Advanced Practice Providers Perceptions of Patient Workload: Results of Multi-Institutional Survey

Transcription

1 Advanced Practice Providers Perceptions of Patient Workload: Results of Multi-Institutional Survey Tamara S. Goda, DNP, RN, ANP-BC Vidant Medical Center Greenville, NC 2017 NPSS Asheville, NC

2 Working Group and Contributors (in alphabetical order): Aaron Begue, MS, RN, FNP, The Ohio State University Health System Lacey Buckler, DNP, ACNP-BC, NE-BC and Vicki Turner, ACNP-BC, APRN, CCRN, University of Kentucky Medical Center Jennifer Derkazarian, DNP, ANP-BC, Lahey Hospital and Medical Center Tamara S. Goda, DNP, ANP-BC, Vidant Medical Center April N. Kapu, DNP, APRN, ACNP-BC, Jason Jean, MSN, APRN, FNP-BC, Elizabeth Card, MSN, RN, and Nancy Wells, DNSc, RN, FAAN, Vanderbilt University Medical Center Maria A. Lofgren, DNP, ARNP, NNP-BC, University of Iowa Hospitals and Clinics Amy Mangum, MSN, NNP, PNP, Duke University Health System Carmel A. McComiskey, DNP, CRNP, FAANP, University of Maryland Medical Center Bonnie McCracken, MSN, APRN, University of California, Davis Medical Center Colleen K. McIlvennan, DNP, ANP, FAANP and Reenie Zaccardi, MSN, ANP, University of Colorado Hospital Julie Raaum, MSN, DNPs, ARNP, FNP-BC, AAHIVMS and Colleen Trevino, MSN, APRN, Medical College of Wisconsin Patricia M. Selig, PhD, APRN, FNP-BC, FNAP, Virginia Commonwealth University Medical Center Cecelia Smith, MSN, ANP-BC, Indiana University Health Barbara Todd, DNP, CRNP, FAANP and Corinna Sicoutris, MSN, ACNP-BC, FAANP, FCCM, University of Pennsylvania Health System

3 Background/Purpose: APRNs and PAs have been shown to contribute to positive outcomes in providing accessible, cost-effective, high quality care, and are increasingly being added to health care practices across the continuum. In the Fall of 2014, a group of Advanced Practice Provider (APP) leaders shared a common interest to investigate the perception of APP workload and develop an understanding of variables that could impact that workload.

4 The Collaboration JONA Volume 46, Number 10, pp Copyright 2016 Wolters Kluwer Health, Inc. All rights reserved. JOURNAL OF NURSING ADMINISTRATION 10 years ago, started with Annual APP Leadership Summit via APPEX APP leaders- both formal and informal coming together to discuss common challenges- outcomes, model development, transition to practice, billing/reimbursement issues and metric creation The Advanced Practice Provider to Patient Ratio Survey first major body of work describing reality of APP work Survey development was accomplished in mid 2014 through collaboration by telephone, and conference call UHC/CAP2 Thought Leaders- widely distributing best practices on a variety of issues (above) Policy creation at the local, regional and national level to establish much needed changes and guidelines, ex. Hospital bylaws and independent practice legislation.

5 Dear Advanced Practice Provider, We are conducting a survey to understand advanced practice provider patient ratios, how many patients advanced practice providers care for, on a daily and weekly basis, in their various areas of practice. The resulting information will enable a multi- institution study to assess advanced practice provider patient workload. Results of this study will be reviewed in aggregate, de-identifying data across multiple institutions. However, each institution will receive its own de-identified data summary in addition to the aggregate summary. Thank you in advance for your willingness to complete the survey. We estimate that this survey will take 10 minutes to complete. Individual participants cannot be identified by the study. Participation is entirely voluntary.

6 The Advanced Practice Provider to Patient Ratio Survey Fourteen institutions sent approximately surveys (actual number received unknown as s may have been forwarded to additional recipients) to PAs and APRNs 26 questions- multiple choice or yes/no; final question open ended for comments Basic demographics of APP and description of current practiceinpt/outpt, primary vs. acute and specialty care. Number of pts seen, time per patient -both new and return visits, do you take call/work with residents/fellows? Required hours, coverage for time off and systems in place for additional help in high volume/acuity times Hours spent doing direct vs. indirect patient care activities, follow up and supportive care. What do you feel would be reasonable and/or safe? How many patients are you actually taking care of.

