Implementation of a Children's Health Collaborative Advanced Practice Provider (APP) Council: An Evidence-Based Quality Improvement Project

In 2023, the United States (US) Bureau of Labor Statistics predicted that the advanced practice nurse (APRN) workforce will increase by 38% and 27% for physician assistants (PA) between 2022-2032. An increase in patient population and changes in healthcare system care models contribute to the demand for Advanced Practice Providers (APPs). As a result, there is a demand for strategies to increase job satisfaction, diminish turnover, promote collaboration, and facilitate the full scope of practice. A regional not-for-profit children's hospital has 391 APPs who are licensed and employed by either a large regional non-profit healthcare system or a large academic center. Each healthcare system has its own APP leadership structure, but no defined collaborative APP leadership structure includes both organizations. As a result, there has been a decrease in interorganizational networking, collaboration, and siloed patient care. This DNP evidence-based quality improvement initiative involved four separate phases. Phase one was an in-depth literature review of APP job satisfaction, factors contributing to job turnover, APP collaboration, development of APP leadership structures and councils, and inter-organizational and interprofessional collaboration. A pre-intervention survey with demographic questions and questions regarding APP job satisfaction and professionalism was also distributed. Phase two involved three discussion groups with APPs guided by questions that informed a SWOT analysis. Phase three was interviews with APP leaders from each healthcare organization and benchmarking of three children's hospitals regarding APP leadership and professional development. The final phase was implementing the Children's Health Collaborative APP Council, creating the charter through an iterative process, and distributing a post-intervention survey to council members to measure usability, feasibility, and satisfaction One hundred and four APPs (26.6%) completed the pre-intervention survey. Across both organizations, most APPs indicated they were either satisfied or moderately satisfied with the 44 APP Job Satisfaction Scale questions, and of the ten questions regarding APP professional development, APPs were either slightly or moderately interested in professional development opportunities. APP discussion groups identified a sense of belonging, care siloing, change readiness, and lack of dedicated time for activities outside of typical workload as topics for the SWOT analysis. All three children's hospitals have defined APP-led leadership structures and committees covering work wellness, quality improvement, and mentorship. The council charter was created at the initial meeting with a mission, vision, objectives, and initiatives. A postintervention survey showed that 80% of respondents thought the council to be sustainable, and 100% were satisfied with its implementation. The process of distribution of a pre-implementation APP Job Satisfaction and Professionalism survey, discussion groups to inform a SWOT analysis, benchmarking of other healthcare systems for APP leadership structure and professional development, and a postimplementation survey provides a framework for other institutions to develop their own APP council. A subsequent survey will need to be distributed one year after council implementation to measure the impact on the APP workforce.

1 Implementation of a Children’s Health Collaborative Advanced Practice Provider (APP) Council: An Evidence-Based Quality Improvement Project Heidi K. White & Megan C. Thomas Hebdon College of Nursing: The University of Utah NURS 7703: DNP Scholarly Project III April 14, 2025 2 Abstract Background: In 2023, the United States (US) Bureau of Labor Statistics predicted that the advanced practice nurse (APRN) workforce will increase by 38% and 27% for physician assistants (PA) between 2022-2032. An increase in patient population and changes in healthcare system care models contribute to the demand for Advanced Practice Providers (APPs). As a result, there is a demand for strategies to increase job satisfaction, diminish turnover, promote collaboration, and facilitate the full scope of practice. Problem: A regional not-for-profit children’s hospital has 391 APPs who are licensed and employed by either a large regional non-profit healthcare system or a large academic center. Each healthcare system has its own APP leadership structure, but no defined collaborative APP leadership structure includes both organizations. As a result, there has been a decrease in interorganizational networking, collaboration, and siloed patient care. Methods: This DNP evidence-based quality improvement initiative involved four separate phases. Phase one was an in-depth literature review of APP job satisfaction, factors contributing to job turnover, APP collaboration, development of APP leadership structures and councils, and inter-organizational and interprofessional collaboration. A pre-intervention survey with demographic questions and questions regarding APP job satisfaction and professionalism was also distributed. Phase two involved three discussion groups with APPs guided by questions that informed a SWOT analysis. Phase three was interviews with APP leaders from each healthcare organization and benchmarking of three children’s hospitals regarding APP leadership and professional development. 3 Interventions: The final phase was implementing the Children’s Health Collaborative APP Council, creating the charter through an iterative process, and distributing a post-intervention survey to council members to measure usability, feasibility, and satisfaction Results: One hundred and four APPs (26.6%) completed the pre-intervention survey. Across both organizations, most APPs indicated they were either satisfied or moderately satisfied with the 44 APP Job Satisfaction Scale questions, and of the ten questions regarding APP professional development, APPs were either slightly or moderately interested in professional development opportunities. APP discussion groups identified a sense of belonging, care siloing, change readiness, and lack of dedicated time for activities outside of typical workload as topics for the SWOT analysis. All three children’s hospitals have defined APP-led leadership structures and committees covering work wellness, quality improvement, and mentorship. The council charter was created at the initial meeting with a mission, vision, objectives, and initiatives. A postintervention survey showed that 80% of respondents thought the council to be sustainable, and 100% were satisfied with its implementation. Conclusion: The process of distribution of a pre-implementation APP Job Satisfaction and Professionalism survey, discussion groups to inform a SWOT analysis, benchmarking of other healthcare systems for APP leadership structure and professional development, and a postimplementation survey provides a framework for other institutions to develop their own APP council. A subsequent survey will need to be distributed one year after council implementation to measure the impact on the APP workforce. Keywords: Advanced Practice Provider, collaboration, professional development, scope of practice, APP council 4 Implementation of a Children’s Health Collaborative Advanced Practice Provider (APP) Council: An Evidence-Based Quality Improvement Project Problem Description Approximately 10% of nurse practitioners (NP) left their jobs in 2018, and half of those who remained considered leaving at some point (Hartsell & Noeker, 2020; Patel et al., 2024). Factors such as lack of leadership support, stressful work environment, partnership/collegiality, and lack of advancement opportunities contributed to them leaving their job, and those who remained in their job identified salary and benefits, ability to practice to full scope, positive relationship with administration and physicians, and a sense of community with peers as factors that caused them to stay (Patel et al., 2024; Venegas et al., 2023; Poghosyan et al., 2022). It is estimated that the direct cost to a healthcare organization to hire a new APP is between $85,832 and $114,929.50, including advertising, onboarding, licensing, physician time for orientation, and non-billable APP during onboarding (Hartsell & Noeker, 2020). A regional not-for-profit, free-standing children’s hospital cares for children from across the Intermountain West and the United States with emergent, chronic, and complex conditions. The Advanced Practice Providers (APPs) at this regional children’s hospital are licensed and employed by a large regional non-profit healthcare system (Organization 1) or a large top 20 academic center (Organization 2) united under a common mission. Each healthcare organization has an APP leadership structure. No defined collaborative Children’s Health APP leadership structure includes both healthcare organizations. As a result, there is diminished communication of Children's Health key performance indicators, inter-organizational collegial networking, and siloed reporting structures. 