Digital Repository Doctoral Projects Spring 2021 Implementing a Standardized Orientation Program Kristyn Steedley, MSN-Ed, RN, NPD-BC Weber State University Follow this and additional works at: https://dc.weber.edu/collection/ATDSON Steedley, K. (2021). Implementing a Standardized Orientation Program Weber State University Doctoral Projects. https://cdm.weber.edu/digital/collection/ATDSON This Project is brought to you for free and open access by the Weber State University Archives Digital Repository. For more information, please contact archives@weber.edu. Implementing a Standardized Orientation Program by Kristyn Steedley A project submitted in partial fulfillment of the requirements for the degree of DOCTOR OF NURSING PRACTICE Annie Taylor Dee School of Nursing Dumke College of Health Professions WEBER STATE UNIVERSITY Ogden, Utah April 15, 2021 Ann Rocha PhD, APRN, FNP-BC__ Faculty Advisor/Committee Chair (Ann Rocha PhD, APRN, FNP-BC) Melissa NeVille Norton DNP, APRN, CPNP-PC, CNE Graduate Programs Director Running head: STANDARDIZED ORIENTATION PROGRAM 1 Implementing a Standardized Orientation Program Kristyn Steedley, MSN-Ed, RN, NPD-BC Annie Taylor Dee School of Nursing, Weber State University STANDARDIZED ORIENTATION PROGRAM 2 Acknowledgments The completion of this Doctor of Nursing Practice (DNP) project was a team effort. I am sincerely grateful for the mentorship and guidance from Dr. Elizabeth Rocha and Dr. Mary Ann Reynolds and the other Weber State University DNP faculty. Their patience in paving the way for this first cohort to complete the projects and graduate is extremely commendable, especially with their demonstration of caring for each student’s extra stress and the burden of the pandemic. I owe thanks to my leader, Emily Shumway, for believing in me to demonstrate the leadership skills needed to pilot this standardized orientation program. It was an incredible opportunity to work closely with the corporate clinical education design team in giving feedback on the content and organization of the orientation program. I am grateful for the facility leadership teams, as well as my team of educators who were brave to be the first to trial the new orientation content in the pilot program. Last, but certainly not least, I am grateful to my family and friends for their support and encouragement. My husband Rob and daughter Lilly for letting me have quiet homework time in the mornings and on weekends. My mom for being my unofficial editor, and my sister for helping with Lilly. We all celebrated when I submitted the final assignment in this program and we are looking forward to more quality family time together. I am grateful to my peers in this DNP program and for the support we were able to offer each other along this journey. I have learned a lot and feel more prepared in my leadership role. I am excited to see what the future brings and look forward to helping to mentor other nurses along their journey of achieving goals in the academic and professional nursing world. STANDARDIZED ORIENTATION PROGRAM 3 Abstract Orientation is required to meet regulatory accreditation standards for hospitals. To consistently meet the regulatory requirements, improve the learning experience of the new hire, consolidate resources of orientation facilitators, and streamline the process of transfers within a healthcare corporation, a standardized orientation program was implemented. Lewin’s theory of change guided the discovery, implementation, and evaluation phases of this standardized orientation program. The success of the orientation process was evaluated for improvements in the following: increased regulatory compliance, new hire satisfaction, reduction in the number of budgeted hours for facilitation, and decrease in the number of days for onboarding new employees. Keywords: orientation purpose, orientation regulatory standards, standardized orientation, interactive learning and employee satisfaction, orientation competency assessment. STANDARDIZED ORIENTATION PROGRAM 4 Implementing a Standardized Orientation Program Orientation to healthcare organizations is required to meet regulatory standards (Joint Commission, 2020), to introduce the new hires to the culture and mission of the organization, and to complete the initial competency assessment for skills required for the position (Walton, Lake, Mullinix, Allen, & Mooney, 2015). To create consistency in meeting orientation regulatory requirements, improving the learning experience of the new hire, consolidating resources of personnel to facilitate orientation, and streamlining personnel transfers between hospitals, a standardized orientation program was designed to be utilized by all facilities in the organization. Implementing standardized orientation content with interactive learning will improve the new colleague’s knowledge and readiness to comply with regulatory requirements in the hospital (Miles, 2018). The standardized orientation program included consistent documentation of orientation competency assessment to allow easy tracking of meeting the regulatory requirements, even if the new hire attended the orientation program at a different facility within the organization. Lewin’s theory of change was utilized to gather information on current orientation programs from each facility, design the curriculum and agenda for the standardized orientation program, and then trial implementation in a pilot program within three facilities. Involving key stakeholders in the change process from development thru implementation and evaluation improved the adoption of the standardized orientation program (Shirey, 2013). HCA Healthcare (HCA) has over 185 hospitals with each facility responsible for the design and implementation of an orientation program for all new hires. Findings of non-compliance for Joint Commission accreditation requirements at HCA Healthcare facilities STANDARDIZED ORIENTATION PROGRAM 5 included incomplete orientation content, inconsistent orientation completion, inaccurate documentation, as well as staff neither recalling nor utilizing the information presented on important care topics pertaining to patient care. Implementing a standardized orientation program improved the consistency of meeting orientation competency regulations, improved employee satisfaction with the orientation experience, consolidation of personnel required to facilitate orientation, and improved efficiency of orientation with weekly options for completion of onboarding. Literature Review The literature review focused on orientation to include regulatory standards, competency assessment, and consistency of programs throughout a healthcare system. CINAHL, PUBMED, and Google Scholar databases were used to find peer-reviewed articles published since 2016. Limited articles were available specific to standardized orientation evaluation and implementation methods resulting in an expansion of the search to include articles published in 2011 and later. Key search words included: orientation purpose, orientation regulatory standards, standardized orientation, interactive learning and employee satisfaction, and orientation competency assessment. Orientation Orientation programs are important to socialize new hires as well as increase their knowledge and skills (Walton, et al. 2015). Orientation can be used to