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Breaking Barriers and Building Up Advanced Practice at University of Colorado Hospital

Posted on October 29, 2018   |   by   |   Advanced Practice Provider, Advanced Practice Structure, Employers, Job Seekers, Leadership

Jennifer Rodgers DNP, APRN, ACNP-BC shares how she’s overcome challenges and championed Advanced Practice at the University of Colorado Hospital.

Jennifer Rodgers DNP, APRN, ACNP-BC is the Director of the Office of Advanced Practice for the University of Colorado Hospital and University of Colorado School of Medicine. Since starting in the role two years ago, Jennifer has been instrumental in formalizing advancement opportunities for Advanced Practice Providers (APPs).

I recently caught up with Jennifer to discuss how she was able to overcome departmental barriers and build up Advanced Practice leaders in her organization.

Q: Jennifer, I know you’ve faced those “silos” of the university world where it seems like each department is its own business entity. As leader of Advanced Practice for the whole organization, it seems like this would be a real challenge.

A. Yes, that’s really true. When I first came, I realized the “division by division” structure was going to be different than what I’d seen before.

I also knew I’d need to work within that individualized concept but centralize some things to create consistency in Advanced Practice Provider (APP) roles across the organization. Coming on board, I did like the fact that APPs are faculty within the school. I think that’s important.

We approached this from several angles. First was gathering data. Across the organization, we didn’t have a good sense of what our overall vacancy rates were. We also didn’t know how many internal transfers we had. We noticed that APPs were moving from one division or service to another because roles weren’t standardized. The problem was that APPs would transfer because there was more money or more differentials somewhere else in the organization.

We also looked at retention and learned that APPs on average stayed about 3.85 years. Just as they were fully trained with the organization, they were leaving. So those data points were helpful as a starting point.

From there, I moved on to build relationships across departments. At CU, we have division finance administrators (DFAs) that handle all the HR functions of the division including compensation. I focused on the largest departments with the most APPs and met with the DFAs individually to see how I could help them. We started a workgroup and met every week for about 6 months to go through different scenarios and see where it might be helpful to standardize.

For background, we were hearing from APPs across the organization that they didn’t think salaries were comparable or transparent. They’d say “people with less experience are making more than me,” and “it doesn’t feel fair that I don’t have a voice.” So that was feedback we had to take to heart.

In my role, I report to the Dean’s office, so I shared information with my physician dyad there as well as our Clinical Leadership Council that makes a lot of decisions. I worked with those to groups to explain how it might be beneficial to get consensus because we don’t want departments to compete with one another for staff or to train up good APPs and then have them leave.

For the first year, I went and met with the Clinical Leadership Council every month, and then every quarter of this year. We found things to agree upon that are key to standardizing the APP role.

Now, job postings look similar across the board. Job descriptions are based on templates that can be modified by departments yet remain consistent. We developed a document called the “Guide to Employment for Advanced Practice Providers.” It outlines topics like workweek expectations and roles on multidisciplinary teams.

Everyone across the organization is now using the same salary grid. That was accomplished through the leadership of the DFAs who worked together to get rid of compression and begin hiring in at the same rate. We have a method for handling shift and holiday differential at 15% to keep things simple. That way whoever does the work gets paid. We have moonlighting or fill-in shifts with consistent rates and other criteria. All of this helped us gain the confidence of our APPs.

Those were our first big steps. Once we got momentum, people started thinking about promotion within the APP group.

Q: Jennifer, it sounds like you were able to overcome some major hurdles in a short period of time. Standardizing promotions can be difficult, especially in such a large organization. How did you address that?

A. Sure. As I mentioned, since our APPs are faculty, they are eligible to promote to Senior Instructor, Assistant, or Associate Professor. However, every division approached this differently so there was a lot of confusion among APPs over whether or not it was possible to promote, if comps was included, etcetera.

We spent a lot of time meeting with department chairs and vice-chairs about what might work. We also worked to educate the organization about the unique role of APPs because most people who aren’t APPs don’t understand our training and needs. By handling it that way we were able to keep the conversation positive. No one is preventing APPs from promoting maliciously; there’s a need for understanding and education.

Once the issues are transparent and you have people working toward consistent criteria, it’s easier to overcome the myths and misconceptions going around. Now we’ve had good success with promoting APPs promoting and they follow the same rigor that our physician colleagues do, and that’s what we want. The increased understanding has resulted in no one getting turned down just because someone said “we don’t think you can.”

