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* Should compliance officers do their own staff training?
* Do I have to tell our compliance officer about my other jobs?
* Pay-per-view Article: Don't wait another year to work on business associate contracts

Compliance Monitor, February 10, 2003

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Should compliance officers do their own staff training?

Q: Should compliance officers do their own staff training, or is it preferable to use in-house staff as trainers? What are the pros and cons of both situations?

A: Conducting effective training depends somewhat on the size of your organization, as well as senior management's personal philosophy about compliance.

In a small organization—Corporate Compliance Officers (CCO) in smaller settings should provide training to all levels of staff. They are the compliance expert, and should impart the pertinent information for each type of employee. For example, coding and billing staff should receive more in-depth training in financial issues than your housekeeping staff. Here's one benefit: Your staff would have the opportunity to meet the CCO in person in a collegial and less formal environment, which would help to promote the importance of corporate compliance throughout your organization.

In a larger organization—You'll probably have the resources to use in-house staff. The CCO should train the staff in a "train-the-trainer" format. The CCO should handpick these individuals as managers and leaders. These trainers will serve as role models for integrity and ethical behavior. Doing this sends an important message and shows a commitment to employees that the leaders of your organization can be counted on to serve as resources. Moreover, the daily visibility of your trainers may help you stave off compliance matters. Your employees will be able to seek out their trainers for answers to compliance questions or ethical dilemmas.

Another advantage to using in-house staff trainers: You'll have the ability to train more staff in less time, and this can help your organization save money. One disadvantage, however, is that your message may become inconsistent if trainers instill their personal biases during the education sessions. The CCO should meet with the trainers to address this issue and then monitor how well the compliance message is being conveyed.

With either of these modes, training will be more effective if it is interactive. Use case studies and real examples, and provide a "low-risk" setting so attendees won't be afraid to share their experiences. Try to avoid "stand alone" training, like showing a video and then giving a quiz afterwards. You'll need to go further than that to ensure compliance in your organization.

Whether the CCO or in-house trainers provide the compliance training, these individuals will be viewed as examples of integrity and lawful and ethical behavior. The goals is that their efforts and message permeate positively through an organization. It's a win-win situation.

This question was answered by Norman Werner, CHE, Associate Corporate Compliance Officer at Westchester Medical Center in Valhalla, New York.

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Q: I am a nurse practitioner affiliated with a large hospital organization that has recently adopted a corporate compliance program. Our compliance officer asked me to disclose other organizations in which I work. I have a part-time job at another facility. I am not involved in any research projects.

I don't mind writing a letter stating that I will not accept money from a pharmaceutical company and will not accept gifts from any vendors, but I am uncomfortable having to disclose my other jobs. I believe if I perform my job well, and agree not to participate in unethical practices, my employer should not have the right to know about my other jobs. However, I have been told I will be dismissed if I do not sign the corporate compliance agreement. What are my options? Does my employer have this right?

A: It sounds like you are being asked to disclose all other employment as part of the corporate compliance program's conflict-of-interest policy.

• Conflicts of interest may exist if you could reap some personal gain from an unethical relationship with another organization. This would compromise your ability to be objective in your job duties. Normally, these concerns increase as you advance in the corporate structure. For physicians, conflict of interest may also implicate the Stark self-referral law. For this reason, it's usually within the hospital's right to ask you about your other jobs, especially if they're in the health care field.
• Most organizations keep conflict-of-interest questionnaires confidential. If compliance officers raise questions about a potential conflict, it's likely they'd discuss it with you and try to resolve any issues privately.
• It may be appropriate for you to simply list other jobs unrelated to health care that might be considered a potential conflict. However, you should always disclose any other health care-related employment.
• Check into whether you have an employment agreement. If you have one, it may spell out what you're required to do. If it doesn't, you'll want to find out why your employer wants you to disclose these things. And if you are still uncomfortable, you could hire a lawyer. Ask an attorney to review the agreement if you are unsure.

This question was answered by Charles Colitre, president of Med-Management Group, Inc., a consulting firm that assists physician practices and hospital systems to develop and implement compliance programs. Additional information was provided by Annaliese Impink, a lawyer with the Arlington, VA, law firm Bianculli & Impink.

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