by Christen Hunt, DNP, NP-C, CPNP-AC
Senior Director, Clinical Team Insights

The health care landscape has been changing over the last 20 years to meet the increased pressure of providing high quality care while controlling costs. While hospital administrators have focused on pressing department leaders to lower supply costs and streamline operations to gain efficiencies, the physician shortage has continued to grow, creating more challenges.

The impact of this shortage was first felt when resident work hour restrictions took effect in 2003, sparking a rise in the utilization of advanced practice providers (APPs) in the acute care setting. In many cases, this was a reactive measure with very little forethought to the ripple effect it would have on an organization. What can an APP do? What should they not do? How are they different than a resident? Who is responsible for directing them?  

Those are all the right questions to ask and organizations utilizing APPs must have a process to answer them when they decide to integrate them into their workforce. To optimize their value, here are three things worthy of consideration.

Clarify roles and responsibilities

The benefits that APPs bring to an organization’s delivery of care is without question, but successfully integrating them into the clinical team has been a common problem. While many physicians were unsure what capabilities the APPs brought to the team, the need to fill holes in the schedule was a bigger priority, so APPs were used to cover resident shifts. Since the role of resident falls into the teacher/pupil hierarchy, and they are only transiently engaged, this confusing structure proved to be counterproductive.

For APPs to become committed, long-term members of your health care team they need to have a sense of true partnership with their peers. Without this sense of partnership, retention can become an issue, creating a “revolving door” scenario that hinders the perception of the value of APPs as well as department growth.

Understanding the contribution APPs make to your bottom line is dependent on several variables, but when full optimized with identifiable clinical and financial outcomes, they can demonstrate their substantial value to an organization.

For example, many APPs are becoming proficient in the multiple procedures that are many times not billable separately as they are included in the bundle codes. Investing in the APP’s training to master these skills, frees the physician for other billable tasks, improves quality outcomes by having consistency in procedures, as well as allowing the APP to be available to help teach residents these skills while insuring protocols are followed. Many residents report they are able to learn more from the APPs as they provide education in a non-threatening environment.

Provide leadership structure

Now that we have a growing workforce of acute care APPs, who is going to lead them?

To continue to develop, to feel valued and to build commitment, APPs need shepherding. The simplest way I can put this, a registered nurse does not direct physicians on professional development. Every profession needs an expert within their field who understands the challenges and can speak the language; someone who understands the practice and can be the voice advocating for their needs. There should be a structure that provides a channel for them to grow. Just as physicians and nurses have leadership representation, APPs deserve a dedicated leader so that all disciplines are equally valued and accountable to the delivery of health care. This speaks volumes to both staff and patients that the organization is committed to team-based care.

Understand scope of practice

We all know the importance of scope of practice. There has to be appropriate limitations to protect the public. What many may not be aware of is that scope of practice is made up of two parts: a state level and an organizational level. The state in which the APP provides care provides a guide for the extent of service they can legally perform. Many professional groups have petitioned state regulators to extend these laws in an effort to allow the APP to work to their full potential based on their education and training.

Although this is very important, a new area of focus has also been identified at the organizational level. A recent study stated that “within-state variation is more significant than cross-state variation” as it relates to APP privileging. In fact, one of the most surprising findings was an organization with the most restrictive APP privileging residing in a full practice state. If state laws are not affecting the limitations of granting privileges to APPs, other factors, such as organizational, interprofessional and contextual, need to be studied. 

Organizations can mitigate this challenge by including the APP leadership team in the credentialing and privileging of their APPs. By having representation of the profession on the medical executive board, they can ensure they are granting privileges to the fullest state law allows, thus allowing organizations to fully benefit from the value the APPs bring to the health care team.  

To meet the growing demands placed on our health care systems, organizations need to examine the available workforce and their capabilities in order to build successful care delivery teams. Equipping teams with the tools they need to succeed will allow organizations to work smarter and provide their patients access to quality, cost effective care.

About the author. At Vizient, Christen Hunt serves as senior director, clinical team insights, a data-driven program focused on elevating clinician scope of practice and deploying clinical care teams of the future. In addition to these responsibilities, she partners with other areas within Vizient to provide subject matter expertise on advanced practice with a goal of improving overall care team utilization. As a strong advocate of advanced practice, she collaborates with research colleagues across the nation in an effort to provide evidence-based solutions addressing difficult questions surrounding advanced practice. Prior to joining Vizient, Hunt served as manager of advanced practice providers for the Department of Pediatric Medicine at Johns Hopkins All Children’s Hospital in St. Petersburg, Florida, as well as a joint appointment with Johns Hopkins School of Nursing.

Published: October 2, 2018