provide pertinent information to employees regarding the history, goals, and values of the company. Employee orientation can introduce the new colleague to coworkers and the leadership teams of the organization (Acevedo & Yancey, 2011). While often costly to the organization, orientation is necessary to meet regulatory requirements with investment in a high-quality program far STANDARDIZED ORIENTATION PROGRAM 6 outweighing the consequences of poor orientation related to increased turnover rates, and unsafe practices by employees unfamiliar with organizational policies and procedures (Kuwaiti & Muhanna, 2019). Standardized orientation programs can improve both the workflow of the unit and within interdisciplinary departments by enhancing the knowledge of job responsibilities and safety standards required by all employees (Andronico, Getting, Hughes, & Ciccolini, 2019). Orientation Regulatory Requirements The Joint Commission (2020) sets the regulatory standards of orientation content for hospitals. HCA Healthcare facilities obtain accreditation by the Joint Commission and therefore comply with the standards and regulations of the Joint Commission. Hospital leadership is required to manage compliance with the standards to improve the patient safety culture and staff accountability (Kuwaiti & Muhanna, 2019). The Joint Commission (2020) recommends communication skills education be provided to all new hires during orientation to improve their confidence and competency in providing psychosocial support to patients and their families. Cincinnati Children’s Hospital Medical Center (2013) introduced this communication skills program as a web-based video, followed by individual discussions between the nurses and their clinical managers. The new standardized content for HCA Healthcare orientation includes a video and guided discussion on communication utilizing the acknowledge, introduce, duration, explanation, and thank you (AIDET) tool. This standardized tool is helpful for communication between caregivers, patients, and families. Utilizing a video and then guided discussion increases the recall of AIDET by the nurses (Correll, 2019). The Joint Commission (2020) requires orientation for all staff to include information on the following hospital-specific information: organization’s mission, values, goals, dress code, STANDARDIZED ORIENTATION PROGRAM 7 location of policies, emergency codes/rapid response procedures, and computer downtime documentation procedures. Orientation must include an overview of the environment of care standards, employee health and safety, risk management and patient safety program, an introduction to the facility security program, and human resource policies. Competency Assessment Joint Commission (2020) describes competency as a “combination of observable and measurable knowledge, skills, abilities and personal attributes that constitute an employee’s performance” (Competency, para. 1). The ultimate goal is for employees to demonstrate the skills necessary for quality and safe patient care. The organization defines competency requirements based on the patient population, types of procedures performed, diagnosis treated, and equipment used. Competency assessment is validated in orientation through post-tests, simulation scenarios, and patient care evaluations (Di Leonardi, Hagler, Marshall, Stobinski, & Welsh, 2020). Miles (2018) noted improved new nurse confidence in providing care and being prepared for work on the unit after revising the orientation program to include simulation and experiential learning. A standardized orientation program with competency-based assessments improves patient safety by validating nurse competence while integrating critical thinking and coordination of care skills in the experiential learning scenarios (Murphy & Janisse, 2017). Consistency of Orientation Fragmented and inconsistent orientation leads to decreased satisfaction feedback from the new hires indicating they did not have all the information they needed to feel more efficient in their new role (Acevedo & Yancey, 2011). Pasila, Elo, and Kaariainen (2017) have found that nurses leave the profession because of a negative orientation experience. For example, a nurse STANDARDIZED ORIENTATION PROGRAM 8 left her position after a few weeks for not feeling welcomed at orientation and also sensing disorganization and chaos from the orientation program’s lack of consistency in information on policies and procedures from the presenters and preceptors on the unit. The major impact on learning and satisfaction occurs when teaching interventions include more than one approach (Brooke, Aitken, Webb, MacLaren, & Salmon, 2019). Strategies with the best satisfaction outcomes incorporate a variety of education options including classroom instruction, observational experience, coaching, and computer-based learning combined with a robust preceptor program. Effective teaching of adult learners is a complex process. Green (2016) suggests new strategies to engage the adult learner in hospital orientation rather than passively presenting the required regulatory content of policy and procedures. Well-designed orientation programs involve a mixture of teaching methods that enhance a new hire’s feeling of being welcome and engaged in the culture of the new organization. A majority of healthcare workers attending orientation prefer to be active in a busy work environment and not attending lectures for the entire orientation program. The content required for orientation can be taught in meaningful and enjoyable ways. When learners are relaxed and having fun participating, learning is enhanced (Green, 2016). Inconsistent delivery of required Joint Commission standards of orientation has negative implications for employee and patient safety as well as a potential financial impact to the organization from fines or loss of accreditation by the Joint Commission (Joint Commission, 2020). Orientation regulations described by the Joint Commission (2020) require completion of background checks, health and drug screens, completion of human resource hire documents, and verification of licenses/certifications required for the position prior to the employee’s initial start STANDARDIZED ORIENTATION PROGRAM 9 date. Delays in the completion of these requirements may extend the anticipated start date for the new hire. This literature review supports the design of a standardized HCA Healthcare orientation utilizing a variety of teaching methods to support consistent information provided. Included in the program is certified preceptor education to standardize teaching methods on the units during orientation. Past orientation programs at the HCA Healthcare Mountain Division facilities included primarily lecture and discussion as teaching methods (HCA Healthcare Center for Clinical Advancement (CCA), 2019). The eleven hospitals in the Mountain Division of HCA Healthcare utilize inconsistent practices in teaching regulatory orientation content and do not routinely integrate a variety of teaching methods for orientation. This results in inconsistencies in the delivery and retention of information, as well as lower employee satisfaction with the orientation experience (Brooke et al., 2019). When a facility within the HCA Healthcare system acts independently and offers orientation