All right, well, good afternoon. Welcome to the webinar today on APP onboarding. I kind of put this together with the idea of a series. About a month ago, I provided the APP survey report from the survey that we did at the end of 23. And this just seemed to make a lot of sense as we talked about some of the current staffing models, a fair amount of challenge related to turnover or growth. In some cases, we're adding more team members related to growth and other cases we're replacing. But every so often on the list, or probably once every six months or so, we'll get a question related to onboarding strategies and just some best practices. So I thought that's a great time to put some things together for you all to think about. So thank you for joining me today. I'm Ginger Beesbrock. I'm the EVP of Care Transformation with MedAxiom. And over the years, I've done a lot of work in the team-based care space. A couple things, so a little housekeeping for the webinar today, you'll find a link in the chat. In fact, it's already there with access to the presentation slides. So you can print off or download the PDF. And then any of your questions, go ahead and insert them in the Q&A, and then we'll follow up at the end. And we'll have some time for potentially any questions. So APP attrition, it's expensive, or it gets expensive. So let me walk you through some detailed data behind this. So first, I want to start a little bit with the workforce data, what we are finding. So if you think about your APP team, and you think about your physician team, and you think about overall the provider team and your provider workforce, we have a lot of complexities going on, or a lot of challenges. We know we've got shortage, especially on the physician side. The data is clear, the data is strong, and the data is aligned, and it does not tell a good story. Primary care is projected to have significant shortages over the next 10 years, and medical specialties are projected to have significant shortages. So in an environment where, and I hear a lot of this from our programs that we work with and our members, cardiology seems in some cases to do a fair amount of primary, secondary prevention that feels like it could be turned back over to primary care. We have challenges with primary care right now as well. So the overall goal is that we get assured that the patients are receiving that care, whether it's from primary care or from us, it's challenging on both sides. And so we just frankly don't have enough. Add on to that the complexity of population growth in the aging of the U.S. population. Both are projected to grow by 10%, with the population age 65 or older projected to grow by 42% due to a 74% growth in the size of the population age 75 and older. So when you start to think of 75 and older, although again, that's wonderful that we're living longer, those are complex patients, right? They've got a number of meds and different comorbidities and things that we're managing. So that provider workforce and combination of physicians and APPs becomes very valuable in really understanding what needs to happen. And in addition to that, more than two of five physicians will be 65 or older within the next decade. So our demand capacity analysis on this does not look very good. Now there is one piece of good news with this, and that is we have a strong workforce for APP, so nurse practitioner PAs. And although I don't have the data on here, you can add pharmacists, you can add other ancillary team members. There's growth in those areas when it comes to the number of trainees and educated team members that are graduating from programs every year. Now it's hard to generate what that need's going to be because the team-based care models are evolving. But the current assessment would suggest there'll be plenty of those team members to assimilate into the team. That all being said, it's less about, it is about people, but it's also about the way we use our people. And so a final thought on all of this is that the utilization and the care delivery model is the key. So defining that on the front end and understanding what your kind of team-based care model looks like and then how do you operationalize that. And I talked a lot about that as part of that survey report in the last webinar. Let's talk about attrition or, more positively, retention. Cost of turnover, I mentioned, it gets expensive. It's somewhere between $80,000 and $120,000 to replace an APP. And that includes the ramp up time. That includes all the administrative time for credentialing and privileging. And that includes any education. That includes the loss of productivity for the person that left. And then the ramp up of the person that started. And then I would say in many of our situations, there's even a gap between when the first person left and when the new person comes. So you start to add some math around that related to loss of productivity and the time to support all of that. It's pretty easy. And I think that might even be a conservative number, that $80,000 to $120,000. In addition to that, there's costs related to team morale. Something happens when one person leaves, two people leave. When people are frustrated over something and part of their team begins to leave, that can create a mindset of maybe there's something better and maybe I need to think about something different. And I think the decisions for the additional people leaving becomes easier and easier. That's why sometimes, and unfortunately, some of you may have experienced this, you end up with these mass exodus. The other piece is sometimes when those new people or that first person leaves, they go to a place and then they come back and they recruit your other team members to go work with them. So we've seen that happen too. So team morale, don't underestimate what can happen when one or two people leave the team. You lose that patient team continuity, the physician team continuity, kind of breaks that relationship and you have to start over