5 Condit and Hafeman (2019) noted the importance of establishing an APP council to increase APP organizational engagement, role clarity, and peer support, ultimately increasing job satisfaction and diminishing job turnover. Hospitals with a higher nurse practitioner (NP) to bed ratio have been shown to have reports of better care quality and safety by patients and staff nursing, such as lower mortality, fewer readmissions, and shorter length of stay (Aiken et al., 2021). Ultimately, a collaborative APP council aims to increase professional growth and job satisfaction to minimize turnover, optimizing APP staffing to increase access to quality, patientcentered, evidence-based patient care by APPs at a regional children’s hospital. Available Knowledge In 2023, the United States (US) Bureau of Labor Statistics predicted that the advanced practice nurse (APRN) workforce will increase by 38% and 27% for physician assistants (PA) between 2022-2032. The workforce increase is attributed to the increased patient population and demand for healthcare services due to the Affordable Care Act and the shortage of physicians, especially in primary care (Proulx, 2021). Additionally, a focus on value-based purchasing models for team-based care and payor pressure to diminish costs to diminish healthcare costs are driving increased utilization of APPs (Proulx, 2021). The development of APP leadership structures within healthcare organizations is a newer concept that has gained traction throughout the United States. Implementation of a leadership structure has been shown to increase APP reimbursement, patient access, and internal alignment and create an atmosphere of career development and engagement (Proulx, 2021; Evans et al., 2019; Broyhill et al., 2023). Benner’s novice-to-expert theory (1982), which describes the incremental skill development of nurses from novice to expert and transformational leadership which encourages others to reach their highest potential, have served as scaffolding for many of 6 the APP structures nationwide (Evans et al., 2019; Arthur et al., 2020; Scholtz et al., 2021; Kramer et al., 2019; Proulx, 2021). An APP leadership structure has been shown to increase APP job satisfaction and decrease job turnover from 22% to 5% (Arthur et al., 2020). A council of APP leaders committed to advancing professionalism and collaboration is integral to an APP leadership structure. The qualities identified to support inter-organizational and interprofessional collaboration are communication, sense of belonging, role clarification, shared goal/decision-making, respect, interprofessional values, ethics, and conflict resolution and reflection have been shown to increase buy-in, thus leading to enhanced team development and sustainability (Karem et al., 2018; McLaney et al., 2022; Wei et al., 2022). Various healthcare organizations have used a shared governance model for their APP councils focused on collaboration and provider engagement, resulting in improved workplace and job satisfaction, thus increasing job retention (Gooden & Cole, 2023; Brown et al., 2022; Swanson et al., 2023). A critical task of APP councils has been the development of a charter that defines the mission, values, goals, and key performance metrics to guide its recommendations and actions (Swanson et al., 2023; Harms et al., 2021; Brown et al., 2022). A council of APP leaders who value effective collaboration will be able to develop a charter with guiding principles such as prioritizing quality indicators (Harms et al., 2021) that will enhance APP professionalism and, ultimately, APP job satisfaction. A regional children's hospital's lack of a unified APP leadership structure has led to siloed care despite being unified under a common mission. Rationale The three key components of the Johns Hopkins Evidence-Based Practice Model (JHEBP) [Figure 1] are inquiry, practice, and learning, and it is an iterative process in which each component informs the next (Dang et al., 2021). Similarly, the steps of the PDSA cycle of 7 plan, do, study, and act are iterative (Agency for Healthcare Research and Quality, 2024). Both models guided the development, implementation, and evaluation of a Children’s Health Collaborative Advanced Practice Provider (APP) Council at a regional children’s hospital. The inquiry component of the JHEBP model guided the understanding of the nature, scope, and evidence of the problem including a literature review, pre-intervention survey, benchmarking, and discussion groups. The practice component is the “doing” piece of the JHEBP model, and the PDSA cycle informed this scholarly initiative's development and implementation steps of the inaugural council meeting. The final component of the JHEBP model is learning, which correlates closely with the studying and acting of the PDSA cycle. In each iterative PDSA cycle that is completed, participants learn about best practices and implement them, and the postimplementation survey results will be used to inform future initiatives. In summary, the JHEBP model and the PDSA cycle are both well-suited to guide this scholarly initiative from start to finish. The SQUIRE 2.0 guidelines were followed to complete the written manuscript for this project (Ogrinc et al., 2016). Specific Aims This Doctor of Nursing Practice (DNP) evidence-based quality improvement (EBQI) initiative aims to implement a Children's Health Advanced Practice Provider (APP) Collaborative Council and associated charter between a regional children’s hospital that is part of a large non-profit healthcare system and a large top 20 academic center and assess the feasibility, usability, and APP satisfaction. 8 Methods Context The initiative location is a regional children’s hospital, a not-for-profit, free-standing children’s hospital that cares for children across Intermountain West and the United States with emergent, chronic, and complex conditions. There are two locations: a 289-bed Level 1 trauma center, including a pediatric intensive care unit (PICU), cardiac intensive care unit (CICU), neuro trauma unit, a level IV neonatal intensive care unit (NICU); and a 66-bed Level 2 trauma center with the state’s first behavioral health service, neonatal surgical services unit, and a PICU (Intermountain Primary Children’s Hospital, n.d.). Three hundred and ninety-one APPs are credentialed and provide specialized pediatric healthcare at these facilities. Of those 391, just over half are employed by Organization 1 and the remainder by Organization 2 within several academic departments. The initiative was sponsored by the hospital nurse administrator, along with the chief medical officer, and the associate chief medical officer advanced practice of Organization 1. Intervention The implementation of the Children’s Health Collaborative APP Council was completed over four phases. The initial phase was comprised of several assessments. Initially, an in-depth literature review was completed, reviewing APP job satisfaction, factors contributing to job turnover, APP collaboration, development of APP leadership structures and councils, and interorganizational and interprofessional collaboration. An APP satisfaction and professionalism survey based on Misener’s NP Job Satisfaction Scale (Misener & Cox, 2001) and the Advanced Practice Nurses Survey developed by Doerksen (Doerksen, 2010) based on the framework of the Strong Model (Ackerman et al., 1996) that addresses topics such as leadership and 9 professionalism was distributed to all credentialed APPs within Children’s Health. At the end of the survey, there was an option to volunteer for a discussion group. The APPs that provided their email for the discussion groups were sent a short survey to indicate which of the two to three discussion groups they could attend. Descriptive statistics