MT-CS-003-02: Compliance Training

CONTEXT / SCOPE

The purpose of this SOP is to provide the Customer Success Department with a thorough understanding of what we are offering our Compliance Module and why, as well as a complete walkthrough of all the enabled modules and submodules. Having this knowledge will improve how CSMs provide their training sessions, as well as be more prepared for questions the admins will have. 

IMPACTED TEAMS

  • Strategic CSMs

  • Core CSMs

  • CS Operations

  • Sales

GLOSSARY

  • CSM – Customer Success Manager 

  • EM - Escalation Matrix

  • IF - Incident Forms

  • IR - Incident Reports

  • IT - Incident Types

  • LMS - Learning Management System 

  • RACI - Responsible, Accountable, Consulted, Informed.

  • SDS - Safety Data Sheets

  • SF - Salesforce

  • SP - Safety Plans

  • TL - Team Lead

RESOURCES

Internal

External

Find what you’re looking for by training session number!

TABLE OF CONTENTS


Before the Training Session

Admin LMS Account Set-Up

  1. Make sure that you have uploaded the completed Locations, Departments and Positions rosters into the system (these will be requested since your first email using the Welcome to MedTrainer! CSM Template available in Outreach). After that,

  2. Ensure to send the admin the downloaded Employee roster from their account’s Employee Center. (this will be required in the Onboarding Call Recap email template) Once that is completed by the admin, you will be able to upload their employee lists with less issues.

Ideally, the admin’s accounts can be set with their employees before training sessions. If this is not possible before then, simply remind the admin it is important to do so in case they would like assistance with initial setup. Please follow the https://medtrainer.atlassian.net/wiki/spaces/CSKB/pages/4154654777, and feel free to forward this file to your admins in its PDF form as well. Remember to log in the “LMS Set-Up Completed Date” field in the Onboarding Object.

  1. Remember to enter the “LMS Set-Up Completed Date” field in the Onboarding Object.

Your Demo Account Set-Up

The purpose of this is to:

  • Ensure you are is familiar with the system, performing all the possible tasks in each module.

  • Showing the admin how the system looks real time, with populated data.

  • Leaving the admin’s account as a clean slate to use from scratch.

Make sure to have:

  • Documents and contracts uploaded

  • Categories and escalation workflows created

  • Incident Reports created

  • SP forms filled in

  • SDS added to your binder

Preparing the Meeting

If your admin would like you to schedule the meeting on a specific date and time, review Options 1, 2 and 3 sections of the Onboarding SOP.

If the admin hasn’t scheduled a training session yet, please send proposed times as shown in the Option 4: Gmail (Inserting Proposed Times) section of the Onboarding SOP.

 

 

We need to have the training sessions logged into the corresponding SF account, and confirm that the meeting also appears scheduled in Gong so that it can be recorded. You can check in Gong if your meeting appears once you click on the “View upcoming calls” section. It should appear if the process was followed. If this is not the case, please perform the following steps:

SchedMeetingGONG.mp4

Organization Management Training

If this is the first training session with your admin, provide Organization Management training covering the following topics (it is suggested to follow the steps on the https://medtrainer.atlassian.net/wiki/spaces/CSKB/pages/4154654777 ,  as it follows the recommended setup order. Feel free to forward this file to your admins as well):

  • Locations

    • How to create and modify them

    • How to designate a location manager

    • image-20240703-182659.png
  • Departments

    • How to create and modify them

    • Department Visibility

  • Positions

    • Both position databases (extended and generic)

    • How to create and modify them

  • Employee Center

    • Creating new users

    • Changing employee status

    • 6 options under each user dropdown

    • Full profile walkthrough

    • Settings:

    • Organization Reports:

  • For accounts that purchased an integration: When the admins try to create employees manually from the employee center, they will see the warning message that remarks the risk of duplicated accounts or incorrect assignments. We want to encourage them to add the new employees only by the integration and to understand the possible consequences of doing manual creation. please refer to the https://medtrainer.atlassian.net/wiki/spaces/CSKB/pages/4159505060 SOP for more information.


Documents and Policies

This submodule allows Admins and Super Admins to upload, create, organize, and manage documents in the manner that is most suited to their organization. It also facilitates the assignment of documents to the staff requesting attestation when needed, always making it easy for the admin to keep track of these processes.

Folders

What first appears in the Documents and Policies Module. Create an example folder to show the admin how to create, edit and delete folders. Go through the multiple folders/subfolders functionality, as this will help the admins to make “nested” folders. Also, these can be location and department specific.

Categories

These assist with organization. Open one of the folders  and guide the admin on how to create, edit and delete categories.