again. That takes time. That takes effort. And there's a little risk there, right? If you've got, you know, even from a patient experience perspective. And then I mentioned the resource use for onboarding and the loss of productivity. Moving on retention, I really think there's probably four, although I don't know that this is an all-inclusive list of things that you need to think about. And we're going to talk, some of these we'll talk a little bit more about in this presentation. But the framework is this, APP leadership. There's good literature to support that strong leadership minimizes turnover, minimizes burnout, minimizes turnover. Utilization, the type of work and the amount of work that they do matters. And I think the knowledge around or just the measurement around top of license or maybe assessment would be the better term or the use for top of license. And then work-life balance, workload management, and kind of assuring that we're not always working understaffed or working under, you know, shorthanded. Those are the sorts of things that over time can really erode. Professional status, so they're feeling a professional and personal growth within their role. So tools and resources to expand their knowledge base, and then opportunities to expand some of their professional roles within the organization. And I'm going to talk about some of those things towards the end. And then finally, compensation and benefits. And you'll notice that I put this one last. And I've said this before, and I'll say it again. I don't think being the top compensating organization in the market is necessarily what your team's looking for. What they want to be is respectfully compensated. So they want a competitive wage, but they also want culture. They want professional satisfaction. They want appropriate roles and responsibilities. They want good leadership and to feel like they have a voice. And when those things are in place, I do believe that the conversations related to compensation and benefits tend to fade. So it'll always be there, but the reality is they just want to be respected within that compensation methodology. And if they don't feel respected in those other three areas, it a lot of times comes back to money. And I don't think the underlying problem is money usually. So anyway, something for you to think about. All right. So I truly believe retention starts with onboarding, with the first day of employment. And there probably could even back it up and talk about recruiting and interviewing and finding the right team members. I'd not include that today, but I do think there's some important pieces there. But let's talk about onboarding. The majority of turnover happens within the first couple of years of employment. And I think a lot of that has to do is we did not solidify several key perspectives or key attributes of the role to create an environment where it turns into a longevity or a longer term role. So let's talk about onboarding. I think there's a few things. It does need to be individualized. At the same time, you need to have some standards. But what do I mean by individualized? Well, you've got people coming in, sometimes they're new grads, sometimes they've done cardiovascular before, sometimes they have cardiovascular experience, but maybe they're not an APP, sometimes they're an APP, but don't have cardiovascular experience. So you need to take those things into account when you put together the onboarding plan. And even better, sit down with them and kind of walk them through your typical methods and then start to, I need more of this, but I might need less of that and build that onboarding plan specific to their gaps in the areas where they need more versus less. The scope of the role, so we're going to talk about hospital versus clinic, but depending on the type of work that they're doing, that onboarding plan might look a little bit different. And then finally, learning style. So again, you don't have to be an educational instructor, you don't have to be an educational instructor and really get into the nuance of people's learning styles. But you will have some that do much better with hands on and do case review and interaction with their mentor. And I'm going to talk about that in a little bit or physician preceptor or APP preceptor. And you'll have others that do really well with the book and need a combination of both. So those are some of the things you want to talk about, resources, reading materials, video materials, and then hands on learning and how you can best instill or expose them to the clinical skills and the clinical knowledge that they need to do the job and at the same time expose them to the type of learning that they do best with and kind of build some of that into your onboarding strategy. I also think that your onboarding needs to be multifactorial, so there's a number of things you need to think about as you put together your plan. One is the clinical skills, so the knowledge base for cardiovascular medicine, the skills of assessing a patient, the skills of treating a patient and understanding all the diagnostics and all the pieces that go along with that. So you even for those that have come in with previous experience, I think this is an area where standardized learning or standardized competencies give you a strong framework to assure that everybody has what they need to do their jobs. I will just kind of lay out from a PA and a nurse practitioner perspective, when we come out of our training program, our training program is typically in primary care. So I'll give you for me, I had one month of cardiology in my clinical, so one clinical rotation through with a cardiology group. I had one month of ICU, which had some fair amount of cardiology in it, but I wasn't working with the cardiologists. I was working with the intensivists. And then I had a month of hospital medicine and another month of primary care. So there was some cardiology in that, but I was not trained by cardiologists. The only