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

The clinical workforce is your health care organization's greatest resource, driving quality patient outcomes, financial health and serving as the ambassador of the organization's brand. The success of a health care organization in today's market requires a significant investment in its clinical workforce to address immediate challenges such as engagement and burnout, role clarity and team optimization, strategic and culture alignment, and significant workforce turnover and staffing shortages.

Many of these are not new challenges. We have a wealth of research dating back over a decade on clinician wellbeing, but the COVID-19 pandemic has created a tipping point, moving these long-standing organizational challenges into a national healthcare workforce crisis. 55% of physicians reported COVID had increased their feeling of burnout.

Hospitals and health systems that participate in Vizient’s Clinical Team Insights complete annual assessments of their organizational structures and process that impact the clinical workforce. We’ve evaluated the responses, which represent more than 9,000 physicians and nearly 5,000 advanced practice providers (APP) across the nation and developed an annual insights brief. Based on that assessment, here are the four imperatives essential to every health care organizations’ workforce strategy.

Leadership structure must support professional growth

Clinicians need a leadership structure that will support their professional growth and development. Our analysis revealed a significant disparity between the leadership support for physicians versus the leadership support for APPs. The data showed that each physician leader supports an average of 36 physicians. When examining the APP leadership structure, 33% of organizations did not have a recognized APP leader. For those that did, those APP leaders were supporting an average of 208 APPs.

Looking deeper within the APP reporting structure, we found that about half of advance practice registered nurses (APRN) report to the chief nursing officer while about half of the physician assistants (PA) report to the chief medical officer. A disjointed leadership structure for APPs can confuse role clarity and expectations when APRNs and PAs have a different reporting structure.

We find that when APPs report to an APP leader there is increased engagement related to growth and development, recognition and coaching and feedback. For example, a midwestern health system created APP supervisor roles and provided leadership development for these new leaders. Subsequently, internal research revealed that APPs who report to APP leaders show markedly higher engagement.

Organizations need system-level APP executive leadership to adequately support this rapidly growing workforce. Adding an APP expert of the state scope of practice to the executive clinical leadership team ensures organizations can best leverage this essential team member.  Many organizations are moving toward a leadership structure with clinical leads supported by local-level and executive system-level APP leaders. This structure can engage the entire clinical workforce while ensuring focus on strategic priorities such as workforce planning, performance, patient experience and clinician engagement. In addition, deploying interprofessional clinical stakeholders into the governance structure helps foster clinician alignment with the organization's strategy. Including the clinical perspective with the operational perspective builds an invested clinical team that feels valued and heard.

Recruitment pathways and onboarding affect retention rates

Retention starts with recruitment. Nearly 60% of respondents reported recruiting APPs through their human resource department, whereas only 27% reported recruiting physicians through human resources. Nearly half of the respondents reported recruiting physicians through a provider recruitment team and only 33% recruit APPs through a provider recruitment team. Since APPs and physicians are expected to work as a team, it is essential for the entire team to be involved early in the recruitment phase. The clinical workforce is expensive, so organizations should rethink the recruitment process to ensure they are hiring someone who will be a good fit for the team.

Once the APP and/or physician has been hired, only 40% of health care organizations reported having a formal onboarding process. Further, we’ve found that the typical onboarding is a two-day orientation providing only the essential information such as electronic medical records and required training.

Having a well-defined and thorough onboarding process demonstrates organizational investment in the clinician which builds loyalty and commitment from day one. Onboarding programs that last six to 12 months focused on fully assimilating the clinician into the organizational culture have been shown to decrease turnover by 40% to 70%. The costs of turnover are immense, with an estimated cost of $250,000 for each APP and between $500K and $1.5M per physician.

Operational efficiencies improve financial health

Operational efficiency and financial health result when the right people use the right processes to deliver the right care. It is a leading cause of wasted health care dollars. Organizations track key metrics such as operating margins, access, and quality, but they need to understand what is driving them.

A key focus area is understanding what tasks the APPs and physicians are spending their time on. About half of the ambulatory clinics are tasking their provider team with administrative tasks like case management activities, form completions and prior authorizations. Analysis from the survey determined that these administrative tasks take up about a quarter of a physician’s time and about a third of an APP’s time. This requires understanding the skill sets for the different types of clinicians employed and positioning them to work to the top of their scope of practice.

Hiring RNs in the primary care setting can be an additional cost-effective strategy to improve the performance of ambulatory clinics. Registered Nurses (RN) as part of the care team in the primary care setting can best work to the top of their scope of practice by performing Medicare annual wellness visits, chronic care management and transitional care management. Yet among respondents, only 54% of clinics employ an RN in their primary care clinics; and of those that do, only half perform Medicare annual wellness visits.

Another example of maximizing clinician capabilities was demonstrated by a sleep medicine clinic that decreased wait time for a new patient appointment from greater than 100 days to 43 days without adding an additional provider to the clinic. They elevated their APPs to the top of their scope of practice and allowing them to perform new patient assessments. This increased APP productivity from the 10th percentile to the 70th percentile and opened access for more new patient intake appointments.

Organizational structure and processes can reduce burnout and improve wellbeing

As stated earlier, clinician burnout is not new; the pandemic has just added more fuel to a longstanding problem. To solve clinician burnout, organizations must work to understand the clinician's needs and address the organizational structure and processes that have the most significant overall impact on clinician wellbeing. Examples of organizational structure and processes include:

  • Compensation methodology
  • Leadership
  • Efficiencies in workflow
  • Inclusive culture
  • Professional development
  • Communication

Vizient’s Clinical Team Insights provides a wide variety of tools, data and resources to help hospitals optimize their clinical teams. To learn more, feel free to email me. The annual insights brief, The Importance of Workforce Strategy, is available for download.

About the author: Christen Hunt serves as a Vizient subject matter expert in clinical workforce optimization while engaging with members to assist them in interpreting and utilizing data to optimize the entire clinical workforce. As a strong advocate of advanced practice, she collaborates with research colleagues across the nation to provide evidence-based solutions addressing difficult questions surrounding advanced practice deployment.

Published: October 6, 2021