106 trimarchi - melnic.com · auerbach, 2012; kline-tilford, 2013. 2/18/2015 2 need for acute care...

2/18/2015

1

Managing Nurse Practitioner Teams

in High Acuity Settings:

Unique Leadership Challenges

Tara Trimarchi MSN, RN, CRNPAdvanced Practice Nurse Manager

Critical Care, Radiology & Sedation

Disclosures

I have no disclosures related to this presentation

Learning Objectives

1. Articulate the trajectory for evolving pediatric

nurse practitioner practice in high acuity settings

2. Describe the unique challenges that face leaders

of pediatric acute care nurse practitioner teams

3. Identify key strategies for the successful

management of pediatric acute care nurse

practitioner teams

Managing teams of acute care NPs

requires unique knowledge and

responsibilities that fall outside the

traditional repertoire of healthcare

leaders, such as nurse managers, nurse

directors, and medical directors

Trajectory for

Acute Care PNP Practice

Growth of the NP Workforce

• As of 2008, there were ~128,000 full-time

equivalent (FTE) NPs practicing in the US

• The NP workforce is projected to grow to 170,000

FTEs by 2015 and to over 230,000 FTEs by 2025

– 94% increase

• 6000 to 7000 NPs per year from 2008 - 2025

Auerbach, 2012; Kline-Tilford, 2013

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Need for Acute Care NPs

• Hospitals are increasingly dependent on the use

of NPs to deliver front-line care to acutely ill

patients

– Early retirement of intensivists

– < 1% of medical school graduates enter critical care

• NPs are absorbing academic workforce shortages

due to the ACGME restrictions on resident duty

hours

Aiken et al., 2009; Riley, Poss, & Wheeler, 2013

Geographic Distribution of ACNP Practice

Klienpell, 2005

Klienpell, et al., 2009

Geographic Distribution of

ACNP Programs

Bolick, et al., 2012

Evidence for High Quality Care by ACNPs

• Acute care provided by NPs improves patient and

family satisfaction and is associated with shorter

length of stay, decreased patient complications,

morbidity and mortality

– Less evidence for pediatrics

NAPNAP Research Agenda

Professional and System Priorities

Priority 1: Role and Practice Issues

Ratio of Actual to Predicted MortalityLower is better – Desire ratio < 1

0.69

0.82

1.03

0.64

0.98

0.90

0.00

0.20

0.40

0.60

0.80

1.00

1.20

7E APP 7W 7S

SMR Based on PIM SMR Based on PRISM

Device Related HAI Rates

0

1.3

0.42

0

1.4

0.73

1.7

1.1 1.1

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

CAUTI Rate (per 100 catheter

days)

CLABSI Rate (per 1000 catheter

days)

VAP Rate (per 1000 ventilator

days)

7E APP 7W 7S

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Nosocomial Viral Infection Rates

0.39

0.8

0.96

0

0.2

0.4

0.6

0.8

1

1.2

7E APP 7W 7S

Nosocomial Viral Rate per 100

Admissions

0.9

1.5

1.7

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

7E APP 7W 7S

Nosocomial Viral Rate per 1000

Patient Days

Pediatricians’ Experiences with PNPsProportion, % (n)

Subspecialists Overall

(N = 1084)

Critical Care (N = 231)

Not currently working with NPs or PAs 31 (335) 45 (104)

Previously worked with NPs or PAs

Yes 39 (131) 35 (36)

No 61 (204) 65 (68)

Reason for not currently working with NPs or PAs

Did not make decision for practice 53 (178) 62 (64)

Too expensive for practice 18 (61) 14 (15)

Patients want to see physician 16 (54) 5 (5)

Prefer to hire/to work with physicians 16 (53) 15 (16)

Other 14 (45) 15 (16)

None available to hire 10 (33) 8 (8)

Never considered it 8 (27) 4 (4)

Inconsistent reimbursement 7 (24) 8 (8)