exposure I had to cardiologists was my one month. And a lot of organizations, that's an elective. So you need to really understand their exposure and likely they weren't exposed to very much. So a lot of the nuances in the deep clinical understanding is going to happen as part of their onboarding. And then the first and I'm going to say up to two years when I used to onboard new team members, I would basically give them the expectation that you're not going to feel completely comfortable in your decision making for probably two years. And even after that, you're going to continue to learn new things and you're going to occasionally see patients that have issues that you hadn't seen before. But at a two year mark, you're you start to get pretty comfortable and confident. So thinking about how are they going to get those clinical skills that I'm going to walk you through some opportunities. Organizational onboarding, that's usually the HR thing where we're teaching you the organizational way. We're going through all of the security and the HIPAA and the training and our culture and our handbook and all of those things. But in addition to that, what do they need from CV? Understanding all the team players, understanding the physicians, the team members, understanding the way within the service line or way within the practice. Are there additional things that they're getting outside of their HR at the organizational level that they need to know about their new role within your team? And then the third one is that team integration and culture. So assimilating them quickly into the team. And I'm going to give you some opportunities there to think about, because I will tell you that is one of the things that. And sometimes as a group of APPs, we can sometimes be our own worst enemies when we have a very high bar. And so when new people come in and they don't have the knowledge base, sometimes we can be pretty critical. So you want to if that's the case, you want to flip that culture and say, listen, you all have ownership and onboarding this new team member. You need this person because otherwise you're working short staff and their success is ultimately associated with your level of engagement around assimilating them into your team and the culture. And those are the things that make it sticky. And I tell you in a year out, if people are still feeling like an outsider and feeling like people are out to not help them, but in some cases hurt them, that drives people out of an organization so quickly. So if you're finding that you've got some turnover, take a look at some of that culture stuff. That being said, being really deliberate about the way you integrate them into the existing team can go a long way to alleviate that risk. So and again, I'll give you some examples. Let's start with clinical skills. I think there's some multiple ways that you can provide or expand their knowledge base, and I'm going to give you four here. The first one is just standard learning through either a locally created curriculum with learning objectives and reading resources and video resources. And here's things that you all need to take advantage of and learn and expose yourself to and read. Medaxeum, we do have an academy that offers an APP essentials course that's specifically just for this. It's a 12 module course. Many of you have used it. So whether you use our course or something else, this creates a couple layers of stickiness. Number one, for the learner, it's giving them some tools and resources to apply their learnings when they're now kind of starting to work with you and give them some of those resources. The second for you, it minimizes or at least gives you a layer to help support some liability down the road because you as an employer can prove that you've exposed them to the knowledge related to the clinical care that you're asking them to provide. And there are times when in a liability perspective where there's something happens and there's some liability concerns, one of the questions comes back as, well, you are the employer of this person. Did you give them exposure or did you give them the tools and resources they needed to do their job? And this is if you work them through a standard learning curriculum, you can go right back and just show, listen, we did. This is all the details and all the information that we provided for them to learn and ask them to be accountable to. And so it really does create some liability or a risk management opportunity for you to alleviate some of that liability. All right, second option, grand rounds. I think just about every hospital in the country still does some level of grand rounds. They may not be every week like they used to be. They may be all virtual in webinars or video conferencing, but the education is there. And even if it's internal medicine based education, a fair amount of that is still cardiovascular medicine. So I would have you explore and just see what local opportunities for continuing education are being provided and tap into those opportunities for your new team members. It also gives them a chance to be exposed to some of the other providers, both physicians and APPs that are in the community and begin to develop some networking that way. So, but that usually requires giving them time in order to do that. So grand rounds are at 7 a.m. on a Thursday morning, creating that expectation of their attendance, but then also providing a later start time or some sort of expectation or incentive around doing that. I'm not talking this about money, but creating an environment where they're able to take advantage of those. The third one, and this isn't true for all organizations, but if you happen to be in an organization that has some academic service where you may have internal medicine or family practice residents that come through cardiology, putting your new APP on that service for a couple of weeks or a month can be really helpful. Because guess what happens? Every single day on that service, you've