Educating for Acculturation: An Opportunity for Healthcare Organizations

In an era in which solo medical practice is on the decline and healthcare systems are getting bigger and more complex,(1) most physicians find themselves employed by larger healthcare organizations. Such organizations espouse a formal set of values that usually are presented in mission statements, formal human resource guidelines, and public relations announcements.

Kotter defines organizational culture as “behavior patterns or style that new employees are automatically encouraged to follow by fellow employees.”(2) While formal ways of transmitting culture are important, much of culture is transmitted in the informal experience of the workplace or “the way things are done around here.”(3)

Being newly hired can be a particularly challenging time for new members attempting to align their own personal values with those of the organization.(4) The gap between the formal and informal culture of the workplace is a crucible in which new members learn about attitudes and behaviors that are expected and those that may deviate from the norm but are tolerated and accepted.

Healthcare organizations have paid relatively little attention to the acculturation process for new physicians. Typically, physicians joining an organization participate in an orientation that primarily focuses on administrative aspects (e.g., office space, computer support/email), salary/benefits, workflow (including EHR training), and organizational resources specific to their role(s). The primary aim of such an orientation is to help newly hired physicians begin their work assignments smoothly and know whom to contact with administrative questions such as those regarding safety, sick leave, parking, violations of HIPAA, and other institutional requirements.

In recent years, the “onboarding” process for professional staff joining the Cleveland Clinic (CCF), a multispecialty academic health center that includes almost 4,000 professional staff members, has been redesigned with a view toward optimizing acculturation to day-to-day practice in the organization. Absent descriptions of a comprehensive acculturation program in the literature, we designed the new program, To Act as a Unit (TAU), with explicit attention to organizational values and culture. TAU is offered to all new members of the CCF professional staff, including physicians, research scientists, and social science educators.

Operational Process

The mission of the Cleveland Clinic is three-fold: “Better care of the sick” (clinical care), “Investigation of their problems” (research), and “Further education of those who serve” (education). Given the origins of the organization as a collaboration among its four founding physicians in a French military hospital during World War I, “To act as a unit” defines an essential feature of the Cleveland Clinic culture.(5) Institutional values and priorities are summarized in Figure 1.

Figure 1. Institutional care priorities, values, and leader behaviors

With growth and in response to some turnover among staff, albeit infrequent, the Cleveland Clinic recruits approximately 300 new staff members annually across many geographically dispersed practice sites. The realization that an earlier onboarding program was ineffective in communicating the organization’s history and culture acted as a catalyst to develop a new onboarding program that would also focus on acculturating new faculty. This perceived need prompted formation of a working group that developed the new TAU program.

The broad goals of TAU are to introduce new members of the professional staff to the culture, priorities, and resources of the organization using professionalism as a guiding concept. Of note, advanced practice providers participate in a separate onboarding program.

Developing and Implementing the Intervention

To get support and fully assess onboarding program needs, the TAU planning committee met with physician and administrative leadership from each of CCF’s 27 clinical institutes. Perceived gaps were identified and best practices were collected. Identified gaps included absence of a standardized onboarding schedule with limited interpersonal interactions, lack of exposure to staff resources, limited enterprise networking, and no exposure to institutional heritage and culture.

Once a proposed program structure was assembled, feedback was again sought from institute leadership and a final proposal was presented to clinical leadership and received final approval.

Educational methods. Adult learning principles(6) and learning science(7,8) provided a foundation for selecting the teaching strategies used during TAU sessions. Sessions typically begin with a brief presentation of relevant information from faculty leaders, followed by an interactive portion during which teaching faculty use active learning strategies to facilitate knowledge enhancement and skill development.(8) Educational methods include questioning strategies, case-based instruction, small- and large-group discussions, role play, and use of appreciative inquiry to generate and share stories.

Faculty Development. Intentional recruitment of institutional leaders as faculty for each of the TAU sessions allowed new staff to meet leaders and reinforced the institutional value placed on these sessions. After initial development of interactive sessions by leaders with expertise in key areas, a train-the-trainer model was used to prepare additional faculty to teach the sessions. Each session requires a pool of two to six trained instructors to allow TAU sessions to be offered year-round.

Curriculum/Program Implementation

The TAU program also is integrated with a traditional onboarding program that addresses all CCF caregivers.

Phase 1 — Preparing for Practice

The initial phase of staff onboarding is integrated into a program for all caregivers joining CCF and occurs during the first week of employment twice a month. This allows for a more efficient process and requires that leaders cooperate on new staff members’ starting dates.

On the first day of employment, physicians are included in a day-long program that addresses all CCF caregivers and introduces enterprise values. The program then becomes physician-specific for the remainder of the first week and includes programming on institutional structure, support and development resources, efficiency exercises, annual professional review, electronic health record training, and documentation and billing. A connection to elected clinical leadership is fostered during lunch with a member of the board of governors (the Medical Executive Committee of CCF).

Phase 2 — To Act as a Unit

During the second phase of staff onboarding, which is the 12–18 months-long TAU series, new staff members are expected to attend six interactive sessions focused on core aspects of CCF professionalism. Staff members include physicians as well as PhD researchers and educators. Advanced practice providers receive separate onboarding.