Freed et al., 2010

Pediatricians are receptive to

working with PNPs

PNP Clinical

Focus

Clinical Focus and Setting (N = 662) %

Clinical focus

Primary care/general 59

Pediatric specialty care 37

Pediatric emergency care 4

Patient care in inpatient hospital settings

None 64

Wards/floors 23

NICU 11

PICU 12

Other: newborn nursery 6

Other 8

Primary venue for care provided

Mostly outpatient 78

Mostly inpatient 12

Mix of inpatient and

outpatient10

Primary-practice setting

Private practice 39

Academic health center 25

Community hospital 14

Community clinic 10

School-based health clinic 7

Managed-care organization 3

Retail clinic/urgent care 1

Nurse-managed center 1 Freed et al., 2010

• Inpatient wards

and ICUs are

employing PNPs

• Frequently in

academic health

centers

46%

Acute Care PNP

Practice AnalysisKarin Reuter-Rice, 2012

• Nurses with 6-20 years of

prior experience as an RN

• Employed in urban

settings

• > 25% in critical care but a

wide variety of pediatric

subspecialties are

represented

Future Plan for Acute Care PNPs Subspecialists

Overall (N = 749)

Critical Care (N = 127)

Neonatologists (N = 201)

Will maintain current no. of NPs 29 (215) 20 (26) 30 (60)

Will maintain scope of work of NPs 19 (141) 19 (24) 24 (49)

Will increase No. of NPs 43 (320) 61 (78) 50 (101)

Will expand scope of work of NPs 25 (184) 34 (43) 18 (36)

Will decrease No. of NPs 1 (9) 2 (3) 1 (2)

Will decrease scope of work of NPs 0 (2) 1 (1) 0 (0)

Unsure 17 (131) 13 (17) 11 (23)

Freed et al., 2011

• >40% of subspecialties plan to increase the number

of PNPs practicing within the next 5 years

• 25% plan to expand scope of NP work

• Primarily for critical care and neonatology

Rate of PNP Growth is Flat

Kline-Tilford, 2013

Retention is critical to success of the role

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Critical Care PNPs & Overall CHOP PNPs

10.00%

80.00%

10.00%

3.10%

9.40%

40.60%

46.90%

0.00%

20.00%

40.00%

60.00%

80.00%

100.00%

Disengaged Ambivalent Content Engaged

Critical Care

Advanced

Practice

Provider

Engagement

All CHOP

Inpatient

Advanced

Practice

Providers

Content but not as “engaged” as other CHOP APPs

Opportunity:

Improve Acute Care NP Work Experience

• Studies demonstrate that NPs are minimally

satisfied to satisfied with their jobs

– Most satisfied with challenge and autonomy

– Least satisfied with opportunities for

professional growth and intra-professional

collegial relationships

• Few studies of AC-PNP job satisfaction

Action

Key to the Success of the Acute Care

PNP Role is Leadership

Action

Who is Leading NPs?Everyone and anyone?

• Directors of Nursing

• Medical Directors

• Nurse Managers

• Emergence of APN leadership roles

–Chief Advanced Practice Officer

–Director of Advanced Practice Nursing

–APN managers

Rhodes, Fusilero and Williams, 2012

Proposed NP Leadership Domains

1. Job Design

2. Recruitment

3. On-boarding

4. Orientation

5. Budget

6. Staffing & Productivity

7. Performance Evaluation

8. Continuing Education

9. Retention

10. Advocacy

Job Design

Recruitment

On-boarding

Orientation

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Acute Care PNP Role Design

• The role of the NP should be synergistic with

the specific needs of the patients cared for in

the acute care unit

• Maintain the Scope of Practice (SOP) within the

constraints of national and state regulations

• As possible, break with traditional medical

model roles, particularly in teaching hospitals


Adapted from APRN Consensus

Work Group & the National Council

of State Boards of Nursing APRN

Advisory Committee. (2008).