for quantitative items and qualitative analysis for open-ended items were used. The second and third phases involved the development of recommendations for a council structure and written charter based on survey responses, discussion group data, and benchmarking of other institutions. The discussion groups conducted with remote conferencing software discussed the knowledge and satisfaction of the current collaborative process between Organization 1 and Organization 2 and defined questions that informed the SWOT analysis. A SWOT analysis assessed internal strengths/facilitators, internal weaknesses/barriers, external/internal opportunities, and external threats/barriers (Raeburn, 2024). The current leadership APP leadership structure and APP collaborative processes for Organization 1 and Organization 2 were assessed and summarized. Benchmarking with three other children’s hospital systems provided external context for APP leadership structures and councils. A written SWOT analysis, a summary of the number of attendees to discussion groups, and a qualitative analysis of discussion, interview, and benchmarking data were completed. Discussion groups and benchmarking interviews were recorded and stored in UBox, a password-protected online cloud storage tool for Organization 2, to facilitate qualitative analysis. Study of the Intervention(s) This DNP quality improvement initiative consisted of strategies to collect quantitative and qualitative data to inform the development of a collaborative APP council. Pre- and postimplementation surveys were created in REDCap, a Health Insurance Portability and 10 Accountability Act (HIPAA) compliant web-based application for survey development and data set management (REDCap, n.d.). The link to the pre-implementation survey with a brief introductory paragraph was emailed using a blind cc from the children’s hospital’s credentialing office to all APPs credentialed at the hospital. Participants were given two and a half weeks to complete the survey. Virtual meetings lasting one to two hours were conducted with representatives from each benchmarked children’s hospital. Additionally, a virtual meeting was held with an APP leader from Organization 1 and Organization 2 to assess the current APP leadership structure and collaborative efforts within each organization. Three hour-long discussion groups of four to nine APPs were held virtually over two weeks. Preliminary quantitative data and qualitative were shared with stakeholders to inform decision-making regarding the identification of council members. Council members were given a narrative PowerPoint presentation a month before the inaugural meeting highlighting assessment data. Three days before the initial meeting, the council members were emailed a sample charter with a vision, mission, and objectives. The primary outcome was the inaugural Children’s Health Collaborative APP Council conducted virtually, co-creating the council charter based on feedback, and evaluating the council’s usability, feasibility, and APP satisfaction. Stakeholders were provided with the results of the pre-implementation survey and qualitative data based on the discussion groups, which guided the identification of initial council members comprised of APPs from Organization 1 and Organization 2. A council charter was co-created with the council members using assessment data, SWOT analysis, and stakeholder feedback, including objectives/goals, vision and mission statements, and council initiatives. The evaluation was completed with a survey distributed to the APPs on the council. The satisfaction survey completed after the inaugural meeting informed council members of recommended alterations to 11 the program moving forward. Descriptive statistics and qualitative analysis were used, and an executive summary was completed. Measures Several measures were utilized throughout the development and implementation of the Children's Health Collaborative APP Council. In the pre-intervention survey, five demographic questions were collected in addition to the following measures: 44 questions from the validated Misener NP Job Satisfaction Scale (Misener & Cox, 2001); 10 questions from Doerksen’s Advanced Practice Nurses Survey (Doerksen, 2010); and three open-ended questions [Appendix A]. The open-ended questions included an opportunity to identify further professionalism needs, state comments, and provide their email for discussion group participation. The Misener NP Job Satisfaction section utilized a 6-point Likert Scale consisting of very satisfied (6), satisfied (5), moderately satisfied (4), moderately dissatisfied (3), dissatisfied (2), and very dissatisfied (1) (Misener & Cox, 2001). Two experts identified ten questions from Doerksen’s survey to align with areas of professional development, and a 5-point Likert Scale was used. The original survey did not assign a qualifier to the second and fourth points. Therefore, a defined scale consisting of no interest (1), slight interest (2), moderate interest (3), very interested (4), and extreme interest (5) was used. The acronyms NP/APRN were replaced with APP for inclusiveness. Quantitative and qualitative results of the pre-intervention survey and questions designed to inform the SWOT analysis were used for the discussion groups [Appendix B]. Participants who provided their contact information on the pre-intervention survey were contacted via email to sign up for one of three discussion groups using an online scheduling program, and the discussion groups were held using Microsoft Teams. A defined set of questions was developed 12 to guide benchmarking of the three children’s hospital systems [Appendix C]. Finally, a postimplementation survey was created in REDCap and distributed to council members with questions addressing the collaborative APP council's feasibility, usability, and satisfaction [Appendix D]. Stakeholder interviews were held to discuss the executive summary and determine satisfaction with the scholarly initiative. Analysis Quantitative Descriptive statistics were used for pre-intervention demographic data, including education, occupation, employer, location of practice, and length of employment. Nonparametric inferential statistics were used to describe the results of the job satisfaction and professional development portion of the pre-intervention survey and post-intervention survey, to understand trends, and to describe demographic relationships with job satisfaction and professional development. The pre-implementation APP Job Satisfaction and Professionalism Survey [Appendix A] was distributed to the 391 APPs credentialed within Children’s Health. One hundred and twentyfive (32.0%) individual surveys were submitted by the end of two and a half weeks. Two responses from the same person with similar responses but different occupations were recorded five days apart. The analysis used the initial response, resulting in 124 (31.7%) individual submissions. Additionally, 20 respondents completed only the demographic portion of the survey, leaving 104 surveys with the majority of questions completed. These 104 (26.6%) surveys were used to complete the quantitative and qualitative analysis. 13 Qualitative Qualitative content analysis was utilized for the open-ended questions of pre- and postintervention surveys, discussion groups, and interviews. Responses to open-ended questions in both the pre-and post-intervention surveys were analyzed, categorized, and summarized with care to maintain content integrity. Discussion groups and interviews were completed virtually and recorded with or without transcription capabilities to facilitate notetaking and a descriptive analysis was completed. Each meeting’s notes or transcription were analyzed line by line to identify categories and sub-categories, which were organized and summarized to inform the themes of each meeting. Ethical Considerations Before proceeding with the initiative, approval was obtained from the University of Utah Institutional Review Board (IRB) and Organization 1’s Nursing Scientific Review Board. The initiative was determined to be exempt from full IRB review due to being a quality improvement project. Anonymity was paramount for the pre-intervention survey to facilitate honest feedback. Participants voluntarily provided contact information to participate in discussion groups. Discussion and interview data were de-identified. There were no conflicts of interest concerning this study. Results Phase One Most of the