7 Results

8 1461 surveys were completed (36%) between November 14, 2014 and January 31, 2015 representing 11 academic medical centers Years as APRN Years in Current Position Years of Experience n % n % < 1 year years years years years years years years

9 Results 600 (41.1%) of the respondents indicated working mostly in an inpatient setting, 609 (41.7%) indicated working mostly in an outpatient setting 233 (15.9%) reported working in both settings; of those, 71.2% see both inpatients and outpatients on the same day Separated out by specialty practice type- cardiology, critical care, cardiac surgery, neuro, behavioral health, etc. Documented % patients that respondents felt was within a reasonable (R) workload and corresponding % of patients that were within the respondents actual (A) workload.

10 Reasonable Versus Actual Patient Load, Inpatient (N = 600) Practice Area (At-Risk Areas in Bold) n Pts., % Pts., % Pts., % Pts., % Pts., % Pts., % Pts., % Pts., % Anesthesia, OR, pain IN-R Anesthesia, OR, pain IN-A Med specialties IN-Ra Med specialties IN-Aa Hema-onc IN-R Hema-onc IN-A Cardiac surgery IN-R Cardiac surgery IN-A Cardiology IN-R Cardiology IN-A Critical care IN-R Critical care IN-A General surgery IN-R General surgery IN-A Neonatology IN-R Neonatology IN-A Neurosurgery IN-R Neurosurgery IN-A Behavioral health IN-R Behavioral health IN-A Surgical specialties IN-Rb Surgical specialties IN-Ab Transplant IN-R Transplant IN-A Hospitalist IN-R Hospitalist IN-A Neurology IN-R Neurology IN-A Orthopedics IN-R Orthopedics IN-A Palliative care IN-R Palliative care IN-A Pediatrics IN-R Pediatrics IN-A Trauma IN-R Trauma IN-A

11 Reasonable Versus Actual Patient Load, Outpatient (N = 609) Practice Area (At-Risk Areas in Bold) n 4-6, % 6-8, % 8-10, % 10-12, % 14-16, % 16-18, % 19-22, % 23+, % Hema-onc OUT-R Hema-onc OUT-A Cardiology OUT-R Cardiology OUT-A Neurology OUT-R Neurology OUT-A Surgical specialties OUT-Ra Surgical specialties OUT-Aa Transplant OUT-R Transplant OUT-A Primary care OUT-R Primary care OUT-A ED OUT-R ED OUT-A Family med OUT-R Family med OUT-A OB-GYN OUT-R OB-GYN OUT-A Urology OUT-R Urology OUT-A Anesthesia, OR, pain OUT-R Anesthesia, OR, pain OUT-A Med specialties OUT-Rb Med specialties OUT-Ab General surgery OUT-R General surgery OUT-A Neurosurgery OUT-R Neurosurgery OUT-A Orthopedics OUT-R Orthopedics OUT-A Pediatrics OUT-R Pediatrics OUT-A Behavioral health OUT-R Behavioral health OUT-A Radiology OUT-R Radiology OUT-A Otolaryngology OUT-R Otolaryngology OUT-A

12 Although staff nursing ratios and resident ratios have been well-studied, these may or may not transfer equitably to APPs (i.e. residents need to focus on education) Of the 19 OUT practice settings listed in Table 2, APPs indicated that, for 9 practice settings, the actual workload matched what they thought was reasonable. In 10 practice settings, APPs indicated that the actual workload was higher-sometimes nearly double than what they perceived as reasonable. Hospitalist, CRNAs, Palliative APPs perception vs actual patient loads were generally more in alignment across institutions.

