Advanced Practice Provider Leadership: The Evolution of a Well-Defined Structure

Abstract:

COVID-19 has accelerated the financial and operational challenges facing the healthcare industry, causing organizations to reevaluate current processes and structures. The pandemic also has presented the opportunity to design more effective care delivery models, right-size cost structures, and streamline organizational processes to enhance financial sustainability going forward. To help support COVID-19 response plans and patient needs, many organizations have relied on their growing advanced practice provider (APP) workforce, including nurse practitioners, physician assistants, clinical nurse specialists, nurse anesthetists, and nurse midwives. Often an overlooked element of success, APP leaders can be a key to the optimization and organization of the APP workforce.

To help support COVID-19 response plans and patient needs, many organizations have relied on their growing advanced practice provider (APP) workforce, including nurse practitioners, physician assistants, clinical nurse specialists, nurse anesthetists, and nurse midwives.

At the height of the initial pandemic surge in May 2020, more than 70 percent of organizations reported redeploying or planning to redeploy non-frontline APPs to frontline specialties to help meet demand.(1) Additionally, many organizations reported using this workforce to perform telehealth visits throughout the initial shutdown and as patient volumes began to return to normal.(2) The role of APPs throughout the pandemic and their use in innovative care model delivery highlights an important story about the flexibility and resiliency of this workforce.

Even before the pandemic, many health systems and medical groups had begun to prioritize the integration, optimization, and engagement of their APP workforce as a strategy to enhance organizational performance and support the transition to value-based care.(3) As one of the fastest-growing workforces in healthcare, APPs constitute, on average, more than one-third of an organization’s clinical workforce.(4) This trend is an indicator that organizations have an opportunity to develop defined-care models and organizational structures to ensure that APPs are able to optimize patient care and support organizational goals in a cost-effective manner.

Often an overlooked element of success, APP leaders can be a key to the optimization and organization of the APP workforce. This article highlights the role of APP leaders in aligning this important workforce and outlines the different types of APP leadership roles and the key elements for developing a successful APP leadership structure.

Background

APPs are used across the care continuum in nearly every specialty and practice setting. In many organizations, growth of the APP workforce has happened organically without an intentional plan in place, which can result in a wide variation in roles, responsibilities, and scope of practice.(3)

Optimizing this workforce can mean developing a defined role on the care team, codifying an approach for practice at the top of experience and licensure, instituting appropriate scheduling processes to get the right patient to the right provider, and removing barriers to efficient care delivery for all members of the care team.

As the APP workforce continues to evolve, many health systems and medical groups that lack a consistent operating model for how APPs are utilized are developing a more intentional model.(3) Consequently, APP leader roles have emerged to help oversee day-to-day clinical operations, support important workforce planning initiatives, and drive overall APP strategy at the executive level.(5) While a well-defined APP strategy and leadership structure has been shown, anecdotally, to increase efficiency and improve APP satisfaction and engagement while also reducing costs, formal studies have not been performed.

Traditionally, this work fell to physician and/or operational leaders. This model often led to non-APP-specific solutions and inconsistent practices related to APP work effort and policies across the organization as each department, service line, and site developed their own approach to APP onboarding, competency assessment, student placement, and more.

Having an APP leader can improve efficiency by centralizing and standardizing key organizational processes such as credentialing, privileging, and onboarding. It also can help reduce turnover, enhance APP engagement and satisfaction through better workforce representation on organizational committees, and improve profitability through more consistency in APP documentation and billing practices.

Establishing an APP leadership structure allows these processes to work more efficiently and consistently. With their expertise, APP leaders are well-equipped to develop and implement APP-specific workforce processes, programs, and solutions to align with organizational goals. Having a defined lead contact for APP-related issues also helps support physician leaders and other key partners in human resources, the medical staff office, compliance, and finance.