monthly a new hire may not be cleared to work until after that date and unable to start the new position for another month. HCA Healthcare facilities hosting orientation more frequently results in frequent utilization of scarce resources from the human resource and education departments. Facilities utilizing an online learning format covering minimal topics on regulatory requirements attempt to allow a new hire to start a position quickly. The new hire is then scheduled to attend formal orientation several weeks after the start date (HCA Healthcare, n.d.). Should HCA Healthcare Mountain Division hospitals decide not to move towards a standardized orientation program, there is a risk of an increase in the turnover rate of employees. Orientation satisfaction has been linked to the employee’s retention factor, especially for the first STANDARDIZED ORIENTATION PROGRAM 10 year. Ultimately, employees not satisfied with the orientation process consider leaving the company, which interferes with the system’s focus on patient safety (Kuwaiti & Muhanna, 2019). Theoretical Framework Lewin’s Change Theory was used to implement the move towards a standardized orientation program for HCA Healthcare Mountain Division. This theory involves three phases: unfreeze, change, and refreeze. Lewin’s theory can be a strategic resource in facilitating participation in change. Change management can be a difficult task for leaders, especially when teams are passionate about the current process and do not immediately see the need for change. Lewin’s theory of planned change requires prior learning to be rejected and replaced with new. For the implementation of the standardized orientation program, facilities must choose to move toward adoption of the new program based on the proven benefits of consistency for regulatory compliance, improved new hire satisfaction, and efficient use of resources. Lewin’s theory emphasizes the importance of involving key stakeholders from the beginning and through each phase to enhance the implementation compliance (Shirey, 2013). The unfreeze stage for this Doctor of Nursing Practice (DNP) project involved collaborating with the facility human resource and education teams to review the current orientation program content and design. This phase also involved proposing the new standardized orientation program content and schedule. The change stage piloted the implementation of the HCA Healthcare standardized orientation program in three facilities of the Mountain Division North Utah Market. This phase involved training sessions for the Education, Human Resource, and Leadership teams to learn the new standardized content and expectation of utilizing the interactive teaching methods included in the program design. The DNP student STANDARDIZED ORIENTATION PROGRAM 11 hosted a debriefing session after each orientation day with the presenters and facilitators to obtain feedback, and make changes to the content and design as needed. Integrating change theory with collaborative evaluation provides an effective framework for translational leadership. The involvement of key stakeholders in the planning and evaluation stages of change increases the adoption of the proposed change (Manchester et al., 2013). The refreezing phase of the DNP project involved the implementation of the HCA Healthcare standardized orientation program to all eleven Mountain Division facilities. This phase continued with evaluation and feedback sessions to monitor compliance and the impact of the implementation (Manchester et al., 2013). The design team planned for quarterly and as needed updates to the orientation program content for regulatory requirements as well as changes for improvement based on feedback received from the new hires’ evaluations or key stakeholder recommendations. Summary of Literature Review A review of current literature supported implementing a standardized orientation program with interactive teaching techniques to improve employee satisfaction with the orientation experience and improve compliance with orientation regulatory standards. The evidence supported updating the teaching methodology and working closely with each hospital to facilitate the transition to a standardized orientation program for HCA Healthcare. HCA Healthcare Mountain Division chose to participate in a pilot program to implement a standardized orientation program with interactive learning designed by the HCA Healthcare Center for Clinical Advancement (CCA) education team. The orientation pilot program implemented a standardized curriculum for orientation that included the use of a variety of adult learning methodologies (HCA Healthcare CCA, 2019). The pilot program also included an orientation rotation schedule that allowed new hires from any facility in Utah to attend a STANDARDIZED ORIENTATION PROGRAM 12 standardized orientation program at another host facility each week. The availability of a full orientation program with standardized content available each week helped new hires gain access to all the information needed before starting, rather than the fragmented orientation some experienced before the implementation of this standardized orientation program pilot. Relying on evidence in the literature, guidance from Lewin’s Theory of Planned Change, feedback from the HCA Healthcare Corporate Education team, and Orientation Committee members, this DNP student coordinated implementation of the standardized orientation pilot program within the eleven hospitals of HCA Healthcare Mountain Division. Project Implementation Plan Implementing a standardized orientation program for HCA Healthcare Mountain Division increased the effectiveness and efficiency of orientation. The goals of this DNP project were to improve consistency in meeting Joint Commission regulatory requirements for orientation, improve the learning experience for the new hire, consolidate resources of personnel required to facilitate orientation, and improve the efficiency of orientation with weekly opportunities for attendance. A standardized orientation program improved patient safety through knowledge and compliance with regulatory standards as well as assisted HCA Healthcare resources to be more efficiently utilized. Setting HCA Healthcare, one of the nation’s leading providers of healthcare services, consists of fifteen divisions, with 185 hospitals and 1800 sites of care located in 21 states and the United Kingdom (UK). HCA Healthcare is comprised of approximately 270,000 employees, also referred to as colleagues, with 94,000 of these being registered nurses (RNs) (HCA Healthcare, n.d.). Orientation and on-boarding of new colleagues were done at each facility with individual STANDARDIZED ORIENTATION PROGRAM 13 processes including pre-boarding requirements, HCA Healthcare, and facility orientation programs. HCA Healthcare Mountain Division consists of eleven hospitals with approximately 9,000 colleagues located in Utah, Idaho, and Alaska. These hospitals range in size from 250 to 2000 employees. In 2018, Mountain Division experienced a turnover rate of 18% of employees and hired approximately 2,000 new colleagues to fill positions in all departments of the hospitals (HCA Mountain Division, 2019). Population The pilot program for standardized orientation impacted all new hires, the Facility General