Consensus Model

Licensure,

Accreditation,

Certification &

Education

Pediatric Acute Care NP Preparation

Bolick, et al., 2012

Pediatric Acute Care NP Preparation Bolick, et al., 2012

Type of ICU Population

Focus

Wellness to Illness

Continuum

Certification Certifying Organization

Adult Medical

and/or Surgical

ICU

Adult-

Gerontology

Acute Care • ACNPC - Certified

Adult Acute Care

Nurse Practitioner

• ACNP-BC - Acute

Care Nurse

Practitioner-Board

Certified

• AGACNP-BC - Adult-

Geriatric Acute Care

Nurse Practitioner –

Board Certified

• American Association

of Critical Care Nurses

(AACN)

• American Nurses

Credentialing Center

(ANCC)

• American Nurses

Credentialing Center

(ANCC)

Pediatric

Medical

and/or Surgical

ICU, including

Cardiac Care

Units

Pediatric Acute Care CPNP-AC

Certified Pediatric

Nurse Practitioner in

Acute Care

Pediatric Nursing

Certification Board

(PNCB)

Neonatal ICU Neonatal Neonatal Care NNP

Neonatal Nurse

Practitioner

National Certification

Corporation (NCC)

Nurse Practitioner Acute Care Certification Options Regulatory Considerations for


• Licensure and certification

• Scope of Practice

– State Board of Nursing

– Possibly the State Board of Medicine

– Federal CMS regulations

• May dictate role in restraints and seclusion,

sedation, informed consent and

pronouncement of death

• Requirements for prescriptive authority

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Regulatory Considerations

• Requirement of supervision and/or collaborative

practice agreement with physician colleague(s)

Iglehart, JAMA,

2013

Elements of an Acute Care PNP

Job Description• Practice setting(s)

• Work hours including back-up or on-call services

• Supervision including degree of autonomy and

independence in decision making

• Reporting structure

• Responsibilities

– Functions and specific activities that are to be

carried out, including performance of

consultative roles, response to emergencies

and procedures

Elements of an Acute Care PNP

Job Description

• Expectations for

– Orienting other NPs

– Teaching

– Research

– Committee participation

– Administrative support / support of systems

Clinical vs. Non-Clinical Activities

• Time acute care NPs spend in direct clinical

care ranges from 30% to 100% (Brown, 2008;

Verger, 2005)

• ICU NPs spent nearly 85% of their time on

patient-care-related activities, of which three

fourths of the time corresponded to billable

services (Carpenter et al., 2012)

Acute Care PNP Recruitment

• Advertisements

• Job fairs

• Development of RN staff

• Networking via schools of nursing and

professional organizations

Acute Care PNP On-Boarding

• Process for granting Credentials and Practice

Privileges conducted by Medical Staff Affairs

– Screen NP

• Job Description with Scope of Practice

–Request for Practice Privileges

• Letters of Reference

• Background checks related to child abuse and

criminal record

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Documents Required for

Acute Care PNP Credentialing

• License and Certification

– Collaborative Practice Agreement (if required by

the state)

– Prescriptive Authority

• Controlled Substance Registration Certification

(DEA Number)

• National Provider Identifier (NPI)

• Medicaid Provider Number

• Medical Liability Insurance

Acute Care PNP Orientation

Competency based

It makes a difference who you hire!

• Pediatric acute care programs guarantee that graduates have completed a minimum of 500 practice hours in a clinical setting associated with management of complex acute, critical and chronically ill children

• Years and type of bedside RN experience

• PALS or other specialty certifications

Hospital-Based NP Orientation IssuesBahouth & Esposito-Herr, 2009

Lack of Role Clarity

Clinical Insecurity

Imposter Phenomena

Unable to articulate

role

Lack of clinical

confidence &

unrealistic expectations

Feeling like in the

wrong role or doing

someone else’s job



Clinical Insecurity

Imposter Phenomena

Access to Resources

Professional Socialization

Acute Care PNP Orientation GoalsSorce, Simone, & Madden, 2010

Clinical Practice

• Appropriately and effectively manages;

