Developing and Expanding APRN and PA Teams

Ruth M. Kleinpell, PhD, APRN-BC, FAAN; April N. Kapu, DNP, ACNP-BC, FAAN; Susan Stempek, MMSc, PA-C, FCCP; Corinna Sicoutris, MSN, CRNP, FCCM; Britney S. Broyhill, DNP, ACNP-BC; Rhonda D'Agostino, MSN, ACNP-BC, FCCP, FCCM


Am Nurs Journal. 2020;15(12) 

In This Article

Vanderbilt University Medical Center

Vanderbilt University Medical Center (VUMC) manages more than 2.5 million patient visits each year, making it one of the largest academic medical centers in the southeast. It's also the primary resource for specialty and primary care in many adult and pediatric specialties for patients throughout Tennessee and the Mid-South. The health system has over 1,200 APRNs and 75 PAs. Many hold faculty appointments in the school of medicine or school of nursing.

Reporting Structure

VUMC has an office of advanced practice (OAP) that serves as a resource and support to all advanced practice providers and physician and nurse leaders. The OAP employs an associate CNO, director of professional development for advanced practice, financial officer, operations manager, and program coordinators. It provides administrative oversight for several service lines, including inpatient practitioners, nurse faculty practices, and Vanderbilt Health OnCall. The OAP oversees the shared governance model for the advanced practice leadership board, council, and associated committees, including grand rounds, standards, preceptor, and clinical advancement. The leadership board, which reports directly through the nursing executive board, has 18 directors and five managers of advanced practice service lines. Members recommend and vote on many strategic initiatives. Credentialing and privileging are reviewed by the advanced practice and allied health joint practice committee before being referred to the medical center credentialing committee and medical center medical board.

Most APRNs and PAs bill for their professional services, and many have quality and relative value unit–based incentive programs. Patient care is paramount across the advanced practice cohort and many APRNs and PAs lead quality improvement, research, and educational initiatives.

Adding Advanced Practice Providers

Key considerations at VUMC when adding clinicians to advanced practice teams or expanding practices to incorporate these roles include patient volume, types of patient clinical encounters, care quality, and access to care. When an increased need exists in any of these areas, APRNs and PAs are considered. For example, when the established advanced practice provider-to-patient ratio is exceeded in an inpatient, acute surgical care team, VUMC considers adding another APRN or PA.

Generally, for inpatient areas, an ICU APRN or PA sees six to eight patients per day, an acute surgical APRN or PA sees about 15 patients a day, and an inpatient consult APRN or PA sees about 20 patients per day. These are general averages and may vary based on the workload, time spent with each patient, and overall responsibilities for the patients the APRN or PA sees on their service.

For an outpatient, clinic-based APRN or PA, the number of patients depends on the type of patient encounter and the time needed for each patient. For both inpatient and outpatient examples, designated quality goals and standards are set to achieve these goals. The work and time involved to ensure the quality standard is met is calculated into the overall advanced practice provider-to-patient ratio. VUMC has added APRNs and PAs to many community primary care, walk-in, urgent care, and specialty care clinics (such as women's health), as well as to online encounters at homes, offices, and hotels, which has expanded VUMC's provision of reliable, quality, and easily accessible healthcare.

Centrally, the advanced practice directors work with the OAP to coordinate consistent regulatory, quality, and operational standards for overall professional practice. The advanced practice service line directors collaborate with APRNs, PAs, physician leaders, nursing leaders, and business leaders to cultivate innovation and strategic expansion, development, recruitment, and operations for many service lines throughout the state and region.