Educator, Human Resource personnel, the Clinical Informatics and facility leadership teams of the four facilities participating from the North Utah Market of HCA Mountain Division (Lakeview Hospital, Ogden Regional Medical Center, Brigham City Community Hospital, and Cache Valley Hospital). The new standardized HCA Healthcare General Orientation day included all new hires. The nursing staff has an additional day of Clinical Orientation and one day of virtual electronic health record documentation instruction before they begin precepted shifts for unit orientation. The facility general educator coordinates all speakers, scheduling classrooms, and presents many of the topics on the agenda. The human resource department completes the onboarding requirements with new hires and communicates the orientation class schedule and location based on the position and employment start date. The clinical informatics team assists new hires with computer access and resetting passwords in addition to facilitating virtual electronic health record training and validation session for nurses. The facility administration team participates in the welcome portion of General Orientation and provides an overview of STANDARDIZED ORIENTATION PROGRAM 14 HCA Healthcare with recognition of the individual facilities represented by the new colleagues in attendance. Program Implementation Orientation includes valuable information to assist the new hire to become familiar with the mission and values of an organization, and also important regulatory requirements for safe patient care (Joint Commission, 2020). Organizations are challenged to support the new hire in building a person-organization fit. Orienting staff to the mission and values of the organization in addition to the regulatory requirements are vital components of a strong person-organization fit and increase new hire satisfaction (Risman, Erickson, & Diefendorff, 2016). Introducing the HCA Healthcare Code of Conduct program in a standardized orientation program will enhance understanding of how employee behaviors must align with the mission of HCA Healthcare which states “Above all else, we are committed to the care and improvement of human life” (HCA Healthcare, n.d.). A component of this DNP pilot project was to pilot a calendar rotation plan for hosting the standardized orientation program for eventual implementation in all Utah hospitals in HCA Healthcare Mountain Division. Each Utah Mountain Division HCA Healthcare facility hosts orientation once or twice per month on a rotating calendar schedule, based on location utilizing the standardized orientation program for new hires. This proposal offered each new hire the opportunity to select an orientation program at any facility on a date meeting the individual schedule preferred. Analysis of hiring data for Alaska and Idaho facilities led to a proposal of an every other week orientation in those markets (HCA Mountain Division, 2019). This proposal increased the effectiveness and efficiency of orientation for HCA Healthcare new hires. STANDARDIZED ORIENTATION PROGRAM 15 Negative feedback from new hires indicated dissatisfaction with the requirements for both online and formal orientation completion. Additionally, budgeted hours for education staff were decreased resulting in a scarcity of resources. Taking into account these issues, HCA Healthcare approved the revision of the current orientation process to the standardized orientation program. The standardized orientation program efficiently utilized the facility general educator’s time for the delivery of standardized content versus designing and maintaining individual facility curriculum to meet regulatory standards. The program also allowed new hires to attend general and nursing orientation at any of the HCA Healthcare facilities and allowed for efficient weekly onboarding of new hires by the human resource personnel. The new hires then attended a short facility-specific orientation program (hosted once a month) at their home facility to meet leadership teams, learn about hospital-specific policies and protocols on a standardized agenda. Employees transferring between facilities after completing the standardized orientation day are required to attend the facility-specific orientation program only, as the other general orientation was previously completed and documented on the education transcript. The new program includes the facility general educator utilizing a standardized agenda to host orientation per the HCA Healthcare Mountain Division schedule. All new hires attend one day of General Orientation. The General Orientation agenda includes a breakout session for clinical versus non-clinical staff to receive applicable information related to infection prevention, patient rights, abuse and neglect, and providing safe patient care (HCA Healthcare CCA, 2019). Although the presenters are employed by an individual facility and presenting at their home facility, the information presented is standardized and generic to match the HCA Healthcare policies. STANDARDIZED ORIENTATION PROGRAM 16 The nursing staff attends an additional day of clinical orientation. The first half of the clinical orientation day applies to both nurses and Certified Nursing Assistants (CNAs) and the remainder of the day is only for nurses related to medication administration, blood transfusion competency, and safe procedural care. The nurses also have one day of electronic health record documentation orientation. The presentation includes interactive online modules followed by a virtual simulation of patient documentation assessed by an online instructor with the ability to provide real-time feedback to the new hire nurse (HCA Healthcare CCA, 2019). Implementation Barriers The HCA Healthcare Mountain Division includes 11 hospitals located across three states and resulting in challenges towards the implementation of a standardized orientation program. Each facility was using different orientation program agendas and new hire processes for meeting pre-boarding requirements, initial orientation, and facility orientation completion plans. These varied processes created difficulty for staffing in the absence of the educator or human resource staff on orientation day. Some facility teams were resistant to accept the new orientation program design and content as they felt their program was adequate and they liked to use their content. A few hospital administrators initially resisted changing their welcome address to the generic HCA Healthcare information and wanted to maintain focus on highlights of their facility. A cross-walk of the Joint Commission orientation requirements compared to the new program content and the facility’s current orientation provided clarity for the need to update to a standardized program. The teams complied with the transition to the new program once they understood the rationale and also the ability they had to individualize the once per month facility orientation day to focus on their own facility’s hires. Ethical Considerations STANDARDIZED ORIENTATION PROGRAM 17 HCA Healthcare organization has an ethical obligation to provide consistent orientation information to all new hires regarding the mission and values of the organization in addition to meeting the regulatory requirements for Joint Commission