• Impending and actual organ system failure

• Fluid and electrolyte balance

• Nutrition

• Analgesia and sedation

• Communicates effectively

• Collaborates

Pharmacology

• Articulates an understanding or drug mechanism of action and rational for prescribing

• Uses safe prescribing practices

• Appropriately adjusts drug doses for age, size and renal and hepatic impairment

Diagnostic Modalities

• Appropriately and effectively orders and interprets

• Radiographs

• CT

• MRI

• EKG

• EEG

• Ultrasounds

Technical Competencies

• Will vary by job

• Safely and effectively performs

• Vascular access (central venous and arterial lines)

• Lumbar puncture

• Endotracheal intubation

• Chest tube placement and removal

Acute Care PNP Orientation GoalsSorce, Simone, & Madden, 2010

Supportive Child/Family Care

• Recognizes and evaluates the psychosocial needs of children and their families

• Identifies and provides access to supportive resources

• Demonstrates respect, sensitivity, and skill in dealing with death and dying with the child, family, and other healthcare professionals

Ethics

• Obtains informed consent

• Protects human research subjects and adheres to ethical guidelines for study enrollment

• Effectively manages end-of-life decision making and care

• Participates in organ procurement activities

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Clinical Insecurity

Imposter Phenomena

Professional Transition to Practice

ProgramsScholtz, King & Kolb, 2014

Transition to Practice ProgramsScholtz, King & Kolb, 2014

Fellowship Day Theme

Day 1 Role transition

Day 2 Clinical practice and the effectiveness of

the APRN role

Day 3 Quality and patient safety

Day 4 OPPE, billing, coding and documentation

Day 5 National perspective on APRN practice,

local and national professional

development opportunities

Transition to Practice ProgramsScholtz, King & Kolb, 2014

Impact:

– Networking

– Patient referral opportunities

– Turnover rate of less than 2%

– Key driver in the final decision in selecting

organization by new hires

Budget

Staffing & Productivity

Salary

• Average salary of NPs working in hospital-based acute care units ranges from $93,943 to $97,680 (Pronsati et al., 2010, Gershengorn et al., 2012)

• Factor in pay for;

– Overtime or “moonlighting”

– On-call differential

– Back-up call

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Acute Care PNP Non-S&W Budget

• Reimbursement for license and certification

• DEA registration

• Fees associated with changes in collaborative

practice agreements (which may be required any

time a physician leaves or joins the practice

associated with the NP team)

• Lab coats

• Conference and other education and travel stipends

• Resources such as computers and smart phones

• Recruitment efforts

The Financial Impact of Acute Care

Nurse Practitioners

• As billing providers, NPs can add revenue via

gross collections

– Must account for lower reimbursement

rates and impact on physician billing

– Salaries can not come from a nursing

department cost center that bills for a daily

nursing charge

Financial Impact of Adding Nurse

Practitioners to Inpatient Care TeamsKapu et al., 2014, JONA, 44

• Estimated savings of $28 million over two years

– Improved charge capture

• Gross collections compared with expenses

were 62% to 32%

• Covered costs of salaries (except SICU)

• Lower resource use

• Most clinical outcomes improved

Financial Impact of

Adding Nurse

Practitioners to

Inpatient Care

TeamsKapu et al., 2014, JONA, 44

• Charges and gross

collections increased

• Except for the SICU,

increased gross

collections covered

the cost of NP salary

and benefits

Inpatient NP Billing 101

• NP’s salary must be listed on the hospital’s Medicare Part B cost report in order for he/she to bill (unbundled from payment to a hospital cost center)

– Otherwise salary is accounted for under Medicare Part A and cannot be billed a second time

• NP must be nationally certified and have a graduate degree

• Serviced billed for must be within Scope of Practice


• Billable inpatient services

– Evaluation & Management (E&M)

• Three types of billing;

1. Direct

2. Shared

3. Incident to a physician’s services = Outpatient

setting only

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• Direct Billing

– NP’s own National Provider Identifier (NPI)and Medicaid Provider Number

• Reimbursement occurs at 85% of the physician fee schedule (payer dependent)

• Shared Billing

– Billed under the NP’s or the MD’s NPI

– Collaborating on the same day and employed by the same group practice / entity (partially)

– Requirement of face-to-face contact is to ensure that the E&M service was “shared”

Staffing and Productivity

• Work Hours

• Provider to Patient Ratio

• Measuring Productivity

Acute Care PNP Work Hours• Safety first

– Shifts or work daytime hours plus time “on call” to

cover nights, weekend and holidays?