pre-implementation surveys were completed by Organization 1 employees (n=75, 72.12%), compared to (n=22, 21.15%) Organization 2 employees [Table 1]. Across both organizations, 67.74% were master-prepared and 32.26% were doctoral-prepared. Of those who identified as nurse practitioners, (n=36, 34.62%) were family nurse practitioners (FNP), and (n=29, 27.88%) were pediatric nurse practitioners (PNP) between both institutions. Thirteen 14 (12.50%) physician assistants responded to the survey. Most APPs (60.58%) provided care at the children’s hospital main campus. The time APPs worked at the children’s hospital varied, with 31.73% (n=33) being newer hires (0-5 years), contrasting with 29.81% (n=31) with over 20 years of practice. The 44 questions from the Misener NP Job Satisfaction Scale [Table 2] were separated into six domains or factors, as described by Misener & Cox (2001). Fourteen questions discussed intrapractice partnership/collegiality; most respondents were moderately satisfied. Factor 2 was comprised of ten questions, and the majority were satisfied with their level of challenge or autonomy. Most APPs were either satisfied or moderately satisfied with their professional, social, and community interaction. Questions regarding APP professional growth showed that most were either satisfied or moderately satisfied. The four questions of Factor 5, Time, and the three questions within Factor 6, Benefit, solicited responses of satisfied or moderately satisfied. Finally, there were slight differences between organizations for the total mean scale score for Organization 1 (205.38), Organization 2 (223.30), and shared employment (212.25) [Table 3]. Across organizations, APPs were either slightly or moderately interested in professional development opportunities [Table 4]. At the end of the survey, respondents were allowed to identify specific professional development needs and other recommendations [Table 5]. The need for APP leadership roles, allotted time for continuing education, and recognition of work effort were highlighted as professional development topics, and comments regarding compensation were the predominant recommendations. Phase Two The four main themes identified across discussion groups were time, professional development, educational opportunities, and communication [Table 4]. The phrase “time is 15 always a barrier” summarized many comments concerning participation in activities outside the established workday. The comment, “I would love to see some more APP-centered training or educational opportunities. For your specific role, or just in general for APPs. Like APP Grand Rounds,” highlighted the desire for APP-specific education and professional development opportunities. The following comment noted the desire for increased collaboration or networking opportunities, “…here I felt very much like an island and not those opportunities and familiarity with other disciplines or other NPs or physicians for that matter.” A SWOT analysis [Figure 2] was completed based on the responses provided during the discussion groups. The strengths identified were established service lines, grand rounds, department provider meeting inclusion, and a sense of belonging at the children’s hospital. Interorganizational access, allotted time, and care siloing, which resulted in a lack of collaboration, were key weaknesses. The desire for change, the anticipation of an increased workforce, and the recent development of leadership structures create an opportunity to develop and implement the Children’s Health Collaborative APP Council. Lack of dedicated time and the challenges associated with coordinating between two healthcare organizations were threats. Phase Three Phase three involved interviewing an APP leader from Organization 1 and Organization 2 to assess each organization’s current APP leadership structure and collaborative efforts and APP representatives from three children’s hospitals within the United States. A predetermined set of questions [Appendix C] was used to guide the conversation with the three children’s hospitals: one hospital based on the West Coast of the United States, another located on the East Coast, and the third a specialty care children’s hospital. 16 Organization 1 is a large healthcare organization comprised of 34 hospitals, including the regional children’s hospital. Care is aligned under service lines; each service line has an APP lead who reports to an APP director. The APP directors report directly to an APP associate chief medical officer, who reports to the chief medical officer. Within Children’s Health, 10 APP directors cover the children’s hospital, primary care, urgent care, and neonatology. The directors at the children’s hospital comprise the remaining affinity group, led by an APP director who reports to the administration. The affinity group has encouraged collaboration among the APP leaders at the children’s hospital. Organization 2 is comprised of five hospitals and 12 community centers. Organization 2 refers to advanced practice providers as advanced practice clinicians (APCs). As an academic center, leadership is aligned with departments, and there are APC directors/chairs for each department (or two if there is an ambulatory and inpatient component). There are also APC division leads within departments. Each departmental director is a member of the APC council led by co-chairs. The West Coast children’s hospital provides care in rural and urban areas, across state lines, and employs approximately 300 APPs. The current APP leadership comprises an executive director, seven managers, and seven assistant managers. The top three identified professional development strategies were culture, needs assessment, and data collection. The initial development of the APP council was organic to increase APP representation, and a charter, leadership, and length of service were defined. APP-led committees exist for work wellness, professional development, clinical informatics, mentorship, and student support. The pediatric APPs collaborate with their adult colleagues monthly at combined APP grand rounds. 17 Opportunities to increase engagement and belonging have contributed to a decrease in APP turnover. The hospital on the East Coast has over 1100 APPs and serves a primarily 70-mile urban geographic radius, although children may come from other states or internationally for care. Many of the APPs are employed by the hospital, while others are employed by specialty practices or surgical practices. They have established an APP professional advancement program (Scholtz et al., 2022) based on Benner’s novice-to-expert framework. The Center for Advanced Practice was formed in 2019 and has executive staff, managers, and team leads. APP leaders within the Center focus on specialty areas such as information technology, patient safety and improvement, APP wellness, and professional development. The Center offers a mentorship program for new and experienced APPs, skills days, weekly continuing education sessions, APP fellowships, a transition to practice program, and a clinical emergent program for new APP graduates to begin onboarding training during credentialing. Although there is no APP council, the Center for Advanced Practice has grown to adapt to the increasing APP staff. An increase in employee satisfaction and a decrease in APP turnover has been noted in the past five years. I spoke with an APP who was a former children’s specialty care hospital employee. The patient population base is in the southwest and nationwide. All APPs are hospital employees, and an APP director directly reports to the chief nursing officer. Professional development opportunities include a year-long transition to practice program for new APPs, a mentorship program, and skills days. The hospital has an APP council, but from an employee’s perspective, inpatient providers were more aware of its presence than ambulatory ones. APP council members are elected and oversee subcommittees, including diversity and quality improvement. 