Dear Director,
It’s been a while since we’ve added a new doc to our group. What do you recommend for orientation and onboarding procedures?
Summer is great for vacations, but every medical director I know is looking forward to their new residency grads starting as much as they are looking forward to vacation.
Recruitment and retention are among the most critical jobs an ED medical director is charged with as those issues can be costly from a time and dollars perspective, so getting new docs properly onboarded needs to be thoroughly planned out.
I’m truly amazed by locum doctors who seem to be able to go to any ED and just get to work. Although the medicine is generally the same from ED to ED, the EMRs, the patient flow, the phone calls, and even how we interact with the nurses seem to change so much.
Dr. Mark Plaster, famous for his decades as the author of Night Shift in EP Monthly, told me he would be good as a locums as long as someone introduced him to the charge nurse, showed him where the coffee and bathroom were, and pointed him in the direction of the patients.
I think it takes about 45 shifts, or about three months of full-time work, to get efficient in an ED and to know how to trouble shoot some of the clinical and administrative hassles that come up during a shift. So, while you might be thinking of onboarding as a one-to-two-week process, I’ll show you a plan that starts with recruitment and may take six to 12 months after the doc has started, to help fully integrate the doc fully into the culture of the department and hospital.
The Recruitment Process
Onboarding starts during the recruitment process. This is the time to lay out your philosophy, vision, strategy and performance expectations for the ER and doc team. That way, you can make sure they’re committed to your plan and there’s no surprises when the new hires join the team.
Whether it’s sign out culture (leaving the shift on time and giving/getting a large sign out or staying late to wrap up), schedule expectations or understanding hospital priorities around quality metrics (patient satisfaction, door to doc, etc..), getting the right people on the boat makes it easier for all of us to row the boat in the same direction.
Don’t let this be the quiet time
Onboarding and communication don’t stop between the contract being signed and the start date. It’s very important to keep in touch with the new hires during the year. While uncommon, it’s not unheard of to lose an expected hire. Therefore, the occasional email to touch base and check in gives you the opportunity to re-recruit the doc reminds them how excited you are to have them join your team, and to remind them to start working on licensing, DEA, and credentialing paperwork.
Realistically, if hiring is done in the fall, this can be an email around New Year’s. This email can also serve as a reminder about credentialing, state license and DEA paperwork and to lay out the time frame of contacts over the spring and early summer before the job starts. If you haven’t already, pin down the start date as well and keep in mind it typically takes three months for a new doc to be credentialed (and this can be much longer if they’ve worked at a lot of hospitals previously).
By spring (and definitely three months before the expected start date), schedule planning needs to begin. If the new doc isn’t connected to the scheduler, now is the time. This will serve as another contact to help welcome them to the team and can also explain and plan for the first schedule, summer holiday coverage and vacations.
As the chair/recruitment director, you should be focused on finalizing credentialing and licensing paperwork. A lot of the time, new docs don’t understand the credentialing process and how long it can take. Spring is the time to confirm the start date and make sure the credentialing process can get completed beforehand by working with your medical staff office.
Time to start
Summer is here and now it gets real. Recruitment is one of my favorite parts of my job and getting docs started on their career is even more fun and satisfying. There’s a lot going on in the weeks leading up to the first shifts. Credentialing and med staff orientation (usually including EMR training) needs to be finalized.
At least two weeks before the start date, you should be sending out your orientation manual to the new doc. So much of our job is learning as we go (thus my 45 shift rule), but it’s important to provide some background knowledge and a reference guide for new hires—how do code strokes or STEMIs work, as well as hot button issues with specialists or hospital admin, etc.
In the week before the first shift, I recommend meeting one on one with the new hire to discuss key issues and flow. I literally take an hour or so to walk them through the orientation manual and prepare them for upcoming orientation shifts, including making sure they can sign on to the EMR and that it is configured correctly.
The first day is here. Particularly for new residency grads, I think orientation shifts are critical. Experienced docs may be able to get by with one or two orientation shifts—and I know many have worked without any orientation shifts—the standard, particularly for new grads, has long been three shifts.
While I’m sure the magic number of three is somewhat related to cost, three shifts generally work out. It’s impossible to see everything and do everything in three shifts, but it does allow enough time to become moderately fluent with the EMR and understand the basics of patient flow.
There are a few things you can do to enhance the benefit of the orientation shifts.
When I started, I was assigned a “buddy” that I was paired with for my initial shifts. This allowed me to establish a bond with an experienced doc that could serve as a sounding board for cases and issues that arose without having to go to my boss and risk looking like a fool.
While it’s easier to just add in the new doc for random orientation shifts to get them started, with a little thought and advance planning, they can be assigned three shifts over three to four days with an experienced “buddy.” The buddy should be an experienced doc who will take the extra time to make sure the new doc gets the case mix they need and to help them learn some of the nuances of the department.
The buddy might also serve as someone who can take the new doc out for a drink, particularly if they’re new to the area. For sites that have an RVU compensation model, it’s worth considering whether the “buddy” should be placed on a flat hourly rate for the orientation shifts since they’re unlikely to see their full complement of patients.
To make it easier on the buddy, a check list of key clinical issues to cover can also make orientation shifts more beneficial. This list could include being involved (or at least watching someone else manage) the following: admission, transfer, cardiac arrest, procedural sedation, STEMI, stroke evaluation and psych patient. Additionally, there should be the chance to review other issues like consent (procedure, transfusion) and review the ins and outs of the discharge instructions and referral processes.
Frequent Check Ins
The chair/recruitment director should be frequently checking in with the new doc as they’re getting started. Checking in during the first shifts is great (I’m always amazed at how many questions I get and wonder what would happen if I wasn’t there) but more importantly, is the chance to discuss the first couple of shifts afterwards.
All of us remember our first patient we saw as an attending (mine was a middle-aged guy with a kidney stone in room 17), and I think my new docs find it useful to retrospectively look at their first couple of shifts off orientation. While I’m happy to help them think about the medicine, usually my role is to help navigate some of the conversations with consultants and to positively reinforce that they’re doing a good job and help them build their confidence.
Onboarding continues after the first week as well. Although I’ll suggest some rough productivity goals for the first few weeks to the new docs and I’ll follow the metrics for them, I don’t do any focused metric reviews for the first few months.
For starters, it usually takes four to eight weeks to start getting billing data. I also allow some time for the new docs to ramp up their productivity. I want them focused on building their clinical acumen by providing good, high- quality care and not focusing on speed. Efficiency comes with time.
Our group is transparent with data, so data is available for them. Very rarely, I’ll have a doc who is really slow, and I might need to push them along. More commonly, I have new docs who are trying to do too much and let them know they don’t have to carry the department and it’s okay to slow down.
By three to six months, the data is reliable, and the conversations about performance metrics can occur. More importantly over the first few months, is to use these check ins to see how the docs are adapting to the hospital and the area, particularly if they’ve moved from another location. While I don’t want responsibility for their social lives, I will try to connect them with events that are going on, whether it’s a med staff meeting so I can introduce them to other docs or an ED happy hour.
Conclusion
Recruitment and retention are critical components of the medical director’s job. We think of summer as the time when new docs are starting and require onboarding. We invest a lot of time in the recruitment process, but it can’t stop when the contract is signed.
In reality, onboarding starts during recruitment and continues to take place long after the doc’s first shift. Proper communication and an equal investment of effort with onboarding will help the physician more quickly adjust to the new environment, leading to a more satisfied doc, which should also help with retention.
