Why The Growing Role of APPs Creates Need for Executive Leadership

Cleveland Clinic is the latest health system to appoint someone to oversee advanced practice providers (APP).

A growing number of health systems and hospitals have been creating APP executive positions, including Vanderbilt University Hospital, CommonSpirit Health, and Corewell Health. The new executive positions recognize the crucial role that APPs are playing in healthcare.

Add Cleveland Clinic to that list.

Cleveland Clinic has been using APPs, such as nurse practitioners and physician assistants for decades. Over the past 25 years, the number of APPs has grown significantly from about 400 to nearly 4,000.

The health system decided to create an executive position to improve the management of APPs at the health system, says Melissa Stoudmire, MSN, who became Cleveland Clinic’s first vice president of APPs in August.

"The organization identified the need to create a dedicated enterprise APP role to manage continued growth in APPs, maintain consistency in APP practice, and streamline the leadership structure," she says. "The health system wanted to give the APP group an executive presence."

The new position gives Cleveland Clinic an opportunity to enhance the health system's leadership model and bring APPs under one leadership structure, according to Stoudmire.

"I will be providing an executive leadership presence and providing direction for all APP teams," she says. "At the executive level, I will be helping to look at operations from a systems approach, look at strategy, and drive the metrics that are expected at Cleveland Clinic for high quality care, patient safety, and patient satisfaction. We will also be looking at the metric for APP productivity."

Melissa Stoudmire, MSN, is Cleveland Clinic’s first vice president of advanced practice providers.

The Role of APPs at Cleveland Clinic

"APPs are an integral part of multidisciplinary teams," Stoudmire says, noting they are a part of every service line at Cleveland Clinic. "The utilization depends on the service line. Ultimately, [they] work with physicians defined by state and national laws. We have APPs and physicians work to top of scope whenever possible."

For example, the Ohio Board of Nursing sets the scope of practice for advanced practice registered nurses (APRNs), which includes certified registered nurse anesthetists (CRNAs), certified nurse-midwives (CNMs), clinical nurse specialists (CNSs), and certified nurse practitioners (CNPs).

With direct supervision of a physician, a CRNA can administer anesthesia as well as perform pre-anesthetic preparation and evaluation, post-anesthesia care, and clinical support functions.

CNMs, CNSs, and CNPs are required to have a written standard care arrangement with a qualified collaborating physician.

In the inpatient setting, APPs participate in multidisciplinary rounds and other team-based functions, Stoudmire says. In the outpatient setting, she adds, either an APP or a physician can see a patient, based on either the service line or the patient’s symptoms.

"APPs play different roles in primary care practices vs. specialty practices," she says. "In primary care practices, APPs help physicians perform at top of license. In some specialty practices, patients have their first visit with a physician, with follow-up appointments managed by APPs. The roles of APPs are also determined by what providers are available. If a physician is not available, an APP can stand in for the physician."

Under some circumstances, Cleveland Clinic APPs lead care teams in collaboration with physicians, according to Stoudmire.

"In follow-up clinics, primary care clinics, and Cleveland Clinic Express Care, you may see more of an APP presence," she says. "But we always go back to the collaboration with a physician. So, while an APP may be the primary provider on a given day in a service line, [they] are always collaborating with physicians."

Nationally, APPs are playing an essential role on care teams, according to Stoudmire.

"We know that APPs improve access to care, and they help to expand the clinical services provided at a health system in multiple service lines," she says. "Nationally, there is a shortage of physicians in many specialties, and [they] can help bridge the gaps."

APP engagement at Cleveland Clinic

Cleveland Clinic has several methods for engaging APPs at the health system, according to Stoudmire.

"APPs sit on many committees throughout Cleveland Clinic alongside our physician colleagues," she says. "For example, [they] are non-voting members of our Medical Executive Council; [they] participate in peer review committees; and [they] serve on safety, quality, and patient experience committees."

Stoudmire says the health system gathers feedback from APPs through several surveys.

"In the APP group, we have an annual process to make sure that leaders are providing what our teams need and are asking for feedback to keep APPs engaged," she says.