Thanks Heather Thanks, everybody. We're definitely on theme here as the different speakers So we'll try to give you the APP perspective On all these on on how do we preserve and maintain? Retain and recruit our APP workforce so you can see our objectives here I'm going to start out by talking a little bit about the pipeline and why it's so critical for us to Maintain and develop this really precious resource and then I'll specifically spend some time talking about drivers for APP engagement and critical care and Summarize some strategies for recruitment retention and try to maybe highlight ones that haven't been spoken about just yet So I'll start with the PA national workforce. This came from the 2022 a PA salary report 130,000 practicing PA's in the United States and this is really taking off I mean the number of PA programs at least in our home state has really exploded in the last couple years So I you'll see some data in a little bit about what we're projecting for the PA workforce in general the top three Specialties that PA's sign up for are 18.4% in primary care 10% in orthopedic surgery and another almost 9% in emergency medicine with an average of five to nine years of clinical experience One of the speakers that we were with earlier this morning also described that the average age According to the 2022 salary report is around 38 with almost 60% of PA's under 40 years of age Here is a distribution of PA's by the most frequently practiced PA specialty you see a majority of PA's are Choosing family medicine in the primary care field You see a little bit of orthopedics hospital medicine really only accounting for six point four percent and This isn't surprising because the NP and PA workforce both started programs nationally in the 1960s 1965 And they started with their roots in in primary care for nurse practitioners The first program was an FNP program. And so the roots are in primary care so some of the statistics aren't aren't surprising given the the That we are still in the beginnings of our APP profession and trajectory So what does it look like for NP's? right now According to the AANP national nurse practitioner database that came out in 2022. There's 355,000 licensed nurse practitioners in the United States 88% of those are certified in primary care and 70% of all nurse practitioners deliver primary care 46 percentage percent of full-time NP's do hold hospital privilege and Privileges and have been practicing an average of nine years But unlike our PA colleagues our NP's have an average age of 46 years And so that kind of speaks to a little bit of the difference in the two professions is a lot of nurse practitioners Especially those in critical care have worked at the bedside as nurses for numerous years before they even qualify To begin their nurse practitioner education. And so there is that discrepancy where our PA colleagues Have a bachelor's degree typically in a science and then can turn you continue to matriculate on into a PA program And so that's why we're seeing The differences here in in years of experience as well as age Really important to talk about the NP consensus model knowing all that background And I find it find often That our physician colleagues and even where even our PA colleagues and others Hospital administrators don't understand the nature of NP background and education and this is the national consensus model These are the different types of NP. So you will see alphabet soup behind many of our names. There's PCs. There's a C's There's PNPs. There's P M H in MPs. I mean we We our profession has created a lot of complications and we change our certifications from time to time as well but this is how my simplified way of educating my physician partners in our Organization as well as administrators to know an NP isn't an NP isn't an NP and in parentheses, I tried to You know match our physician colleagues with our certification for nurse practitioners to make it a little bit easier But each of these NP certifications require clinical hours just in the population foci So unlike PA's who get a more broad education over their formal education and training where they rotate through Most of the specialties nurse practitioners actually pick the population that they want to care for long term So our two-year program will be related to that specific population foci whether it's pediatrics whether it's primary care whether it's primary care for pediatrics or acute care for pediatrics and all of our clinicals all of our pharmacology all of our path of physiology and Our board certification is tied to that population foci Previous nurse nursing experience as a registered nurse does not equate to APRN preparedness to scope of practice and so if you Have an RN who has been at the bedside in critical care for 10 years and they attend a primary care nurse practitioner program That does not qualify them for a scope of practice to practice in an ICU so very important for leaders to understand this but also to know that the Expectations for nurse practitioners on where they would be Working needs to be tied to what they've been formally educated and trained to do So, what does that matter for us in critical care? I pulled this data again from the 2022 AANP survey about where are all of our nurse practitioners Certified and you can see the majority are FNP 70.3% and here's the different certifications and You can see by the arrows I pointed out exactly how many nurse practitioners of this precious resource to to staff our ICUs only 9% Hold a critical care or acute care adult certification accounting for around 32,000 and even smaller for acute care