got education happening. We're learning about disease management, we're learning about cases and treatments, and there's a lot of knowledge that's happening, knowledge exchange is happening on those services. So if you have that, and I'm not talking necessarily about your fellowship, I'm talking about internal medicine or family practice residents that rotate through your cardiology service as part of their education, putting your new APP into that model or giving them some exposure to that can be really beneficial and be a great way for them to learn. And then the last one is that one-to-one kind of teaching case-by-case. And that really comes down to peer APPs or physicians that they're working with to just be cognizant of taking opportunities or advantage of learning opportunities for interesting cases. And then just basic feedback in one-on-one about how do you manage patients and that kind of thing. And that does have to be built in. So the idea around the expectations of building that in both on the physician or APP preceptors, I'm gonna talk about that in just a minute where you can do that, that oftentimes you have to be deliberate about setting those expectations and creating an environment to allow that to happen. So skills and competencies. So I think feedback early and often. So again, thinking about making your organization sticky and minimizing that attrition, I often hear when I go in and work with organizations, I'll interview the APPs and some of the newer ones, oftentimes what I hear is I get no feedback. And if I do get feedback, it's because I did something wrong. So I don't really know when I'm doing something right. I think I'm doing something right, but we can all say that's a tough environment to work in where no news is good news. We all feel better when we're provided positive feedback and negative feedback. We need to know we wanna do the right thing. You know you have the right people if they wanna do the right thing. So if you did a good job of hiring, your team wants to do the right thing and they need to get the feedback when they did it and they want that. So I think, and they want the positive as well. So building into that onboarding plan early and often feedback and touch points with preceptors, with the physicians they might be working with from yourself and providing them feedback in the things that you're hearing, that can go a long way in kind of integrating them deeper into your teams and into your culture. Position and peer sharing, that's that in the concept of talking about patients, hey, I have an interesting case, I just saw a patient has got a really interesting murmur, you wanna come take a listen? Let's talk about what happened with this patient or what we're thinking about with this patient, what the next steps are with this patient. Both of those things just provide a really nice environment for continued learning. Precepting and mentoring. So I think of precepting as a, I'm sharing my knowledge with you and I am creating an environment where you're sharing your knowledge back with me and we're talking about that and our goal is to increase your knowledge base related to the clinical work that you're doing. I think of mentoring as almost like a phone a friend, is having somebody appear that provides, just pick up, if you have a question on something and you don't have anybody to ask or you're afraid to ask, it's a safe spot, pick up the phone and call me and let's meet every so often and make sure you're doing okay and provide you the resources that you need and make sure you know the phone numbers and you know the people and you know the processes. So the mentoring is kind of the, what's the role and how do I be a good APP within this team? The precepting is the clinical knowledge and making sure that they have what they need to do their jobs clinically. And then finally, we've got some great opportunities for at the college for some standard learning activities as well. One is the CCKE, which is an ACC cardiology certification that was launched last year. The team member needs to be practicing for a year and then they have the opportunity to sit for an exam. There's learning objectives that are associated with it. And if you kind of align that with some of the other standard learning opportunities, this is a really great, I would say professional pathway for your new team members to solidify their clinical cardiology knowledge. All right, so that's kind of the clinical, think about that as the clinical onboarding. Let's talk about organizational and I'm gonna do all the questions and answers at the end, but I appreciate it, see those popping in. So thanks, keep them coming and then we'll get to them all at the end. From an organizational perspective, I mentioned this already, but again, I think you just need to be deliberate about to make sure that your new team members are getting all of these things. So it's the organizational way and those HR processes, typically those are built in for you. EMR access and EMR training. And I would say there's two levels of training. There's the go to the training session and then there's the elbow to elbow when I'm in clinic for the first few times or I'm on service for the first few times, that somebody is with me while I'm actually in real time doing those new processes. And then I would say the third one would be that phone a friend. And so that could almost come back into a mentoring situation where you've got a super user or somebody that sits with your new team member a month or two in and helps them develop or optimize their flows, their favorites. Now that they've used it, let's make sure that they've either not created some bad habits or no understand all of the easy buttons for kind of getting some of the work done that we do. A lot of times those things are lost on the new users when they go through those initial training sessions. So revisiting at a 60 or 90 day can be really beneficial for efficiency and to solidify some of those