Russell et al AJS 2014

Southwestern Surgical Congress
Optimal utilization of a breast care advanced
practice clinician
Katie W. Russell, M.D., Mary C. Mone, R.N., B.S.E.,
Victoria J. Serpico, A.P.R.N., Cori Ward, M.B.A., Joanna Lynch, P.A.-C.,
Leigh A. Neumayer, M.D., Edward W. Nelson, M.D.*
Department of Surgery, University of Utah, 30 North 1900 East, Salt Lake City, UT 84132, USA
KEYWORDS:
Advanced practice
clinician;
Nurse practitioner;
Physician assistant;
Independent breast
care clinic;
Improved utilization;
Lean principles
Abstract
BACKGROUND: Incorporation of ‘‘lean’’ business philosophy within health care has the goal of add-
ing value by reducing cost and improving quality. Applying these principles to the role of Advance
Practice Clinicians (APCs) is relevant because they have become essential members of the healthcare
team.
METHODS: An independent surgical breast care clinic directed by an APC was created with mea-
surements of success to include the following: time to obtain an appointment, financial viability, and
patient/APC/MD satisfaction.
RESULTS: During the study period, there was a trend toward a decreased median time to obtain an
appointment. Monthly APC charges increased from $388 to $30,800. The mean provider satisfaction
score by Press Ganey was 96% for the APC and 95.8% for the surgeon. Both clinicians expressed sig-
nificant satisfaction with clinic development.
CONCLUSIONS: Overall, initiation of an APC breast clinic met the proposed goals of success. The
use of lean philosophy demonstrates that implementation of change can result in added value in patient
care.
Ó 2014 Elsevier Inc. All rights reserved.
In the healthcare environment of today, providing higher
value by increasing quality while lowering cost challenges
the structure of how care is organized and delivered.1–3
Increased demands on healthcare systems and providers
from the Affordable Care Act, resident work hour restric-
tions, and the influx of 80 million older adults from the
‘‘baby boomer’’ generation add additional pressure on a
system already known primarily for excessive expense
and inefficiencies.4,5
In cancer care alone, data from the
National Cancer Institute and Association of American
Medical Colleges project that while the number of patients
needing care for cancer will increase by 48% between 2005
and 2020, the corresponding increase in the physician
oncology workforce will increase by only 14%.6,7
Pro-
posals are abundant and change imperative to accommo-
date healthcare evolution and to maximize productivity
while improving the value of health care.8
Advanced Practice Clinicians (APCs) have become
more an essential member of the healthcare team. Research
has shown that the addition of APCs across multiple
specialties can add continuity, increase patient satisfaction,
improve compliance, and often provide more affordable
care.9,10
Specifically in the area of breast care, British
The authors declare no conflicts of interest.
* Corresponding author. Tel.: 11-801-581-7738; fax: 11-801-585-
0168.
E-mail address: edward.nelson@hsc.utah.edu
Manuscript received April 22, 2014; revised manuscript September 2,
2014
0002-9610/$ - see front matter Ó 2014 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.amjsurg.2014.09.007
The American Journal of Surgery (2014) 208, 1054-1059

literature dating back more than 20 years documents the
role and value of nurse practitioners in breast oncology
and provides good evidence that there can be a high degree
of both patient and provider satisfaction when these ‘‘physi-
cian extenders’’ are incorporated into a breast-focused prac-
tice.11–13
Although a recent report from the Institute of
Medicine endorsed including APCs in a team approach to
cancer care, a combined review from California and Mich-
igan concluded that employment of APCs in breast cancer
care remains modest, especially among surgeons.14,15
As part of an institution-wide philosophy that empha-
sizes healthcare delivery based on adding value by
increasing quality while reducing cost, we designed a study
to optimize the role of a clinically skilled APC, in this case
an Advanced Practice Registered Nurse, working as a
member of our surgical breast cancer team. The initial goal
was to establish an independent breast clinic run by an APC
with back up by a well-established breast surgeon in a
collaborative practice model for the future. The primary
goal of this study was to broaden the APC scope of
practice, thus allowing her to work at the top of her license.