peds only, you know point six of a percent. So 2,100 Pediatric acute care nurse practitioners nationally and point five percent of neonatal nurse practitioners So really tiny little population of the NPS that currently hold a certification that qualifies them to be in our ICU even more of a reason to make sure that we're focusing on retention strategies as well as you know Advocating for our nurse practitioner faculties and programs to be matching our Programs our formal education and training to what the workforce demand is across across the country This I snapped from Becker's most of us in health care leadership Spend some time getting caught up in in the latest news from Becker's and this one came out in October of 2022 it showed a Significant 333,000 providers that's physicians nurse practitioners and PAs that left the workforce in 2021 and so it dove into the specifics that by the end of q4 2021 we lost a hundred and seventeen thousand physicians 53,000 nurse practitioners and 23,000 physician assistants for various reasons through retirement or just attrition But also from a supply and demand standpoint Hopefully you guys saw the most recent Data that came out from the US Bureau of Labor and Statistics that the NP Profession is supposed to be the fastest growing in health care still We're expected over the next 10 years to grow the number of NPS by 46% and the PAs are right behind at 20% so we are Increasing the pipeline of these providers, but not perhaps within critical care What does SCCM have in their data around our workforce for for critical care around 29,000 acute care nurse practitioners 1,500 PAs practicing critical care in the United States compared to our physician intensivists at around 29,000 headcount with 20,000 FTE When you when you break it down into their clinical FTE so a PPS are going to continue to be a vital workforce Component of our ICUs and we need to be working on ways that not only Enhance their ability to provide critical care, but also Increase our supply because we need APPs to take care of our Sicker and sicker population as the baby boomers continue to come into Medicare age So that's a little bit about our pipeline what are some of the factors in APP engagement We talk a lot about scope of practice For APPs and how that leads to workforce engagement and satisfaction But what is scope of practice really mean? And so I've I've put it down into a few bullets of what I consider and what we look for in some of our Optimization projects for APPs so that I can say okay this workforce or this specialty within my organization has their APPs optimized So are they always independently seeing patients where bylaws and scopes scope allows a lot of practices will have Tandem type visits where the APP will go in start the visit physician will come back right behind them do this whole thing over again And bill for it We really need to define what the APP role is and what they should be what type of care They should be delivering for the patient and have them do that and have our physician colleagues focus on what they can do and need To be doing as physicians knowing that there's some crossover for sure, but we want to make sure that Organizations do not have Bylaws or certain practices culturally that prohibit the APPs from independently doing their work they also need to bill for their work a Physician leader of our medical group who's now retired. He used to call the APPs the great invisible workforce Because everyone knew that if we lost all of our APPs within our facility What would happen and the and things would crash? But we couldn't show up in the data So all the things about staffing ratios, or how do we show that a team is productive enough to be adding resources? sometimes when the APP workforce isn't Optimized you can't see them They're invisible in the data because they're doing the work but not receiving credit for it formally So in addition to some compliance rules around billing for their work We need to allow them to truly take credit for the work that it is that they're doing and I think CMS is making some pretty big changes and have over the past couple years to continue to To show that piece of the workforce in our work RBU data and productivity data Third perform the procedures that scope allows so I've had the privilege of being in this executive position where I've been Going around to different facilities and seeing what our APPs are doing in ICUs in different states And we all know that cultures are different as well as scope of practice laws in the various states But when I find APPs that in critical care that aren't able to do the procedures that they've been trained to do in in their formal Education and training program. They're gonna leave within a year because they're losing that skill set So we need to make sure that our delineation of privileges Match a national standard that we've set for ICU APPs. Are they doing intubations? Can can they lead codes? Are they putting in the vascas? Can they do central lines if they're there at night by themselves? It's ridiculous to have to call down and ask up an emergency medicine physician to come up and put in your central line when an APP has been trained to do that in their formal education and training program So making sure that they can perform the procedures that their scope allows Do they have clinical staff to delegate non-medical decision-making to this was a big thing in the pandemic because we as a PRN Specifically have our nursing background to fall on to and we were called to work as nurses And stand in a lot and we're working on taking that back And you know