SCCM Resource Library-PAs and NPs in the CCO

Video Transcription

Hello, I'm April Kapu, I'm an acute care nurse practitioner, my background is in the cardiovascular ICU.  I will be speaking with you today about physician associates and nurse practitioners in the CCO, particularly optimization of structure, value, and utilization.  We will discuss ideal staffing and care delivery models, draft a business plan or proforma,  considering staffing productivity and quality expectations, and then discuss the recruitment and retention of NPs and PAs within the CCO. My disclosures are here.  As this panel was being assembled, I thought it was quite profound that we're looking towards the future of healthcare.  How do we most effectively redesign healthcare delivery to improve quality, safety, efficiency, patient-centered care, timeliness of care, and equity?  How do we standardize that care and also our technologies? And also, while participating in quality assurance research and cost control.  This is really an exercise in idea expansion and looking towards the future of critical care organizations.  I really want to talk about three main topics when we're talking about structure and utilization of NPs and PAs within the CCO.  That is workforce development, making the business case for adding NPs and PAs, and thirdly, recruitment and retention of NPs and PAs in the CCO.  When we're talking about advanced practice workforce development, first we want to better understand the expectations for the role.  Then how do we staff appropriately for that role and what are the care delivery models in that particular critical care area, ICU, or within that organization?  We could literally talk for hours when we're talking about expectations, development, and implementation of NPs and PAs in the ICU.  However, we have about 20 minutes, so the bullets that I'll be pointing out will really be just high-level thought points as you are considering adding to, enhancing, or integrating  NPs and PAs in the ICU. So first, what are your expectations for the role? What will their clinical responsibilities be? How will they round?  How will they care for patients, present patients on rounds? What will their structure of the day be?  For example, in my institution, in our cardiovascular ICU, we pre-round in the morning. We prepare our presentation to the multidisciplinary critical care team.  We present this on rounds, and then others will participate in that discussion, and then we will form our plan of care.  After rounds, we will follow back up with the families about the plan of care. Then we will start the plan of care, putting in those orders. We'll also be performing procedures.  We'll be documenting that care. We'll be putting out fires throughout the day and coordinating and collaborating with consult teams, with our intensivists, and so forth.  So what is that care delivery model? I think that's very important in terms of understanding the clinical responsibilities for the role.  But also, will that nurse practitioner or physician associate be responsible for academic production? Will they be involved in research, in quality improvement projects?  Will they be responsible for teaching at any aspect, either in PPA students, or will they be part of the overall teaching team?  Will they have administrative tasks that they're responsible, such as scheduling, or recruitment, or orientation?  All of this needs to be configured as you're thinking about what your staffing model is going to be. You really must understand the care delivery model.  Before getting too deep into the utilization of NPs and PAs within the critical care setting, we really want to better understand the regulations around this.  So there are both institutional regulations, as well as state and national regulations. These are very important to understand because they can have impact on that overall care  delivery model. For example, what are their expectations in terms of maintaining their board certification? What are their requirements to the state?  Are they overseen by both the Board of Nursing and the Board of Medicine? Or one or the other? And if so, what are those requirements?  What are the bylaws for the institution regulating advanced practice? Are there nursing bylaws that have impact? Policies, procedures?  What is the credentialing and privileging process? And then, are there any accrediting bodies that have impact on advanced practice, such  as the Joint Commission, CMS, Magnet, or otherwise? This can have impact as you're developing your overall model of care.  And then understanding better, how is that care going to be delivered? What is the role? We've talked about expectations for the role, but how is the NP or PA's role delineated  from other members of the team? What are the specific responsibilities of that NP or PA going to be? How many patients is that provider going to need to care for?  And that really, you have to take into account complexity of care for that patient. So what I have done over the years is talk to different organizations about patient-to-provider  ratios for NPs and PAs. And we have found that anywhere from one to six to eight patients is a good number of patients to be able to provide comprehensive care.  However, if the patient is much more complex, if this is an ECMO patient or an open chest, there may need to be less patients for that NP or PA to oversee because of the simple  needs related to that patient care. What is the average census for that ICU? Understanding that will help you to better understand how many NPs or PAs you will need.  And then what is the coverage model or the staffing model? So will you be asking these advanced providers to be in the ICU 24-7, every single day of  the week, holidays, nights, et cetera, that has a better understanding that will help you understand the hours as well as the overall staffing model.  One error that is made time and time again is we might think we need only one NP added to the team.  But if you only add one NP and you have 30 beds and you're covering 24 hours a day, seven days a week, as you can see, that would be quite impossible.  So determining the correct number of NPs or PAs is very important in understanding the overall census, the acuity of care, the provider to patient ratio, et cetera, as well as the  responsibilities for the role are important. If you are integrating house staff, what are the NP or PA's role in comparison with house staff? How are they integrated?  Are there specific outreach services that the NP will be responsible for? Will they be seeing rapid response patients on the floors?  Will they be required to provide telehealth to other ICUs? So what are those outreach services that will be in addition to the NICU services that they will be providing?  And finally, when developing the staffing model and taking into account everything we just discussed, we really want to look at the average amount of hours that we would  like for that NP or PA to work on any given week. So that could be 40, that could be 40 to 50, et cetera, but what is the average amount of hours?  Now, will they be working days, nights, weekends, et cetera? All that should be determined up front as you are discussing this with a potential new NP or PA to your ICU.  You'll want to give them that information so they'll know what to expect on the front end.  Also, how are you incorporating non-productive time, meaning vacation time, time away, leaves of absence, holidays?  Are you going to be giving them any time away for continuing education, conferences, et cetera? So I've given an example of a model. This is a hypothetical model.  