Based on our assessment of other specific needs with
measureable outcomes, we established the following sec-
ondary goals of this new APC dedicated breast care clinic:
a 50% reduction in time to obtain an appointment for a new
patient in the breast clinic; positive financial benefits; and
improved patient, surgeon, and APC satisfaction.
Patients and Methods
To facilitate this effort, we chose to use an approach
following ‘‘Lean Principles’’ previously well documented
as successful in maximizing ‘‘change for the best’’ or
‘‘Kaizen’’ in medical care.16–18
Based on these principals,
we assembled a team that comprised 2 breast surgeons, 2
APCs, a Master of Business Administration trained admin-
istrator, a surgical resident, and a research nurse. All partic-
ipants underwent basic training in lean principles in an
institutionally run course. The lean principle of ‘‘Gemba’’
(‘‘going to the real place’’) was followed by the team mem-
bers visiting the breast care clinic for an on-site evaluation
and needs assessment. From this preliminary appraisal, a
focused problem statement was developed: ‘‘the surgical
breast clinic is a perfect environment for an independent
APC practice.’’ Regular team meetings were held and a
progress map was developed and refined that outlined the
current state of the surgical breast clinic, the noted limita-
tions, possible changes, and proposed outcomes.
The entire time period over which data were collected
included the 4 months before establishing the APC clinic
(October 2012 to January 2013) and the 11 months that
followed (February 2013 to December 2013). Data were
collected on those patients who were new to the system and
the initial clinic visit was termed ‘‘new patient visit’’
(NPV). The variable was further described as the calculated
time (days) to obtain this appointment with the value
determined by subtracting the date of the actual appoint-
ment from the date the call was made to obtain an
appointment. Financial data included all charges billed
and collections received by the APC through the study
period. Patient satisfaction was determined by using Press
Ganey scores (Press Ganey Associates, Inc., South Bend,
IN), reporting the mean value for the care provider based on
10 specific questions.
After establishing the above parameters, an independent
breast clinic run by an APC was established and the APC
began to see patients in January 2013. Scheduling for the
APC clinic was initially designed to accommodate follow-
up patients or those likely to have benign conditions (eg,
breast pain, history of cysts). With experience, the APC
began initial evaluations of new referrals who were then
presented to an attending surgeon. Additions to usual APC
functions included the following: independent initial pa-
tient evaluations and follow-up, ordering and acting on
diagnostic studies, and independent performance of minor
procedures such as Port-A-Cath removals, breast injections
for sentinel node procedures, and breast cyst aspirations.
Relevant data were collected in Microsoft Excel 2013
and analyses were performed employing IBM SPSS
Statistics Version 21 (Chicago, IL). A P value of less
than .05 was considered statistically significant. Data for
Press Ganey scores are reported as an average. Values for
time to appointment are reported as the median per month.
The study was submitted to our Institutional Review
Board for review, and it was determined that oversight was
not necessary to review or report these data and received an
exempt status.
Results
The total number of NPV in the surgical breast care
clinic, including those seen by the surgeon and the inde-
pendent APC, did not change from October 2012 to
October 2013 (Fig. 1). Over this same period, the range
of patients seen per month for the surgeon ranged from
10 to 44 and from 3 to 16 for the APC.
The median number of days between calling for an
appointment to being seen for an NPV fluctuated over the
study interval, but when the time for APC and the surgeon
are combined (per month), the trend steadily decreased
(Fig. 2). The widest range of time to get an appointment in
a single month for the surgeon before the APC clinic
(October 2012 to January 2013) was 1 to 53 days (median
11). In the 3 months after the APC clinic (February 2013 to
April 2013), this narrowed to a low range of 0 to 16 days
(median 6). The median time comparing 2 similar time pe-
riods for 2012 versus 2013 (February to October) is de-
picted in Fig. 3. The median time is statistically lower for
2013 as compared with 2012 (9 vs 16 days, respectively,
P , .001; Mann–Whitney–Wilcoxon and Median testing).
The financial results of this independent APC breast
clinic are seen in Table 1. The monthly charges billed by
K.W. Russell et al. Optimal use of breast care APC 1055

the APC increased from a low of $388.00 just before start-
ing the clinic to a high of $30,800.00 with corresponding
collections of $284.00 and increasing to a high of
$9,075.00. The charges from October 2012 to December
2013 totaled $190,986.00. In conjunction, monthly work
relative value units for the APC increased dramatically
from 3 to 206 over the same period.
