A health care transformation is underway through which system consolidation and strategic partnerships allow complex care to be delivered in community settings. Surgical programs are a critical part of this “branding,” resulting in an expectation for surgeons to expand into practice environments away from their home institutions. Transitioning to a new practice setting poses many unique challenges. Even experienced surgeons must negotiate differences in responsibilities, local resources, and institutional culture. Unfortunately, onboarding processes are commonly limited to logistical considerations while crucial aspects of work expectations, cultural idiosyncrasies, and interpersonal connections are omitted.1 Failure to adequately prepare surgeons places patients at risk and may further contribute to the surgeon burnout epidemic.2,3

The need for robust onboarding is well-recognized in the corporate world. The Society for Human Resource Management distinguishes between orientation, the process of completing paperwork and other routine tasks, and onboarding, a more holistic longitudinal process of integrating a new hire into the institution and providing necessary tools for optimal role performance.4 In their model onboarding consists of four interlinked components: compliance, or legal-related and regulatory-related tasks; clarification, or understanding the job role and available resources; culture, or formal and informal organizational norms; and connection, or the interpersonal relationships needed for role performance. Other high-risk fields, including aviation and nuclear power, employ effective, reliable processes for onboarding.5,6 These processes are designed to reduce known safety hazards posed by working in unfamiliar surroundings, lack of familiarity with equipment and task requirements, and hesitance to call for help. In medicine, however, onboarding practices are routinely limited to compliance-related activities rather than providing knowledge, resources, and relationships for the provision of safe, effective care.

In recognition of this practice gap, Ariadne Labs developed a framework for onboarding physicians into new practice settings, along with implementation guidance to assist institutions adopting this framework.7 Newton-Wellesley Hospital (NWH), a 273-bed community center affiliated with Mass General Brigham, partnered with Ariadne Labs to develop and pilot a customized surgeon onboarding program. Here we describe our approach and the results of this partnership in hopes that other institutions may develop similarly robust onboarding systems.

IMPLEMENTATION OF THE SURGEON ONBOARDING FRAMEWORK

Before this partnership, there was no standardized process for onboarding in the Department of Surgery; required activities comprised only drug testing, malpractice enrollment, and credentialing. The implementation team, which included the Chair of Surgery as executive sponsor, a prominent surgeon as team lead, and opinion leaders from surgery, anesthesia, nursing, and administration, began by soliciting feedback from frontline staff. They identified three major themes: (1) the need for a well-defined, standardized, and timely onboarding process, (2) the need for a responsible party to oversee the process, and (3) the need for specialty-specific guidance. The Ariadne Labs framework was modified to reflect local needs identified by recently onboarded surgeons and other staff members, including differences in resource availability (eg, interventional radiology and gastroenterology support) and surgeon responsibilities (eg, primary management of patients in the open intensive care unit).

The final onboarding process developed and refined through iterative field testing is shown in Figure 1. The program was designed to last 1 month, with a core 4-hour session consisting of scheduled meetings to develop key relationships and provide critical information. Each meeting was guided by a prespecified agenda and set of objectives in the form of a checklist (Supplemental File 1, Supplemental Digital Content 1, https://links.lww.com/SLA/E760). These were distributed to surgeons and session leaders in advance to provide a common set of goals and discussion topics, and participants were encouraged to supplement the checklist with their own specific questions. Although orientation activities such as badging and parking passes were outside the purview of the Department of Surgery, coordination with credentialling and human resources allowed them to be delivered in the same session, streamlining the process for new surgeons. Afterward, surgeons and their assigned “onboarding buddies” were encouraged to communicate regularly and were instructed to check in formally after 1 month. Adherence was mandated by the Chair of Surgery, and case scheduling could commence only after the completion of the initial onboarding session. Progress through the process was tracked electronically by a departmental administrator.

FIGURE 1:

Composition of the surgeon onboarding process. The core element of the new process is a 4-hour session with administrative meetings, orientation to surgical and perioperative processes, introduction to inpatient and outpatient areas, and assignment of an onboarding buddy. ICU indicates intensive care unit; NWH, Newton-Wellesley Hospital; PACU, postanesthesia care unit.

