Application

Name*

First Last

Title*

Organization*

Section I: Advanced Practice Leadership

Advanced Practice Executive (name)*

Credentials*

Title*

Role*

Years of Experience (in advanced practice leadership)*

I.1: Describe the history and development of the advanced practice executive role and any other APRN/PA leadership roles at your organization, in detail.*

I.2: Describe the current role and responsibilities of the advanced practice executive, in detail.*

I.3: Describe the current role and responsibilities of any other advanced practice leaders, in detail.*

Section II: Advanced Practice Infrastructure

II.1: Resource Justification. Describe how your organization determines the need for additional advanced practice providers. Address any standardized staffing review process and any required information or criteria that must be met to add or replace APPs.*

II.2: Recruitment & Marketing. Describe how your organization recruits and markets to advanced practice providers. Address the application process (via an online career portal) and any advanced practice-specific marketing materials or strategies used to cater specifically to advanced practice roles.*

II.3: Interviewing & Hiring. Describe how your organization interviews its advanced practice providers. Address the review of prospective applicants, coordination of scheduling, who is involved in onsite interviews, how questions are determined, and how feedback is provided and collected.*

II.4: Credentialing & Privileging. Describe how your organization credentials and privileges its advanced practice providers.*

II.5: Onboarding & Orientation. Describe how your organization onboards and orients its newly hired advanced practice providers.*

II.6: Preceptoring; Mentorship. Describe how your organization precepts advanced practice provider students, new graduates, and new hires. Address how preceptors are selected, trained, and compensated, and, if there is a continued process for ongoing support and mentorship.*

II.7: Advanced Practice Council. Describe the history, development, and accomplishments of your organization’s Advanced Practice Council (or comparable group, if any).*

II.8: Shared Governance/Shared Leadership. Describe which nursing councils and medical staff committees have advanced practice providers as members and how those APPs have meaningfully contributed to the success of those groups.*

II.9: Competency; OPPE/FPPE. Describe how (and how often) your organization assesses the competency of advanced practice providers. Additionally, describe how your organization fulfills the requirements of ongoing and focused professional practice evaluation for advanced practice providers.*

II.10: Peer Review. Describe how your organization conducts peer review for advanced practice providers. Address how cases to be reviewed are determined, the composition of any group or committee, how often it meets, and examples of determinations.*

II.11: Billing: Independent, Incident-To, and Split/Shared Visits. Describe all aspects of advanced practice provider billing at your organization.*

II.12: Quality & Performance Metrics (KPIs). Describe how your organization assesses the impact of advanced practice providers on quality and outcomes. Address how metrics are determined and measured (e.g., dashboard) and how the EHR may be used to facilitate.*

II.13: Utilization & Productivity. Describe how your organization determines if advanced practice providers are being utilized appropriately and to their fullest scope of practice, and, how inappropriate and/or underutilization may be corrected. Address any methods to assess productivity of advanced practice providers.*

II.14: Professional Development & Continuing Education. Describe any opportunities or resources available for training or career growth at your organization. Indicate if there is an advancement pathway/model in place and if there is dedicated financial support or other resources for continuing education.*

II.15: Performance Evaluations. Describe how your organization conducts performance evaluations for advanced practice providers. Address if evaluation is tailored to the advanced practice role and/or specialty, who provides input/feedback, and how often evaluations take place.*

II.16: Reward & Recognition. Describe any resources and/or methods your organization deploys to reward and/or recognize advanced practice providers.*

II.17: Post-Graduate Residency/Fellowship Programs. Describe the history, development, and achievement of any post-graduate training programs at your organization for advanced practice providers.*

II.18: Burnout. Describe any resources and/or methods your organization deploys to prevent burnout, available to all staff, all medical providers, or specific to advanced practice providers.*

Section III: Survey (online)

Provide the total number of advanced practice providers employed and credentialed at your organization:

# of PAs:*

# of NPs:*

# of CRNAs:*

# of CNMs:*

# of CNSs:*

Provider the total number of physician (MD/DO) leaders, nursing (RN) leaders, and other administrators who are involved with advanced practice providers are your organization:

# of MD/DO Leaders:*

# of RN Leaders:*

# of Other Administrators:*

Section IV: Documents & Policies

Documents

Upload any documents related to the following advanced practice domains. If the organization does not have any pertinent documents for a certain domain, indicate none by checking the box.

