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Compliance Training for Medical Staff

Because of the many different roles in the healthcare industry, there is no one-size-fits-all compliance training for medical staff. Furthermore, the nature of healthcare compliance training modules can vary according to location, specialty, or responsibility. Nonetheless, it is a legal requirement that all medical staff undergo HIPAA compliance training.

If a Covered Entity is located in Texas, the nature of the privacy and data security training provided for medical staff will be a lot different from the training provided for medical staff located in New York. This is due to the Texas Medical Record Privacy Act (and subsequent amendments in Texas HB 300) which has tougher privacy protections for health data than HIPAA.

Similarly, if a medical professional works in an area of healthcare in which they are likely to be exposed to HIV, HBV, or HCV, their compliance training will include compliance with the OSHA Bloodborne Pathogens Standard, while a person with responsibility for health and safety on a general ward should be trained on OSHA´s Incident Reporting procedures.

Despite the different types of compliance training for medical staff, all medical staff are required to undergo HIPAA training to understand what HIPAA is, what its objectives are, and what policies and procedures have been introduced to ensure compliance with the HIPAA regulations. Even then, the content of some training modules can differ from Covered Entity to Covered Entity.

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HIPAA and Healthcare Compliance Training Modules

With regards to HIPAA compliance training for medical staff, the content of some training modules will always be the same. Medical staff should have an understanding of the HIPAA Privacy and Security Rules, patients´ rights, allowable disclosures of Protected Health Information (PHI), and the consequences of HIPAA violations – to the patient, the Covered Entity, and the employee.

However, the content of some HIPAA healthcare compliance training modules may vary depending on the outcomes of Covered Entities´ risk assessments. For example, if a Covered Entity has identified the risk of a data breach due to password sharing, the content of a training module addressing how to safeguard PHI will likely include a section on password best practices; whereas another Covered Entity may not have the same issue or may have mechanisms in place to prevent it.

Healthcare compliance training modules can also vary in content depending on whether medical staff are public-facing employees or work behind the scenes. Public-facing employees are more likely to encounter certain types of threats to patient data than those working in a lab – for example, the unintentional disclosure of PHI to a patient´s friend. Therefore, it may not only be the case the content of training modules varies between Covered Entities, but also between departments.

When is HIPAA Compliance Training for Medical Staff Required?

Although the Privacy and Security Rules stipulate training is mandatory, neither Rule provides a timeframe of compliance training for medical staff. The Privacy Rule states training is required for “each new member of the workforce within a reasonable period of time after the person joins the Covered Entity’s workforce”, while the Security Rule states training is required “periodically”.

It is also a condition of the HIPAA Privacy Rule that training should be provided when “functions are affected by a material change in policies or procedures”. This clause could apply to any change in working practices, any new technology deployments, or any guidelines issued by the Department of Health and Human Services (HHS), and consequently it may be necessary for a Covered Entity to provide training to just a few individuals, a department, or the entire workforce.

Due to the “within a reasonable period of time” clause, most Covered Entities incorporate material changes to policies and procedures into annual refresher training. However, it is important to stay on top of compliance training for medical staff – and document training when it is provided – to avoid the potential of a substantial penalty if a data breach occurs and the HHS interprets a lack of HIPAA compliance training as a willful neglect of the HIPAA Rules.

Author: Steve Alder is the editor-in-chief of HIPAA Journal. Steve is responsible for editorial policy regarding the topics covered on HIPAA Journal. He is a specialist on healthcare industry legal and regulatory affairs, and has several years of experience writing about HIPAA and other related legal topics. Steve has developed a deep understanding of regulatory issues surrounding the use of information technology in the healthcare industry and has written hundreds of articles on HIPAA-related topics.