18 The hospital has seen a higher APP turnover due to the nature of the care provided and the urban city in which it is located. Phase Four The fourth phase was the first meeting of the Children’s Health Collaborative APP Council, charter development, and a post-implementation survey measuring the council's satisfaction, usability, feasibility, and sustainability. A stakeholder meeting was held two and a half weeks after the initial council meeting to receive feedback on the executive summary and charter. The stakeholder executive committee was composed of the chief medical officer and chief nursing officer of the children’s hospital and the executive director for advanced practice providers at Organization 1. The council has seven members; four are Organization 1 employees, and Organization 2 employs the other three. Three of the Organization 1 employees are APP directors recommended by stakeholders to serve, and the third holds an elected position as the APP representative to the Medical Executive Committee at the children’s hospital. The three Organization 2 APP leaders are the Department of Pediatrics APC Council chair, the Department of Rehabilitation APP leader, and the Pediatric Surgical Services APP Council co-chair. The development of the Children’s Health Collaborative APP Council Charter [Appendix D] was iterative, and council members and stakeholders contributed recommendations. It is comprised of a mission, vision, objectives, and initiatives. The phrase “key performance indicators” was changed to initiatives per stakeholders' recommendations to include both organizations. Three initiatives were chosen based on the six objectives with entry, target, and stretch milestones. An executive summary [Appendix F] was distributed to the 19 stakeholders, and a final meeting was held to review the summary, charter, and SWOT analysis and determine the council's reporting structure. The post-implementation survey [Appendix E] was distributed to six of the seven council members. As the Pediatric Surgical Services APP Council co-chair, I did not complete the survey due to potential bias. Five of the six (83%) council members completed the survey. Of the five respondents, one (20%) was neutral, one (20%) considered it likely, and three (60%) considered it very likely that the council would be sustainable [Table 7]. Dedicated participation time and a clear mission, vision, objectives, and council structure were considered key to the council’s sustainability [Table 8]. Respondents considered that the council would likely (n=2, 40%) or very likely (n=3, 60%) encourage APP collaboration and professional development and increase satisfaction. Additionally, the survey showed that most council members indicated that the charter, mission, vision, objectives, and key performance indicators would encourage APP collaboration and increase satisfaction. Of those who responded, all (n=5, 100%) were satisfied with the implementation of the Children’s Health Collaborative APP Council. Discussion Summary The development and implementation of the Children’s Health Collaborative APP Council was largely successful due to the strong support of the stakeholder executive committee, APP staff, and council members who are strong advocates for the APP role and professional development. The inaugural council meeting and the creation of the council charter are the first necessary milestones in increasing APP collaboration and engagement. The inter-organizational communication skills of fostering a sense of belonging, shared goal/decision-making, respect, interprofessional values, ethics, and conflict resolution and 20 reflection were key to the success of the initial council meeting (Karem et al., 2018; McLaney et al., 2022; Wei et al., 2022). Clarification of roles within the council will be forthcoming. It is the hope that investing in these skills will result in increased buy-in, thus leading to enhanced team development and, ultimately, council sustainability (Karem et al., 2018; McLaney et al., 2022; Wei et al., 2022). Benchmarking of children’s hospitals and a literature review have shown that an APP leadership structure fosters an atmosphere of engagement, leading to increased job satisfaction and patient access due to increased job retention. Further study will be needed to determine the implementation of a Children’s Health Collaborative APP Council, and the associated charter will exhibit similar findings. Interpretation A prevailing theme was the availability of time to devote to activities outside of the established workload. The pre-implementation survey findings showed that APPs were moderately dissatisfied with compensation for time spent on additional activities across both organizations. Many of the comments made during discussion groups identified time as a barrier to the implementation of a new process but, at the same time, expressed a desire for change to the siloing of providers within the hospital. The council members also expressed concern about the time commitment to push a new initiative forward. It will be imperative to continue identifying and empowering APP champions willing to invest in promoting collaboration, engagement, role advocacy, and professional development of APPs at Children’s Health to ultimately diminish job turnover, resulting in organizational cost savings and increasing access to specialized, high-quality pediatric healthcare. 21 The elements of the council’s charter aligned closely with published literature (Swanson et al., 2023 & Harms, 2017). The council members identified the seven objectives, and the first objective to “promote advanced practice top of training/license in Children’s Health,” was similar to studies that prioritized top-of-license practice as a key focus of the council (Swanson et al., 2023 & Harms, 2017). The inability to practice at the top of licensure has been shown to be a top driver for an APP to leave their job (Patel et al., 2024). As a result, advocacy for top-oflicensure practice will be instrumental in increasing APP satisfaction and job retention. The time commitment for this scholarly project was significant. However, with an atmosphere for change driven by the support of key stakeholders with a vested interest in the APP council's success, emerging literature (Gooden & Cole, 2023; Brown et al., 2022; Swanson et al., 2023; Harms et al., 2017), and the satisfaction of the council members with the council implementation and confidence in its sustainability, the time investment has been rewarding. Time will be the ultimate test as the council’s impact, specifically regarding APP job satisfaction, professional development, and collaboration is measured and studied in one year, two years, and five years in the future and whether the findings align with studies that have shown substantive improvements (Gooden & Cole, 2023; Brown et al., 2022; Swanson et al., 2023) with the implementation of APP councils. Limitations The established parameters limit the generalizability of the initiative. Since the credentialed APPs that practice within one hospital are employed by one or both of two large healthcare organizations, the focus of the council and charter development was on APP collaboration and professional development, not the development of a new APP leadership structure. The initiative's scope was to implement a Children’s Health Collaborative APP 22 Council. It did not include long-term follow-up to determine if the council increased APP job satisfaction and professional development and ultimately decreased job turnover. Additionally, the initiative was designed considering inter-organizational collaboration and may need restructuring to apply to a hospital where the same organization employs all APPs. Of the 391 credentialed APPs at the children’s hospital, 104 (26.6%) completed the APP Job Satisfaction and Professionalism survey, and the majority were employees of Organization 1, which can diminish the generalizability of the survey results across both organizations. A higher response rate to the pre-implementation survey would have been desired to confidently generalize findings for all Children’s Health APPs. There was a lower response rate from physician assistants than nurse practitioners, limiting the inclusivity and diversity of data. The only available method to reach the desired APP population was to send an email through the credentialing office that has an email address associated with Organization 1. Multiple reminder emails were sent within a designated time period for survey completion. Emails originating from Organization 1 often are not recognized by or go to a spam folder of Organization 2 employees. Conclusions An increased APP workforce necessitates strategies, such as APP councils, to increase job satisfaction, mitigate turnover, promote collaboration, and facilitate the full scope of practice. The development and implementation of a Children’s Health Collaborative Advanced Practice Provider