Sessions are 2–4 hours long and are offered 6–8 times a year to accommodate new staff joining the organization at multiple points during the year. Most sessions have 40–50 participants from a wide variety of specialties and practice locations across the Cleveland Clinic Health System, which consists of 11 hospitals and 18 family health centers in northeast Ohio. Sessions are clustered on certain days to facilitate completion with minimal disruption to clinical activities.

Regarding operational costs, total participation time for a new staff member in this program is 14 hours over 18 months. The budget for the program is modest, approximately $18,000 for materials and food as well as support from an administrative assistant who attends the sessions and coordinates attendance, evaluations, and CME. Table 1 provides an overview of the topics covered, learning objectives, and descriptions of sessions and teaching strategies in TAU.

Results

Since its inception in 2012, 1,795 unique new staff members have participated in the onboarding program. Evaluation has included ordinal ratings of perceived value of the sessions, whether learning objectives were met, and open-ended narrative comments. Based on 5,936 surveys of individual sessions, the overall rating for the value of sessions is 4.5 out of 5 and for meeting of learning objectives, 4.6 out of 5.

In addition to numerical ratings, several open-ended questions, including “What one thing are you taking from this session?” were posed. Narrative comments have yielded several themes, including appreciation that the organization emphasizes the need for training/onboarding, ability to meet others in the organization, and the value of discussing challenging cases/situations with colleagues.

The basic structure of the TAU program in terms of tempo and length has remained largely intact for eight years. The core topics have not changed. Feedback from participants has allowed refinement of the sessions over time with changes to put more emphasis on case-based discussions and to limit didactic slide presentations.

One unexpected positive outcome of the program was the creation of a new staff leadership group. Selected from among staff members hired within the past one to two years, this group functions to provide feedback on the onboarding process, needs of new providers, and relationships of new providers with leadership.

Discussion/Operational Implications

The practice of medicine has shifted from a solo practitioner model to large-group practices. Traditional onboarding programs have focused on getting physicians ready to practice successfully, but they have not addressed organizational culture and professionalism directly.

The reported high turnover rate of up to 25 percent of physicians within three years speaks to the need for additional acculturation beyond a basic orientation.(9) Additionally, there is increasing recognition of the need for healthcare organizations to respond to their patients and also to their caregivers.(10)

The 2017 Charter on Professionalism for Health Care Organizations outlines “the responsibility of leadership to describe a healthcare organization’s desired culture, articulate its rationale, and create the structures that support it.”(11) TAU addresses this gap.

TAU is novel in several ways. First, to our knowledge, this is the first description of a comprehensive acculturation program in an academic medical center. The program was designed to reflect the heritage and values of CCF, advancing organizational success through alignment of new faculty with the organization’s mission, thereby enhancing recruitment and retention.

Several elements in TAU helped us to successfully launch and sustain this program.

• There was an initial recognition of the need to examine and improve our onboarding programs, a “burning platform.”

• Key physician leaders formed a planning group that sought input from chairs of clinical institutes.

• Our structure, which includes a physician CEO, physician-led institutes, and salaried physicians, has facilitated endorsement and participation in the TAU program.

• The program components are offered several times a year to make it convenient for new staff and to minimize disruptions to clinical practice, an action that has also facilitated participation.

• Participation is not mandatory per se, but is expected and reinforced by leadership.

• Topics chosen reflect key elements of professional responsibilities that are central to CCF culture.

• Evaluations from participants reflect appreciation that the organization values professionalism and culture and is willing to allocate time for staff to explore these topics.

• Interactive case discussions that reflect professional challenges and the opportunity to meet a broad representation of physicians from other specialties are highly rated components of TAU.

Physician leaders, including the system CEO, have shown a deep understanding of the value of professionalism programming in building physician culture. As a consequence, the program is well-supported with time and administrative assistance from CCF. Staff are given time and are expected to attend; each volunteer faculty member dedicates approximately 10–20 hours per year to facilitate the sessions. The total budget for TAU since inception is less than the turnover cost of one physician.(12) The CCF turnover rate for the past three years (2017–2019) averages 6.3 percent, which is consistent with turnover for the last several years.

Physician turnover clearly depends on many organizational factors. We do not currently have data on the extent to which participation in the TAU program correlates with retention but hope to pursue this in the future.

One unresolved challenge is that the program currently focuses only on new staff joining the organization. Current staff may attend sessions, although this is not an expectation as it is for new staff members. Over time, an increasing percentage of our staff will have participated. Another challenge is development and delivery of programming in a way that engages both physician and non-physician staff. We have addressed this by progressively acknowledging the history and value of research staff in advancing the institutional mission.

Many key features of TAU can be adapted to other healthcare organizations. Specifically, leaders can identify key elements of the culture and values of their organizations and intentionally design interactive sessions to acculturate new staff. This approach aligns with the concepts of organizational professionalism and lifelong learning in serving the needs of the professional staff.(11)

Acknowledgments: We thank Amy Lawrence for her support of the To Act as a Unit series and her help in preparation of this manuscript.

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