• Use ACGME standards with great caution!

– Career not a training program• A maximum of 80 hours of duty per work week

• Duty periods of no greater than 16 hours for new providers

• A maximum of 24 continuous hours, with a scheduled break after 16

hours, for intermediate and more experienced providers

• 10 hrs between duty periods and 14 hrs free from duty after 24 hrs

of in-hospital duty

• No more than 6 consecutive nights of night duty

Pastores, et al., 2011

• Evidence that providers who are over 40 years old

are more likely to experience the negative

cognitive effects of sleep deprivation due to

prolonged night duty (Dean, Scott, & Rogers, 2006;

Reid & Dawson, 2001)

• The average age of new NPs entering the

workforce is 38 years (Auerbach, 2012)

Work Hours

• National Association of Neonatal Nurses (NANN)

and the National Association of Neonatal Nurse

Practitioners (NANNP) Standards - 2012

– Maximum shift length of 24 hours

– A period of protected sleep after 16 hours of

consecutive work

– A maximum of 60 work hours per week

Work Hours Provider to Patient Ratio

• Recommendations are based on benchmarking

• Have not been systematically studied for safety

or effectiveness

– Often based on trainee ratios

• Intensive Care Units

• Days: 1 APP per 5-7 patients

• Nights, Weekends and Holidays: 1

APP per 10-14 patients

• Intermediate and General Inpatient Units

• Days: 1 APP per 7-12 patients

• Nights, Weekends and Holidays: 1

APP per 14-24 patients

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0

20

40

60

80

100

120

140

160

180

200

0

20

40

60

80

100

120

140

160

180

200

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23

Tota

l V

olu

me

Hour

Critical Care Activities & Time of DayPERIOP COMPLEX ADMISSION EMERGENCY DEPT ADMISSIONDIRECT ADMIT IP TRANSFERDischarges/Transfers Radiology Tests

Multiple activities occur at night

and during change of shift handoff

and morning rounds

Measuring Productivity

• Critical for calculating FTE needs

– % clinically productive

• Example; 13% non-productive / 87% clinically

productive

–FTE = 2080 hrs/year

»87% of 2080 = 1800 hrs of clinical

service per year

Sample Productivity Calculations

McKenna et al., (2011), Critical Care Nurse, 31

Monthly Analysis

Annual Budget

Type of Paid Hours Per Pay Period

0

100

200

300

400

500

600

700

800

900

1000

1100

1200

1300

1400

1500

1600

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33

Regular OT Bereavement Jury Duty OrientationTraining National Holiday Sched PPL Unsched PPL FMLA