best practices or workflows that you have. The third one is documentation and coding requirements. So they're gonna end up needing to meet with your revenue cycle team. They need to understand related to coding and any of their responsibilities there. And then the fourth one is communication. So how do we communicate with each other? What do we use our secure chats for? What don't we use our non-secure chats for? And what are your rules and guidelines for that? And then even what are the local practices? So if I'm working with certain physicians, are these phone calls? Are these secure chats? Are they in basket messages? The more of those that you can kind of get those things solidified, the less ambiguity you create and it's easier to feel like you're successful in your job. And that communication is a really key piece of that. And then I added there's oftentimes we're working in other software platforms. So just gotta be cognizant of all the different areas that we'll be working in and making sure they have the right training and that those things are set up in advance. I think all of these things can be mapped out ahead of time and put into a nice formal standardized format for your onboarding. And most of these things happen within the first week or so. All right, let's talk team culture and integration. I mentioned this already, but I think there's a lot of power in assigning a mentor or a friend at work. And in fact, I've done that even in this organization when I've had new people come in, I try to find a like person and not even necessarily in the same role, but within the organization that might be at similar point in life or have some of the similar interests, just to start to create a friend. I mean, I don't know how many, I think we all do employee engagement surveys at this point, but back in the day when I was in a role where we did a number of those, one of the questions at the time was, do you have a friend at work? Do you have a best friend at work? I think the more we can potentially engineer our team feeling connected with somebody and early on, it may not end up being their long-term friend, but they've got somebody that knows their name and somebody that's taking interest in them very early and somebody that's outside of the administration leadership that's doing that. I truly believe that can be very powerful. And I've seen where that model can evolve into really nice friendship moving forward, even outside of work, especially if you've got somebody that moved in from out of town and doesn't really know anybody, the more you can sort of engineer some of those friendships and relationships early can go a long way to solidify the longevity of them being in that role. Position and team engagement. I talked about this earlier. I think there's a lot to be said to the teams themselves to say you have some direct responsibility in our ability to keep these people. And that means I need you to be nice and I need you to integrate them into the team, assist in their learning process, support them with feedback, both positive and negative, but do the negative in a constructive way. And we're all in this together. And even better when they're part of your recruiting process and some of the interviewing, then they feel engaged in the process. They feel a little bit ownership over who got chosen, but make sure that that continues. And so the more you can kind of, again, integrate that in as part of the expectation, I think the better that you'll be because it doesn't always just happen on its own. So I would think through that. The third one is marketing and communication. This is the idea of when you onboard somebody new, does the team internally know we just added a new person and are you celebrating that? Are you getting them exposed to the people that are not only on their team, but on some of the other teams? And then are you externally marketing that and adding them to the website, adding them to the list on the front door and all of the other marketing communication, kind of a get to know you. So think about some of the ways that you onboard your physicians. There's likely a number of those activities that would benefit a new APP as well, both internally and externally. And then I mentioned that team and group culture already. I just, I can't, do not underestimate the power of a negative team culture versus a positive team culture and your ability to keep people. Let's talk about just a few best practices. So these are some things to think about as you put together your onboarding plan. First of all, be organized. So the more you can get this formalized in a standard plan, the easier it's gonna be on you because then every time you onboard somebody, you just pull out the plan and plug the new person in. You have a series of meetings and educational opportunities and you can start to get all that scheduled. And the more prepared you are on day one with all of that baked and organized, there's a lot of security for your new people when you come in and you hand me my onboarding plan for the next six, 12 weeks, or even 24 weeks, if you go out for a full six months. I do believe for APPs, a six month, it's probably a six month onboarding plan. The first 12 weeks is where a lot of the learning is happening and the ramp up periods and all the extra training. The week 13 to week 24 is just kind of settling in, but I'm not on my own yet. I still have my phone a friend. I still have my preceptor. I still have multiple touch points. I may still have some more learning to do and some additional learnings available to me, but I'm starting to see patients. I'm starting to work independently, but I would say the six months is really required. I mentioned the two years to be comfortable. I don't think they need to be in an onboarding plan for two years, but for six months, it really probably takes six months before you can really kind of step back and let them start working a bit more independently. Again, they're doing some work independently