You can change out any of these figures, but basically in this particular ICU, the way we want to staff, because let's just say there are 16 beds in this ICU and you want  to have two NPs or PAs every day, two NPs or PAs every evening. Then you want to have a lead.  They're providing some support in terms of scheduling, recruitment, onboarding, et cetera. Let's say your expectation for the PA is that they be there 14 hours a day and that will  allow for some overlap between the daytime provider and the nighttime provider for handover, rounding together, et cetera.  This is how I've put together a quick spreadsheet model and I can change all of the figures quickly as needed.  What I've done here is shown each week, I'm going to need this many hours per week. If you'll look over each day, we're going to need two NPs each working 14 hours each  night, two NPs each working 14 hours, and then I have the total hours per week. Then I've calculated based on an average FTE, which is about 40 hours a week, how many FTEs  that would require. Then I've added a percentage to account for that non-productive time. So I've taken a look at the average leave of absence.  If somebody is out on parental leave, I've taken a look at our numbers of vacation days that we generally give, time away, et cetera, and that has come up to about 14%.  So the adjusted FTE total would be 12 FTEs total if I was going to have 16 to 18 patients on any given day that the NP or PA would be caring for.  Now again, every critical care organization, every ICU is different and therefore you have to account for the variances in roles, care delivery, the expectation, the complexity  of the patient, et cetera, but this is giving you an idea how to develop a template to determine how many FTEs you're going to need.  So let's start to making the business case for PAs and NPs in the critical care organization, taking into account expenses, productivity or revenue, and quality of care.  When we are considering the expense portion of the pro forma or business case, we really have to think about much more than just how much does it cost to hire an NP or a PA.  We have to think about a lot of different expenses that go into the implementation and sustainment of that role.  When we're talking about compensation, certainly we know there is a high demand for APPs in the critical care organization.  Salary should really be based on years of experience and their specialty. So if it's neurocritical care, cardiovascular critical care, surgical critical care, et  cetera, I would always recommend a benchmarking plan. So if you are using benchmarking associations, if you're using multiple, a blended market  rate, or if you're using one standard, using benchmarks and being consistent, nothing is worse than bringing in NPs and PAs at different salary models that can create a great deal  of consternation on the team. So being consistent and using benchmarks is very important. Also looking at internal equity, looking at making sure that there's not compression,  that as you're bringing on new NPs and PAs, that that's equitable with the existing NPs and PAs that you already have on your team. Are there any production incentives?  Will there be RVU incentives or quality incentives? Will the NP or PA be paid more if they are working nights or if they're working weekends?  All of this is to be considered, not saying that one is better than the other, but to consider it on the front end because you'll want to have that information as you are extending  an offer or negotiating a contract. Other expenses to be considered, will you have a training program?  Will there be a time where that NP or PA will not be fully productive or caring for patients but they will be in training and how do you account for that time?  Will there be professional development support? Will there be a stipend for that provider to be able to attend conferences or participate in CE events?  Will there be licensure reimbursement? Will they have membership reimbursement to associations? What will the cost of malpractice be as well as other non-salary expenses?  And don't forget the overhead or support or administrative personnel support for that NP or PA. So all of these components go into the expense line of that PROFORMA.  Moving on to the revenue line for the PROFORMA, first the question is will your advanced practice  professionals be billing? Some institutions do not have them in a billing role while others do and there's a lot of factors that go into making that decision.  But if they will be billing practitioners, taking into account their average billing activity on any given day or night, will they be billing time-based critical care?  Will they be billing for complex evaluation and management? Will there be consultations? Will they be billing for procedures?  And then looking at the overall institution and understanding the payer mix for that patient  population, the average collection rate, and then also very important, the ability to document and code accurately so that you can optimize the return on billing.  So on the right side of the screen, you can see an example PROFORMA. I haven't built out all of the cells to the right of that PROFORMA, but you can see an example.  Here's an expense line. I'm taking into account salary and then fringe benefits, everything that it costs for insurance and things like that, benefits to that employee.  I have a line for professional development stipend, training and supplies, if we're going to be paying for a lab coat and scrubs, they might need some office supplies, I definitely  want them to have a telephone or pager. Here's some internal departmental taxes for administrative support, and then I've accounted for malpractice coverage.  Again, this is just an example. There may be different expenses that you might want to weigh in.  On the revenue line, I've taken into account how many encounters on average will each NP be seeing on a daily, weekly and annual basis, critical care, time-based billing, both the  first module as well, the 99291 and the 99292s, as well as subsequent day E&Ms, will those be seen in the ICU?  I've taken into account consultations for outreach activity, and then I've given a couple of examples for some procedures that this NP or PA might be performing.  So these are all items to include on your proforma. The last component is recruitment and retention of critical care NPs and PAs.  So important, so important to recruit qualified, experienced NPs and PAs to your organization to integrate them and fully onboard them to the team, and then to look at overall job  satisfaction because you want these very valuable team members to stay with your organization for years and really contribute to the expertise of your team.  So this is my short list for recruitment. Believe me, there are a lot more components I would probably add if we had a lot more  time, but these are the key components to look for in terms of qualifications and candidate selection.  First, I would recommend an experienced recruiter, a recruiter that has hired NPs and PAs in  critical care before, a recruiter that understands the national certification requirements, the  education requirements, and licensure requirements, a recruiter that knows all of the different sites to recruit, both local and national sites to recruit qualified NPs and PAs.  You just really can't go wrong if you have an experienced or dedicated, if you can, recruiter for critical care providers.  The job description needs to be well-developed so that that potential candidate can review what is this job going to entail? What is the patient population?  