Tips for Trainers

by Chris Dimick

Most HIM professionals weren’t taught to be trainers, yet more and more find themselves in front of a class. Luckily, training is an acquired art.

Chairs swiveled, voices silenced. All eyes in the room focused on Donna Wilson.

The time had come in the physicians’ meeting to discuss HIM issues, and Wilson was in charge of bringing the room up to speed.

Wilson, then the coding quality manager at Charleston, SC-based Roper St. Francis Healthcare, was new to public speaking and training. For a moment, the calm turned into mental panic. The room became brighter, air became hotter, and for a brief instant all memory of both her material and her expertise melted under the lights.

Though training is now a routine act for Wilson, she admits that the first time she stood in front of a room of her colleagues was harrowing.

“When you first start out, it is intimidating because you have the audience in front of you and all eyes are on you,” says Wilson, RHIA, CCS, today the organization’s revenue integrity manager. “How do you get past that? Just start talking. After a while you realize you are the expert.”

More Training Today

More and more, HIM professionals are being called upon to conduct in-house training. Electronic health record (EHR) implementations, quality assurance measures, privacy and security compliance, and coding regulations have increased the amount of new knowledge HIM professionals must share both within their departments and throughout their facilities.

That can be a tall order, because many have never formally been trained on how to train others. Most must find their own way. “I think [hospital administrators] just assume we know how to do these things, how to write a procedure or how to train a person,” says Mary Sierra, RHIA. “And I think that it takes some talent and skill to be able to train a person.” As director of medical records at 47-bed OSF Saint James-John W. Albrecht Medical Center in Pontiac, IL, Sierra has taken on a range of training responsibilities over the years.

Learning by trial and error—the route many take—has its faults. For one, it takes time, something in short supply in a busy HIM department, Wilson notes.

In-house HIM training of old was simple, she says. Back when she started as a coder in 1982, her in-house training consisted mainly of her boss answering questions and correcting mistakes over her shoulder. It was more one-on-one and less structured. “There was never the education that we have now. I never even saw a physician.”

Things started to change with the introduction of DRGs, Wilson says. HIM departments faced a new set of rules and a new emphasis on specific medical record documentation. “That was the big push, and as time has gone on, the rules and regulations as to what you can code have changed and have gotten a lot more restrictive.”

An update to ICD-10 will set off a similar wave of new training programs.

A New Era of Compliance and Technology

Since DRGs, a crop of compliance and IT efforts created a whole new group of HIM trainers.

HIPAA put many HIM professionals in front of a class for the first time. The implementation of the privacy rule in 2003 created the need for organization-wide training. At OU Medical Center in Oklahoma City, OK, more than 3,000 employees needed to be instructed on HIPAA regulations. That responsibility fell to Jindria Alvarado, RHIA, the center’s compliance and clinical documentation improvement manager.

Alvarado used a train-the-trainer method, in which she first trained small groups of hospital directors and managers. These groups then trained their individual employees. “That [technique] can cut your job in half compared to what you’d have to do if you have to go out and teach every single person on campus,” Alvarado says.

Since the initial HIPAA training push, Alvarado has been busy training on everything from the hospital’s annual code of conduct to general education on their medical records systems. Some of her time is spent updating staff on privacy and security issues like release of information.

OU Medical Center’s EHR is a constant source for training. As each piece is implemented, new training must be rolled out, says Alvarado. “Every time something comes up that is new, as far as electronic, we have to train everybody.”

With one of the most advanced EHRs in the nation, the Department of Veterans Affairs (VA) offers extensive in-house training on its ever-evolving system. When the VA was getting its EHR system off the ground 20 years ago, large classrooms of staffers were trained on EHR software and use. The VA also employs the train-the-trainer technique for both rollouts and updates, says Linda Nugent, RHIA, director of HIM.

Nugent also points out that the growing interest in documentation improvement made it inevitable that HIM professionals would soon find themselves holding in-house training sessions with both coders and physicians. “Data quality gets at the issue of training: Are we doing this right? Do employees know how to do this work?” she says.

At OU Medical Center, a consultant helped the facility implement a clinical documentation improvement program in June 2006. After the coders and clinical documentation improvement specialists were trained, it was up to Alvarado to train the facility’s physicians on the program. For months, Alvarado led training at the physicians’ service meetings.

The difference between training HIM professionals and physicians was immediately evident, she says. “Our coders had always known about queries and what they meant. The physicians, they knew vaguely what queries were, but they really didn’t understand why they were being asked a question.”

HIM professionals are also being called to conduct training with hospitals’ ancillary departments such as radiology and lab to help them understand just how HIM collects information and why it is important for specific documentation to flow free and clear.

HIM professionals have even found themselves mixing training and recruitment. With professional coders coming at a premium, some hospitals have decided to grow their own through in-house training.

At Roper St. Francis, HIM department staff was called upon to conduct a 12-week coding course that taught people from around the hospital—from registration workers to business office personnel—how to become coders. Wilson led the course in 2000, which started out with 50 people and eventually produced two-full time coders. In the process, many people throughout the hospital learned just what HIM does.

