Nursing professional development (NPD) practitioners’ work to design ambulatory care nursing orientation is challenging due to unique skill sets, limited exposure to ambulatory care nursing in pre-licensure programs, specialty area idiosyncrasies, and evolving practice (Wojnar & Whelan, 2017). In a Midwest health care system, the NPD team aimed to redesign ambulatory care orientation by employing the tiered skills acquisition model (TSAM®) to address opportunities, resolve reliance on checklists, and improve standardization and stakeholder accountability in the process. TSAM® was originally designed for inpatient new graduate RN orientation, and no literature existed to inform application in these new settings. This visionary team planned their new ambulatory care orientation using three main TSAM® concepts, including a tiered orientation record, resource time, and preceptor/preceptee in a continuous partnership (Joswiak, 2018). Understanding ambulatory care nursing practice was essential to the redesign and adaption of TSAM concepts in a new setting. The team used job descriptions, professional practice standards, and nursing workflows (Brixey & Newman, 2018) along with TSAM® concepts to design a core orientation record, resource time activities, and continuous partnership strategies that supported telehealth and ambulatory care workflows. The orientation record was organized in a tiered structure with short self-study resource time activities that allowed learners to engage in reflection and critical thinking. The TSAM® re-design produced one core orientation record, standardized resource time activities, and realistic continuous partnerships across 25 primary and specialty care clinics and has been successfully sustained post-implementation. 1) Brixey, L. & Newman, C. A. (Eds.). (2018). Ambulatory care nursing orientation and competency assessment guide (3rd ed.). Pitman, NJ: American Academy of Ambulatory Care Nursing. 2) Joswiak, M. E., (2018) Transforming orientation through a tiered skills acquisition model. The Journal for Nurses in Professional Development, 34 (3), 118-122. 3) Wojnar, D. M., & Whelan, E. M. (2017). Preparing nursing students for enhanced roles in primary care: The current state of pre-licensure and RN-BSN education. Nursing Outlook, 65(2), 222-232.