Table 1.

Ten key points from a decade of lessons learned

Key points	Benefits/Importance	Challenges	Institutional example
Institutional support	Support from high‐level leaders is vital for the conceptualization and implementation of an APN/PA group including clinical service‐line development and financial support for leadership roles and professional development opportunities	Key stakeholders with limited knowledge of or experience with APN/PAs may hesitate to invest in and develop an APN/PA workforce	Support from both CNO and CMO for integration of APN/PAs into clinical care models
			Clearly established leadership structure of APN/PA directors (with FTE support), service line managers, and medical directors allows for a bidirectional flow of information, extending from providers to higher‐level clinical and administrative leaders
			Dedicated physician FTE support for medical directors who work directly with APN/PAs
Developing a leadership structure	A strong leadership structure creates stability and accountability, promotes provider confidence, increases job satisfaction, and allows for APN/PA development and mentorship	Limited leadership opportunities and/or unclear leadership structure for APN/PAs restrict individual professional development and institutional visibility	Intentional development of varied APN/PA leadership roles (e.g., Director, Lead, Manager, committee leads) with FTE support and expectations based on the needs of clinical units and service lines
			Hiring and developing clinically active APN/PA leaders who demonstrate excellence with interprofessional collaboration
		Creating a robust APN/PA group with the proper balance of professional leadership and clinical support requires the right team of individuals who have the experience, skills, and desire to foster APN/PA career development
			Designated collaborative physicians who are involved in day‐to‐day supervision of and communication with providers
	Bidirectional leadership between APN/PA and physician leaders fosters collaboration and advances an APN/PA culture
		Clinical leaders who are disconnected from their providers in terms of presence, communication, and supervision
Institutional need	APN/PAs are established providers with institutional and medical knowledge/clinical expertise, providing the potential for lateral mobility during times of crisis (e.g., COVID‐19 pandemic, workforce disruptions), and can be leveraged to address emerging healthcare needs/policies	Identifying specific populations where skills and expertise align with institutional needs/requirements to avoid both underutilization and overextension of scope of practice	Specific service lines were created to enhance throughput and decrease discharge delays by allowing APN/PAs to round independently
			SSU cares for postprocedure and lower acuity patients with expected short lengths of stay, optimizing capacity and educational opportunities on resident services
			During pandemic surges, APN/PA services increased patient capacity/worked with hospital‐level leadership to redeploy providers to understaffed clinical areas
Service structure	Clearly outlined expectations, clinical roles, and leadership structures provide for training tailored to specific conditions and clinical situations, creating opportunities for APN/PAs to become experts in defined patient populations	Navigating utilization pitfalls, such as poorly defined clinical and supervision expectations, varied or changing job descriptions, schedules, and census caps	Created an Administrative Employee Policy Manual outlining shifts, required weekends/holidays, and call expectations
			Multiple services have clearly identified a collaborative physician with scheduled on‐call availability
			HM APN/PAs manage their own panel of patients with an available collaborative physician on comanaged services, with an expectation to present in multidisciplinary rounds
Scope of practice	Allowing APN/PAs to practice to the extent of their license and scope of practice maximizes clinical potential and professional development while increasing access to patient care	Effective utilization of APN/PAs can be impacted by varied and conflicting state and institutional regulations/policies magnified by nuanced differences between APN/PAs	Clearly outlined SSU expectations about the autonomous practice including the role of MD supervision and communication to assist with questions and concerns
			Inpatient APN/PAs are capable of full‐spectrum inpatient care (i.e., admitting, daily care, and discharging)
		Limited understanding of regulations/policies and APN/PA training and capabilities by clinical leaders restricts potential
Onboarding and continuous training and education	Institutional investment is demonstrated through having an established onboarding process that sets expectations, reduces attrition, and allows for provider growth through a formal review	Due to the varied backgrounds, training, and experience levels of new hires, significant resources are required for a successful onboarding program, which includes a process for assessment and/or remediation	Developed a hospital‐level onboarding committee that created a 30‐page document based on a provider needs assessment, focusing on institutional best practices
