In an earlier post, I discussed the idea that the nursing new-hire orientation activity can be viewed as a process. A process has been defined as a set of activities and tasks that, once completed, will accomplish an organizational goal. The orientation of new hire nurses surely fits this definition.
Processes have one or more inputs and produce a well-defined output or outcome. To measure the performance of a process, organizations usually collect data on:
1) cycle time (length of the orientation process)
2) efficiency (cost of the resources used per new-hire going through the process)
3) effectiveness (outcome or result of the process)
Some would add adaptability (variability of the other measures under different loads such having one new hire in orientation on a unit versus having three new hires in orientation).
Ideally, any process improvement actions would reduce the cycle time, lower cost, increase the effectiveness and improve the adaptability – all at the same time.
Each of these basic performance measures presents challenges today as no existing hospital information system will provide this information.
To measure cycle time, we must have agreement on when the process starts and when it is complete. For our purposes, does the time start on the first day of employment (encompassing general hospital orientation, general nursing orientation, and unit-based orientation) or the day/time of the first shift on the assigned unit for the new hire to begin their unit-based orientation with a preceptor(s). We have similar issues for knowing when the new hire nursing orientation is complete. This information is important because it starts and stops the consumption of resources discussed next.
Efficiency is about the resources (people, materials, facility, capital, etc.) used per completed output from a process. The total resources can be normalized by converting all the resources used to a dollar amount. However, this information is not readily available generally.
Consider just the value of the people resources. For example, it is difficult to separate the resources needed to provide patient care (via the preceptor/preceptee team during unit-based part of the new hire orientation) from the resources actually used for the orientation process (orienting/training the new nurse). Few systems can pull this out of the overall patient care costs in an ongoing way.
In most hospitals, the best approximation available is the cost of the new hire (preceptee’s) time for the shifts worked during orientation) and possibly some part of the cost of the preceptor’s time for the shifts worked during orientation. Likewise, the unit educator time used for a particular new hire or the allocated cost of the orientation program coordinator or nursing unit manager’s time is not readily available and can only be approximated.
Effectiveness of the process is also somewhat difficult to know with today’s hospital data systems. Measuring effectiveness requires knowing the outcome of applying resources during the process to change the value of the input (in this case the new hire nurse’s knowledge, skills and attitudes) compared to the value of the output (the knowledge, skills and attitudes of a new hire nurse who completes the nursing orientation). Also, an effective process should consistently create the desired value. Thus, the variance of the outcome should be measured as well.
Measuring pre and post-orientation levels of the desired knowledge, skills and attitudes of a newly hired nurse is difficult for hospitals. Doing job performance level measurement is even more difficult. Also, there are other results of the new-hire orientation process such as the level of confidence of the new hire after orientation and their attitudes toward staying with the hospital as a result of the orientation experience that could be considered.
Considering the above, I believe the answer to our original question of whether hospitals can measure the performance of nursing new-hire orientation is – not yet. However, given the cost of this process and importance of consistent, high-level outcomes to patient safety, it is worth the effort to capture and use as much performance data as possible.
Also, hospitals can certainly do periodic projects to test and evaluate potential improvements to the nursing new-hire orientation process. In designing these special projects, all the dimensions of process performance certainly should be considered.