that week 13 to 24, but you're still touching base often and maybe reviewing notes and making sure that they have what they need at that six month mark. If everybody, and again, I would recommend some level of competency assurance or competency evaluation. Then if all those skills seem to be accounted for, then they in essence graduate from their onboarding plan and move into a regular employment plan. Number two, concentrating on one site at a time. Many of you will have APPs that work both at the hospital and in the office. And I would tell you that those skillsets are very different. The processes are different. Even if you have the same EMR, oftentimes the EMR processes are different, but the patients are very different. There's a big difference between taking care of a STEMI or a non-STEMI and taking care of a follow-up patient that walks into the clinic. And regardless of, even though patient-wise, one seems much more high risk than the other, honestly, sometimes the harder of the two is the patient in the clinic because we don't get immediate feedback. In the hospital, you get immediate feedback when you make a decision and you're surrounded by a whole team of people. In the clinic, you're seeing a patient today, you're sending them on and they come back in three months. So it's a very different skillset. I would recommend concentrating on one site at a time. So they may spend their first six months really solidifying the outpatient processes and skills. And then if they're gonna be a hybrid role, then maybe you spend the month seven through nine or seven through eight in a hospital setting or in the acute care setting. And then, and maybe again, don't completely ignore the office. Maybe one day a week, they're coming back to the office and then move them into that hybrid role. But if you immediately put them in a hybrid onboarding role, it is very overwhelming because I'm just telling you, it's different. Those are very different skill sets. So one site at a time. Number three, exposed to all areas of cardiovascular care. So if they're gonna be working in the clinic, that's great. And that's our full-time role, but send them to the cath lab for a day, send them to the testing center for a day, send them over to EP for a day or the device clinic for a day. Get them exposed to the areas where they're gonna be ordering things for their patients or receiving reports on or processes. Give them, put them in the hospital for a week with the hospital service. Even if they're not gonna be in the hospital, that allows them to see the processes there. It helps them understand the notes and the things that they're getting back. And it also solidifies the relationship between the teams, even if we practice in different sites. So as you think about that first 12 weeks, I recommend building in exposure to all of those places in a shadowing, observing sort of environment so that they can meet people and see the type of work that's happening and how that care is delivered. And then the fourth is a deliberate ramp up plan. So again, if you're in the office, you start with maybe one patient every hour and a preceptor that's available for questions, could be an APP, could be a physician. You do that for three or four days. Then they move to one patient every 45 minutes, one patient every 30 minutes. And then maybe if you're moving, if you're to the 30 minutes, you do two patients and then a break, two patients, a break. And that can all happen over a four to six week period. So they get, because they're thinking, they're looking things up. They're trying to figure out their workflows and the EMR. There's a lot of learning that happens. Now, I like a deliberate plan where you lay it out for them the expectation, because if you just start with, well, let's just start with every hour. We'll see how you do. And I'll check back with you in a couple of weeks. Sometimes we forget to check back and they sit in that one every hour for six weeks. And we just sort of short changed ourselves and them. Now, if you have a planned ramp up and you get through the first phase and you get ready to move to the second phase and they're not quite ready, the risk is that you might have to back off a little bit. Then I think laying it out to understand what the expectation is over that 12 week period can go a long way to just alleviate any concerns and just lay out what we expect. So we expect you to ramp up to your 15 patients a day, but we're gonna start with six. Now we're gonna go to eight. Now we're gonna go to 10 and we're gonna change it maybe every week or every two weeks. We're gonna touch base often, see how you're doing. If you're doing well, we'll just keep on the plan. You're not doing so well, we'll figure out if we need to back off the plan or not, or if we need to do something different. So be deliberate about it, map it out, write it down. And that will all go a long way to just calm everybody and keep everybody on the right path forward. All right, so let's talk about some retention best practices. These are people that have been on your team for a while. I will tell you, I mentioned the two years of starting to get to where you get really comfortable. Well, guess what happens when you get really comfortable? You start to get bored a little bit. So if you look at the average APP kind of time in a job, I don't know if this data is true as of now, but it's a number that I've seen multiple times in the past. It's about four years. So, cause I think what happens in year three and year four, you're really comfortable and you start to get itchy and you start to get bored and you wanna do something different. So how do we maintain? Cause those are the people we wanna keep. They're efficient, they're seasoned, we're confident in their care. So we do that through a number of ways. One, you can create some subspecialty career ladder. So we hire everybody into clinical cardiology. They work in clinical cardiology for a period of time. When our specialty positions