OBSERVED BENEFITS OF STRUCTURED SURGEON ONBOARDING

Of 19 surgeons credentialed in the year after implementation, 100% completed the onboarding program. The new program significantly improved preparedness to practice, as measured by Likert-style surveys distributed to surgeons credentialed before (June 2019 to April 2021) and after (May 2021 to April 2022) implementation of the program (Supplemental File 2, Supplemental Digital Content 2, https://links.lww.com/SLA/E761). Before onboarding, there were no differences between groups. After onboarding, only 24% of the baseline cohort was comfortable handling emergency cases, compared with 86% of the intervention cohort (P=0.002). Understanding of operative capabilities at NWH and knowledge of key contacts for assistance were also higher in the intervention group (P<0.001 and P=0.019, respectively).

Critically, our program relied on a “forcing function,” with operating privileges withheld until the completion of the crucial 4-hour session. Mandatory training is often met with resistance, but satisfaction with the program was outstanding: 100% of the intervention group was somewhat or extremely satisfied. Concerns that the time commitment may be overly demanding were also unfounded. An impressive 93% of postimplementation onboardees felt that the duration of the onboarding process was about right; over half of the baseline, group felt that their onboarding was too short (P=0.007).

Free-text responses indicated that, although surgeons struggled to make time for the mandatory session, they found the time to be well-spent. Several participants noted that they had never experienced such a thorough introduction to a new practice setting, that the program addressed needs they would not have anticipated, and that it reduced stress. Aspects of the program related to institutional culture were particularly valuable, with one surgeon, in particular, noting that these sessions helped her avoid conflicts due to differences in norms and expectations. Culture is an underappreciated contributor to patient safety; investing time to promote cultural cohesion with new hires can improve communication and teamwork and subsequently prevent patient harm.1 Participants identified 2 specific areas for improvement: hands-on electronic medical record training and introduction to the emergency department. These will be incorporated into future versions of the program.

ONBOARDING IN A HIGH-RELIABILITY ORGANIZATION

The concept of high reliability indicates an organizational mindset that prioritizes safety in complex environments. Systems thinking is used to identify risks and design resilient processes to prevent error. Our onboarding program is a clear example of such a process. It anticipates risks from surgeons operating in unfamiliar environments, proactively identifying differences in resources, processes, and institutional culture that could contribute to patient harm. These risks will only grow as health systems continue to expand nationwide. Many academic centers are now partnering with community centers to deliver care closer to the communities in which patients live; this trend requires surgeons to work across multiple sites with variable cultures and capabilities.8 Many surgeons are unprepared for these transitions. Our cohort represents a relatively high-risk group, with a disproportionate representation of early-career surgeons and surgeons with limited clinical time at NWH. Newly-practicing surgeons may be less open to asking for help and may not recognize knowledge deficits; standardized onboarding processes are thus of particular value here.9 Call-only surgeons were recognized as a particularly high-risk group by frontline staff during the development phase of this project, as these surgeons care for patients intermittently, including overnights and weekends, often with insufficient understanding of hospital resources and processes.

FUTURE DIRECTIONS AND CONCLUSION

As the NWH program progresses, it will need to be maintained and adjusted to meet evolving needs. A semiannual evaluation schedule is planned to assess process adherence and review participant responses to a brief exit survey. Monitoring has been delegated to a small group of departmental administrators who interface directly with credentialing staff. Routine processes have been automated and streamlined using administrative planning software to minimize cognitive demand and variability in program delivery. In addition, the program has been recognized as a best practice and is now being implemented in additional specialties.

Thanks largely to a mandate by the Chief of Surgery, we achieved 100% compliance, but efforts should also be made to facilitate participation by busy surgeons. Many programs reduce productivity requirements early in a surgeon’s tenure; such approaches may promote longitudinal engagement. Contrarily, there is likely to be a temptation to move to a virtual format. Despite the barriers, the intangible benefits of in-person onboarding, particularly with respect to institutional culture and relationship-building, would argue against virtual onboarding.

Although designed specifically for an academic-affiliated community hospital, the principles we employed should be applicable to any center. While local needs may differ, the Ariadne Labs framework is explicitly designed to be adaptable to a variety of contexts, and surgeons transitioning to new environments are likely to share many common challenges. Future efforts should identify specific onboarding needs in a variety of settings and develop context-specific implementation guidance. As demonstrated by this pilot study, robust surgeon onboarding is feasible and can be readily implemented by a local team. To optimize patient safety, health system efficiency, and provider well-being, meaningful surgeon onboarding should become the norm rather than the exception.

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