Not Available

N/A

Organizational Chart (advanced practice-specific, if available)*

Drop Files Here or

Not Available 2

N/A

Bylaws (Medical Staff)*

Drop Files Here or

Not Available 3

N/A

Credentialing Application, Forms, and/or Checklist for advanced practice providers*

Drop Files Here or

Not Available 4

N/A

Delineation of Privileges Forms for advanced practice providers*

Drop Files Here or

Not Available 4

N/A

Delegation of Services Agreement for physician assistants*

Drop Files Here or

Not Available 5

N/A

Collaboration Agreement (or comparable) for nurse practitioners*

Drop Files Here or

Not Available 6

N/A

Job Descriptions, Advanced Practice Roles (APRNs & PAs)*

Drop Files Here or

Not Available 7

N/A

Job Descriptions, Advanced Practice Leaders (e.g., director, manager, supervisor, lead/chief)*

Drop Files Here or

Not Available 8

N/A

Onboarding & Orientation Manual, Booklet, and/or Checklist for advanced practice providers*

Drop Files Here or

Not Available 9

N/A

Proctoring Form; OPPE/FPPE Form(s) for advanced practice providers*

Drop Files Here or

Not Available 10

N/A

Annual Evaluation for advanced practice providers*

Drop Files Here or

Not Available 11

N/A

Reward & Recognition for advanced practice providers*

Drop Files Here or

Not Available 12

N/A

Other documents (related to advanced practice providers)*

Drop Files Here or

Policies

Upload any policies related to the following advanced practice domains. If the organization does not have any pertinent policies for a certain domain, indicate none by checking the box.

Not Available 12

N/A

Advance Practice Council (charter/bylaws)*

Drop Files Here or

Not Available 13

N/A

Peer Review; OPPE/FPPE for advanced practice providers*

Drop Files Here or

Not Available 14

N/A

Continuing Education for advanced practice providers*

Drop Files Here or

Not Available 15

N/A

Professional Development Pathway/Clinical Ladder for advanced practice providers (e.g., NP I, II, III criteria)*

Drop Files Here or

Not Available 16

N/A

Other Policies (for advanced practice providers)*

Drop Files Here or

Section V: Exemplars

The first exemplar is required. The organization may select two (2) of the remaining topics in which to provide exemplars.

Exemplars should be between 500 and 2,000 words and may include supporting documents (e.g., graphs, tables, figures).

V.1: How have APPs in your organization have positively impacted the patient experience?*

V.2: How have APPs in your organization contributed to safer, higher quality care and improved outcomes?

V.3: How have APPs in your organization positively impacted productivity and efficiency?

V.4: How have APPs, and/or your organization as a whole, educated physicians, staff, patients, and the community on the role of APRNs & PAs?

V.5: How have APP leaders and APPs alike removed unnecessary or outdated restrictions/limitations on their scope of practice at your organization, or more broadly, within the state?

V.6: How have APPs, and/or your organization as a whole, educated physicians, staff, patients, and the community on the role of APRNs & PAs?

V.7: How have APPs in your organization contributed to the community, beyond their traditional roles in the workplace?

V.8: How have APPs in your organization contributed scholarly work (e.g., published articles, conference presentations, poster presentations, awards, etc.) that have promoted and forwarded the importance and value of APPs?

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Application

Application

Section I: Advanced Practice Leadership

Section II: Advanced Practice Infrastructure

Section III: Survey (online)

Section IV: Documents & Policies

Documents

Policies

Section V: Exemplars

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