Q: That’s amazing. One scenario where standardization can be hard is when a high-level physician joins the team and does not follow comp or other hiring standardization because they are not aware of the established processes. What are your thoughts on that?

A. To avoid scenarios like that I think it’s imperative to keep your hospital senior leaders apprised and in alignment. Our leaders were a big part of the process as we worked on the compensation grid I mentioned. It required negotiation and budgetary considerations. We agreed that if we weren’t consistent across the board, then we wouldn’t be successful in other areas.

Now we have a methodology that is agreed upon and people are sticking with it. If we catch wind that someone isn’t on board we initiate a conversation and say “what’s going on? What are our options?” Over time, people get used to the new norm. But we have to work together and it does take a while.

Q: Your approach is so solid because you’re doing it at the system level, creating shared knowledge, and getting everyone on board. Once a week meetings, getting the right decision makers on board, developing a process everyone buys into, that’s really a model for driving change. What are your thoughts on standardizing APP roles?

A. Yes, it’s so important to standardize APP roles. When we’re hiring for a position we want to know if an APP is necessary. It needs to be set up so there is scope of practice, not just a stand-in for a resident or a scribe.

Our job description templates are a starting point, especially since our organization does not have a centralized recruiting function. The other thing we’re doing is the “one-off.” Maybe during an exit interview we recognize there’s a problem with a position. We’ll evaluate why people aren’t getting what they need or why they’re not working top of scope of practice.

The other thing we’re working on this year is standardizing our on-boarding plans. When there are on-boarding plans in place, we can work with the divisions and departments to get them to reflect what the APP should be doing. It’s a good stop-gap measure to check in.

We don’t really have good productivity measures yet, so that’s an area where we have work to do.

Q: Can we talk about your Advanced Practice Structure? Do you have APP Leads and Managers within each department?

A. Sure. Within our office we have CNS who works part time on on-boarding and precepting. We also have a PA at almost full time who is the Senior Clinical Lead and focuses on competencies, credentialing, and privileging. She keeps us apprised of PA license changes, and really helps me with anything else.

Most of our divisions and departments do have lead APPs. I think we’re up to 38. Our goal is that eventually every department with 4 or more APPs would have a lead. This person is a .1 FTE until they grow to have 9 or 10 APPs and then it depends on what all they’re doing. Maybe then they’ll have .2 of their time. This model really works and we’ve been able to add leads one or two at a time and tell leadership the story of why it’s beneficial.

Q: Wow. With all that you’ve accomplished so far, what’s the biggest victory?

A. I’d say I’m most proud of the relationships I’ve built with our APPs. When I joined the team, I met all these wonderful people who were very disengaged. They were a large group spread out over different areas. We only had about 12 AP leads. They didn’t feel like they had a voice. Many were a “flight risk.”

To gain their trust, we listened to their concerns, and got input where it was appropriate. We clarified the issues that were under their influence versus the issues that were out of their control. Then we brought back all that information and developed several different forums to handle it.

At the time, we had a Practice Council Structure in place but no one came. So we worked to get people there and said, “here’s what we’ve heard from you. Here’s what we’re working on. Are we working on the right things?” Then we developed a steering committee and broke the issues into buckets. I also did a lot of rounding in the area, just spending time with people. I thought it was important to meet with people who expressed challenges, then follow up to let them know the result or what we were doing about it.

Now we have about 80-100 APPs who come to our council meetings every month. It’s really exciting.  And they’re telling their peers about it. The steering committee is now a thing that everyone wants to be a part of which is really cool. I think that if you ask people what is going on or what we’re working on they can tell you. We have communication strategies using an internal website, newsletter, and twitter feed to report on our council meetings.

It’s a big win to see people happy, engaged, involved, and volunteering for things on the front lines. That counts a lot every day.

Q. I admire you and all the work you have done. So what’s next for you Jennifer? What’s your next big mountain to climb?

A. On-boarding is one of our big initiatives this year, again to make sure everyone has a competency-based plan. I think that will be huge to foster success for our APPs and to ensure that everyone has the same competency. Of course the plan will look different for new grads than for experienced people, but everyone needs a plan.

So as we tackle this we’ll face some of the same things. People might say “oh, we have a plan but it’s not written down.” Or, “we needed to hire this person yesterday, so there’s just not time right now.” So again, I think we’ll need to start with the baseline data and then bring in the story. To be competitive we need to defend days off for continuing education, whether the division is making money or not.

