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Orientation of Personnel to Ambulatory Clinics (2.04)

Orientation of Personnel to Ambulatory Clinics (2.04) - Policies, Clinical, UWHC Clinical, Department Specific, Ambulatory, Staffing and Operations


2.04 Orientation of Personnel to Ambulatory Clinics
Effective Date: May 28, 2014


To provide all ambulatory clinics staff with a standardized orientation designed to give
them a general preparation to work in an ambulatory clinic setting.


All new UWHC employees will attend New Employee Orientation (NEO) prior to
Ambulatory Orientation (AO) as directed by their Human Resources (HR) recruiter.
Transferring employees usually do not attend NEO. All employees who are new to the
clinic setting (transfers and new employees) will attend AO. AO will be provided and
documented by the Nursing Education Specialist (NES). The orientee is responsible for
completing and returning a standard orientation competency checklist. Additional clinic
specific orientation competencies are added to this checklist and reviewed by Registered
Nurse (RN) Preceptor or Medical Assistant (MA) Partner or Scheduler Trainer and the
clinic manager.


New to UWHC
Transfer Inpatient to
Transfer Outpatient
to Outpatient
Per Diem,
Agency or
Attend all sessions Attend all sessions Manager or NES/CNS
choose sessions
employees in their
clinic will attend
choose sessions
employees in
their clinic will

A. HR or Nursing Recruitment will schedule the new employee to attend NEO if
needed. Nursing Recruitment and/or manager will inform the NES for ambulatory
clinics of the new employees to be scheduled for AO.
B. Managers will plan start dates for new hires to be the week of AO.
C. Attendance at AO sessions will be as outlined in the table above:
1. New UWHC employees will attend all AO sessions.
2. Transfer employees will attend all or selected sessions of AO.
3. Per Diem or Agency employees will attend AO sessions as directed by
manager and/or NES or CNS.
4. Required AO sessions for outpatient to outpatient transfer employees will be
selected by the manager with guidance from NES and CNS based on the
employee’s needs, their role in their new clinic, and regulatory requirements.

D. Any employee transferring from an Inpatient to an Ambulatory area is required to
attend all AO sessions.
E. If it has been more than one year since an employee attended orientation, they may
need to attend AO.
F. Clinic staff will attend the appropriate training during the week of AO to use the
electronic medical record (HealthLink) clinical module used in their clinic.
G. At the time of employment or transfer, the manager will assign a primary Preceptor
to each new RN, a Partner to each new MA, or a Trainer to each new scheduler. This
person will be an experienced staff member with an interest in training.
H. The Preceptor, partner and/or trainer will assess the learning needs and learning
style of new and transfer employees to determine orientation needs.
I. With the assistance of the manager, the Preceptor/Partner/Trainer will develop a
clinic‐specific orientation plan based on the person’s skill, experience and
knowledge and will function as a resource person to the new employee. The NES
will be available for consultation.
J. If an employee needs further assistance to become proficient with new skills, the
NES and CNS may be consulted to assist in developing an individual plan with the
manager or Preceptor/Partner/Trainer.
K. The Joint Commission requires that the new employee complete orientation
competencies/checklists prior to caring for patients independently. The general
expectation for ambulatory clinics will be that orientation checklists are returned
three (3) months from the date of hire. Managers will contact the NES prior to this
deadline if the employee will not be independent and has not completed their
checklist to discuss a new due date.
1. If an orientee cannot be checked off on a specific skill because there has been
no opportunity to perform, the Preceptor/Partner/Trainer may explain,
discuss, review policy and note this on checklist. Orientee will be expected to
ask for assistance, when the opportunity to perform this skill arises.
L. In order to ensure patient safety, 100% compliance of completion of orientation
competencies is expected.
1. For active employees, there is no grace period permitted.
2. For inactive employees returning from leave, a 45 day grace period will be
permitted. Upon return from leave, the employee is responsible for
contacting their supervisor/manager for completion of required
competencies that are outstanding.
3. If competencies are not completed within the defined timeframe, the
employee will be taken off work without pay until it has been completed. A
Pre‐Disciplinary Investigation (PDI) may be necessary which could result in


The Joint Commission.org. Program: Hospital. Chapter: Human Resources. Sections
HR.01.04.01, HR.01.05.03, HR.01.06.01
Nursing Administrative Policy 3.13 – Registered Nurse Orientation

Preceptor Worksheet Qualifications/Payment UWHC Nursing
RN Competency Checklist
MA Competency Checklist
Scheduler Competency Checklist


Nursing Education Specialist, Ambulatory Clinics
Ambulatory Policy and Procedure Committee
Ambulatory Education Team
Clinics Administration


Deborah D. Tinker, MSN RN CENP, Director, Ambulatory Nursing