COMPLIANCE TRAINING: Which Type Is Right for Your Staff?
Tailor your approach to fit your practice.
By Jeffrey S. Peters, J.D., and William A. Sarraille, J.D. 

If you're like most ophthalmologists or ophthalmic practice managers, you know that there are a seemingly infinite number of rules and regulations involved in the business of modern medicine. You sincerely want your practice to do things "the right way." But how do you ensure that this message gets delivered to the billers, coders, nurses, technicians and other staff members who are a part of your practice?

Your organization's compliance with the regulatory morass will depend on the timing, as well as the effectiveness, of the education and training received by all of the individuals involved in the operation of your practice. According to the Office of Inspector General, training is a crucial component of a practice's compliance efforts. But who should do the training? When should the training be done, and how frequently? What kind of training does your organization need? In this article, we'll provide answers to these questions.

What to do first

If your organization is committed to compliance, then it should be conducting both compliance training and a compliance audit. A compliance audit is essentially a systematic review of the practice's regulatory vulnerabilities. One question that frequently doesn't receive much attention is whether the compliance training should be conducted before or after an initial compliance audit. The "when" may not seem to be an important issue, but the timing of the training can have important implications for your practice.

Training before auditing

Providing training prior to conducting a baseline compliance audit can make sense for some practices, especially those with sensitive and relatively inexperienced employees. The potential advantages of a "train first" approach include the possible psychological benefit of putting a nonthreatening face on initial compliance efforts. This approach makes it easier to get individuals and the entire organization to buy-in to the program before they have to confront the harsh realities of the audit results. For some practices, a "train first" approach gives the organization a chance to put a subsequent audit in a big picture context. Simply stated, the noncritical, nonconfrontational nature of the "train first" approach encourages a receptive employee response, or at least avoids an overtly hostile reaction. However, practices with older, more experienced staff may find that many of their employees will tune out training because they will feel that the sessions are a waste of time unless an audit first tells them there's a specific need for training. To avoid wasted time and effort, managers must attempt to understand the learning style of their employees.

An additional reason why some organizations find it in their best interest to train first is that it may reduce the overpayment liability that can come with initiating a compliance program. To the extent that you view training as the activity that's most likely to get your practice doing things right, you can't set up your training program fast enough.

Auditing before training

With an "audit first" approach, organizations may be concerned about the time that it will take between conducting the audit and translating the findings into a focused training program with the chance to change behavior. This "compliance gap" can leave potentially noncompliant behaviors in place and expose the practice to continuing risk.

However, despite the arguments to be made for a "training first" approach, which is clearly best for some practices, we nevertheless tend to be proponents of conducting a baseline compliance audit prior to training. We think the most significant advantage of the baseline audit is that it will clarify your compliance issues and bring focus to every component of your compliance activities that follow, including the training. This factor should be a key consideration for practices of all types.

Once a baseline audit has been conducted and a report has been issued, your practice's compliance vulnerabilities will be clear, or at least a lot clearer. The audit report should identify corrective actions that need to be taken. In most instances, adequate training will be a significant component of the corrective action. Using the audit report as a training "roadmap" will ensure that the training and your training resources aren't squandered on issues that just aren't problems for your practice. It also means that even highly experienced staff are much less likely to dismiss training sessions as a waste of time.

Another factor to consider is that one of the most effective compliance training techniques involves actual factual scenarios. The advantage of conducting training after the completion of the compliance audit is clear: the factual "scenarios" will be real, and the examples will hit home. Employees who may have believed that there are no potential issues in their practice will now know otherwise and be less likely to dismiss the training. It becomes much harder for employees to disregard the training after a baseline audit has brought potential compliance issues to light.

One often-overlooked reason for conducting the training only after the audit has been completed is to avoid the risk of creating your own whistleblower. By conducting training without knowing whether your practice has a particular vulnerability -- and without having a corrective plan in place -- the training program can serve to uncover compliance problem after compliance problem without any means of containing the damage. In a practice with significant communication gaps, problem employees or morale issues, this could be a particular risk.

Who should conduct the training?

You must consider a variety of issues before hiring a compliance trainer, or adopting a particular compliance training approach. In other words, even after you have answered the question of when to train, you have to ask yourself the question about who should do the training. The basic question is whether an internal employee familiar with compliance issues should do the training, or whether the practice should hire an outside professional with compliance expertise and training experience. This decision is highly practice-specific and will depend on a number of factors, including the size, location and financial resources of your practice. In evaluating who should do the training, you should consider who offers:

• the most flexibility in scheduling training sessions
• the most cost-effective training
• training that can be repeated and reproduced as needed
• the most familiarity with sensitive documentation issues; the ability to properly document training and the ability to update training material as required
• the best option to maximize the educational opportunity for the persons most responsible for internal compliance efforts.

Selecting a trainer

The Office of Inspector General acknowledges that using either internal or outside trainers can be appropriate. Determining who's best for your organization depends, at least in part, on the size and resources of the practice. For some practices, the cost of engaging an outside trainer may be prohibitive. Other organizations may feel they have sufficient internal resources (compliance officers, billing and coding experts) to eliminate the need for an outside professional. In all cases, however, practices should be aware of the advantages and disadvantages of each option.

To be sure, a compliance trainer from within the practice or entity has advantages in terms of cost, flexible scheduling, and the ability to repeat the training as needed. In many cases, an outside trainer or training company with the necessary specific expertise won't be local, adding travel and travel costs to the equation. With an outside professional trainer, the training will have to be done on her schedule, and finding a mutually acceptable date and time can often be time-consuming. The ability to repeat the training may, at least on a live basis, be limited and costly, as refresher courses or training for new employees will necessitate additional travel and expense. This additional cost may be reduced by the use of some videotaped training.