13 Only one-third of the 18 IN fields of practice indicated a comparable reasonable and actual workloads; Critical care, 30.1% of 143 respondents indicated that 4-6 patients constituted a reasonable patient load; whereas 22.9% of those respondents indicated that they had an actual workload of patients Cardiac surgery 34% of 58 respondents indicated that 6-8 patients constituted a reasonable patient load; whereas 37.2 % of those respondents indicated that they had an actual patient workload of 6-12

14 Hours per Day providing Direct and Supportive Patient Care by % (n = 1444) 2% 7% 5% 23% 1% 26% < 8 hrs. 8 hrs. 10 hrs. 12 hrs. 14 hrs. 10 hrs. 24 hrs. 36% 48.6% indicated they spent approximately minutes completing an outpatient return visit or inpatient subsequent encounter, including time to write the note. 44% of respondents agreed that they spend minutes completing an outpatient new patient workup, inpatient admission or discharge.

15 Enough time to complete all of the work in the required hours per day? 29% reported no 36.1% reported yes 29.9% reported sometimes Plan in place to bring in additional providers in times of high volume/acuity? 80.3% reported no 7.6 % reported yes 11% reported sometimes Back-up staffing/coverage plan for scheduled time off, (vacation, sick and/or FMLA)? 54% responded that there were no plans for coverage

16 Workloads for APRNs/PAs are often stretched frequently with both direct and indirect care activities requiring time at work or on call beyond the typical workweek. Do you work the same hours as you are required each week? n = 1450 Always less 14% 0% 1% Usually less 17% 31% Usually the same Usually more Always more Sometimes less, sometimes more 37%

17 Indirect Activities EHR in-basket messages- pt questions, medication refills, follow up on lab results Returning/making follow up phone calls- same as above Phone in referrals/authorizations for insurance or specialists Social work type activities- assistance obtaining pt resources Secretarial type activities- finding charts, filing

18 54.4% indicated working on a team that included physician interns, residents, and fellows, and of those, 65.2% (498/1453) reported that their specific role on the team was to provide comprehensive, multisystem care, rather than provide a portion of the care or specific aspects of the care. 17.3% of respondents reported that they are involved in taking call- 20% of those stayed in the hospital and 58% reported call from home.

19 Two Common Themes Inadequate Resources There is too much focus on the number of patients rather than what the patient needs and having adequate time to meet those needs. I do not feel we have enough advanced providers to actually support our facility numbers, provide safe care, have good patient satisfaction, and happy providers I am consistently coming in after hours to complete documentation Inefficient Workflow If there were fewer secretarial tasks that we have to perform perhaps we could accommodate a greater volume Requires all 8 hours to be face to face time with patients. It would be helpful to have some time allotted for charting, reviewing labs and returning calls.

20 Conclusions/Discussion APP perceptions of reasonable workloads within a given field of practice were found to be surprisingly common and generally in alignment across institutions lending to the belief that there is likely a range of patients that can be seen while still ensuring the provision of high quality care. Optimal workload for an APP may vary based on systems, processes and a variety of other factors, however commonalities and unique variables that affected individual practice were identified. Direct and indirect care activities and the impact of various extraneous factors on APP workload were also common across specific practice sites and populations.

21 Limitations 1. Variations in systems and practice models across organizations, which contributed to a broader range of actual and desired workloads. 2. Accurate response rate- ed to a specific number of individuals, designated as the advanced practice providers within the respective organization; however, we could not predict whether the survey was forwarded to additional participants other than the fact that we received over 70 entries where the participant chose not to identify with an institution or health system and a number of surveys that the participant identified with a different organization from the individuals to which the survey was sent- not included. 3. Self-reported perceptions as opposed to objective observers comparing workload and associated outcomes may have led to bias. However, perception was important to the study investigators as this is often the primary driver for satisfaction with workload.

22 Need a better understanding of optimal workloads and how they support the provision of high-quality, efficient, cost-effective, and safe care while supporting APP job satisfaction and retention. Future research needed in terms of specialty practice, i.e. critical care, to understand the important variables and how they impact establishing safe and consistent patient provider ratios Continual evaluation of APP models to improve outcomes and improve the delivery of care. Direct and indirect care activities. Dissect these activities and assign appropriate resources to the model of care. Publication/dissemination so that health systems value and adopt these ratios as standards of care Work hour limits/coverage like what has evolved for GME work hours Work life balance, APP retention leads to expertise and turnover is costly and time consuming.

23 Tamara S. Goda, DNP, RN, ANP-BC Administrator, Cardiovascular Services Vidant Medical Center (252) NPSS ASHEVILLE, NC