Data suggest that APP leaders can have a significant impact on APP engagement and turnover. Recent data show APP turnover is 2 percent less in organizations with an APP leader than those without.(4,5) With top APP leaders present, the reduction in turnover is likely multifactorial and related not exclusively to increased representation of the APP workforce within the organization. For example, there is an inverse relationship noted between utilization and turnover: The lower the perceived utilization, the higher the flight risk. The presence of the APP leader can help reduce this risk by ensuring that APPs are being used optimally (see Figure 1).(6)

Figure 1. Perception of utilization

Evolution of APP Leadership Structures

The rise of the APP leadership structure mirrors the rise of physician leadership. Within the past decade, the growth of physician leadership roles has skyrocketed as the focus on population health, optimized models of care, and the transition from volume to value has intensified.(7) Just as this “…environment presents outstanding opportunities for physicians to develop lasting improvements,” so does it present natural opportunities for APP leaders who work alongside their physician counterparts to help align the APP workforce with these same organization-wide initiatives.(7)

“At Atrium Health, we are on a journey to be the best place to care for patients – a place where APPs and physicians thrive and find joy in their work. Our APP leaders and our Center for Advanced Practice are key to achieving the best outcomes for our patients as well as creating the best environment for practicing medicine. Our organization was one of the first in the nation to create and execute a comprehensive and strategic approach for optimizing the role of APPs. Since 2013, the Center for Advanced Practice has been driving education, innovation, and leadership of our 1,600 APPs — all thanks to the close partnership our APP leaders have with physician, nursing and other leaders across our entire team.”
– Scott Rissmiller, MD, Executive Vice President and Chief Physician Executive, Atrium Health

In a series of interviews SullivanCotter conducted with chief medical officers and other healthcare executives, it was reported that many APP leadership groups first met informally to discuss practice and professional development opportunities. As these councils were chartered, leaders to govern these groups were identified.

Over time, APP leadership roles and responsibilities became more formalized as executive leadership called for greater focus on key workforce initiatives such as APP recruitment, retention, engagement, and optimization. These required a more defined leadership structure with specific roles and responsibilities and dedicated time to carry out this important administrative work.

At the same time, other APP leadership roles were developing at the department or specialty levels. This evolution often developed unintentionally, with APP clinical leaders assisting with operational responsibilities such as interviewing, onboarding, and scheduling. Organizations often had different titles, responsibilities, and expectations by department and specialty.

The organic growth of the APP leadership position mirrors the growth of the APP profession overall and underlines the need for organizations to clearly define these leadership roles, responsibilities, and structures. Understanding different roles, responsibilities, and spans of control can serve as a roadmap for organizations looking to develop APP leadership structures and practices tailored to their unique cultures, goals, and operating models.

The Top APP Leader Role

The top APP leader role is one of strategy and influence. SullivanCotter’s data show that top APP leaders have oversight ranging from 5 to 2,000 individuals with a median of 510.(8) According to the data on more than 3,000 APP leaders, 38 percent of organizations have identified a top APP leader, with the most common title being director/senior director (71 percent), followed by vice president (8 percent), chief (5 percent), and associate chief nursing officer (5 percent).(4,8) In SullivanCotter’s experience, titles may vary to align with comparable leader titles and structure within the organization.

The top APP leader role has evolved similarly to the chief medical officer position. Traditionally, CMOs were “focused primarily on medical staff issues such as peer review, credentialing and privileging…they rarely had strategic or operational responsibility.”(9) This has changed drastically over the years, however, and CMOs now play an integral role in developing strategy, clinical resource deployment, processes, and systems. (9)

Data from SullivanCotter’s 2019 Advanced Practice Provider Leadership Survey show that the scope of the top APP leader role has grown to include several strategic responsibilities, such as involvement in: (8)

Organizational strategic planning initiatives. (100 percent)
Academic partnerships and APP student placements. (96 percent)
APP workforce planning and requests for new and/or replacement APP positions. (96 percent)
Consultation on individual clinician and professional issues. (96 percent)
Organizational APP compensation strategy. (71 percent)