Council was based on an initial APP job satisfaction and professional development survey, qualitative data from discussion groups comprised of both healthcare organizations, and benchmarking three children’s hospitals. The council has decided to convene monthly with quarterly reports to the associate chief medical officer. The second initiative of the charter is already in process by planning a 23 Children’s Health APP symposium focused on APP collaboration and professional development and the first steps taken to coordinate the first of six brown bag lunches and learns. The redistribution of the APP Job Satisfaction and Professionalism Survey one year after council implementation is recommended to measure the effectiveness of the council on APP satisfaction and professional development. Tracking the APP turnover rate within Children’s Health over the course of the next year will also serve as an additional assessment of the council’s impact. In general, the steps taken in this DNP evidence-based quality improvement (EBQI) initiative to establish an inter-organizational collaborative APP council can provide a framework for other institutions looking to increase APP job satisfaction, collaboration, engagement, and professional development with the intent to diminish turnover. 24 Acknowledgments This DNP initiative has been the cumulative result of my passion for advocating for APP leadership and professional development. 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Journal of Interprofessional Care, 36(5), 735–749. https://doi.org/10.1080/13561820.2021.1973975 30 Table 1 APP Satisfaction and Professionalism Survey: Demographics Highest Level of Education Received Master’s Degree (MSN, CNS, MPA) Doctoral Degree (DNP, PhD, DMSc) Grand Total Occupation Acute Care Nurse Practitioner Clinical Nurse Specialist Family Practice Nurse Practitioner Neonatal Nurse Practitioner Pediatric Nurse Practitioner Physician Assistant Other Grand Total Primary Children’s Campus Location Larry H. & Gail Miller Family Campus in Lehi Salt Lake City Campus Both Grand Total Length of work at Regional children’s hospital(years) 0-5 6-10 11-15 16-20 20+ Grand Total Organization 1 n(%) Organization 2 n(%) Both n(%) Grand Total n(%) 57 (71.83) 21 (22.54) 5 (5.63) 84 (67.74) 28 (72.73) 8 (18.18) 4 (9.09) 40 (32.26) 85 (72.12) 29 (21.15) 9 (6.73) 124 (100) 4 (100) 2 (100) 23 (63.89) 0 (0) 0 (0) 10 (27.78) 0 (0) 0 (0) 3 (8.33) 4 (3.85) 2 (1.92) 36 (34.62) 14 (93.33) 22 (75.86) 7 (53.85) 3 (60) 75 (72.12) 0 (0) 4 (13.79) 6 (46.15) 2 (40) 22 (21.15) 1 (6.67) 3 (10.34) 0 (0) 0 (0) 7 (6.73) 15 (14.42) 29 (27.88) 13 (12.50) 5 (4.81) 104 (100) 5 (100) 0 (0) 0 (0) 5 (4.81) 46 (73.02) 24 (66.67) 75 (72.12) 14 (22.22) 8 (22.22) 22 (21.15) 3 (4.67) 4 (11.11) 7 (6.73) 63 (60.58) 36 (34.62) 104 (100) 21 (63.64) 12 (66.67) 12 (85.71) 6 (75.00) 24 (77.42) 75 (72.12) 12 (36.36) 4 (22.22) 2 (14.29) 1 (12.50) 3 (9.68) 22 (21.15) 0 (0) 2 (11.11) 0 (0) 1(12.50) 4 (12.90) 7 (6.73) 33(31.73) 18 (17.31) 14 (13.46) 8 (7.69) 31 (29.81) 104 (100) 31 Table 2 APP Job Satisfaction and Professionalism Survey: Misener Job Satisfaction Scale Item Factor 1: Intrapractice Partnership/Collegiality Your immediate supervisor Amount of administrative support Consideration given to your opinion and suggestions for change in the work setting or office practice Input into organizational policy Freedom to question decisions and practices Recognition for your work from superiors Evaluation process and policy Reward distribution Opportunity to develop and implement ideas Process used in conflict resolution Amount of consideration given to your personal needs Monetary bonuses that are available in addition to your salary Opportunity to receive compensation for services performed outside of your normal duties Respect for your opinion Factor 2: Challenge/Autonomy Percentage of time spent in direct patient care Patient mix Sense of accomplishment Organization 1 (n=75) M(SD) Organization 2 (n=22) M(SD) Both (n=7) M(SD) Grand Total (N=104) M(SD) 5.14(1.51) 4.59(1.54) 5.40(1.45) 5.03(1.66) 5.44(1.13) 4.67(1.73) 5.25(1.47) 4.734(1.59) 4.32(1.60) 4.90(1.44) 4.44(2.07) 4.51(1.63) 4.00(1.70) 4.59(1.74) 4.44(2.07) 4.22(1.76) 4.42(1.55) 5.07(1.39) 4.44(2.07) 4.61(1.58) 4.45(1.56) 4.93(1.46) 4.56(1.94) 4.61(1.59) 4.45(1.58) 4.10(1.66) 4.64(1.48) 4.83(1.58) 4.41(1.90) 5.31(1.20) 4.67(1.87) 4.33(2.00) 4.78(1.79) 4.60(1.61) 4.23(1.76) 4.85(1.47) 4.60(1.41) 5.10(1.29) 5.11(1.27) 4.79(1.40) 4.58(1.46) 5.07(1.56) 4.67(2.12) 4.74(1.56) 3.19(1.96) 3.90(2.11) 3.78(2.68) 3.46(2.09) 3.30(1.94) 3.97(2.03) 4.00(2.50) 3.56(2.05) 4.69(1.50) 5.24(1.18) 4.56(1.81) 4.85(1.48) 5.26(0.98) 5.52(1.06) 4.89(1.54) 5.32(1.06) 5.37(0.88) 5.27(1.08) 5.41(1.09) 5.48(1.12) 5.44(1.01) 5.11(1.54) 5.41(0.95) 5.31(1.13) 32 Item Expanding skill level/procedures within your scope of practice Ability to deliver quality care Opportunities to expand your scope of practice and time to seek advanced education Level of autonomy Sense of value for what you do Challenge in work Flexibility in practice protocols Factor 3: Professional, Social, and Community Interaction Quality of assistive personnel Social contact at work Status in the community Social contact with your colleagues after work Professional interaction with other disciplines Interaction with other APPs including faculty Recognition for your work from peers Acceptance and attitude of physicians outside of your practice (such as specialist you refer patients to) Factor 4: Professional Growth Support for continuing education (time and $$) Opportunity for professional growth Time off to serve on professional committees Amount of involvement in research Opportunity to expand your scope of practice Organization 1 (n=75) M(SD) 4.62(1.48) Organization 2 (n=22) M(SD) 4.93(1.58) Both (n=7) M(SD) 4.67(1.80) Grand Total (N=104) M(SD) 4.73(1.54) 5.13(098) 4.45(1.50) 5.56(1.02) 5.10(1.40) 5.33(1.32) 4.78(1.64) 5.27(1.04) 4.67(1.52) 4.54(1.62) 5.01(1.33) 5.36(0.94) 4.64(1.25) 5.31(1.37) 5.40(1.29) 5.52(1.18) 5.21(1.26) 5.33(1.58) 5.11(1.69) 5.33(1.12) 5.33(1.12) 4.81(1.60) 5.14(1.36) 5.42(1.02) 4.86(1.28) 5.11(1.29) 5.42(1.03) 5.21(0.95) 5.04(1.21) 5.55(1.18) 5.48(1.21) 5.21(1.32) 5.34(1.17) 4.89(1.54) 5.22(1.09) 4.78(1.56) 4.67(1.58) 5.23(1.30) 5.42(1.08) 5.21(1.11) 5.11(1.24) 4.87(1.15) 5.00(1.39) 5.11(1.45) 4.95(1.24) 4.90(1.21) 4.59(1.94) 5.11(1.36) 4.88(1.43) 4.76(1.20) 4.90(1.52) 4.56(1.81) 4.81(1.46) 4.82(1.14) 5.14(1.30) 5.00(1.41) 4.94(1.22) 4.89(1.40) 4.66(1.63) 5.11(1.36) 4.89(1.46) 4.78(1.52) 4.55(1.91) 4.89(1.54) 4.78(1.62) 4.13(1.65) 4.72(1.71) 4.44(1.74) 4.34(1.70) 4.37(1.60) 5.17(1.31) 4.78(1.48) 4.63(1.57) 4.44(1.60) 4.79(1.72) 4.89(1.54) 4.60(1.64) 33 Item Factor 5: Time Time allotted for answering messages Time allotted for review of lab and other test results Time allocation for seeing patient(s) Patient scheduling policies and practices Factor 6: Benefits Vacation/Leave Policy Benefit Package Retirement Plan Organization 1 (n=75) M(SD) Organization 2 (n=22) M(SD) Both (n=7) M(SD) Grand Total (N=104) M(SD) 4.61(1.46) 5.17(1.31) 4.89(1.36) 4.80(1.44) 4.65(1.46) 5.14(1.33) 4.78(1.48) 4.81(1.45) 5.11(1.14) 5.48(1.24) 4.78(1.48) 5.20(1.21) 5.01(1.20) 4.59(1.86) 4.89(1.97) 4.94(1.45) 4.46(1.46) 4.13(1.57) 4.55(1.55) 5.09(1.06) 5.79(0.98) 6.00(.76) 4.14(1.86) 5.11(1.27) 5.00(1.32) 4.57(1.45) 4.64(1.61) 4.96(1.52) 34 Table 3 APP Job Satisfaction and Professionalism Survey: Misener Job Satisfaction Survey Scale Score Organization 1 (n=75) Scale Score 205.38 Organization 2 (n=22) Scale Score 223.30 Both (n=7) Scale Score 212.25 Grand Total (N=104) Scale Score 207.1 Factor 1: Intrapractice Partnership/Collegiality 60.46 67.72 63.89 63.02 Factor 2: Challenge/Autonomy 49.65 53.31 51.33 50.96 Factor 3: Professional, Social, and Community Interaction 39.82 41.14 39.33 40.36 Factor 4: Professional Growth 22.61 23.90 24.11 23.22 Factor 5: Time 19.38 20.38 19.33 19.75 Factor 6: Benefits 13.13 16.88 14.25 9.60 Item Total Scale Score 35 Table 4 APP Job Satisfaction and Professionalism Survey: Professional Development Organization 1 (n=75) Organization 2 (n=22) Both (n=7) Item Participate in strategic planning for the service, department, or hospital M(SD) 2.89(1.31) M(SD) 2.57(0.87) Grand Total (N=104) M(SD) M(SD) 2.83(0.98) 2.82(1.21) Provide direction for and participate in unit/service quality-improvement 3.20(1.19) 3.05(1.11) 2.83(0.75) 3.14(1.15) Provide leadership and actively participate in the assessment, development, implementation, and evaluation of quality