What will my responsibilities be? Understanding what your preferred level of experience might be, you might be willing  to take new graduates, or you might be seeking more experienced NPs to complement your team. My recommendation is a critical care team that's balanced with both new graduates that  have had education and training in critical care, as well as more years of experience. It brings a depth and breadth of perspective that can really add to the team.  They must have or be in the process of obtaining their state license to practice as an NP or PA. They must have a board certification.  If it's a nurse practitioner, it needs to be in acute care. We often hear of nurse practitioners that have their education in primary care.  That is not going to meet the needs of the patient population in the ICU.  So you specifically want to seek an NP that has had their education and training and are board certified in acute care, and for PAs, looking for that program that has given them  experience in critical care.  I would recommend that the entire team interview the candidate. I know that takes a little bit more time, but for this person to feel as they are a  member and they're a good team fit, it is always important to have as many of the team interview the candidate as well.  Sometimes what we will do is have a smaller group interview a larger number of candidates and then have the top two or three candidates interview with the larger team or additional  stakeholders.  References are key.  Background checks are key. Pick up on things that could be red flags in references right away, and it may not come out on the interview.  It may not come out when you're having that phone conversation or Zoom conversation. So it's very important to get those references before extending an offer.  Some organizations have offer letters.  Some other organizations may have contracts. Depending on your organization, every legal department or department should review those  offer letters and contracts for consistency and making sure that they are clean contracts and that they state everything that is needed or expected up front.  There will be opportunities for negotiation. Again, benchmarking those salaries is key for consistency, looking at years of experience,  making sure that those salaries are consistent across your team. However, some NPs will want to negotiate, so building in a little latitude for negotiation is never a bad idea.  One thing that could be a potentially bad idea is to bring in a newer NP with less years of experience making a higher salary than your existing NPs that have more years of  experience.  Again, a small window for negotiation, but also making sure that you have internal equity and you're consistent and that you're really looking across the entire team that you have  balance in their salaries and compensation.  Many organizations will offer faculty appointments. That's certainly based on that organization and their preference, and if they do, they'll  want to include the information that the responsibilities that go with that academic appointment.  And lastly, retention, keeping your NPs and PAs engaged, satisfied, and very high performing on your team is so important.  You want those NPs and PAs to stay with your team and your organization for years to come  because their developed expertise over time is going to add to a very rich multidisciplinary team model for care.  The team environment is very important. Everyone is important on that team. Everyone contributes and has high value on that team, whether it's respiratory therapist,  occupational therapist, physical therapist, NP, PA, physician, resident, fellow, everyone is contributing to the team. So mutual respect is very important.  Allow for that NP and PA to ask questions, allow for conversation, that environment of  respect and education and teaching is so important for them to feel comfortable and to feel integrated  in the team and ultimately to be confident in what they're doing and providing care.  Some teams allow for flexibility and scheduling or even self-scheduling, or they'll work together as a team to work out their schedule based on their lives.  This is very important and we've seen this quite a bit over the past couple of years how important this is. Ongoing coaching and feedback.  This is more than just the performance evaluation or the annual faculty review. This is really ongoing coaching and support and feedback.  And a lot of this will come from the more senior NPs or PAs on the team, or it'll come from the intensivists, or it'll come from the physicians that are on the team, really  supporting the growth of that individual.  Support for training and education, allowing that NP or PA to attend an annual conference, go to SCCM to take part in all of the new and hot topics in critical care.  That's so important. And then a cultural of safety, not having a blaming environment, but a blame-free environment.  I've never seen this more than ever before during this last two years where the stressors were so high, but we really want to work to not have a blaming environment.  So when you have the day NPs reporting the plan of care on rounds, and they're looking back at what happened overnight, not quarterbacking what happened overnight, but saying, now  we're going to continue the care. So not blaming one another for things that might go wrong or decisions that are made, but also a culture of safety with patients.  We're seeing more and more patients, issues of patient violence. We really want to help protect every team member from that situation.  Checking in routinely. And then oftentimes you may want to do a more formal check-in in terms of job satisfaction.  I recommend a tool, it's called the Meisner tool, was developed by Dr. Ruth Meisner. And it really looks specifically at NP and PA job satisfaction.  And it looks across different areas, not just benefits and compensation, but it looks at opportunities for professional growth and development, opportunities for ongoing education.  So that's a great tool if you're wanting to look at overall job satisfaction.  In conclusion, and I know there are several other sessions specific to burnout, because that is huge right now. And it has been even before the pandemic.  How do we sustain the workforce?  How do we mitigate burnout? How do we mitigate the physical exhaustion, the mental exhaustion, the emotional exhaustion  that can come with taking care of very complex, critically ill patients day after day, night after night? How do we keep that team sustained?  And I just want to highlight the study that was done by Dr. Kleinfeld et al.  And published in Critical Care Medicine in 2020. So the work was done well before the pandemic, but had a huge impact on the pandemic.  I'd also like to highlight much of the work that was done by the National Academy of Medicine. But in Kleinfeld's group, Kleinfeld, Moss, Good, and Sesler, here is one of the quotes  that came from one of the participants in this study. The majority of well-being projects seem to stress individual wellness and ignore the overall environment we work in.  There needs to be a balance of individual wellness, as well as creation of an actual work environment that doesn't lead many to burnout.  They recommended promoting restructuring of workflow in the ICU, advocating for flexible and self-scheduling ICU team building events, limiting the maximum number of days to work  consecutively in the ICU, and making sure that those team members took time off for self-care.  And that is time away from the job, long periods of time, several days at least for vacation, time away refueling, rebuilding, and being able to come back and do what they really  love to do. And that is to care for critical care patients.  Thank you so much for the opportunity to spend some time with you today. And I look forward to questions at the end, as well as from hearing from my fellow colleagues on the panel.