The amount of dedicated administrative time given to top APP leaders varies based on individual role. Anecdotal reports indicate that, early on, these leaders may have been given one day every two weeks to perform their leadership and administrative duties. As the scope of responsibility grows and the number of APPs increases, organizations are providing more dedicated administrative time to top APP leaders. Data suggest that just less than half are now given 91–100 percent of dedicated administrative time, approximately one-third are given 71–90 percent, and the remaining are given 10–70 percent.(8)

During the early stages of the pandemic, the value of the APP leader quickly became evident. SullivanCotter conducted a COVID-19 pulse survey in May 2020 that captured many of the key initiatives in which APP leaders were involved, including conducting an inventory of APP skillsets, coordinating training for APPs redeployed to the intensive care unit, COVID-19 units, screening/testing services, and telehealth visits.(2)

“We have always viewed our APPs as an integral part of our health system and our APP leaders as essential partners in our operations and strategic planning. The COVID-19 pandemic presented a unique set of challenges for healthcare organizations and our APP leaders and teams proved critical to the agility and success of our response. From telemedicine to critical care, we relied on their tireless dedication to positively impact so many lives over the past year.”
– Paul Casey, MD, Senior Vice President and Chief Medical Officer, Rush University Medical Center

Many top APP leaders reported having roles in the incident command center. A recent survey of some top APP leaders across the country outlined new responsibilities that have been incorporated into their roles long-term as a result of changes related to COVID-19 (see Figure 2).(2) These include:

Emergency response planning.
APP optimization, workforce planning, and onboarding.
Operational leadership of additional departments or functions including employee health, urgent care, medical staff services, telemonitoring, and more.
Integration of newly acquired practices and APPs.

Figure 2. Prevalence of top app leader responsibilities during COVID-19 response

The pandemic has highlighted the critical role that top APP leaders play in the successful and efficient integration, optimization, and engagement of the APP workforce and the role they play in helping to achieve organizational goals.

“The role of the Director of Advanced Practice is not only key to program development and strategic alignment in normal times, but [also] its benefit to the organization has become even more apparent during the COVID-19 crisis. Our Director of Advanced Practice has organized planning and logistics for redeployment of this uniquely flexible workforce during two separate ‘surges’ thus far. This directly benefited our patients, their families and the organization. It is clear we would not have been able to respond as well as we did without this role.”
– Timothy Liesching, MD, Chief Medical Officer, Lahey Hospital and Medical Center

Clinical-Level APP Leaders

Clinical-level APP leaders, at the division or department level, have operational responsibilities such as APP interviewing, onboarding, and scheduling. These positions became more formalized as physician and service line leaders recognized the value this role had in departmental operations, retention, and engagement.

SullivanCotter’s 2019 Advanced Practice Provider Leadership Survey reports that 94 percent of organizations have APP leaders at the clinical practice level.(8) The most common title at this level is lead (60 percent) followed by manager (20 percent), and supervisor (10 percent).(8) Again, this often corresponds with the organizational structure and titles of comparable leaders within the organization. SullivanCotter’s experience shows that an informal leader typically emerges when a division or department reaches 10 or more APPs.

Key responsibilities for clinical-level APP leaders are much more focused on daily operations and include important activities such as recruitment and interviewing (93 percent), clinical scheduling (93 percent), onboarding (92 percent), annual performance reviews (81 percent), and competency assessments (74 percent).(8) While these leaders spend most of their time in direct patient care, a majority (62 percent) have dedicated administrative time ranging from 10 percent to 30 percent (depending on number of FTEs, sites, and/or different specialties for which they are responsible).(8) Data show that the current span of control ranges from 4 to 42 with the mean and median both at 15.(8)

Currently, 44 percent of clinical-level APP leaders have practicing APPs reporting to them. Of those, 66 percent are direct line to the APP lead, 29 percent are joint with a physician, and 9 percent are joint with another leader.(8)

Other APP Leadership Positions

In larger healthcare systems and medical groups in which their APP workforce has grown to hundreds and in some cases thousands of individual APPs, other APP leadership positions are emerging beyond top and clinical-level APP leaders. These positions typically are either (1) traditional leadership roles in which APP clinical leaders report to them or (2) more functional leadership roles in which the APP leader is responsible for overseeing a specific program such as APP onboarding, student placement, academic partnerships, or an APP fellowship/residency program.