We also need a broader definition of professional advancement. Not everyone wants to go after a formal promotion, and that’s okay. But, we want to make sure that everyone has a plan for advancement, whether that means taking advanced preceptor courses or adding clinical expertise or serving on a quality team. Now that we’ve conquered promotion it’s time to ask “what does promotion look like for people who don’t want to be formal leaders but have other goals.”

Q: Great point. It reminds me that there are real benefits to the organization when you focus on professional development.  You help the finance and operations team understand that the cost of providing continuing education funds and professional development time is less than the cost of disengagement and turnover.

As a matter of fact, giving APPs professional time (as long as it is a structured process focused on projects involving efficiency, quality, or safety) delivers a higher ROI on the investment in APPs then APPs who work 100% clinical time.

In today’s tight job market, many HR societies are recommending that giving opportunities for people to grow and develop themselves is better for retention, regardless of the industry.

A. I like the way you spelled that out. It’s true. And quite honestly, I’ve found ways to get the CFO and COO on-board for financial support. First, don’t leave them out of the educational process I’ve described, and two document what you’re doing and why.

Q: Great point. I’m excited because what you shared can provide a lot of value for other people. What’s one word of advice you’d have for them

A. We’ve hit on this already, but I think it comes down to three things:

First, go to your frontline people and really listen to what’s going on. Be sure to close the loop with them, even if you’re not able to fix all the issues right away. They will buy into the dream and trust that you’re working on it.

Second, get your stakeholders on board. Go to them one-on-one and find out what’s in it for them. Then be willing to do the legwork so that by the time you have a big group onboard you already know how they’ll respond.

Third, use your data and reach out to other APPs around the country who have been where you are. Bounce ideas off of them. Don’t reinvent the wheel and don’t be disappointed when there’s a lot of work to do. You just have to prioritize one or two things, tackle it, and then move on. Some people try to do thirty things at once and never really get traction.

And as a final thought, get people on your team. Be respectful of where they come from but at the same time don’t be afraid to push the envelope. Sometimes you have to say, “We need to do some things differently and here’s why.” And then include them along the way: “Here’s what I’ve heard. Does that make sense to you?” or “Here’s what I think we should do. What part of this work are you interested in being involved in?”

Clearly outline expectations, especially when everyone is getting to know you. And if you’re going to ask for people’s input you have to let them do the work. In all of the examples I described, I had groups of leads on my team working on each one.

Anytime it’s appropriate, I have front line people involved. I take every opportunity to highlight others’ accomplishments and have them present with me as much as possible to leadership and to their peers.

A team of many accomplishes more and has a lot more expertise than one person alone. Recognizing that is the key to good leadership. I believe in shared decision making and leading from the bottom. I also believe in having tough conversations. Overall, I see my role as a barrier breaker and a conduit and a cheerleader to others.

Thank  you, Jennifer. Your insights are incredibly valuable for other AP Leaders and it’s been a pleasure talking with you!

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About Jennifer Rodgers DNP, APRN, ACNP-BC

Jennifer Rodgers DNP APRN ACNP-BC
Jennifer Rodgers, DNP, APRN, ACNP-BC

Jennifer is the Director of the Office of Advanced Practice for the University of Colorado Hospital and University of Colorado School of Medicine. She has been instrumental in the formalization of the Promotion advancement opportunities for Advanced Practice Providers (APPs) and has the development and leadership of a System-wide Surgical APP Post Graduate Fellowship. She serves as a voting member of the Medical Board at the University of Colorado. She leads nearly 500 advanced practice providers (APPs) and nearly 40 APP Leads. She is responsible for the oversight and support of APP workforce, recruitment, hiring, development of new APP models of care, strategic and operational oversight, promotion, mentoring, and professional advancement, and student placement.

She received her Doctorate in Nursing Practice in 2017 from the University of Alabama. She is board certified as an Acute Care Nurse Practitioner, with 18 years’ experience as a pulmonary nurse practitioner, caring for adult patients from critical care to hospice. Her current clinical practice is in the COPD Clinic. In her leadership role, she serves on the National Advanced Practice Advisory Council and as the President for the Colorado Society of Advanced Practice Nurses.

At the American Academy of Nurse Practitioners National Conference in June 2015, Jennifer was awarded the State Award for Clinical Excellence. This prestigious award is presented to one nurse practitioner from each state who exemplifies excellence in practice.

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