Document Set-up

For setting up documents, be as thorough with the admin as possible, as the differences in format and between creating options may be confusing. Guide the admin through the following steps:

Uploading a Document

  • Remember to mention that all fields marked with a * are mandatory.

  • Make sure that you let the admin know about the supported files the system accepts, as well as the size limit (50 MB).

  • Settings:

    • Requires Acceptance: To ensure that assigned users have to read and acknowledge the document.

    • Requires Fillable Responses: This will only work if the uploaded document is an already fillable form. It does not become fillable in the system. For a full walkthrough, please refer to the following MedTrainer Fillable PDF Forms video.

    • Allow Downloading or Printing: Comes in handy if super admins want to allow their students to download or print.

    • Expiration Date: Not mandatory but suggested, if applicable.

    • Sending a Notification: Checking this option will allow the admin to select which colleagues from the administrational staff will be notified.

Creating a Document

  • Remember to mention that all fields marked with a * are mandatory.

  • Guide the admin on how to create both a PDF and a Word document.

  • Make sure that you let the admin know about the supported files the system accepts, as well as the size limit (25 MB).

Editing a Document

Both Drafts and Published Documents have an Editing option. Make sure to guide the admin through both scenarios.

  • For uploaded documents, walk through the following steps:

    • Keeping the existing file or uploading a new version.

    • The information Fields

    • The Setting checkboxes again, if applicable.

    • Setting a document’s signature and date fields.

  • For created documents, the view to edit is the following:

Document Bundles

Document Restrictions

Approval (Escalation) Workflow

The user can build their own approval workflows based on their needs. These approval workflows will be used to send out a document draft for approval, allowing the user to make sure the document gets to the right people in the correct order before publishing.

  • Guide the admin through the dashboard, and then, create a new matrix to show the steps.

  • When creating the escalation levels, the 3 following are suggested:

    • Author

    • Reviewer

    • Approver 

  • Remember to let the admin know that there can be more than one person per level.

  • To enable an Approval Workflow:

    • Go back to the Documents Dashboard.

    • Select the document that needs approval.

    • Select the necessary workflow and click Send.

Adding Signatures

To add signatures to a document, the document lifecycle has to be changed to “Content Complete“. Both drafts and published documents have this option available. There are three signature options available:

Single Signers

The single signer option lets you assign a document to just one person, either internal or external to the organization.

Once signatures are placed, change the lifecycle to Published.

Assignment Signers

This means that whomever you assign this document to will have their signature requested.

Signing Groups

You can request signatures from a specific group of people.

Conversations

The conversations allow users to discuss anything related to a specific document. The system keeps track of every conversation in one place but also keeps them linked and available from the app bar actions of each document.

Version History and Logs

The system keeps track of everything that is done to a document, from the moment of creation to the moment of deletion. This section of the system allows the user to visualize all of those changes, as well as all document versions that have been created.

Document Assignment

This section gives the user a detailed explanation of how to assign documents to the staff and how to easily keep track of deadlines. Make sure to remind them that assignees will be able to accept/sign the policies on their Student Dashboard.

To track an assignment, click on the Assignment Tracking button of the app toolbar.

Attesting a Document

Guide the admin through the Student Dashboard and show them how the notification for acceptance looks. Then show them the Accepted Policies, of the Documents and Policies Binder.

User Preferences

Users are now able to save the user preferences for the documents table in Documents & Policies. The User preferences feature allows administrators to effortlessly save their preferred document table configurations, ensuring quick access to vital information every time they enter the Documents & Policies 

module.


Compliance (In-App) Reports

MT-CS-003-01 Learning Training

Company Settings Part 1

These help our admins tailor out how they want their LMS accounts to work. Remember to go into module-specific settings here.

  • Under Modules:

    • Massive Assign

  • Under Reminders:

    • Policy Notifications

Pending System Actions

If a document/policy is not fully assigned to all staff members, the first place to check will be this page. If anything appears as a pending action, it may be due to one of these two reasons:

  • The assignee already has had that course assigned to them in the past.

  • The assignee already has that course in progress.


Admin and Student Dashboards

While the Admin Dashboard has no Documents and Policies widgets, go into the Student Dashboard and review the following items:

  • Notifications at the top (how to review and accept policies)

  • Document Binder (how to view the policies, review acceptance history, visualize by categories, and export)


Contract Management

“Contracts are the glue holding every operation together within the healthcare industry. They connect employees and employers, suppliers and buyers, ensuring each party remains protected. Whether dealing with hiring, your supply chain or equipment, contracts can be long and complex and require time and effort to ensure they’re structured in your best interest. Understanding the different types of contracts and how they work is the first step to an effective contract management operation.“

Some contract examples are:

  • Supply Chain Contracts

  • Labor Contracts

  • Special Healthcare Labor Contracts

  • Purchased Services Contracts

  • Informational Technology Contracts

  • Pharmacy Contracts

To learn more about each different contract type involved in the healthcare industry, visit https://www.pathstonepartners.com/types-of-healthcare-contracts/.