accreditation. This project complied with ethical obligations by completing an International Review Board (IRB) application. Institutional Review Board (IRB) review protects participants and prevents potential harm (Grace, 2018). IRB review was needed to determine if this project met the common rule and does not need consent as it involved evaluating feedback obtained from surveys completed by new hires regarding the standardized orientation program as well as the forty-five-day new hire employee engagement survey. Additionally, the feedback was received from the implementation team members on recommendations for change and updates of the orientation program. The results from new hire surveys were posted anonymously. The 45-day new hire survey results were sorted by division, facility, and department level as long as there is a minimum of five surveys. Implementation Coordination The DNP student’s leadership role was to coordinate the implementation plan for the HCA Healthcare standardized orientation program in the Mountain Division. The first meeting for the project was with the Vice President of Clinical Education for HCA Healthcare Mountain Division and the Corporate Manager of Curriculum/Project Lead for New Employee Orientation (NEO). This meeting provided an overview of the program, a link to review all the curriculum content and facilitate an understanding of the expectations for implementation. As part of the Mountain Division implementation team, the DNP student met weekly to present on assigned tasks for each of the four sub-groups (Pre-Hire, General Orientation, Clinical Orientation, and Facility Orientation). The Vice President of Clinical Education and student planned the pilot STANDARDIZED ORIENTATION PROGRAM 18 orientation calendar for the HCA Healthcare Mountain Division standardized orientation with a rotation of host facilities in the four North Utah Market facilities (Lakeview Hospital, Ogden Regional Medical Center, Brigham City Community Hospital, and Cache Valley Hospital). Facility leadership teams participated in a presentation of the program overview three months before go-live. This presentation included the justification and rationale for the transition to a standardized orientation program, the program implementation plans, access to the communication materials for new hires to know when and where to attend orientation based on the proposed pilot rotation calendar, and an introduction to the standardized curriculum. Collaboration among the facility general educator, human resource personnel, clinical informatics, and leadership teams of the HCA Healthcare Mountain Division North Utah Market hospitals for the initial pilot was essential to present the proposal and gain acceptance for participation in the standardized orientation program pilot. Prior to implementation, the DNP student met individually with each presenter to review the standardized orientation presentation content focusing on HCA Healthcare rather than facility-specific. As there may be new hires attending from other facilities, it was important for participants to hear information regarding the mission, values, and expectations of HCA Healthcare as an entire enterprise. The student attended orientation weekly at the different locations for the first three months to validate presenters were using the new curriculum and to host a debriefing session to acquire feedback from the facility teams on content, agenda, and implementation plan for rotation of facilities. The electronic survey results from the new hires were evaluated for feedback on the HCA Healthcare General Orientation pilot program. STANDARDIZED ORIENTATION PROGRAM 19 The HCA Healthcare Mountain Division standardized orientation implementation team met bi-weekly and as needed to discuss any updates needed based on the feedback of the debriefing sessions and orientation evaluation results. Possible changes to the program based on feedback were evaluated further before implementing at all facilities in the Mountain Division. After two months of the pilot program, implementation began in the remaining four HCA Healthcare Mountain Division facilities. The DNP student coordinated with the South Utah Market Director of Clinical Education to implement the pilot program, with the approved updates, for the South Market. One month later, the standardized orientation program was implemented in the two hospitals in the Idaho Market and one hospital in the Alaska Market of HCA Healthcare Mountain Division. Full implementation of the program was completed by end of 2020. A weekly meeting with the Market Directors of Clinical Education and Vice President of Clinical Education was held to hear feedback from the orientations hosted during the week. The Division Implementation team met monthly for the first six months and then as needed to evaluate the process, identify any barriers or concerns that needed to be addressed, and make changes to improve the new hire evaluation scores. The Market Directors were expected to communicate any immediate concerns to the DNP student and the Vice President of Clinical Education for HCA Healthcare Mountain Division for review and to propose potential updates to the corporate team. Due to COVID-19 and mandated pandemic restrictions for class size in an attempt to stop the spread of the virus, all new employee orientation was moved to an online learning format. The standardized orientation presentation content was converted into interactive online modules and the facility orientation was hosted virtually to encourage interaction between the new hires STANDARDIZED ORIENTATION PROGRAM 20 and the facility leadership team via chat and video. The online modules were completed independently and the new hires turned in a time record to their director to receive payment for the time. New hires and leaders were provided an outline of the required online modules as well as the completion times to set expectations for the time card. A completion report from the Healthstream learning management system was utilized to track compliance in completing the requirements. Evaluation and Data Analysis Methods To evaluate the impact of implementing a standardized orientation program for HCA Healthcare Mountain Division, the following outcomes were analyzed: consistency in meeting Joint Commission regulatory requirements for orientation, learning experience for the new hire, efficiency of onboarding for new hires, and consolidation of personnel resources utilized to facilitate orientation. The program’s success was determined by improvements in the following: regulatory compliance, new hire satisfaction with the orientation program, impact on the budget for reduced productive hours for the facilitation of orientation, and decreased the number of days for onboarding of the new hire following initial offer to orientation date, as well as an improved overall satisfaction rating for the onboarding experience by HCA Healthcare employees. To evaluate compliance with Joint Commission regulatory standards, the Quality Improvement teams at each facility completed an assessment of compliance and compared findings before and after implementation of the new standardized orientation program. This was also assessed with the consistency of documentation of orientation completion which was a finding on some