Why focus on PAs and NPs? For one, recruiting them is extremely competitive. We have more open positions than qualified applicants.
Another reason we want to create a great PA/NP practice is to help limit turnover. As a group, PAs and NPs generally change jobs more frequently than physicians — probably due to the competitive market and abundance of opportunities available.
Provider turnover creates two types of costs for a practice. First is the direct cost. Recruiting and training a new provider can run 1.5 to 2.5 times that provider's annual salary. There are also considerable operational costs associated with getting the new person functioning in their new environment.
Finally, PA and NP provider satisfaction scores for our practice (which we assess every fall) have remained good but flat over the past few years. Ideally, we'd like to see these numbers improve year by year.
To develop a deeper understanding of the factors driving PA/NP practice satisfaction, we held two focus groups for our site leads (practice-level leaders). Based on the results, we identified six priorities for engaging, retaining, and integrating these providers:
1. Include the PAs and NPs in monthly provider group meetings.
2. Practice financial and operational transparency.
3. Offer diversification of clinical practice to manage fatigue and burnout associated with working long periods in the ED's frontend.
4. Set behavior expectations that physicians treat PAs and NPs with courtesy and respect.
5. Compensate fairly.
6. Integrate PA/NP leaders into the site management team.
These recommendations had a unifying theme: to treat PAs and NPs with respect and appreciation, like professionals. But attempting to change established human relationships is a risky, emotionally charged undertaking. To help underscore the idea that we're all in this together, we decided to apply collaborative learning to the problem.
Translating Recommendations Into Practice
The Institute for Healthcare Improvement's collaborative change model brings participants from many hospitals together to focus on a problem, implement possible solutions, and learn from one another in the process. Vituity has successfully used "collaboratives" to improve ED turnaround times and patient experience. We hoped to achieve similar results with PA and NP satisfaction.
The PA and NP practice collaborative ran from June 2015 to January 2016. Seven practices were invited to participate based on Regional Director recommendations and 2014 satisfaction survey scores. They represented three states and EDs of all sizes.
We first brought the participants together for a one-day kickoff event. The faculty included our Chief Operations Officer, Vice President of Operations, Vice President of Talent Management, Senior Human Resources Manager, Director of PA/NP Operations and our PA/NP Regional Leads.
Each of the participating hospitals sent an "integrated leadership team" that included the PA/NP site lead, medical director, physician liaison, and regional director. The kickoff provided participants with protected time to explore best practices, assess their strengths and weaknesses, and develop an action plan.
Over the next few months, the participants worked with their frontline providers to implement their plans. During this time, they held regular coaching calls with the regional lead PA/NPs. This increased accountability, maintained forward momentum, and provided opportunities for troubleshooting.
During the collaborative, our PA/NPs took their annual satisfaction survey. We hoped the results would help us to measure the initiative's impact.
The Sites Report Back
The seven site teams reconvened in January 2016 at the Medical Director Meeting to formally close the collaborative and share their learnings.
The most effective practices varied by site. Many teams had begun including the PA and NP leadership in meetings and key decisions. Having greater input into practice matters raised PA and NP morale and satisfaction.
Teams also appreciated changes to the front-end ED process. Working in this environment can be demanding and fast-paced and can quickly lead to fatigue and burnout. To prevent this, clinicians rotated in and out of the frontend every few hours, allowing them to practice in a wider range of settings (fast track, main ED). The latter in particular gives our PAs and NPs the opportunity to grow professionally through working alongside physicians on more complex cases.
All seven sites reported significant improvements in working relationships. Once medical leaders raised their expectations and provided individual feedback to physicians, teamwork improved dramatically.
Some of the biggest positive changes were unintended. "Teams said the collaborative experience opened up the dialog among team members about how to improve the practice," says Cyndy Flores, Director, PA/NP Strategy and Innovation and collaborative faculty member. "At many of the collaborative sites, this was the first time they really sat down as a group to work on it."
At the end of the collaborative, several of the medical directors and site lead PA/NPs said the department had experienced a cultural shift. "They implemented many best practices, but the greatest impact came from understanding that they were most effective — and most satisfied — when working as one team," says Aimee Nalle, Senior Human Resources Manager and collaborative faculty member.
PAs, NPs, and physicians were all very pleased with the experience. Several commented that they wished the collaborative could have happened earlier. They also noted that the changes implemented weren't particularly demanding. Simple awareness and intention made a big impact on everyone's satisfaction.
About Those Survey Results
Collaborative participants' subjective reports of increased satisfaction were backed up by the results of our annual survey:
- Five of seven sites saw improvements in "sense of belonging." Some gains were quite marked, with scores rising by as much as 0.67 points on a 5-point scale.
- All but one site exceeded the 4-point benchmark for "sense of belonging." (The other was very close at 3.94).
We the faculty thought those results were pretty impressive, especially considering that the survey fell relatively early in the collaborative. We'll need to watch trends over a number of years before we draw any strong conclusions. We're also curious to see how well the teams sustain these gains.
The Leaders React
The teams' achievements within the collaborative exceeded our expectations as faculty members. We were impressed, proud and even a little moved. We felt that the experience had made a difference. While we'd given the teams a blueprint and tools for change, they'd gone a step further by transforming their culture and relationships.
Perhaps more than any other collaborative we've undertaken at Vituity, this one required courage. "The focus was highly personal," Flores says. "No one wants to be told they're being disrespectful or marginalizing their colleagues. The work these teams undertook required insight, dialog, humility, and honesty. We are impressed at their commitment in rising to this challenge."
We asked the participants whether there should be a second PA and NP satisfaction collaborative, and the answer was a resounding YES. Plans for the program are currently in the works.
We hope that over time, the collaboratives will provide us with intelligence that informs our recruiting and retention efforts. We'll also be studying how improved PA and NP satisfaction translates into other benefits for our group and client hospitals. Most of all, we hope to create a top-notch PA and NP practice that attracts and retains the best and brightest to our organization.
[Image credit: Photo by DIAC images licensed under CC BY 2.0]