ONBOARDING AT SANFORD HEALTH: IT’S ALL ABOUT RELATIONSHIPS

Summary of the February 15, 2007 webinar presented by Deborah Letcher

Sanford Health: Imrpoving the Human Condition

Sanford Health is an organization that has an intentional desire to create a comprehensive and integrated healthcare system. With an overall vision to improve the human condition, Sanford Health’s mission has been dedicated to the work of healing. Their network represents 150 healthcare facilities in the region, over 350 physicians, and 10,000 employees. Based out of Sioux Falls – the southeast corner of South Dakota – the Sanford USD Medical Center is the flagship facility consisting of 534 beds. Sanford Health is magnet accredited and also services a tertiary hospital.

Key Points Covered in this Article

• The core curriculum provided in the early on-boarding process
• The interaction between clinical nurse educators and first year nurses
• The affect of those relationships on retention
• What Sanford Health is doing to address retention of other staff

Why Pay Attention to On-Boarding?

• It is a critical process for all businesses, and nursing is not the only profession that will be affected by the on-boarding issue.
• The media and other avenues show the aging workforce, and the Population Reference Bureau website shows the nation’s shift in age trends. This shift in age directly impacts staff resources and brings a new challenge to the workplace at Sanford Health.
• Traditionally, the healthcare system has had 12 hour rotating shifts, but that may not make sense anymore based on the changing composition of their workforce.
• A lot of work has been done on the notion of compassion fatigue – especially in the oncology and HIV/AIDS research fields - and the same issue is beginning to surface in surgical areas as well.
• A new notion of compression complexity has been noted due to the fact that workloads are continuously increasing in intensity or acuity when caring for someone who is ill and the length of time available to provide care and services is simultaneously decreasing.

The new workforce generations hold different expectations, and like personal relationships the concept is viewed and valued very differently between the new and old generations. Newer generations value quality of work life very highly, which is why Sanford Health is focused on discovering meaningful experiences for new hires.

Primary Objective

The primary objective at Sanford Health has always been to enhance the quality, safety, retention, and internal mobility of the nursing workforce system that is organization-wide. At Sanford, it is important to recognize nursing as the predominant workforce representing 4,200 nurses out of 10,000 total employees. Because nurses make up the predominant workforce, the retention efforts created for nurses are also influencing systems in other areas of the organization.

Essentials for the On-Boarding Process

Relationships are identified as one of the four Golden Threads by Sanford, and both written and verbal communication is considered to be a very important component. A relationship is about being intentional and not assuming that it will always be there, and an understanding that the intentional connection will continuously make a difference in how the relationship is developed over time. A welcoming attitude is important when anticipating the new hires needs and being prepared so that new hires know that there is a plan for them. Assumptions cannot be made and even if someone experienced comes onboard, culture and environment are still areas that they must adjust to.

Initial Goals

The initial goals were to redesign the process of acculturation; in other words, entering a complex healthcare organization, which is not an easy process. Retaining nurses for continued employment has been an important goal for Sanford Health and it continues to demand their attention. In order to provide a welcoming context, Sanford believes that it is important to highlight the values of respecting, honoring and valuing new individuals as they join Sanford Health. With this in mind, three key areas were highlighted as goals for the new program to address:

• New hires should feel welcome, and their individual differences and needs must be embraced and met along the path to learning that has been created.
• To improve the quality of new hire transition to Sanford, the healthcare system should provide consistent experiences that will represent key issues in quality ways.
• The program supports the journey of the role and the person’s professional development. Along these lines, Sanford Health’s efforts embrace the strategic value of lifelong learning on an organizational level.

Who Should Own It?

More than one person should own the responsibility of on-boarding. The three key owners for the on-boarding process include:

• The Center for Learning and Innovation at Sanford Health holds the primary responsibility.
• Learning and Development (L&D) is a key partner in the process.
• Human Resources (HR) is another important partner in the process and the HR department at Sanford Health has been essential in creating a supporting process for new hires.

These departments have worked together to set new hire on-boarding dates assuring that key information is shared with the new employee, and meaningful follow-up is carried out. It is also the responsibility of all employees to provide a welcoming and nurturing environment for the new hires.

How Do Clinical Nurse Educators Interact with New Hires?

A two-week curriculum has been created with the help of individuals within the organization. These individuals include:

• The staff
• Department-coordinated educators
• Preceptors
• Mentors
• Department directors
• Directors and administrative personnel

New individuals who come into the organization spend two weeks, or a total of 80 hours, learning and growing together in their preparation for entering the system. Professional development pathways have been developed to serve as a guide or a roadmap for the new nurses. Developmental phases are included in the roadmap and are built upon each other, intended to provide growing abilities to critically synthesize key elements necessary to provide quality and safe care at Sanford Health. The Clinic of Educators provides a periodic follow-up with new hires and mentors. The staff then regularly connects with new hires according to the following:

• Initially every 2 weeks
• Monthly
• 3-month intervals
• Overall, there is a yearlong commitment

Figure 1 provides a visual representation of how the departments at Sanford Health interact.