improvement programs 3.14(1.28) 2.76(1.14) 2.60(0.89) 3.03(1.23) Provide leadership in the development, implementation, and evaluation of standards of practice, policies, and procedures 2.96(1.30) 3.10(1.04) 2.50(1.22) 2.96(1.24) Serve as a mentor 3.44(1.09) 3.50(0.95) 2.33(1.21) 3.39(1.09) Advocate for the Advanced Provider role 3.63(1.11) 3.65(0.88) 3.33(0.82) 3.61(1.04) Facilitate clinical research through collaboration with others in investigations, analysis of practice problems to generate researchable questions, enable access to clients and data 2.94(1.21) 2.67(1.11) 3.00(1.26) Disseminate knowledge through presentation or publication at local, regional, national, and international levels 3.03(1.24) 2.57(1.16) 2.50(1.05) 2.90(1.22) 2.89(1.9) 36 Organization 1 (n=75) Organization 2 (n=22) Both (n=7) Item Represent advanced practice providers in institutional/community forums focused on the educational needs of various populations M(SD) 3.03(1.24) M(SD) 2.90(1.00) Grand Total (N=104) M(SD) M(SD) 3.00(0.63) 3.00(1.16) Provide leadership in shaping public policy on healthcare 2.58(1.21) 2.40(1.10) 2.50(0.84) 2.54(1.16) 37 Table 5 APP Job Satisfaction and Professionalism Survey: Qualitative Data Theme/Category Professional Development Needs Subcategory Leadership Survey Statements APP Supervisor Time Time to attend grand rounds and educational lectures at work. Time to work in our community such as school or PTA activities Have not been able to attend the leadership course through Intermountain and want to do that in future. Recognition Recognition/compensation for going above and beyond Low autonomy, and fairly low respect in this particular job. This isn't true for other jobs I've worked as an NP General Comments Compensation I am extremely unsatisfied with the PTO and the way Intermountain "takes" your PTO on holidays. I feel this is psychologically unsatisfying; then as a Psych NP, I do the equal level of work and on call work as my U of U psychiatrists with less pay and nonequitable PTO. There needs to be better pay and an APP career ladder. Those of us who are salary are making less even if we work more as we don't make overtime or get paid fairly for all that we do 38 Table 6 Discussion Group Qualitative Analysis Theme/Category Subcategory Time Discussion Group Statements Time is always a barrier. Work Schedule Professional Development I think the biggest way that an organization can support you is by, like, blocking your schedule. So when we are looking at hiring, like, new faculty candidates, I am one of the people that will interview them too, which gives me job satisfaction because I feel like my opinion matters. Mentorship I think the ability to mentor the newer NPs is for me a job satisfaction. So being a part of that, being a part of their curriculum as well, we've trying to set up a fellowship for ICU so that we can actually mentor new people and actually grow a critical care NP. Leadership Skill Development (Crucial Conversations, Emotional Intelligence) So not necessarily the clinical skills that we need to develop, but how do we learn skills and help support each other in some of that professionalism? Educational Opportunities I would love to see some more APC-centered training or educational opportunities. For your specific role, or just in general for APCs. Like APC Grand Rounds. Increase collaboration I think like creating events or like meetings or luncheons and CME things that are just like able for us to be in the same room together. APP Symposium I think there's actually is a lot of discussion and momentum with this. So we're trying to find ways that we can collaborate better. 39 Theme/Category Communication Subcategory Networking Transcription Statements But I think one of the things that has given me a lot of satisfaction is working with other teams. But here I felt very much like an island and not those opportunities and familiarity with other disciplines or other NPs or physicians for that matter. Access (Teams, Umail, I found another barrier just recently it's just the ect) ability to access…. 40 Table 7 Children’s Health Collaborative APP Council: Post-Implementation Survey Question Will the Children’s Health APP Collaborative Council encourage APP collaboration and professional development and increase satisfaction? Very Unlikely Unlikely Neutral Likely Very Likely Will the _____ for the Children’s Health APP Collaborative Council encourage APP collaboration and increase satisfaction? Charter Very Unlikely Unlikely Neutral Likely Very Likely Mission Very Unlikely Unlikely Neutral Likely Very Likely Vision Very Unlikely Unlikely Neutral Likely Very Likely Objectives Very Unlikely Unlikely Neutral Likely Very Likely Response N=5 (%) 0 (0%) 0 (0%) 0 (0%) 2 (40%) 3 (60%) 0 (0%) 0 (0%) 1 (20%) 2 (40%) 2 (40%) 0 (0%) 0 (0%) 0 (0%) 2 (40%) 3 (60%) 0 (0%) 0 (0%) 0 (0%) 2 (40%) 3 (60%) 0 (0%) 0 (0%) 0 (0%) 1 (20%) 4 (80%) 41 Question Key Performance Indicators Very Unlikely Unlikely Neutral Likely Very Likely Will the Children’s Health APP Collaborative Council be sustainable? Very Unlikely Unlikely Neutral Likely Very Likely How satisfied are you with the implementation of the council? Very Unlikely Unlikely Neutral Likely Very Likely Response N=5 (%) 0 (0%) 0 (0%) 0 (0%) 3 (60%) 2 (40%) 0 (0%) 0 (0%) 1 (20%) 1 (20%) 3 (60%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 5 (100%) 42 Table 8 Children’s Health Collaborative APP Council: Post-Implementation Survey Qualitative Theme/Category Sustainability Subcategory Time Comments APPs will need protected time for a lot of this work. The challenge is scheduling the time to continue to move the recognized initiatives forward. Time and consistent participation…I think are all barriers to sustainability. Clarity having a clear mission and vision will sustain. identifying clear objective that are within the councils control will be important The barriers currently are keeping the work simple Council Implementation APP Professionalism …focusing on initiatives aimed at supporting the APP in their profession and improving the care we provide children will be important. I think it is an excellent way to support APP engagement, professional growth and quality of care. Recommendations Council Structure identify roles and responsibilities 43 Theme/Category Subcategory Comments Clear objectives for each meeting, providing opportunity for collaborative feedback, establish short and long term goals, guidelines for building the program and how to get it up and running. 44 Figure 1 Johns Hopkins Evidence-Based Practice Model 45 Figure 2 Discussion Group Swot Analysis •Service Lines •Grand Rounds •Inclusion in department provider meetings •Sense of belonging at Primary Children's •Time •Different Organizations •Access •Time •Silos-lack of collaboration Strengths Weaknesses Threats Opportunities •Desire for change •Increase in workforce •Recent leadership structures developed 46 Appendix A APP Job Satisfaction and Professionalism Survey 47 48 49 50 51 Appendix B Discussion Group Qualitative Survey Questions 1. Inter-organizational collaboration opportunities/efforts a. What current efforts for APP collaboration between Organization 1 and Organization 2 are you aware of? Can you list them for me? b. Are you aware of past efforts in APP collaboration between Organization 1 and Organization 2? What has happened in the past? If so, did you find them helpful in developing relationships/connections with colleagues? Are there examples that we can learn from? 2. APP Job Satisfaction a. What specific roles or activities contribute to your job satisfaction? b. What would increase your job satisfaction? c. What types of activities would contribute to your engagement at Primary Children’s? d. I want to get a sense of how everyone is doing. On a scale of 0-5, with 5 being the highest, using your fingers, how many feel a sense of belonging at Primary’s. Of those that responded less than 5, can you describe why? 3. Internal strengths/facilitators a. Can you identify specific Organization 1 or Organization 2 traits that encourage collaboration? b. Can you identify specific strengths of Organization 1 or Organization 2 that would encourage the development of an inter-organizational APP council? 52 4. Internal weakness/barriers a. Or identify specific Organization 1 or Organization 2 barriers that would discourage collaboration. b. Can you identify specific Organization 1 or Organization 2 barriers that would discourage the development of an inter-organizational APP council? 