previous accreditation site visits. A completion report on the learning STANDARDIZED ORIENTATION PROGRAM 21 management system Healthstream abstracts data for all completions of the orientation program on the student transcript demonstrating the level of documentation compliance. The learning experience of new hires was evaluated by a survey utilizing a Likert scale and open comment methods to answer questions on the content and delivery methods used in the orientation program. After the in-person orientation program, a scan code link to an evaluation was displayed and participants completed the evaluation. At the end of the online orientation curriculum a survey was completed in the learning management system. New hires, facility educators, human resource personnel, and presenters were asked to provide feedback on the content and design of the orientation program, as well as the communication process for informing the new hire of curriculum completion requirements. Hovelja, Vavpotič, and Žvanut (2016) recommended the participation of the key stakeholder groups in program/curriculum evaluation. The key stakeholders in the standardized orientation project were the new hire colleagues, the facility educators, and the hospital leadership teams. Utilizing a combination of the Likert scale and open-text comments in an evaluation provided feedback on the orientation experience from the perspective of the different key stakeholder groups (Huria, Palmer, Beckert, Lacey, & Pitama, 2017). Evaluations were reviewed by the HCA Healthcare Mountain Division CCA leadership team and corporate CCA team responsible for the content and design portion of the orientation program. To evaluate the impact of the standardized orientation program in consolidating staffing resources needed to facilitate orientation, the hospital accounting department provided a record of productive hours reported to the entity for the facilitation of orientation by the education, human resource, clinical informatics, and administration teams to quantify changes in the cost of STANDARDIZED ORIENTATION PROGRAM 22 personnel. As several of the personnel were salary employees, they were asked to submit an overview of their hourly activity during new hire weeks at the facility. The impact of the standardized orientation program on the efficiency of onboarding was evaluated by gathering data from the human resource department on how many days passed from the date of the job offer to the date the new hire attended the general orientation day. This included a review of the tracker board for the date of hire offer comparing it to the orientation date with the inclusion of the comment section for a review of delays and analysis for any common themes. The overall impact of the project was measured by the new hire employee engagement survey results completed 45 days after hire through an electronic survey, specifically the score related to orientation/onboarding satisfaction. Survey results were reported by new hires anonymously to the HCA Healthcare human resource department on a Glint survey and the results were shared on a data dashboard with the ability to sort results by division level or individual facility. HCA Healthcare changed from a 60 to 45-day survey in June 2020. Evaluation of the implementation process was completed by analyzing the feedback received from meetings with key stakeholders. Debriefing sessions were held after each of the live orientation programs for the first six weeks. When the orientation program transitioned to an online platform due to COVID-19 restrictions, a bi-weekly virtual meeting was held for stakeholders to offer feedback and discuss any concerns or ideas for improved communication to the new hire on how to complete the online orientation program. These meetings assisted in developing a standardized communication template with specific names of the online course and building all the required courses into a curriculum bundle within the learning management STANDARDIZED ORIENTATION PROGRAM 23 system to assist new hires to determine which online modules were required for compliance with completing the online orientation program. The key stakeholders gave positive feedback on their involvement and effective communication for the implementation of both the live and online orientation programs. COVID-19 restrictions required a quick change from the live orientation program. This required collaboration with the HCA Healthcare CCA curriculum development team to build interactive online modules for the standardized orientation presentations in a short amount of time. With the short timeline to transition to an online platform, there was limited availability to communicate independently with each facility for change in orientation plans. A virtual meeting was held to demonstrate how the student would access the online modules and a sample email communication template was sent to the human resource teams to inform the new hires of the orientation program completion instructions. This virtual meeting was followed by answering questions in the chat, as well as instant messaging and email options. The DNP student met with each facility human resource team member within the first week of moving to the online orientation program and continued meeting at least monthly to gain feedback on issues or concerns. The Division Operations Supervisor, who is the administrator of the online learning management system, was instrumental in managing the automatic assignment of the correct orientation curriculum based on job code in the system and validating accounts for new hires prior to the Monday morning assignment of the orientation program. The open communication and availability to answer questions or help clarify any misunderstanding of instructions enhanced the facility teams having a positive experience with the standardized orientation program to include the online option utilized due to the pandemic. Results STANDARDIZED ORIENTATION PROGRAM 24 Implementing a standardized orientation program for HCA Healthcare Mountain Division improved the consistency in meeting Joint Commission regulatory requirements for orientation, enhanced the efficiency of onboarding new hires, and consolidated the resources required to facilitate orientation for the HCA Healthcare Mountain Division. The orientation program completion documented on the student transcripts of the online learning management system of Healthstream for HCA Healthcare indicated 94.5% compliance versus 73% compliance prior to the implementation of the standardized program. Feedback from the facility Quality Department personnel validated improvement of staff’s recall and application of regulatory requirements for safe patient care following completion of the orientation program. Onboarding Efficiency Before implementing the standardized orientation program new hires frequently had to wait for the monthly orientation program at the facility while others completed a quick start online before starting unit orientation resulting in the feedback of a fragmented orientation. Having the ability to start new hires every Monday with the standardized orientation program created additional opportunities for new hire onboarding for the HCA Healthcare Mountain Division facilities. Human Resource data revealed an average of 27 days