Video Summary

April Kapu, an acute care nurse practitioner, discusses the optimization of structure, value, and utilization of physician associates (PAs) and nurse practitioners (NPs) within critical care organizations (CCO). She emphasizes the need to redesign healthcare delivery to improve quality, safety, efficiency, patient-centered care, timeliness, and equity. Kapu discusses workforce development, care delivery models, regulations, staffing models, and responsibilities of NPs and PAs. She also emphasizes the importance of understanding regulations, expectations, and responsibilities when considering the utilization of NPs and PAs. Kapu provides suggestions for making a business case for adding NPs and PAs to critical care organizations, including considerations for expenses, revenue generation, and quality of care. Lastly, she highlights the importance of recruiting and retaining qualified NPs and PAs and discusses key factors such as qualifications, recruitment strategies, and job satisfaction.

Asset Subtitle

Administration, 2022

Asset Caption

In recent years, mandates to improve healthcare quality and safety have created new challenges for hospitals in the United States. Medical centers now place great emphasis on redesigning healthcare delivery and improving their systems and quality of care to ensure broad-based safety, effectiveness, efficiency, patient-centeredness, timeliness, and equity. Critical care leaders are being challenged to address the rising patient demand for critical care services, the intensivist workforce shortage, education of new generations of critical care medicine physicians and advanced practice providers. Critical care leaders are being asked to standardize care and technologies in hospitals with many ICUs, optimize ICU integration in inpatient care and hospital throughput, and participate in quality assurance, cost control, research, and fundraising initiatives. In response, medical centers are developing new organizational models—critical care organizations (CCOs) of centers, institutes, and service lines—to provide nimble and flexible suprastructures across their entire organizations.

Meta Tag

Content Type Presentation

Knowledge Area Administration

Knowledge Level Intermediate

Knowledge Level Advanced

Membership Level Select

Tag Workforce

Tag Economics

Year 2022

Keywords

acute care nurse practitioner

critical care organizations

healthcare delivery

workforce development

regulations

job satisfaction

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