Hiring APP Leadership: Questions Health Systems Must Ask

By Diane Smith, RN, BSN, and Karen S. Sharrah, DNP, APRN, FNP-C

Advanced practice providers (APP) are delivering a significant amount of care in today’s healthcare environment – in the U.S. alone, there are approximately 250,000 nurse practitioners and 115,000 physician assistants. As such, there is an increased need for leadership in this area. In our experience, many organizations struggle with how to manage Nurse Practitioners (NPs) and Physician Assistants (PAs), group the two together, and determine the appropriate leadership structure. While APPs frequently report up to a department director or practice administrator (in addition to individual physicians), the role of an APP leader/manager has rapidly grown in acceptance. This article examines questions that hospitals and health systems must ask as they prepare to hire an APP leader – often titled Director or Executive Director of Advanced Practice Providers.

How will the role be defined?

As APP practice grows, most hospitals and health systems recognize that a leadership role is vital to the success of the APP program. The responsibilities for this role include creating staffing plans, establishing the scope of APP practice and its relation to clinicians, determining metrics for success, and measuring productivity. In organizations where there is a lack of understanding of the APP provider, this role is often challenged with aligning system strategies. Therefore, it is important for healthcare systems to identify objectives before hiring a leader and offer support for success.

Clinical practice is imperative for continued certification for APP leaders. To meet this need, most organizations have established clinical time – of 10-20 percent typically. In some academic organizations, there may be a faculty appointment as well. The scope of APP program size, direct reports, indirect reports, and whether the role is new should be considered when making this decision. For example, it is not realistic for a new APP program leader to have a high clinical component when tasked with growing and establishing the program.

What competencies and credentials should strong APP leaders have?

There are key skillsets for success in an APP leadership role. The individual should have the ability to quickly establish relationships with physicians and nursing leaders, as it is imperative to collaborate and establish trust between them. It is beneficial to have leadership experience and exposure to dealing with multiple groups in complex organizations with a focus on working with both nurses and physicians. Program development is also an experience that is helpful, as this role can capitalize on previous work such as onboarding, developing precepting and mentorship programs, creating councils and developing reporting structures. The ability to understand finances related to productivity and key performance factors is also important.

In terms of credentials, an APP leader must be a certified PA or an Advanced Practice Registered Nurse (APRN) including NPs, Clinical Nurse Specialists (CNSs), Certified Registered Nurse Anesthetists (CRNAs), and Certified Nurse Midwives (CNMs). Depending on needs, some organizations may desire or prefer additional degrees of accomplishment such as a Doctorate of Nursing or MBA.

What will the reporting structure look like?

Many successful APP leadership roles have dual reporting structures to the Chief Medical Officer (CMO) and Chief Nursing Officer (CNO). This structure allows for physician assistants to report through the leader to the CMO and advanced practice nurses to the CNO. For the leader, this allows for support and representation in both groups and more importantly, to be identified as a provider for physician recognition and support.

Alignment to nursing in some form is imperative for nurse practitioners if there is any interest in Magnet designation for the organization. This alignment will also allow for NPs to continue to have a role in nursing. It is important, however, to recognize that without APP leader alignment in any form to physicians, the role of the APP as “provider” can be lost with physicians and nurses. This can make the role of the individual APP more difficult and not understood by all. The APP might, therefore, be seen as a bedside or direct care nurse and not as someone who can perform the role of medically managing the patient.

Where will these leaders fall in system compensation model pay scales?

In our most recent work, we have placed APP leaders in roles at a health system, a renowned cancer center and a large academic medical institution. Generally, salaries are comparable to a Vice President in the institution. Many of these roles include a bonus or an incentive bonus which may be based on patient satisfaction, quality, productivity, or organizational goals and performance within the role.

Future Outlook

The role of APP leader is still being defined, but it is one that is becoming increasingly vital to tomorrow’s healthcare industry.

Diane Smith, RN, BSN, is a consultant in WittKieffer’s Mid-Level Executive Search Practice. Karen S. Sharrah, DNP, APRN, FNP-C is Executive Director, Advanced Practice Provider Services at Roswell Park Comprehensive Cancer Center in Buffalo, New York.

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