Advanced Practice Provider - Professional or Shift worker?

Friday, June 28, 2019 | Ginger Biesbrock

A month ago, a very important question was posed on the MedAxiom member listserv: “How many hours a week should a full time APP work?” Now, this question comes up about every 6 months and there is definitely tension around the answer to this question. It’s a common issue that I see both administrators and APPs are dealing with. But I actually think that the question is deeper than just the number of hours. I believe that this tension comes from the difference between treating the APP team as a team of professionals versus as a team of shift workers. The difference lies in the expectations that go both ways. Expectations of administrative/physician leadership in the communication and oversight for APPs and expectations of the APPs in their responsibilities to patients and to the program in which they work. I promise I will get to the answer for how many hours should a full time APP work, but I want to start with an outline of what I think are reasonable expectations from both perspectives.

Physician/Administrative Leadership

From my perspective, there are several key expectations of the leadership team that are required in order to have a healthy team-based environment where APPs grow, thrive and give back to the program.

  1. A commitment to the team-based care model where the APP role is defined, the expectations are provided and the vision is shared by all. If an APP is hired with and handed a clinic schedule with no clear definitions around patient type, communication, their role in the care pathway or delivery model, the program will fail. I promise you that.
  2. A commitment that the APP is a valuable member of the team and recognition that team outcomes are better with them on the team versus not on the team.
  3. A commitment to professional growth and development where the APP receives routine education (both formal and informal) and routine feedback on clinical decision making, documentation and their interaction with the rest of the team. APPs want to do great work and need feedback in order to grow and improve.
  4. A seat at the leadership table where the APP role is represented for organizational decisions that affect the APP team. For programs of eight to 10 or more APPs, I suggest an APP lead or supervisor that has regular interface with administrative and physician leadership. Many programs will include the APP leader in program leadership committees where they can provide valuable input around program development and performance.
  5. System equity. If your program is part of a large system, then a commitment to compensation and benefit equity is extremely important. This can take some blocking and tackling to assure that the role of the cardiovascular APP is recognized for any call, off-shift work, scope of work and acuity of patient management. If the system has a one-size-fits-all compensation philosophy, you will never win as you will be competing in your own system for better hours and possibly better pay. If you have ‘special’ deals within your own team where folks have been given special hours, bonuses or compensation models as one-offs, you will also lose. You will lose any trust that you had with the entire team when special deals begin to happen.
  6. A patient-focused philosophy on total hours worked. We all know that patient volumes fluctuate and last minute patient needs occur. However, if the reasonable ‘work week’ expectation is prolonged due to physician need or lack of appropriate resources to manage the workload, then the definition around total hours worked is no longer meeting responsibility #1. I often see APPs get their portion of the work done for the day but have to stay late to co-round with physicians who have had administrative, procedural or even personal responsibilities that cause the schedule to be behind. Another example is clinics that run late due to no support for rooming or chart prep, creating an increased workload for the APP without a reduced expectation on patient volumes. I suggest that neither of these scenarios are fair to the APP on the team.

Advanced Practice Providers

You are not off the hook as the expectations need to go both ways. Many of you have emerged into the world of professional from a previous role as a shift worker or hourly employee. The rules have changed.

  1. A commitment to team-based care where you commit to your role on the team and the requirements for communication, work hour fluctuation and program engagement.
  2. A commitment to professional growth that includes both clinical skills but also administrative skills that will promote efficiency, good team communication and leadership influence within the team.
  3. A commitment to understand the needs of the program and patient population in which you are working and how those needs are best met even when that may mean a change in work hours, a need to stay late or a need to change your role. This is a hard one because many of us have taken an 8 a.m. – 5 p.m. position only to have the expectation changed months or years later. Or you have taken a position that fit your lifestyle but when your lifestyle changes that position is no longer a good fit. Remember cardiology is a 24/7 business and part of working in the field is respecting that and knowing that the clinical need of the APP role could change. I am not saying that you have to stay in the role, but I am saying that when I hear an APP describe their role as ‘unfair’ or ‘unreasonable’, it is often not that the position is unreasonable, it just no longer fits with their life priorities. Those are two different issues. Make sure you call it what it is.
  4. A commitment to professional leadership and influence within your team and your organization. The role of an APP is more than just patient care, it’s often a resource to others on the team (RNs, MAs, schedulers, etc.). Never underestimate both your ability to have positive influence but also negative influence.

So, back to the question at hand. How many hours are considered reasonable for a full-time APP? We put together a survey and had 61 responses to help answer that question and many others. The majority response was greater than 40 hours (see Figure 1). I typically recommend 45 hours on average with the caveat that if it creeps up to closer to 50 hours on average, then it’s time to think about a realignment of responsibilities or consider adding an additional APP to the team. In addition, the question of employee type was asked, and 97 percent answered that the APP role was an exempt role in their organization. Hence, the importance of understanding the expectation for both leadership and the APP in this professional relationship.

Figure 1

Finally, I have been thinking a lot lately about organizational health. I have worked in both healthy and unhealthy organizations. The health of an organization starts with expectations and any time those are not aligned there will be a struggle. That being said, there are so many challenges in our industry currently that alignment requires trust, communication, hard work and constant surveillance. When I work with organizations that are struggling, rarely do I find that the wrong people are in the roles but rather there is a misalignment of expectations. I appreciate you allowing me to go deep to answer a fairly easy question. As I stated when I started, if this is a hot topic in your organization, there may be a misalignment of expectations and I would start there as you look to come up with an answer that meets the needs of both the organization and its APPs.

Illustration: Lee Sauer

About the Author
Ginger Biesbrock

Ginger Biesbrock, PA-C, MPH, MPAS, AACC, is Executive Vice President, Care Transformation. She is a respected executive, provider and teacher with 20+ years of experience in the health care industry with a concentration in clinical care and operations. Before joining MedAxiom Consulting, Ginger was Director of Operations at West Michigan Heart, a 39 Physician practice with 24 mid-level provider. At West Michigan Heart, Ginger oversaw all operations for ambulatory services, tertiary care and rural health practices. Prior to that Ginger was the COO of the Cardiovascular Group at Centra-Health.

Her areas of consulting expertise include APP Utilization, Care Team Optimization and Transitions of Care.

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Posted by: Edward Fry on June 30, 2019 @8:05:52 am

Ginger, great blog post. APP's are valued professionals integral to the high function of a well integrated care team. The success and satisfaction of the APP is dependent on the professionalism of the APP, collegial collaboration with the physician team members, and the philosophy and structure of the care team itself. Each leg of the three legged stool supports the other. Each has its own goals and accountabilities. But, together creates a stable platform for patient focused care. Conversely, frictions occur when each component is not fully developed or is not coordinated with the others.

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