5. External threats/barrier a. Can you identify specific threats outside our two healthcare organizations that would discourage collaboration? Or the development of an inter-organizational APP council? b. Do you think that after our conversation regarding our strengths, weaknesses, and our opportunities is one way to increase your sense of belonging? 6. Closing question a. So, after having this conversation, about the development of a collaborative APP council, do feel this work would enhance your sense of belonging at Primary’s? 53 Appendix C Healthcare System Benchmarking Questionnaire 1. Who employs the APPs at your hospital? 2. What geographic area does your hospital serve? How much of that is rural vs urban? 3. What activities does your organization offer to increase APP professional development and collaboration? 4. If you identify your top three strategies for APP professional development, what would they be? 5. Do you have an APP council, and if so, what led to its creation? 6. What barriers did you have to overcome? What facilitated the creation of your APP council? 7. Do you have different committees that the council oversees? If so, what are those? 8. What changes have you seen at your hospital since the implementation of the council? 9. Have you seen a change in your APP job turnover since the development of the APP leadership structure/council? 10. What changes would you like to see implemented? 54 Appendix D Children’s Health Collaborative APP Council Charter Mission: This council is dedicated to the collaboration, advocacy, engagement, and professional growth of APPs to promote clinical excellence in the care of pediatric patients. Vision: To be the leading network of Advanced Practice Providers in pediatric healthcare known for delivering exceptional, compassionate, and patient-centered care through collaboration, driving innovations, and improving the health and well-being of children, families, and their providers. We envision a future where our APPs are empowered to foster an environment of mutual respect, innovative practice, shared learning, and collective growth. Objectives: 1. 2. 3. 4. 5. 6. 7. Promote Advanced Practice top of training/license within Children’s Health Promote inter-organizational collaboration Mentor APP clinical and research development Create APP-led continuing medical education (CME) Develop opportunities for APP integration of professional development skills. Improve inter-organizational APP communication Strengthen APP wellness across Children’s Health. Initiative: 1. Promote inter-organizational collaboration a. Entry: Create Children’s Health Collaborative APP Council b. Target: Identify areas of collaborative opportunities c. Stretch: Chose one opportunity and develop a supportive program 2. Create APP-led CME a. Entry: Successful completion of the April symposium b. Target: Arrange CME for monthly Brown Bag Lunches and schedule the first six c. Stretch: Collect feedback to determine improvements to the symposium and first six brown bag lunches 3. Improve APP communication a. Entry: Map where APPs work in the CH network b. Target: Create APP champions on committees at PCH, such as Magnet, the Physician Safety Committee, and the communications team c. Stretch: Create and publish an APP quarterly newsletter for PCH; Create a roster of APPs within Children’s Health 55 Appendix E Children's Health Collaborative APP Council Post Implementation Survey Will the ________ for the Children's Health APP Collaborative Council encourage APP collaboration and increase satisfaction? 10) What comments do you have regarding the implementation of the council? (e.g. barriers, support) __________________________________________ 11) What changes would you recommend moving forward? 56 Appendix F Children’s Health Collaborative APP Council Executive Summary Project Topic: Implementation of a Children’s Health Collaborative Advanced Practice Provider (APP) Council: An Evidence-Based Quality Improvement Project Name: Heidi K. White, MSN, CPNP-PC Date: April 18, 2025 Objective: This evidence-based quality improvement initiative aimed to implement a Children’s Health Collaborative Advanced Practice Provider (APP) Council and associated charter and assess the feasibility, usability, and APP satisfaction. Background: Approximately 10% of nurse practitioners (NP) left their jobs in 2018, and half of those who remained considered leaving at some point. The estimated cost of APP job turnover is $85,000-115,000. Therefore, APP job retention is key to diminishing healthcare system costs. Engaging in the full scope of practice and increasing APP organizational engagement, role clarity, and peer support lead to increased job satisfaction and decreased job turnover. The APPs credentialed at a Primary Children’s Hospital are employed by Intermountain Health or University of Utah Health and unite under a common mission. No defined collaborative Children’s Health APP leadership structure includes both healthcare organizations. I was tasked with developing an inter-organizational council to facilitate APP collaboration and professional development within Children’s Health. Research Methods: • Phase 1: An extensive literature review was completed, and an APP satisfaction and professionalism survey was distributed to 391 credentialed APPs within Children’s Health. • Phase 2: Three APP discussion groups to discuss knowledge and satisfaction of current inter-organizational collaborations and questions designed to inform the SWOT analysis. • Phase 3: Benchmarking of three children’s hospitals to provide external context for APP leadership structures and councils and assessment of the current APP leadership structure and collaborative processes for Intermountain Health and UHealth, • Phase 4: Identification of council members, the inaugural council meeting, and the development of the council charter. A post-implementation survey was designed to assess usability, feasibility, and APP satisfaction with the Children’s Health Collaborative APP Council. Conclusions: • Phase 1: One hundred and four (26.6%) completed surveys were received for the APP satisfaction and professional development survey. Across both organizations, most APPs indicated they were either satisfied or moderately satisfied with the 44 APP Job Satisfaction Scale questions, such as questions regarding challenge and autonomy. However, APPs from both organizations were moderately dissatisfied with compensation for services completed outside of the expected workload. Of the ten questions regarding 57 • • • APP professional development, APPs were either slightly or moderately interested in professional development opportunities such as Advanced Provider role advocacy and mentorship. Phase 2: Content from discussion groups informed the SWOT analysis and identified the following: a sense of belonging, service lines, and grand rounds as strengths; interorganizational access, care siloing, and time allotted for activities outside of work as weaknesses; change readiness, increased workforce as opportunities; and lack of dedicated time and inter-organizational coordination as threats. Phase 3: All three children’s hospitals have defined APP-led leadership structures and committees covering work wellness, quality improvement, and mentorship. Two of the three have established APP councils. Phase 4: The inaugural council meeting occurred on January 22, 2025, and was attended by six of seven council members. The first draft of the council charter was developed with a mission, vision, objectives, and initiatives. Eighty percent of respondents considered the council likely or very likely to be sustainable, with dedicated participation time and a clear mission, vision, objectives, and council structure that are key to the council’s sustainability. All respondents considered that the council would likely (n=2, 40%) or very likely (n=3, 60%) encourage APP collaboration and professional development and increase satisfaction, and all (n=5, 100%) were satisfied with the implementation of the Children’s Health Collaborative APP Council. Recommendations: It is recommended that the Children's Health Collaborative APP Council proceed with the following: • Clear and concise mission, vision, and objectives • Actionable initiatives to promote inter-organizational collaboration, APP professional development, and job satisfaction • Promotion of APP top of training practice • Dedicated allocated time for council membership