FY 2014

Target productive hours

Original Staffing

Target 1000

Additional night time provider

Target 1200

Addition of weekday triage provider = Target 1330

900

1000

1100

1200

1300

1400

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33

Productive Hours of Service

FY 2014

Steady increase in the number of hours of clinical care

delivered by the APP team

Percent Non-Productive Hours

and Percent of Productive Hours Paid as Overtime

%

0

5

10

15

20

25

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33

% Non-Productive % Productive as OT

FY 2014

Expected correlation between non-

productive time and use of OT

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%

0

5

10

15

20

25

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33


FY 2014

Unexpectedly high use of OT during

time of low non-productive hours

Winter months when

calling in extra help



%

0

5

10

15

20

25

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33


FY 2014

Unexpectedly low use of OT during

time of high non-productive hours

May reflect better staffing levels

at start of FY 14

Performance Evaluation

Continuing Education

Retention

Advocacy

Balanced Score Card for an

Acute Care PNP Team

Staffing, Productivity

& Care Model

Clinical Outcomes

Patient SafetyJob

Satisfaction

Financial

Process

Customer

Employee

• Clinically

productive

hours of

service

• Use of OT

• Hand-overs

• Work hours

and work load

• Mortality

• Infection

rates

• Employee

engagement

in the NP role

Kapu &

Kleinpell,

2012

Acute Care NP Professional Practice Evaluation Model FPPE

• Focused Professional Performance Evaluation

– Joint Commission 2007

• Process whereby the organization evaluates the

privilege-specific competence of the practitioner

who does not have documented evidence of

competently performing the requested privilege

at the organization

– Orientation (also called a New PPE)

– Practice concerns

• Performance Improvement Plan

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OPPE• On-going Professional Performance Evaluation

– Joint Commission 2007

• On-going monitoring of the privilege-specific competence of the practitioner

– Peer review

– Chart audit

– Procedure logs

– Simulations

– Continuing education

– Monitoring of practice patterns (prescribing, allergy verification, use of protocols)

• Annual performance

evaluation is only ONE

element

• Must be an on-going

process - e.g. quarterly

Professional Performance Evaluation

Definitions

Mackary et al., 2011, AMA

Acute Care PNP Continuing Education

• Required for OPPE

• Likely required for recertification and license

renewal

• Specific credits in pharmacology may be needed

to maintain prescriptive authority

• Clinical and professional knowledge (regulatory

and legislative issues)

Acute Care PNP Professional Development

• Opportunity for professional development and

advancement is a frequent cause of job

dissatisfaction

– Critical to retention of senior staff

Clinical Ladders for NPs

• Structure and processes for NP professional role

development, financial compensation, and

improved job satisfaction

– Evaluative schema of;

• Clinical experience

• Academic preparation

• Professional accomplishments

• Translational research activities

• Community service involvement

Paplanus, Bartley-Daniele and Mitra, 2014

• Program goals included;

– Professional advancement foundation for newly

graduated NPs

– NP practice level delineation

– Structured mentorship

– NP behavioral competencies development

– NP practice accountability

– NP job satisfaction and retention

Clinical Ladders for NPs


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Clinical Ladders for NPsBased on Benner’s novice to expert model


Newly hired < 2 years

of NP experience

Newly hired > 2 years

of NP experience

5 years NP experience

Exceed competency

performance criteria

8 years NP experience

Exceed competency

performance criteria

Level 1B clinical

competence and

behaviors exceed

Level 2 clinical

competence and

behaviors exceed

Level 1B clinical

competence and

behaviors met

Doctoral degree or enrollment in a doctoral program,

or equivalent level of combined NP experience and performance

Acute Care PNP Retention

• Studies of mixed samples demonstrate that NPs

are minimally satisfied to satisfied with their jobs

– Most satisfied with challenge and autonomy

– Least satisfied with opportunities for

professional growth and intra-professional

collegial relationships

• Acute care NP studies identify additional concerns

with role confusion and lack of appreciation of

expertise as compared to physician trainees

Known NP Job Satisfiers

• Reduction of non-APN tasks

• Provision of administrative support

• Mentoring programs (particularly for new APN

graduates)

• Roles that allow practice at the fullest scope of

expertise

– Avoid use of acute care NPs and resident substitutes!

• Career advancement opportunities

Faris et al., 2010

Advocacy

• Advocate for;

– Leadership and infrastructure that supports

acute care PNP practice within the institution

– Legislation that removes barriers to practice at

the state and federal level = political action

– Requirements for higher education and specialty

certification

– Access to education

– Design of roles/jobs that fully utilize NP talents

– Career advancement opportunities

All of the above!

Summary: NP Leadership Domains

1. Job Design

2. Recruitment

3. On-boarding

4. Orientation

5. Budget

6. Staffing & Productivity

7. Performance Evaluation

8. Continuing Education

9. Retention

10. Advocacy