to onboard new hires before the standardized orientation program compared to 18 days following implementation of the program. There was an increase in delays for background check processing related to COVID-19 staffing for some of the agencies which had the greatest impact on the delays for onboarding new staff. Resource and Productivity Implementing a standardized orientation program had a positive impact on decreasing the hours supplied by the human resource, education, clinical informatics, and administration teams STANDARDIZED ORIENTATION PROGRAM 25 for the facility. The North Utah Market of HCA Healthcare Mountain Division four hospitals invested approximately 189 hours per month to facilitate orientation offered one to four times per month. Analysis by the accounting departments of the descriptive productivity records of the same departments after implementation of the standardized orientation program documented approximately 50 hours per month were spent facilitating orientation. The reduction in hours was even more significant since the majority of the orientation program was online with COVID-19 restrictions. Facilitation time was primarily focused on communicating instructions and troubleshooting technical difficulties with new hires. An additional benefit of the standardized orientation program was no longer requiring transfers within HCA Healthcare Mountain Division to repeat a full orientation at another facility. Instead, transfers were only required to attend the facility orientation. Key stakeholders also helped identify the decrease in new hire nurse productive hours from 24 hours to about 12 hours. In a year of critical budget restrictions, these reduced hours spent in orientation increased employee satisfaction while decreasing the costs associated with onboarding. Overall Program Evaluation Forty new hires completed an evaluation for the in-person standardized orientation program in the North Utah Market before moving to the online platform due to COVID-19 restrictions in April 2020. A scan code was projected on the screen at the end of the orientation program for attendees to complete an evaluation in Survey Monkey for the in-person presentation. The evaluation results for the limited in-person orientation program had an 82% orientation satisfaction level and provided positive feedback comments on the use of mixed adult learning methodologies to engage the audience. With limited facilities reporting data, an average of 80% orientation satisfaction level was reported for the old orientation programs. STANDARDIZED ORIENTATION PROGRAM 26 After the change to the online orientation program, due to COVID-19 restrictions, an online survey was included. This evaluation was completed anonymously by all new hires in the online learning management system to provide valuable feedback on the orientation program. One hundred and ten new hires from the North Utah Market of HCA Healthcare Mountain Division (Lakeview Hospital, Ogden Regional Medical Center, Brigham City Community Hospital, and Cache Valley Hospital) completed the new hire evaluation between May 2020 and January 2021. This North Utah Market new hire population answered with a 79.5% positive rating for the online orientation program. A total of 571 new hires from all of the HCA Healthcare Mountain Division completed the evaluation for the online orientation program during the same time period with an 84.4% positive survey rating. A majority of the feedback comments were positive related to the flexibility of completing the online program at home on an independent schedule. A question on the survey did evaluate the new hire’s preferred learning method with nearly 50% split preference of online and in-person learning and only a few staff preferring a virtual classroom or handwritten packets for an orientation program. Receiving approximately an 80% positive rating from the online orientation program was strong, especially considering that nearly 50% of the new hires stated they preferred in-person learning. HCA Healthcare utilized an online survey link to gain feedback from new colleagues on their onboarding experience. From March thru June of 2020, the 60-day evaluation revealed a positive onboarding evaluation score of 88%. In June 2020, the survey was changed to be administered at 45 days and this revealed a 94% positive rating for overall onboarding experience for employees hired between June and December 2020. The same survey completed at 100 days post-hire by the same group of new hires showed a 71% positive onboarding STANDARDIZED ORIENTATION PROGRAM 27 evaluation with many positive comments on the initial orientation program, but negative comments on the chaos and lack of organization around the unit orientation and preceptor assignments which were greatly impacted by the surge in number and acuity of patients from the COVID-19 pandemic. Overall feedback on the process of the project was positive. Key stakeholders recognized the benefit of standardizing the content, especially when the HCA Healthcare CCA team was able to convert all 185 facilities to an online orientation program within approximately ten days due to the restrictions of in-person gatherings resulting from the COVID-19 pandemic. The increased flexibility with the online orientation allowed facilities to hire staff with a start date each Monday for the online orientation program. The new hire staff was not permitted to begin unit orientation until verification of online orientation curriculum completion. Discussion, Recommendations, and Conclusion Discussion Implementing a standardized orientation program had a positive impact on the consistency of information provided to meet regulatory requirements, consolidation of personnel and resources, and the hours spent facilitating orientation within the market. This project impacts healthcare and nursing practice by decreasing the hours charged by new hire personnel for completing the program and identifying alternate methods for implementing an effective orientation program while maintaining an overall positive experience of learning. The time spent with key stakeholders in the planning phase of the program to standardize the content, designate presenters for the information, finalize the hosting facility orientation schedule, and approve the evaluation survey was beneficial in achieving a positive reception to the new program since each facility was represented in the project team. This became even more STANDARDIZED ORIENTATION PROGRAM 28 important when the COVID-19 restrictions necessitated a short transition time for all facilities to an online orientation program. The collaboration of the key stakeholders in reviewing the online content for accuracy and ease of navigation was instrumental in the success of the quick transition as well as providing continued support for the onboarding of the new hires during the pandemic. The decreased hours to complete onboarding while maintaining positive feedback from new hires on the online orientation program presents opportunities for continuing the online curriculum and supplementing with a short in-person session to answer questions and emphasize the most important topics as requested in the evaluations. The online orientation feedback provided a framework for other classes within healthcare to move towards