Onboarding360: A Layered Learning Pathway

Learning outcome: After completing this learning activity, the participant will be able to design and implement a layered learning onboarding pathway that integrates education, clinical skills training, EHR simulation, and competency standards.
Purpose: The layered learning program, called Onboarding360, aims to address the lack of system standardization and the overwhelming amount of information ambulatory care new hires currently receive in onboarding. The goal of Onboarding360 is to standardize practice, improve patient quality outcomes, reduce adverse events, and increase new-hire satisfaction and retention. The onboarding program was developed for new-hire clinical staff (RNs, LVNs, and CMAs in primary care and specialty clinics), combining education, clinical skills, EHR simulation, and competency standards in a layered learning approach. Layered learning breaks down complex information into more manageable pieces, building upon the knowledge learned in the previous layer, resulting in a comprehensive learning experience.
Description: The Onboarding360 program was developed by NPD specialist RNs at an academic medical center with 120+ ambulatory care departments. An inventory of required onboarding education, competencies, clinic workflows, and practice needs was analyzed and placed in a layered learning pathway. The new hire progresses through the pathway by attending a series of onboarding classes, starting their first week and at 30, 60, and 90 days. To integrate technical and clinical skills, the classes include didactic learning, hands-on skills, EHR simulation, and mock clinic events. This provides a realistic and safe environment to acquire knowledge and skills to fulfill clinical duties. Implementation included approval from executive leadership and working with facilities and IS/IT teams to set up classrooms and skills labs. The program was presented to nurse leaders and operations managers during lunch-and-learn information sessions. Preceptors participated in refresher training focused on the layered learning pathway to ensure alignment between Onboarding360 classes and in-clinic training.
Evaluation: The program started on August 26, 2023, with 15 successful cohorts to date. Patient quality outcomes improved from 4.13 (July 2023) to 4.54 (February 2024), exceeding the organization’s goal of 4.42, on a 5-point scale. Improvement in patient quality outcomes confirms that new-hire staff are addressing patient care gaps and wellness needs. Adverse events (medication errors, specimen labeling, and falls) were reduced by 21% over the 9-month post-implementation period. Overall satisfaction with Onboarding360 was reported through new-hire surveys. The initial class session surveys averaged 4.64 out of a 5-point Likert scale in overall satisfaction, with a steady increase over each class session, ending at 4.9 for the 90-day classes. The retention rate for staff who completed Onboarding360 as of June 2024 is 83%, compared to the region's overall retention rate of 79%.