3 Challenges to Benchmarking Data to Measure Patients Access to Care by NPs and PAs
Author Cassandra Bunker, MSN, CPNP-PC
Author Jill Gilliland, MBA
Editor Elizabeth Moran, MSN, RN, CPNP-PC
Advanced Practice Provider (APP) benchmarking is currently a hot topic of discussion throughout clinics and hospital systems across the country. Though APP benchmarking—encompassing both Nurse Practitioners (NPs) and Physician Assistants (PAs)—is a newer concept, benchmarking for physicians has roots in the early 1990s (1).
Benchmarking is used to set a target for an outcome by establishing performance metrics based on similar data from other organizations. This allows organizations to learn how well their targets perform and to make changes when teams, practices, or providers are underperforming. In healthcare, benchmarking is used nationally to provide high-quality healthcare at a lower or affordable cost. Healthcare benchmarking of providers focuses on three major areas: the number of patients seen, quality outcome measures, and patient satisfaction.
Gathering benchmarking data can be challenging, and each clinic and hospital system has a unique structure for doing so. To learn more about the strengths and weaknesses of different structures, three APP leaders at Omaha Children’s Hospital, Levine Children’s Hospital, and Dallas Children’s Hospital have shared with us their institutional framework of gathering data to benchmark their NPs and PAs.
Courtney Robinson, MSN, CNS, CPNP-AC, Director of Advanced Practice at Omaha Children’s, explained that support for an APP structure at her institution, with supervisor and lead roles, began as a grassroots efforts to support the 140 APPs across all levels throughout the hospital system, including inpatient and outpatient subspecialties. Somewhat different in structure, Levine Children’s Hospital in Charlotte, North Carolina, situated within the larger medical system Atrium Health. There are 190 pediatric APPs, and the position of Pediatric APP Director, held by Erin Dugan’s, MSN, RN, CPNP-PC, is new within the APP framework. Thirdly, Dallas Children’s was one of the first hospitals to establish an Advanced Practice structure, with Joe Don Cavender, MSN, RN, CPNP-PC, as Senior Vice President and Associate Chief Nursing Officer. Joe Don is an innovative thinker whose strategy for developing an organizational structure had a focus on care models, billing, executive buy-in, physician engagement, team building, autonomous roles for APPs, increasing patient access to care, compliance, and efficiency.
Though these hospital systems all have different benchmarking structures, all of their APP Directors agreed on the need for national data and moreover, that gathering the data presents as one of their biggest challenges. Through discussion of such obstacles, the APP leads identified possible solutions to benchmarking, with a specific focus on the number of patients seen—the significance of volume metrics being to improve access to patient care. They identified challenges with role differences, environment variations, and scope of practice disparities in the utilization of APPs.
Clarify the Role of the APP to Identify Accurate Benchmarking Data
A universal identified challenge to benchmarking data at all of the institutions is that the role and responsibility of the APP can vary significantly—even within the same department. This can result in inaccurate conclusions regarding APP efficiency. APP leaders recommend institutions shadow providers to understand and clarify each role. This is important to ensure similar benchmarking data is used to create accurate metrics. For example, in outpatient gastrointestinal (GI) patient care, there may be an APP who sees all of the patients with bowel management and another APP that solely focuses on bowel transplant. The APP doing bowel management may have 30 minutes per patient, whereas the APP working with transplant patients will have 45-minute appointments. As a result, even though both APPs would fall under the GI APP role, the constipation APP would look more efficient than the APP who saw transplant patients. Therefore, benchmarking data for GI APPs who focus on patients with bowel management would be compared to each other and bowel transplant APPs would be compared separately.
Align Practice Environments to Identify Accurate Benchmarking Data
When using benchmarking data to measure patients seen, APP managers need to accurately account for inefficiencies in practice environments. Variations include space constraints, scheduling, no-show rates, and work ethic. For example, when providers are below 50% compared to benchmark data for similar providers, it is important to ensure APPs have enough exam rooms to see patients. Another factor to consider is limitations regarding the type of patients the providers can see. If APPs are limited to only seeing follow-up patients in a particular specialty then scheduling can be difficult to optimize. No-show rates can be as high as twenty-five percent and thus are vital to take into consideration when comparing benchmarking data. Finally, individual provider personal schedule planning can create variations too, i.e. canceling appointments later in the day due to a personal scheduling conflict. Of note, APPs who are full time or part-time roles should be compared to similar APPs. These considerations are significant as evidenced by the optimization model developed by Aurora Health Care which states: “Schedule barriers lead to decreased patient access, creased, practice efficiency, and physician/APP productivity.”
Benchmarking Data for APPs can Identify Variations in the Scope of Practice
Once practice variations are identified, managers can use the data to compare similar APPs and implement specific changes. When providers see the appropriate number of patients, it will optimize productivity. As a result, practices can also optimize staffing needs to provide the highest level of access to care for patients and to ensure that APPs practice to the fullest scope of their practice. When this happens, the entire team is more efficient. When metrics are established, it is easier, for example, to identify which APPs spend two hours calling patients with lab results—inactivity which could be delegated to another appropriate staff member, such as a Registered Nurse. Identifying these practice differences will also help APPs complete more patient visits. Another example of APP role optimization includes identifying APPs who complete patient education, prior authorizations, and paperwork which could all be assigned to an individual in a different role. Scribes are also becoming more popular in some organizations to optimize APP and physician time.
In conclusion, access to benchmarking data can positively impact the number of patients seen when similar APPs are compared and metrics are established. Using internal and external data to create dashboards leads to increased visibility. Then, addressing issues or building accurate financial-based incentives can optimize provider utilization and efficient processes. For example, if the sixty-fifth percentile is the expectation, providers can get an incremental additional salary for results between 65% and 85%, and even more so if above 85%. Additionally, providers with the lowest productivity can help to determine inefficient processes and behavior to make changes that result in additional patients seen.
If you would like to discuss building an APP service, APP leadership coaching, or hiring APPs, please contact Jill Gilliland, firstname.lastname@example.org, President, Melnic.
- Ettorchi-Tardy A, Levif M, Michel P. Benchmarking: a method for continuous quality improvement in health. Healthc Policy. 2012;7(4):e101–e119.
- Trenschel R. McDonald M, Bowman-Dillenburg K. A Lean Approach to Physician Schedule Optimization. Presentation: https://www.eiseverywhere.com/file_uploads/71d2c7f7d299468dfde9efe140f6bca5_PM412McDonaldTrenschelDillenberg.pdf
has 6 years of pediatric nursing experience and two years as a nurse practitioner. She specializes in pediatric endocrinology, specifically type 1 diabetes. Cassandra graduated from the University of Detroit Mercy with my BSN, and from the University of Michigan with a Masters of Science in Nursing. In her free time, she enjoys running and crafting. This past year, she even ran her first full marathon!