open up, if you're interested in adding more knowledge and moving into a specialty area, it's kind of an internal recruitment plan. You use your clinical cardiology team to grow. In other cases, I may stay within my role, but we're gonna add a cardio-oncology clinic one day a week or a couple of days a month. And I can be that cardio-oncology APP that works with that position. So I maintain my clinical cardiology on the rest of the days, but I have the opportunity to take on a new set of skills in this niche kind of area as part of a program development. Special projects. We do a great job of process improvement and quality improvements when given the skills and put on a team that's doing that work. So if you've got working groups or areas around clinical programming that you're trying to either optimize or develop, or you're working through a quality area or area you wanna optimize, giving them a little bit of time and tapping somebody to do some of that work or seeing who might be interested, I think you'd be surprised. That creates a ton of professional satisfaction. Same thing with leadership, whether that's leadership growth within the team or clinical programming and clinical operations. You'll see a lot of APPs kind of work their way into clinical operation leadership roles where they're overseeing clinical programs. Now they need leadership skills, just like physicians. We have clinical skills. We don't have leadership skills, so you need to do some training with them, but that's a great way to provide some professional growth. And then finally, education and precepting. And that's another great way for recruiting. If you have local APP programs, PA, nurse practitioner, or if you have pharmacists that you work with and have a local pharmacy program, that's a great way to tap into some potential recruits for you to bring those students in. But for some people, they get a lot of satisfaction about teaching and precepting and supporting those newer team members that are coming on board or that are part of these education programs. All right, incentives. I mentioned this already. They need to be fair and respectful, but you don't have to be the top dollar. I promise you, you don't have to be if everything else is in line. Productivity, citizenship, co-management metrics, additional things that you can incentivize your team for besides just a base salary can go a long way to help engage in certain behaviors or engage in certain things that you'd like to see the teams doing. Providing work-life balance. I've seen a number of programs, especially post-COVID, begin to get a little bit creative around the way the APPs are scheduled as well as their role. And there's a lot of virtual care that can be tapped into within cardiology for the way we deliver care. In fact, we had a fabulous presentation at the CVT a couple of weeks ago related to a whole virtual care program that was delivered by APPs that created a fabulous environment to allow APPs to spend a day at home working from home, but still delivering really great care and helping them manage some of that work-life balance. And then celebrate the wins. I think that just goes back to positive culture. Celebrate when people have done a nice job, when you get patient experience, comments in those surveys that call people out, call them out for that, celebrate that. When people get more education or people present things or anything that happens, the more that you can celebrate that within the team, that just supports a positive team culture. And everybody likes to have themselves called out when they've done something above and beyond. So that, again, don't underestimate some of that cultural activity can go a long way to really solidify your teams. And then the final one is leadership. So again, I'll go back to, I do, I've been doing this work long enough. I used to think it was operations. I used to think it was lack of knowledge. I now think that probably one of the biggest reasons why some organizations struggle more than others does come down to leadership. And leadership being feeling respected, leadership feeling valued, as far as through the leadership, the team members feeling respected and valued, being inspired and then having opportunities to support growth. It's hard, it's hard to be a leader in 2024. I also think that you don't have to be a named leader and you've got positive people on your teams, tap into some of that, really push that team culture. Those are the things that people want. They wanna feel respected. They wanna feel valued. They wanna be inspired and they want opportunities to support growth. And if you really feel like there's people on the team that don't value those things, they may not be the right people for your team. Because if you have a team of people that do value that, that means they're also doing that for each other. And that can, again, create a really nice environment for retention. Managing change. I said leadership was the last one, but we're getting close. So team culture, things happen, things change. Our business needs change. Our clinical needs change. Cardiology is ever evolving. So the way we hired you and what we expected then might be different than now. All of us have probably had that conversation. I need you to take call. I need you to work a night. I need you to work a weekend. I think the biggest things that you need in order to manage those conversations, and there'll be times where people are like, listen, it just doesn't match up with my lifestyle, my life, other commitments. And that means that this is hard, but that means that, well, but this is what we need in the role. So the role and you might not fit anymore. So we have to decide that. That's a harder conversation. But sometimes it is just logistically, it just isn't gonna work, but this is what we need from the role. Most of the time, it's more of a matter in the way we manage the change. So that kind of that culture of respect and value means when we have a new change