This module will allow the admins to upload most, if not all existing contracts pertinent to their organization. Please provide them with a dashboard overview:

Adding a Contract

Contracts can be added both in the All Contracts view, as well as the Dashboard view:

Viewing All Contracts

Here, the user will be able to see all contracts that have been created/uploaded. They will be organized per category.


Safety Plans

“Safety plans are comprehensive tools that detail a framework for safety practices. Each plan is targeted to a specific activity or department – every company probably has dozens of safety plans in their arsenal.”

For more information, visit Implementing Safety Plans in the Workplace

In this submodule, please walk the admin through the following steps: uploading and creating safety plans, tracking assignments, and a general dashboard overview.

Creating a Safety Plan

 


SDS (Safety Data Sheet) Management

“A Safety Data Sheet (formerly called Material Safety Data Sheet) is a detailed informational document prepared by the manufacturer or importer of a hazardous chemical. It describes the physical and chemical properties of the product. SDSs contain useful information such as toxicity, flash point, procedures for spills and leaks, storage guidelines, and exposure control.“

Visit https://blink.ucsd.edu/safety/resources/SDS/index.htmlto learn more about Safety Data Sheets and how to read them.

Here, the admins can add SDSs from our vast database into their account binder, or they can upload their own. Please guide them through the steps below.

  • Looking for safety data sheets in the SDS Library:

    • Adding them to their SDS Binder

    • Downloading SDSs

  • The SDS Binder:

    • Downloading

    • Deleting

    • Editing titles

    • Editing categories

 

 


The Onboarding Path

Make sure to let the admin know that they can also set up the following as “welcome kits/packets” for either new employees or any other specific matter:

  • Documents and Policies

  • Docs & Policies Bundles

  • Safety Plans


Company Settings Part 2

Walk the admin through the following:

  • Under Modules:

    • Onboarding Path

    • Safety Plans

  • The SDS Management Tab


Incident Reports

“Incident Reporting is the process of capturing, recording and managing an incident occurrence such as in injury, property damage or security incident.

It typically involves completing an incident report form when an incident occurrence has happened and following it up with additional incident follow on forms such as an investigation, corrective action, hazard report and sign off. These follow on forms ensure that the incident occurrence causes are investigated to potentially mitigate and aim to prevent the same type of incident from happening again. This might involve discovering hazards in the workplace or implementing new risk management or training processes to help staff understand the root causes of what happened in order to prevent it from happening again.”

Visithttps://www.incidentreport.net/whatisincidentreporting/ to learn more.

This submodule makes it easy for admins to manage their incident reports from the set-up to the resolution. They can build their own custom forms, create custom escalation matrices so the right people are notified automatically, and solve incident reports with just a few clicks.

Escalation Matrices

There are three different escalation matrix models available to choose from based on the structure needed to solve each incident report:

  • Functional Escalation Model: allows to have multiple users per level if needed by just enabling the “Allow multiple users in a level” setting when creating the matrix.

  • RACI Escalation Model (Responsible, Accountable, Consulted, Informed): The roles go as follows:

    • R- Responsible

      • Resolve (Request review is done by the Accountable)

      • Open Conversations

      • Request Responsible change

    • A – Accountable

      • Change Responsible

      • Open conversations

      • Review Resolutions (Reject/Approve)

    • C – Consulted

      • Answer/Open conversations

    • I – Informed

      • Receive email notifications

  • Anyone Escalation Model: escalates the report to everyone in the matrix and anyone from the list of users in the matrix will be able to solve the incident; in other words, the first person to respond to the escalation will be able to resolve the incident for everyone. However, if that person cannot resolve it, they will always have the option to choose someone else from the list of people involved in the escalation matrix to escalate the incident to.

Creating a New Escalation Matrix

Create an escalation matrix from scratch with the admin as shown below:

Once you get to this stage, please explain the incident types to the admin:

  • By Incident Type displays the list of incident types for which this matrix will be used for. This
    means that when a report is created for that specific incident type, this matrix will be used for
    the escalation of the incident report.

  • By Reporter displays the list of people that will likely be creating reports. This means that when
    one of these people creates a report, this matrix will be used for the escalation of the incident
    report.

  • By Location displays the list of locations that will be covered in case there is an incident report
    created. This means that whenever there is an incident created for the location, this matrix will
    be used for the escalation of the incident report.