			Created a mandatory 12‐week structured onboarding process, including an orientation signoff, competency checklist, and required quality improvement project with the capability to tailor a timeline for specific needs based on prior clinical experience
	Establishing structured learning opportunities (i.e., lecture series, APN/PA grand rounds) recognizes the importance of ongoing education, provides teaching opportunities, and enhances institutional visibility	Lack of consistent, dedicated time and funds for formal ongoing education for APN/PA acts as a deterrent to full participation in structured learning opportunities
			Created SSU lecture series with participation from specialist consultants on commonly seen conditions, designed to build relationships with frequently utilized consultants and align care plans with institutional practices
Right provider—Right patient	Clear role expectations with directed training, defined patient populations, and specific service structure allow providers to practice autonomously and to the extent of their licensure leading to improved patient outcomes, clinical efficiency, and provider satisfaction	Poorly defined clinical roles and expectations may negatively impact patient care, damage APN/PA reputation, lead to provider dissatisfaction or contribute to skepticism regarding APN/PA utilization	Specific APN/PA service lines, individually trained to provide inpatient management of certain conditions/therapies/specialties (e.g., heart failure)
			SSU has a list of defined conditions suitable for the service, many of which have institutional best‐practice care pathways and clinical care protocols for postprocedure patients
			Leadership and admitting providers coordinate with triage personnel to place appropriate patients on APN/PA services and protocol in place for transferring a patient off service if needed
Financial considerations	APN/PA's ability to bill can increase financial flexibility leading to additional revenue generation	Dynamic and competitive market forces cause difficulties navigating salary differences between APN/PA and MDs and academic and nonacademic positions	SSU and HM APN/PAs bill independently and complete annual billing training
			As opposed to increased salary, offer bought out time to APN/PA leaders to assist with the balance of clinical and administrative responsibilities; resulting in streamlined services and a return on investment through reduced attrition, enhanced professional development, and academic advancement of APN/PA workforce
	Supporting compensation for leadership and promotional pathways leads to further impact of APN/PA leadership and academic footprint
			UCM supports physician champions of SSU through FTE salary support for collaborative physician medical directors
		Budgeting considerations often narrowly focus on salaries and revenue generation limiting the financial investment in physician supervision and APN/PA leadership and pathways for professional development
Outreach	Early and sustained outreach to clinical leaders and providers of specialty service lines establishes and broadens networks while allowing for ongoing assessment, improvement, and education	Clinical leaders and providers may be resistant to APN/PAs due to institutional politics, individual skepticism, and interest in maintaining or protecting clinical “turf”	SSU medical and APN leaders met regularly with clinical leaders of services (Interventional Radiology/Pulmonology/Gastroenterology) whose patients are cared for by the service, followed by periodic check‐ins to discuss concerns or issues
			HM incorporates an annual 360‐degree interdisciplinary review process of the APN/PAs based on the AAPA Physician Assistant Core Competencies
Building a culture	Identifying APN/PA groups, with established roles, institutional activities, and leadership positions establishes institutional presence, improves provider satisfaction, and enhances the reputation of APN/PAs	Time‐consuming process that requires sustained effort, and buy‐in from physicians and institutional partners, can suffer from the loss of key champions if not broadly implemented	Creation of SSU as APN/PA pilot model with subsequent expansion based on its successes
			Mirroring expansion of APN/PA services and institutional leadership roles and committee involvement
			Equal consideration for APN/PA/MD applicants for professional development opportunities (e.g., conferences, fellowships, leadership roles)

Abbreviations: APNs, advanced practice nurses; CMO, chief medical officer; CNO, chief nursing officer; FTE, full time equivalent; HM, hospital medicine; PA, physician assistants; SSU, short stay unit; UCM, University of Chicago Medicine.