Cleveland Clinic Excels at Integration and Development of PAs

EOE Winner Says Investing in PAs from Beginning is Key to Success

September 5, 2018

By Eileen Denne, CAE

The Cleveland Clinic, based in Cleveland, Ohio, calls PAs part of its foundation and central to patient care for more than 40 years.

“Back in 1972, we started with one or two PAs and a couple hundred physicians,” says Michael M. Michetti, Esq., Executive Director, Professional Staff Affairs. “We were a much smaller hospital at that point. Now we’re a system of a large main campus hospital, 11 regional hospitals, 2,300 Advanced Practice Providers (APPs), including 670 PAs, and approximately 3,500 physicians. In the last 10 years, we’ve been increasing the number of APPs employed in the system at a rate of more than 15 percent per year. PAs have been a consistent area of growth for our organization.”

“PAs are central to the care we provide. They are the care we provide, just like a physician, so we think of them as integral parts of the team. What makes us unique and successful,” Michetti adds, “is investing in PAs the same way you would any other critical caregivers on your teams.”

Vince Cedarland, Lynn Pagliaccio PA-C, Leah Schmitz PA-C, Jenna Jeganathan PA-C, Josanne Pagel PA-C, Keith Kovacic, Mike Michetti, J P Thompson PA-C
(L to R) Vince Cedarland (recruiter), Lynn Pagliaccio PA-C, Leah Schmitz PA-C, Jenna Jeganathan PA-C, Josanne Pagel PA-C (Executive Director, PA Services), Keith Kovacic, recruiter, Mike Michetti, J P Thompson PA-C.

Cleveland Clinic has excelled at providing leadership opportunities for its PAs, recruiting and onboarding new hires, which garnered them a 2018-2019 Employer of Excellence (EOE) award from AAPA’s Center for Healthcare Leadership and Management (CHLM) last May. Among the EOE criteria exceeded by Cleveland Clinic  were: involving PAs in leadership efforts to improve the quality of patient care; establishing a positive and supportive PA work environment; and providing opportunities for meaningful input that lead to positive organizational change.



Unique reporting structure

Part of the integration and development of PAs at Cleveland Clinic were changes to the PA reporting structure. Cleveland Clinic  formed a central PA office and created the position of Executive Director of PA Services, currently held by Josanne Pagel, MPAS, PA-C, M.Div., DFAAPA. PA Services is a resource for ‘everything PA’ and is, according to Cleveland Clinic, one of the keys to sustaining an engaged PA workforce.

Cleveland Clinic officials say it has created more than 140 leadership opportunities for PAs through an APP leadership ladder. PA leaders have monthly networking meetings, regular electronic communications, annual professional development workshops, and an opportunity to serve on a variety of committees and development workshops, among other things.

“Two years ago, we reorganized,” Michetti says. “PAs were under varied reporting structures and we realigned so PAs report up to an APP director or manager, and from there they follow the same reporting lines as our physician staff to ensure alignment.”

When opening a new regional hospital, Cleveland Clinic  also created a position for director of APRNs/PAs as a part of that hospital’s executive team, the first of its kind in their system.

Many things they do are sourced to internal PA leadership, according to Michetti, whom they highlight when recruiting. “We will use the EOE award to attract people who want to come to the Cleveland Clinic and who don’t know about the great things we’ve been doing or how we work with our PAs and integrate them within our teams.”

Onboarding: Transitions to Practice

Michetti says that when it comes to recruitment and retention, they look at not just hiring a PA or hiring an individual to do a job, they try to provide a career progression. Their Transition to Practice program is a year-long onboarding program to help new graduates go from book smart with some clinical practice to the ability to fully function in a tertiary/quaternary care facility.

“The onboarding program consists of taking a new grad or someone who is given a transfer to a different department and spending almost a full year developing skills, goals, and knowledge to make sure they are ready to engage in the new opportunity. I think it’s a really good practice, both in terms of a PA being satisfied with their experience as they come into the system and also with recruitment and retention.

“If you think about something that is going to drive people away in the organization, feeling like they’re not getting it, feeling like they’re not up to speed, feeling unsafe or insecure, these are all things that may lead to somebody saying, ‘I don’t think I want to work here.’ Putting together a program that’s really supportive and helps a person grow into a new opportunity is key when it comes to driving both recruitment and retention.”  Cleveland Clinic’s attrition rate for PAs is less than 2 percent and Michetti says the leading causes of turnover are usually things out of their control, such as a spouse finding a job in another city.

Impact on patient care

Asked why Cleveland Clinic thinks it is important to have a Director of APRN/PA in the leadership team at regional hospitals, Michetti responds that the Clinic is all about teamwork.

“Having PAs and APRNs who have a voice at the leadership table is just inherent in treating patients and being able to optimize our efficiency as a team. We look at the way PAs enhance care as a way to increase patients’ access to care. We intend to have PAs practice at the top of their licenses, so they have their own patients and are independently responsible for them. This gives our patients quicker access and more opportunities, more options for the way they’re going to access the healthcare system.”

Throughout Cleveland Clinic, PAs manage different express and urgent care clinics that offer patients different opportunities than traditional access channels. Michetti believes that PAs working on Clinic teams help leverage their ability to touch more lives and maximize the care they’re providing.

“PAs are hands-on, face-to-face with patients, making a difference in their lives, managing their care, helping them be healthier and achieve better states of well-being, helping them work through their disease as any other caregiver in our organization.”

Teamwork at all levels

What makes Cleveland Clinic unique? “The degree to which we integrate PAs as co-equal members of the care team is something that differentiates us,” Michetti says. Teamwork even extends to Cleveland Clinic’s new health education campus that will open in January 2019. It will house Case Western University’s medical school, nursing school, dental school, and PA program.

“That’s just another example of how healthcare professionals should be training together because they’re the team that will have to work together. The new health education campus is a good embodiment of the kind of teamwork we drive.”

Cleveland Clinic plans to re-apply for the EOE award in 2020 to take advantage of the opportunity to be recognized as a great place for PAs to work.

Apply for Employer of Excellence Award

The EOE Awards are designed to recognize and showcase employers that create a PA-positive environment and encourage collaborative provider teams. CHLM partnered with HealthStream in 2017 to better understand what PAs value in their place of employment. Based on the findings, CHLM identified five key drivers as criteria for its EOE Awards, including:

  • Establishing a positive and supportive PA work environment.
  • Providing opportunities for PAs to provide meaningful input that leads to positive organizational change.
  • Keeping PAs informed of organizational activity and decisions.
  • Involving PAs in leadership efforts to improve the quality of patient care.
  • Creating processes for effective conflict management.

Applications for 2019-2020 EOE Awards will open on Nov. 1, 2018. CHLM works directly with hospitals and health systems to enhance team-based patient care and optimize PA practice.

Eileen Denne is director of Corporate Communications at AAPA. Contact her at [email protected].


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