an online curriculum or virtual classroom option based on positive feedback from the staff regarding flexibility for attending courses in between scheduled shifts. Key lessons learned in the implementation of a standardized orientation program were the importance of collaboration, communication, and flexibility. Following Lewin’s Change Theory and recognizing that each facility previously owned its independent orientation program that functioned within its mandate. Selecting representatives from each facility to collaborate on the HCA Healthcare Mountain Division Orientation Committee was instrumental for the entities to provide input on the implementation plan. Validation of the rationale for standardizing the content by individual facilities provided a positive impact on the remainder of the facility team for the adoption of the program. Maintaining open communication and having professional discussions with key stakeholders that initially were hesitant to accept the standardized content was essential to bring about eventual agreement on the benefit of the program plans. Flexibility to change the program implementation plans a short time after starting the rotation schedule was STANDARDIZED ORIENTATION PROGRAM 29 vital to meet the COVID-19 restrictions and still be able to onboard new colleagues for essential healthcare worker positions. The transition to an online orientation program also encouraged the key stakeholders to explore more alternative teaching methods which became important skills to manage other classes during the pandemic. Recommendations The foundation of the HCA Healthcare orientation program is based on the Joint Commission regulatory requirements which are adhered to by other healthcare agencies for accreditation. This orientation program has been positively and effectively implemented in all HCA Healthcare facilities. Other healthcare systems would be encouraged to consider the standardized template for implementing the program. After reviewing the evaluation feedback and with COVID-19 restrictions changing, the HCA Healthcare Mountain Division facilities are trialing the integration of an extended in-person skills orientation session for nursing new hires to complement the online orientation program. Effective February 1, 2021, the Utah hospitals of HCA Healthcare Mountain Division began utilizing the host facility orientation rotation calendar to have nursing staff attend a two-hour skills session after completing the online orientation modules. This time is focused on hands-on skills validation and review of policies specific to restraints, hospital-acquired infection prevention, and a review of resources available for staff in the facilities. These were areas identified on the evaluation survey and also by the quality teams as opportunities to improve compliance with the appropriate use of equipment, skills, and policies pertinent to patient safety. The findings of this DNP project will be shared with the HCA Healthcare Mountain Division facilities as well as the HCA Healthcare CCA team report through sharing of a brief overview of the positive feedback from staff and employees as well as the benefits to the STANDARDIZED ORIENTATION PROGRAM 30 organization. Consideration will be given to present this project at the American Nurse Professional Development convention for possible dissemination across other healthcare systems. Conclusion Implementing a standardized program improved the efficiency and effectiveness of orientation for HCA Healthcare. New hires reported increased satisfaction with orientation and also demonstrated improved compliance with regulatory standards. HCA Healthcare Mountain Division noted a decrease in personnel hours to facilitate orientation following the pilot program. Feedback from the pilot program was shared with the HCA Healthcare CCA team for revision and updates before proceeding to implement the standardized orientation program to all 187 facilities in the HCA Healthcare enterprise. Having the content improvement suggestions already in motion created an advantage when COVID-19 restrictions limited in-person gatherings and a rapid transition to the online orientation program was mandated. An improved orientation program positively impacts the patient and employee experience with HCA Healthcare by increasing understanding and adherence to the mission and values of the system with a commitment to patient safety. Adapting Lewin’s Change Theory and facilitating effective communication in collaboration efforts of key stakeholders can have a positive impact on adopting the new program, especially when coordinated by a DNP-prepared nurse leader. STANDARDIZED ORIENTATION PROGRAM 31 References Acevedo, J. M., & Yancey, G. B. (2011). Assessing new employee orientation programs. Journal of Workplace Learning, 23(5), 349-354. doi:10.1108/13665621111141939 Andronico, J., Getting, C., Hughes, C. H., & Ciccolini, K. (2019). Developing and standardizing an orientation for outpatient charge nurses. The Journal of Continuing Education in Nursing, 50(11), 517-521. doi:10.3928/00220124-20191015-08 Brook, J., Aitken, L., Webb, R., MacLaren, J., & Salmon, D. (2019). 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International Journal of Nursing Studies, 71(2017), 17-27. https://doi-org.hal.weber.edu/10.1016/j.ijnurstu.2017.02.021 Risman, K. L., Erickson, R. J., & Diefendorff, J. M. (2016). The impact of person-organization fit on nurse job satisfaction and patient care quality. Applied Nursing Research, 31, 121- 125. doi:10.1016/j.apnr.2016.01.007 Shirey, M. R. (2013). Lewin’s theory of planned change as a strategic resource. Journal of Nursing Administration, 43(2), 69-72. Walton, A., Lake, D., Mullinix, C., Allen, D., & Mooney, K. (2015). Enabling nurses to lead change: The orientation experiences of nurses to boards. Nursing Outlook, 63(2), 110- 116. doi:10.1016/j.outlook.2014.12.015 STANDARDIZED ORIENTATION PROGRAM 34 IRB Letter STANDARDIZED ORIENTATION PROGRAM 35 Figure 1. Table representing overall outcomes of the project. Fewer hours for facilitating and attending orientation. Improved documentation compliance and onboarding efficiency with a decrease in the number of days from the offer letter to orientation date attendance. Overall evaluation of the program was nearly equal compared to programs before; however, comments on the evaluation showed positive remarks on the flexibility of completing, the clear communication on how to complete, and the ease of navigating the online program. 0 20 40 60 80 100 120 140 160 180 200 Overall Evaluation of Program Orientation Documentation Compliance Onboarding days Facilitation Hours Nursing Orientation Hours Program Outcomes Before After STANDARDIZED ORIENTATION PROGRAM 36 Figure 2. Data from evaluation questions for new hires to state their preferred learning style. Nearly equal amounts preferred online and in-person learning. This is important when reviewing the overall evaluation since the program still achieved an 80% favorable rating despite only being able to offer the online learning option with COVID-19 restrictions. 0 10 20 30 40 50 60 Online Virtual In-Person Written Packets Preferred Learning Style ORMC BCCH CVH LVH STANDARDIZED ORIENTATION PROGRAM 37 Theoretical Model STANDARDIZED ORIENTATION PROGRAM 38 Program Evaluation Survey