  • By Department displays the list of departments that will be covered in case there is an incident
    report created. This means that whenever there is an incident created for the department, this
    matrix will be used for the escalation of the incident report.

  • By Location and Incident Type displays the list of locations and incident types that when
    combined, the system will use the matrix for. T his means that whenever there is an incident
    created for the location and type combined, this matrix will be used for the escalation of the
    incident report.

Functional Escalation Matrix

Hierarchical (RACI) Escalation Matrix

Anyone (or Group) Escalation Matrix

Incident Forms

Creating a New Incident Form

Customizing a New Incident Form

  • Blue buttons with gears that appear after you have new checkbox, radio button or drop-down menu elements display their specific settings. You can add options for these elements using these settings.

  • Orange buttons with ellipsis that appear after you have a new element in a section display the general settings. You can alter the design of the element, add notes and enable restrictions using these settings.

  • Red buttons with cross that appear after you have a new element can remove it from the form after you accept confirmation.

Managing Incident Types and Subtypes

Managing Severity Levels

In order to identify the impact on the organization of each incident report, the system allows the user to select a severity level for each incident report at the moment of resolution as it is at that moment when the investigation and analysis of the facts is entered in the system. Selecting a severity level for each incident helps identify those that require an immediate response from senior management and specialized response teams.

There are four default severity levels, however it is possible to add up to ten depending on the organization's necessities. It is also possible to give each severity level a description. Please guide the admin on the stops to add, edit and delete severity levels.

Managing Incident Reports

To add a new incident report to the system, click the New Incident button available on the Created reports tab of the module’s main screen. There will be two options to choose from: Upload and Create.

Uploading an Incident Report

Creating an Incident Report

Viewing Incident Report Details

Guide the admin through these steps:

Resolving an Incident Report


Admin and Student Dashboards

Though the Admin Dashboard does not have an Incident Report widget, guide the admin through the Student Dashboard, and show them where Incident Reports can be created and shown:


Compliance Toolkits

In these submodules, we provide the admin with general fillable forms pertinent to both OSHA and HIPAA Regulatory Compliance. Functionality is practically the same in both, and as easy to use as our Safety Plans, except for the tabs being subject specific in HIPAA Toolkits.

OSHA Toolkit

“OSHA is a federal agency that was founded alongside the Occupational Safety & Health Act of 1970. The OSH Act sought to protect the rights of workers and to offer long-term solutions for regulating workplace hazards. OSHA serves most private sector employers and employees. The organization also monitors federal employers and employees. The only difference between the two is that OSHA cannot fine a federal agency.

The agency goes beyond simply setting workplace standards; OSHA also trains employers on workplace health and safety. The aim of the agency is to prevent workplace injuries or deaths before they occur by educating employers about potential hazards in the workplace.”

To learn more, visit these websites:

Create a form from scratch (by choosing one of our templates), and guide them though how to fill them in. We suggest the OSHA Inspection Form, as it is commonly used.

HIPAA Toolkit

“HIPAA (Health Insurance Portability and Accountability Act) is United States legislation that provides data privacy and security provisions for safeguarding medical information. The law has emerged into greater prominence in recent years with the many health data breaches caused by cyber attacks and ransomware attacks on health insurers and providers.

HIPAA, also known as Public Law 104-191, has two main purposes: to provide continuous health insurance coverage for workers who lose or change their job and to ultimately reduce the cost of healthcare by standardizing the electronic transmission of administrative and financial transactions. Other goals include combating abuse, fraud and waste in health insurance and healthcare delivery, and improving access to long-term care services and health insurance.”

To learn more, visit https://www.techtarget.com/searchhealthit/definition/HIPAA

Walk the admin through the dashboard and fill a HIPAA Compliance Agreement form with them, as this one can be assigned to staff:


Company Settings Part 3

Walk the admin through the following:

  • Under Modules:

    • Incident Reports v3

  • Under Reminders:

    • IRv3 Notifications


After the Training Sessions

A Recap for the Attendees

Once the training session has been completed, send a email using the Outreach Training Recap Outreach Email Template immediately after the training session recording has been processed (or at least before the end of day), and fill in necessary information such as:

  • Participants

  • Modules

  • Pending Subjects

  • Relevant Links

Our Customer Support Department

It is paramount to not only encourage, but reinforce the admin on the use of our Customer Support Department. Provide the contact information below:

Other Training Sessions

If the account acquired the Learning and/or the Credentialing Software Modules, please refer to any of the following SOPs:

Adoption: The Next Steps

Lastly, please refer to the https://medtrainer.atlassian.net/wiki/pages/resumedraft.action?draftId=4135616513&draftShareId=a3711c8d-3de8-4bf5-95fb-6db42e50e83c, in order to continue with the account adoption following the instructed guidelines.