Becoming a Better Trainer

Taking some basic steps in producing in-house training can have a big effect on its success. Before training begins, write out procedures for the workflows your department trains on, Sierra advises.

“I have spent a lot of time writing procedures so that I can communicate them. Just in case any of us drop dead tomorrow we want to be sure that we are consistent,” Sierra says. “This is especially important in medical records. You want to make sure that you provide a consistent procedure for chart location, patient identification, and to ensure accuracy with other procedures.”

Enacting a mandatory set schedule for training helps, too. A recurring monthly training meeting can help decrease staff schedule conflicts and attendance problems.

When class starts, good trainers remind themselves that they may not be the end-all expert on the topic. “Become humble,” Wilson recommends. “Don’t act like you are better than your audience.”

Alvarado advises to never underestimate the knowledge of the people in the room when conducting training with your own department. With their day-to-day experience in the operation, HIM staffers sometimes identify trends before management. “Your employees can always give you feedback that will shock you, make you think ‘Why didn’t I think of that?’” she says.

Nugent agrees. “You are going to have people on your staff that know it better than you do,” she says. “Give them the floor. I just believe in using the expertise you have around you and allowing them to share with the rest of the group.”

That advice extends to others beyond the HIM department. A medical facility is full of experts, most willing to take some time out of their day to help the HIM department better do its job, Wilson says.

“Bring in physicians, that is a biggie,” she says. “I tell them ‘Don’t do a formal presentation, just let my coders pick your brain.’” The exchange not only allows HIM to better understand clinical procedures, but physicians get to understand how to better work with the HIM department while on the floor.

Discussions also engage audiences and create active listeners. Wilson suggests bringing up hot coding topics and asking staff for opinions. “I don’t stand up there and dictate the entire time,” she says. “I ask for their opinion on Present on Admission. I say, ‘Help me here. How would you consider doing this one-give real examples.’ I get their feedback.”

There may be times, though, when HIM is tasked with training that is beyond their expertise. Nugent notes that you have to know when to ask for help. Usually a department has the expertise it needs to conduct training, she says, but if limited subject knowledge is the problem, it is the HIM director’s job to find a way to get staffers trained. “If you don’t feel comfortable doing it yourself, then you have got to garner some resources to make sure your staff gets the training they need,” she says.

A Simple Lesson on Simple Lessons

With training, less can be more. Keep it simple, experts say. Most beginning trainers provide too much information and too many details. People are more apt to come away from a presentation having learned something if the information was presented in a simple manner, says Nanette Miner. Brains can overload, so only the most important information should be shared during training.

Miner is the founder and president of the Training Doctor, a company that designs training primarily for corporate clients. She also runs the Accidental Trainer, a Web site for people in all industries who have “accidentally” become trainers in their organizations.

People highly experienced in a particular field can make great employees, Miner says, but they often make awkward trainers. Ask a subject matter expert to conduct training, and they usually struggle to choose the right information and present it in a way that is learnable.

Miner suggests that trainers think back to when they didn’t know the subject matter they are presenting. Build the training in a simple fashion, being careful not to start over or under the audience’s head. This will help you set strong objectives.

“To ‘know’ or ‘understand’ is not an objective,” Miner says. “An objective has to be provable, it has to be measured. Most people would say, ‘You are here to learn the alphabet.’ Well, what does that mean? ‘Recite the alphabet’ is an objective one can conquer, because that is measurable.”

Miner also suggests that trainers only teach what people need to know to do their jobs. Adding “nice to know” information just dilutes the message and prolongs the training, she says. Have the guts to slash out from your training everything that is not vital, she says. The audience will thank you. “You have such limited time with people, and they have limited brain capacity,” she says.

Becoming a great trainer won’t happen overnight. Practice makes perfect, Wilson says. Most people are nervous the first time they are called to train. Nerves can be calmed by remembering your experience. “You have to put that in your brain,” Wilson says. “You have to say to yourself, ‘I do understand this. This is my expertise.’”

How It All Pays Off

Although her first few training presentations were scary, Wilson now eagerly volunteers to speak with both HIM staff and physicians. A 10-year training expert, Wilson has seen how just a little training on documentation can go a long way in creating better records that are good for patient care and reimbursement.

“I thrive and I hunger for that. I can’t wait to get up and talk in front of [HIM professionals and physicians] because it is going to make my job so much easier,” Wilson says. “I love picking up a report the next month and seeing a huge difference in my coding quality because [staff] really and truly paid attention to the education. That is very invigorating.”

Training keeps people sharp and current, Alvarado adds, two critical aspects of providing good healthcare.

As people learn how to better perform their jobs, they become more engaged and proud of their work. The VA sees training as an investment in its employees. “The better they get at what they are doing, they become more proud of what they do,” Nugent says. “I certainly believe that if people feel confident in what they are doing that their skill sets improve and they are better employees.”

In-house training is important for all HIM departments, in all hospitals, Wilson says. “It is definitely necessary and mandatory for everyone to have in-house training sessions. I don’t care how big or small your organization is, you need to have consistency.”

Chris Dimick (chris.dimick@ahima.org) is staff writer at the Journal of AHIMA.