making sure that we have the clinical staff to get to delegate to like our physicians It happened in many specialties where I have allergy APPs working and they've been doing Allergy shots because we haven't had staff Whereas our physician colleagues would never be asked to do that. It's not within their scope to do either and so You have to make sure that APPs have clinical staff designated to them to be able to delegate non-medical decision-making to Can they prescribe all the medications within their scope autonomously? I've seen practices where an APP would have to call and ask Their attending whether or not they could prescribe a medicine or all their orders that require co-signature most of the time the medicines already been given so the Co-signature is just a burden for the attending to have to go through and select all and sign but also This gives the empowerment for the APP to lean back on their education and training to make sure that they are Fully practicing and unlocked as an APP data visibility Another dissatisfier for APPs so many times we have APPs who don't know what they're contributing to quality They don't know their productivity And they don't see their patient experience metrics, and so we've really tried to at least quarterly Provide the same reports to our APP Partners as we do our physicians a little bit more difficult in the EHR where a lot of times an APP will be admitted under An attendings name versus a team's name, but even the APPs need to see the team Productivity they need to see the team quality Scores they need to see the team patient experience because they are contributing to it in a very meaningful way We are just as competitive in a type as most of our physician Colleagues and so I find if you give a goal to an APP they are going to chase it down in fact We had a goal that was incentivized on HCC coding because we had a big opportunity Within our organizations the APPs outperformed our physician. They went after it I think that they improved the never miss HCC codes by 30% whereas our physician colleagues did 14% So they they will go after it, but they have to have visibility to the data Do you have APPs represent represented on key departmental decision-making committees? in Every way that an APP can be a part of a decision-making body and bring their perspective. It's really important Given the fact of the amount of time that they send Spend at the bedside not only with the patient, but also nurses and other colleagues and in their coordinating of care They have a unique perspective and experience. That's important to include them there Alignment of physician and APP compensation and incentives really important if you've created a compensation plan or incentives that cause a You know infighting between the physicians and APPs where the physicians need work RVU's to unlock their compensation But yet we're asking APPs to be productive as well even if their compensation is not tied to it or the physicians have incentives for quality that the APPs do not have for quality then you haven't set up an environment to properly create a team-based approach To providing care in the unit and so that is a fundamental Element in creating a team-based environment and finally Partnership with the physician rather than serving as a resident replacement. I find this a lot in in especially in our inpatient pediatric places right now where Attendings may have only been in an academic environment with other physician learners I think it more and more they are working closer with with APPs and see the value and knowledge and skill set that we bring to the table, but I always talk to our physician partners and say If you do it, right, we're in it for the long run. We're gonna be your partner in this practice for years I mean some people may stay 10-15 years spend their whole entire career as your partner just like a Physician joining the practice may do and our physician trainees Hopefully some will stay but others are they're constantly moving in So if you do a good job and train the APP make them feel engaged and want to be there They're gonna be there forever and you're not gonna have to teach them again And so having that respect Between the physician and APP to know that they're in it for the long run Can make a really big difference in in the satisfaction and engagement of your APPs All right We'll look really quick on what are some strategies and I'll hit the highlights that weren't hit in the previous I think selection of candidates really important Obviously alignment with the consensus model is huge You can't expect to put a primary care trained nurse practitioner into an inpatient environment Where they haven't had any clinical training even if they've worked as a nurse before and expect them to perform It's unfair to them and it's unfair to the team that you're bringing them in And so the selection of candidates are really important knowing the culture of your unit I think that was really important to say to point out as well because I just did an exit interview this week from a NICU PA and She said I was moving from a level three to I came down to Charlotte to work in a level four I wanted that upskilling But where our team is culturally right now in the NICU that she joined they're not at a capacity to be able to teach And so you have to know is it okay to bring a new grad into that environment Do they have the ability and time to teach or are you do you is it better for you to wait another month to bring? in somebody who has experience so knowing the background and experience and matching the certification critical to Maintaining your