New Hire Onboarding

Question:

Is there any risk with having staff do mandatory new hire onboarding in the first month of hire instead of before assuming duties? They are proposing it be done in the first 30 days instead of before assuming care, treatment, or services which we used to do on day 1 of orientation.

Answer:

The CMS guidelines contain a statement regarding nursing personnel oriented prior to providing care.  TJC standard HR.01.04.01 EP1 references the CMS 482.23 as well. CMS has other topics such as that listed in 482.13 stating before they perform those activities, they receive the necessary training and competency validation, etc. 

We would need more clarification on what aspects of new hire onboarding orientation occur during the 30 days after hire and after staff start providing care. Your hospital can define the orientation timeframe, 30 days is not unreasonable.  The tricky part is that some training needs to be done prior to providing care — it’s the providing care part that could be tricky depending on how they would monitor staff so they don’t do something before they get the proper training/orientation.  

We suggest that you look at the topics for applicability to the key safety content as described in HR.01.04.01 EP1 since that is very clear about orientation topics that need to be addressed prior to providing care. EP3 seems less prescriptive with “other” topics (i.e., no mention of orienting before care being provided) 

This might be a good one for you to get an email approval from TJC SIG group. Consider drafting some specifics on what you include in your new hire onboarding orientation topics. TJC includes all levels of clinical personnel in their definition of staff. I wasn’t able to find TJC glossary definition of “orientation” to see if it offered us any further information. 

§482.23(b)(6) – All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). 

Interpretive Guidelines §482.23(b)(6)

The hospital must ensure that there are adequate numbers of clinical nursing personnel to meet its patients nursing care needs. In order to meet their patient’s needs the hospital may supplement their hospital employed licensed nurses with volunteer and or contract licensed nurses.

The hospital and the director of the nursing service are responsible for the clinical activities of all nursing personnel regardless of whether they are hospital employees, contracted staff, or volunteers.

All licensed nurses who are working at the hospital must adhere to the policies and procedures of the hospital. The hospital and the director of the nursing service are responsible for ensuring that licensed nursing personnel know the hospital’s policies and procedures in order to adhere to those policies and procedures.

The hospital and the director of the nursing service ensure that nursing care staff person is adequately supervised and that their clinical activities are evaluated. This supervision and evaluation of the clinical activities of each non-employee nursing staff person must be conducted by an appropriately qualified hospital-employed RN.

Survey Procedures §482.23(b)(6)

Review the method for orienting all licensed nurses to hospital policies and procedures. The new hire onboarding orientation should include at least the following:

• The hospital and the unit;
• Emergency procedures;
• Nursing services policies and procedures; and 
• Safety policies and procedures.

Determine if all nursing personnel are appropriately oriented prior to providing care. 

Training Intervals §482.13(f)(1)

Staff must be trained and able to demonstrate competency in the application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restraint or seclusion –

(i)  Before performing any of the actions specified in this paragraph;

(ii)  As part of orientation; and

(iii)  Subsequently on a periodic basis consistent with hospital policy.

Interpretive Guidelines §482.13(f)(1)(i) – (iii)

All staff designated by the hospital as having direct patient care responsibilities, including contract or agency personnel, must demonstrate the competencies specified in standard (f) prior to participating in the application of restraints, implementation of seclusion, monitoring, assessment, or care of a patient in restraint or seclusion. These competencies must be demonstrated initially as part of new hire orientation and subsequently on a periodic basis consistent with hospital policy. Hospitals have the flexibility to identify a time frame for ongoing training based on the level of staff competency, and the needs of the patient population(s) served.