like this, let's sit down and talk about it. Let's figure out the best way to operationalize that or execute on that. I know nobody wants to take call and I know nobody wants to come in on Saturdays, but our patients need this. And so let's talk about what that looks like and how we can create an environment. Assure value for that and the equity piece of it. And so is that in addition to how you incentivize it, I think also goes a long way. Providing the choice I mentioned. So let's talk about how we do this. What makes the most sense? What would work for all of you? And then I think transparency and trust that we're not baiting and switching. If we say we're gonna do something as administrators and leaders, we say we're gonna do something and we don't do it. You're just, you're kind of messing your own morale up that way. So follow through on the things you say you're gonna do and as much as you can be transparent and really, again, support that trust. And the biggest way to support the trust is to follow through on the things that you said you were gonna do. And if you can't, just be transparent about it and why. So a few things for you to think about. I am going to now, let me pick time. We got 15 minutes. So I will, Ari, I don't know. I know there's some questions in there, so. Yes. So how do other systems incentivize APPs to take ACC slash HRS slash IBHRE certification exams? Is there a monetary incentive? So I think there's a couple of ways you can go about that. Some cases there's no monetary incentive, but the program, if they value it, will cover the cost of the exam and any study materials that are needed. Not necessarily provide time to study, but we'll provide the materials and the costs. And the way I've seen it is we'll provide all of this. We need you to pass the exam. And oftentimes we'll say you can have two chances to pass the exam. And if you don't pass the exam on the second chance, then you have to pay us back for anything that we provided to support taking those exams. Most people, if they put the work in, will pass on the first time. And then a few that maybe are more challenged with test taking might need a second time. But kind of figure out what that is. So in that case, there's no incentive outside of covering the cost. But that's a professional growth opportunity and people feel supported with that. The second would be is there is opportunities to create that as part of your career ladder. So let's say you've hired somebody into EP and you would like them to get one of the EP certifications because they'll be smarter about devices and smarter about some of the medicine that's associated with it. It's a great way for them to study. You create an environment where if you pass the exam, then we'll move you up to the next pay grade. So in some cases you have like a tier one, tier two. Tier one is entry level. Tier two would be those that have gone on to get some certifications and things. You'll wanna define that on the front end and be very deliberate about that. And that's usually turns into an HR kind of question and you really have to formalize that. But that's a great way to, especially in the subspecialty areas, assure that they have what they need to do those and also provide some professional growth. And then a whole thinking about that tier and that pay grade, it really elevates them professionally within their compensation plan. The third one would be more of a spot bonus. So we cover the cost of the exam. We really need you to spend your time studying, but if you study and you pass, we'll give you a spot bonus for doing that work. Or, and then the fourth one, I should say there's four. If you have an incentive model that includes an annual review where there's additional dollars that can be associated with different activities, you could make a certification activity one of those activities. And it almost turns into like a menu. If I precepted a student, I get some points. If I did my certification, I get some points. If I was part of a special project, I get some points. And the value of those points kind of add up to whatever that either bonus was for that year or a percentage of what their raise is gonna be for the following year. So you could easily build that into part of your incentive model for that non-base salary sort of incentive options that you might have. But those are the things that I have seen. I don't know that I've seen outside of onboarding and the standard learning where you might give them a few hours a week to do some of that reading in addition to their onboarding. I don't know that I've ever seen where further down the line, they now wanna go get certified where people are protecting time and giving them admin time for that. The typical expectation is that you're studying on your own time, but we're providing some celebration incentive if you pass or at least we're covering the cost of the materials. Any other questions? Just a reminder that the Q&A button is there at the bottom if there are any last minute questions. All right. Well, we appreciate your time today and the engagement. This is recorded. So if you have any colleagues or coworkers that couldn't join, it will be available to you over the next week or two. And then again, tap into our APP Hub. There's a lot of resources there related to compensation, related to utilization, related to standard learning and even some additional resources around retention. So again, we're here if there's anything you need and we appreciate you joining today and good luck. It's a tough place, not these days for hiring and retention, all those things, but I truly believe what we provided was a nice framework of best practices that can go a long way to really stabilize or optimize your APP workforce. And I think a lot of these things can be applied to other roles. So a lot of this is very applicable to your other team members. So thank you for joining and have a good rest of your day.

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