Despite the disadvantages in terms of cost and flexibility, outside trainers are usually the better choice, particularly with respect to initial training and large-scale follow-up programs. This is because -- rightly or wrongly -- it often takes an outside expert to lend credibility to the compliance enterprise. It's a fact that employees frequently perceive external trainers as more credible than internal personnel with whom they work on a daily basis. It's likely that a credentialed outside professional is more likely to engage the attention of your practice's trainees.

There are additional advantages to hiring a professional to conduct the training. Professional compliance trainers are far more likely to be sensitive to the important documentation issues that confront a practice embarking on a compliance program. In addition, by hiring an outside professional trainer, the practice's own compliance professionals are able to avail themselves of an important educational opportunity.

What type of training is best?

You can choose from a variety of types of compliance training. Often, the choice of trainer will dictate the type of training. Conversely, the type of desired training may dictate the choice of trainer. The method that works best will depend greatly on the type, size, and resources of the practice.

Some important factors to consider include:

Trainee engagement. The effectiveness of a compliance program is highly dependent on whether the staff is engaged in the exercise.

Credibility of the trainer or training approach. Credibility (perceived or actual) is crucial for the buy-in of the entire organization. Third-party vendors tend to be perceived by employees as more credible.

Cost. How much is the training effort going to cost the practice?

Reproducibility. Can the training be reproduced easily for new hires and to meet refresher-course needs?

Ability to update. Regulations and requirements change, which may render old training manuals or videotapes inaccurate.

Measurable results. It's important to ensure that all staff and physicians understand the materials and that there's a means of measuring the participation and, hopefully, the impact of the training.

Once you've evaluated each of these factors and determined their relative importance to your practice, you should choose one of the following formats for the actual training program:

External lecture. Many practices have found the lecture/course method of compliance training by an outside professional to be beneficial. The credibility of the trainer in the eyes of the employees is likely to be high, and good trainers will usually have easily updateable material and strong assessment/measuring tools. Flexibility in scheduling may well be an issue, however, as may costs. The use of hypotheticals and case studies can drive messages home in a meaningful way, limit the risks of a boring lecture, and give the audience a chance to participate.

Internal lecture. Another option is for the practice's compliance personnel to conduct the training in an internal lecture/course format. Despite the internal trainer's level of expertise, her perceived credibility is likely to be lower than the outside professional. An internal lecture, however, is easily reproducible, low in cost, and its timing can be highly flexible, depending on the trainer's workload. Because an internal trainer isn't a training professional, she's unlikely to have experience with sensitive documentation issues, or be able to easily update the relevant training.

Lunch meetings. Many practices find that compliance-related lunch meetings are a less formal, more relaxed means of presenting training topics. Lunch sessions offer significant advantages in terms of scheduling and flexibility. Frequently this will mean that there's no need to shut down the office, with the inevitable loss of revenue, for a half- or full-day training session for all the physicians and office staff. Lunch sessions can be spread out over time, and attendance staggered, so that they're less disruptive. In many cases, the informal nature of a lunch program may make staff less defensive and more receptive to the training message.

As might be expected, this approach can also have disadvantages. The use of frequent lunch sessions may mean that the practice's choice of trainers is limited. Bringing in an expert from out of town isn't cost-effective for a lunch meeting. The natural fit for this type of training is either an in-house trainer or, if possible, a local expert. Another disadvantage of conducting lunch sessions rather than full- or half-day lecture sessions is the possibility that some employees may perceive this approach as showing a lack of commitment to serious training. In addition, trainee engagement may be low because lunch sessions may be too easy to skip, with employees allowing themselves to be called away to their "real" duties.

Computer-based training. We're frequently asked about the utility of computer-based training. As with everything else, this approach has advantages and disadvantages. Computer-based training is likely to have high perceived credibility from the trainees, with tremendous scheduling flexibility and reproducibility. In addition, many of the companies that provide computer-based training offer periodic updates, which is a significant plus. Other factors to consider when looking at computer-based training are whether the module comes with assessment tools, and its ease of documentation.

The negatives of computer-based training include cost and focus. Computer-based training tends to be expensive, and usually can't be tailored to the specific needs and issues of your organization. In other words, the training program you get on the computer may be one designed for all physician practices, not the cataract, refractive, with glaucoma and retina practice that you have.

Written self-study. We've found that the utility of self-study largely depends on whether there are "end tests" to confirm that the individual actually listened to and comprehended the program. Positives of this approach include credibility (third-party vendors tend to be perceived as credible), scheduling flexibility, and high reproducibility, which is important for the training of new hires. In addition, these materials tend can be easily updated. But these products can be so generic as to be of limited value.

Meet your practice's needs

As we've mentioned, no single trainer or training approach is appropriate for every organization or situation. We've steered clear of sweeping generalizations because a "one size fits all" training component will lead to disaster -- or at least to a serious dose of frustration.

It's important that your practice chooses the approach that's calculated to work best for you. Choosing the right training approach will entirely depend on an accurate assessment of your organization's needs.

William A. Sarraille is a partner and Jeffrey S. Peters is an associate at the Washington, D.C., law firm of Arent Fox Kintner Plotkin & Kahn, which represents ophthalmologists across the country in regulatory, compliance, litigation, fraud-and-abuse and corporate matters.
Mr. Sarraille and Mr. Peters both speak and write nationally on a wide range of ophthalmic topics, including ambulatory surgery, physician contracts, fraud and abuse, and HIPAA.