workforce Onboarding program. I think we spoke to that Significantly in the last talk can't talk. We can't speak highly enough of formal fellowship programs. Not only does it impact their clinical skills, but their networking and their ability to do QI projects and just overall Professional preparedness of the APP it is I I'm just jealous that they weren't there when I was Transitioning into into my MP role leadership opportunities There are some leadership opportunities that require a physician That you have to have a physician as a medical director of certain things for for various reasons But is there an opportunity for the APP to lead? operationally creating lead creating chief creating APP manager type roles really important But I also have challenged our folks that if there needs to be a chair of an outcomes committee If there needs to be a role on medical staff or medical exec Does it always need to be a physician and know the APP's that are in your workforce who have those? Aspirations some of us just want to take care of patients and go home Which is great. I think there's some physicians that are the same but other people were really aspiring for more and Something beyond the bedside and so giving them those opportunities and carving out time for them to do it is important Quality improvement and research resources. Do they have access to the data? Do they have access to? PhD and statistic Statisticians to be able to help them do things that are really neat and innovative But they have to have the resources to do it and and we hope they do because then they end up at SCCM presenting night shift education and inclusion Hear this all the time. We're hiring more and more nocturnist I would never be able to work full night shifts, but some people do and love it and we are grateful for it But don't forget about them if they're there at night all the time They miss the camaraderie of the rest of the team and most the time they're missing out on opportunities to get education That's that's ongoing. So be intentional about that if you are hiring nocturnist and give them Opportunities to feel like they're part of the team but not miss out on education M&Ms other things that go on during the day. We spoke to the partnership between physicians and a PPS that's critical to feel valued important and You know not a resident replacement or have second choice to physician trainees Recognition on a local level we've been having listening sessions I think like most organizations across the country after the pandemic where we have and we saw Tessa's data about Work-life balance and well-being at the front of all of our minds And what I'm hearing from a PPS is that? Brittany we love hearing from Center for Advanced Practice and thank you for sending me my anniversary stuff And thank you for celebrating National a PP week. The only people that I really care to hear from and that is impacting my well-being are the physicians that I work for every day the Nurses that I work with and the patients that I take care of They want recognition on a local level to to know that them showing up and being with you every day Makes a difference and makes an impact and so really focusing on how do we recognize their contributions in the unit that they work it with within the team and And finally I have developing their network, I think this is really important Is not just within the ICU that they work with but their national network I can't tell you I see so many familiar faces in the in the audience It's rough being and I being in critical care It's rough being in in leadership as a physician or a PP and just being able to text folks commiserate together cheer for each other Celebrate wins That's really crucial so that they realize that their world is way beyond that unit and those beds that they take care of and There's an opportunity for them beyond just the daily grind of getting patients in the ICU and getting patients out One thing I didn't include here, but I think we mentioned on the last bit that I think we need to start thinking a lot more about as Leaders is the flexibility part within the schedule We implemented what we call effect flexibility policy for physicians and a PPS where they can elect to reduce their FTE and their shift count Obviously that's commiserate with compensation, but we've also heard that compensation isn't the Number one driver. It's get a given that everyone wants to be fairly compensated, but especially the younger generations They are choosing to be lower competent low having less compensation with better work-life balance they're okay with that and so giving people the opportunity to be a point eight or a point six and not always just having to Be a 1.0 It's something that we need to think about for both physicians and a PPS as well as seasonal staffing You know if we ever get back to a place where we have a flu season or you know We have ebbs and flows of lower census in the summer higher census in the winter We need to be able to be flexible There's some and you saw that the age range of our a PPS you saw that we're predominantly female most have children Younger children than our school age if we could staff up in the winter offer more shifts And you work a lot in the winter But then staff down in the summer so that you can spend more time home with your kids Being flexible and creative in the way that we're doing it rather than just thinking about you know 40 hour weeks 80 hour pay periods. I think it's going to behoove us Significantly so I think that's I think that's all

Advanced Practice Providers

APPs

PA workforce

NP workforce

engagement

retention