational approach to healthcare compliance. Effective compliance training can help every employee understand their compliance obligations and make them extensions of the compliance team.
Christine Thomas, Content Development Team Manager at HCCS, shared that training plays a vital role in setting the compliance tone for the entire organization, especially in terms of its commitment to compliance. If done well, compliance training can facilitate more successful communication between employees and your compliance office, particularly if training occurs in person, so that compliance becomes a function involving people, not just spreadsheets and meetings. Even in online training, learners can benefit by learning who your organization really is and that all input from staff is welcomed. This enables training that encourages employees to become your eyes and ears—detecting suspicious behaviors or activity and aware of what to do when it is identified.
Compliance Training Completion Should Always Be Tracked
Thomas mentioned earlier that many healthcare organizations make the completion of annual compliance training and review of the code of conduct a requirement for pay increases and sometimes for continued employment. A system that tracks completion of required training plays a strong role in effective compliance programs. Thomas offered that anyone who has had to work under an Integrity Agreement (IA) or Corporate Integrity Agreement (CIA) can attest to the power of proof of training, especially if the OIG wants verification of training completions. She suggested, “Maybe you're getting audited or suddenly receiving subpoenas from the government and suspect there may be a whistleblower case—that is where all your hard work with training is going to pay off.” Robust training as part of a proactive compliance program can help to lessen the damage in the event that there's an enforcement action.
What exactly constitutes proof for the OIG? Thomas added, “If you're bumping up against the OIG or another enforcement agency, they are likely to request proof of learning—I think that's exactly how they phrase it.” They may ask for evidence such as sign-in sheets or computer logs, showing dates, attendance, who conducted the training, how much time was spent in the training, etc. They'll also look for proof of completion, including passing percentages. Thomas advised, “And as you would expect, 100% is always the goal.” Additional proof can include copies of training materials, whether digital or printed, and any policies regarding training.
Watch the full webinar here.