APP Leadership Resources

An often-overlooked element of any APP leadership structure is the support system necessary for these leaders to be able to achieve expected outcomes. Nearly 60 percent of organizations have a designated cost center to support APP leaders and specific activities such as internal APP education/recognition events (78 percent), support staff salaries (61 percent) and APP council meeting expenses (50 percent).(8)

Additionally, 76 percent of top APP leaders have administrative assistant support and nearly 74 percent receive formal executive coaching and/or development as part of their role.(8) Other organizational resources/roles that have been identified to support APP practice and the top APP leader include APP recruiter (82 percent), business analyst (53 percent), project manager (32 percent), education coordinator (30 percent) and an HR business partner (28 percent).(8)

“Our 560+ APP workforce is integral to our care model. Dedicated APP leadership has helped to elevate performance across a number of related clinical and business metrics, and healthcare organizations should be resourcing APP leadership development just as we do for physicians.”
– Alan Kaplan, MD, Chief Executive Officer, UW Health

Conclusion

The presence of a well-defined APP leadership structure can help drive organizational performance and support a comprehensive APP workforce strategy, which can help increase patient access and revenue while increasing clinical productivity. Understanding the evolution of APP leadership positions at the top, clinical, managerial and functional levels, along with their roles and responsibilities, can serve as a roadmap for organizations as they continue to build out and develop APP structures and programs.

References

SullivanCotter. 2020 COVID-19 Physician and Advanced Practice Provider Compensation Practices Survey.
SullivanCotter. 2020 COVID-19 Pulse Survey: National APP Advisory Council.
Hartsell Z, Ficco D, English L. Optimal Use of Apps Can Enhance a Health System’s Post-COVID-19 Financial Recovery. hfm Magazine. July 30, 2020. www.hfma.org/topics/hfm/2020/august/optimal-use-of-apps-can-enhance-a-health-system-s-post-covid-19-.html . Accessed January 12, 2021.
SullivanCotter. 2020 Advanced Practice Provider Compensation and Pay Practices Survey.
Hartsell Z, Noecker A. Quantifying the Cost of Advanced Practice Provider Turnover: Assessing the Financial Implications. SullivanCotter. https://sullivancotter.com/quantifying-the-cost-of-advanced-practice-provider-turnover . Accessed January 13, 2021.
SullivanCotter. 2018 Advanced Practice Provider Workforce Individual APP Survey.
Angood P, Birk S. The Value of Physician Leadership. Physician Exec. 2014; 40(3):6-22. https://csms.org/wp-content/uploads/2015/04/The-Value-of-Physician-Leadership.pdf
SullivanCotter. 2019 Advanced Practice Provider Leadership Survey.
Sonnenburg, M. Chief Medical Officer: Changing Roles and Skills Sets. Physician Leadership J. 2015;2(1):16-21. www.physicianleaders.org/news/changing-roles-skill-sets-chief-medical-officers. Accessed January 14, 2021.

Also contributing to this article were:

Paul Casey, MD, MPH, FACEP, senior vice president and chief medical officer, Rush University Medical Center, Chicago, IL; Alan S. Kaplan, MD, chief executive officer, UW Health, Madison, WI; Timothy Liesching, MD, CPE, FCC, chief medical officer, Lahey Hospital and Medical Center, Burlington, MA; and Scott Rissmiller, MD, executive vice president and chief physician executive, Atrium Health, Charlotte, NC.