Figure 1: Sanford Health On-boarding Model

Guiding Principles

Guiding principles committed to safe quality care, communication, teamwork, and leadership development allowed Sanford Health to continue growing and embrace concepts along the way that held future opportunities to further engage new hires. Legal and ethical practices are also used to guide the work, technology proficiencies, strategic improvements, innovation, and career self-development that encourage lifelong employee learning.

Customer Service Day

A customer service day has been embedded in the traditional healthcare, clinical, and on-boarding learning activities. The unlicensed assistant personnel group was the starting point, and represented roles such as the nurse aide, monitor technician, or patient care technician. During these sessions professionals and non-professionals are engaged in group dialogue, anticipating what and how Sanford Health might be like during high-stress incidents where quick decisions need to be made. Participants learn together how important everybody’s work is, as well as how to interact with others and the core concepts of relationship building.

Why Invest in Relationships?

If you look at published works, there is a lot of material focusing on the value of encouraging meaningful relationships. There are three important themes of this type of relationship:

• The notion of communion, or being with others
• The notion of love, or reverence and respect for others
• Truth, or listening to the voice of individuals, hearing their story and hearing what’s important to them

The healthcare business is really a service of human products and processes, so relationships are embedded in all of the work. If people invest in relationships, it promotes the creation of a sense of community and belonging.

Is there an Impact of Relationships on Retention?

Nationally there has been an increase in RN turnover rates, and Sanford Health has discovered there are critical decision points made by new hires at 6 months and 9 months post-hiring. Whatever the organization is doing seems to be working, since their turnover rates after 6 months are less than half of the national average.

Turnover Rates Six Months Nationally 20% Sanford Health 9% Table 1 Turnover rates

Sanford Health is really intentional about connecting with new hires at 6 months. With a follow-up visit from the clinical nurses educators, RN turnover rates have dropped from 15% down to 12%, and now 9%.

Table 1 highlights Sanford Health’s turnover versus the national average. Looking at those national averages, it is important to note that the average cost to replace one nurse is 1.3 times the nurse’s annual salary. Therefore 1% turnover cost savings per 1,000 nurses impacts the bottom line dramatically, and makes a difference from a return on investments (ROI) point of view.

Graduate Nurse Re-Entry (GNR) Program

The Graduate Nurse Re-Entry program (GNR) is offered to participants who have failed their National Council Licensure Examination (NCLEX). Sanford Health partners with a local college, allowing individuals to continue to act as an employee, and the organization will work with them and help them to be successful. A 190-hour practicum coupled with a 40-hour didactic course helps individuals work in growth areas where they may need work. Test taking skills, self-esteem and self-confidence, and critical synthesis are some areas that are targeted with individuals who did not pass the NCLEX.

Results are evident, since national pass rates on repeat exams are below 50%, but the pass rate for Sanford Health in 2006 was 100%. The ROI is tricky to estimate, but up to $1 Million is what the organization is realizing in net gain. The GNR program not only brings the value of retention, but it has also become a great recruitment tool. Graduating nursing students view the program as a safety net, and there has subsequently been a great deal of “word of mouth” advertising throughout the region.

Strategic Objectives

The strategic objectives link to the information provided thus far, as well as what is envisioned for the near future. Integration of the CNE model system-wide is in the best interest of Sanford Health, because the ROI represents a multiple of salaries and will lead to the success of the organization in terms of workforce development recruiting and retention. Reduction and/or maintenance of RN turnover rates is important, and an intentional focus on unlicensed assistant personnel development and turnover rates will aide in the success of retention and recruitment efforts down the road. Table 2 lists the ROI results achieved through the new on-boarding process.

Measurement	Previous Performance	Current Performance	ROI
Labor & Delivery turnover rate	100%	13.6%	$650,000 - $845,000* * (Average cost to replace one nurse is 1.3 X the nurse’s annual salary ($50 – 65K) ROI – 1% turnover cost savings/1000 nurses is estimated)
Pass rates on repeat exams	Below 50%	100%	$178,000 - $1 Million

Table 2:ROI results for Sanford Health On-boarding Process

In addition, GNR has provided added value not only as a retention program but also as a recruitment tool. Graduating nursing students view the program as a safety net and we have gained incredible “word of mouth” advertising throughout the region.

Future Opportunities at Sanford

As far as the future is concerned, the hope is to create another dedicated team that would support a wider range of similar roles within Sanford Health. As a result there would be an on-boarding relationship that is nurtured by individuals who would follow all new hires, whether they’re employed to work in dietary services, admissions, the business office, or any other department. The outcome of this strategy would be the creation of higher retention rates across the organization by creating a sense of belonging and community.

 

Corporate University Xchange Members may view an archived version of the complete webinar presentation summarized in this article, and also download a copy of the PowerPoint presentation from the research Collaboratory in the Members section of the website.