Background: Nurse Practitioners (NP) & Physician Assistants (PA), also referred to as Advanced Practice Providers (APPs), have become an integral part of Hospital Medicine Groups (HMG). As per the State of Hospital Medicine report (1) from the Society of Hospital Medicine, 83% of HMGs had APPs in 2020. Over the next few years, the average annual growth of the number of physicians is projected to be 1.1%, compared with 4.3% for PA and 6.8% for NP graduates (2). This significant growth in the APP workforce will help fill the gap (3,4). APPs with varied clinical backgrounds and clinical exposure during training may face a significant challenge in their new roles. A failure to orient and integrate a new APP into an HMG could lead to low provider job satisfaction and a high turnover rate. A carefully designed onboarding process could provide the new APP’s required skills, knowledge, and resources to succeed in an HMG.

Purpose: To create an effective onboarding process to successfully integrate APPs in an academic HMG

Description: After discussions with senior faculty, other programs, and conducting a needs assessment, a systematic onboarding process was implemented. (ref. Table 1).Week one includes orientation required by the institution. A new APP starts clinical onboarding in week two. He/she is paired with a senior APP and works on a collaborative team with a physician. The first month is focused on system-based learning and focuses on patient care under a senior APP, who guides and mentors the new APP. Expectations are standardized. An evaluation is collected at the end of each month during onboarding, which helps plan for the next month (see attachment).In the second month, a new hire is paired with a physician under direct supervision. This gives direct exposure to patient care in a physician-APP collaborative model. There is a stepwise increase in the number of patients for a new APP to carry. In the following months, the new APP works directly with a physician under direct or indirect supervision based on her/his performance. Physicians provide real-time constructive feedback to the APPs. New APP’s concerns are addressed in a timely fashion, and adjustments are made to optimize the experience. The total duration of onboarding depends on individual performance and evaluations. A survey of new APPs who underwent this systematic onboarding experience over a 1.5 year period found that a majority of APPs required only three months of onboarding. Half of the respondents were happy with the senior APP assigned to them, while the other half felt they would have benefited from working with more than one senior APP. By the end of their onboarding period, 84% of respondents achieved the intended patient census target. We plan to include a more formal APP mentor-mentee program, as well as SHM’s educational modules, and several brief teaching sessions focused on daily work. Compared to the period before the launch of this initiative, annual turnover improved from 30% to 15% among APPs who experienced this systematic onboarding process.

Conclusions: An ideal onboarding process helps integrate new APPs in a way that allows an HMG to function optimally. Done properly, this process will help increase job satisfaction and reduce turnover and therefore save on cost. Our turnover rate has decreased after implementing the systematic onboarding process, coupled with an improved recruitment process. We plan to keep refining our onboarding process for new APPs, and we believe this successful transition would serve every HMG in providing excellent care to their patients.

IMAGE 1: APP Onboarding Evaluation form Page 1

IMAGE 2: APP Onboarding Evaluation form page 2 with Table 1- Onboarding plan