To evaluate patient satisfaction, Press Ganey scores
were compiled from the breast care clinic setting for the
APC and the attending surgeon (March 2013 to December
2013). The section for the standard care provider was used,
which is based on 10 separate questions with an average
score calculated. For the surgeon, 140 total patient
satisfaction forms were evaluated and the mean monthly
score was 95.8 (range 87.2 to 100). For the APC, there
were 56 patient forms returned and the average standard
care provider score was 96 (range 83.8 to 100). Press
Ganey scores for the APC began in March 2013. The mean
score for the surgeon during the 4 months before adding
the APC to the clinic was 95.5 (October 2012 to January
2013, n 5 92). From April 2013 to December 2013, the
Press Ganey survey captured the score accessing the ‘‘abil-
ity to get the desired appointment.’’ For the surgeon, the
mean score was 89.1 (n 5 110) and for the APC the
mean score was 87.8 (n 5 43).
For the period of study, no delays or failures in diagnosis
of breast cancer were noted secondary to implementation of
the APC clinic.
Comments
The makeup of the healthcare workforce in the United
States and its relationship to changes in quality of the care
delivered represents a major concern to providers, payers,
and patients.19
Historically, patients and payers have ex-
pected that referrals for speciﬁc problems, such as breast
care, be seen by a specialized physician. However, when
functioning as part of a specialized team, expanding the re-
sponsibilities and scope of practice of APCs has been
recently shown to maximize productivity without compro-
mising patient acceptance or satisfaction.14,20–22
Within the practice of breast care, there remains wide
variation as to the exact role and level of participation of
APCs. In a survey of breast care specialists in California
and Michigan, Friese et al found that while 39.6% of breast
Figure 2 Median number of days for new patient visit deﬁned as the difference between actual appointment date and call for appointment
date combined APC and surgeon time. Institution of APC clinic is noted by arrow.
Figure 1 Total number of combined new patient visits by month of occurrence: surgeon plus APC. Institution of APC clinic is noted by
arrow.
1056 The American Journal of Surgery, Vol 208, No 6, December 2014

practices employed APCs, there was a statistically lower
likelihood of finding them in a breast surgeon’s practice
when compared with that of a medical oncologist (28.7%
vs 56.3%). In addition, APCs were more likely to be
employed by physicians in practice less than 10 years and
in groups with more than 3 physician partners. The authors
conclude that increasing the now current modest utilization
of APCs in breast cancer care is one way to close the gap
between demand and supply of cancer care.14
At our institution, as in healthcare delivery in general,
there has been a renewed emphasis on changes in practice
that result in better value through increased quality at
decreased cost. Because we observed that the many APCs
we employ may not be working to their full potential, we
chose to approach the problem of optimal utilization of the
APCs using methods learned from lean philosophy
developed in the auto industry.16–18
A lean team was
assembled and an initial problem statement developed
that proposed to include better utilization of all APCs work-
ing within our general surgery division, but it was soon
noted that this broad goal was not ‘‘SMART’’ (specific,
measureable, attainable, relevant, and timely) according
to lean principles. The goal was therefore revised and
made specific to the simple statement ‘‘the breast clinic is
the perfect environment for an independent APC practice.’’
Overall, after comparison of data pre and post initiation of
the APC breast clinic, the stated goals of this project were
generally met. Although improvement in the time required to
obtain a scheduled appointment with a surgical clinician did
not meet the goal of 50% overall reduction in time, there was
a trend toward a reduction in the time to being seen when the
APC clinic was added. Despite the fact that the surgeon gave
Figure 3 Comparison of median number of days for new patient visit defined as the difference between actual appointment date and call
for appointment date: 2012 versus 2013 for combined APC and surgeon.
Table 1 Monthly charges, payments, and work RVU for APC over 15-month period
Charges ($) Net payments ($) Work RVU
October 12 590.75 369.05 4.85
November 12 590.75 428.07 4.85
December 12 387.60 283.94 3.08
January 13 748.90 301.18 5.03
February 13 15,833.25 4,171.72 106.87
March 13 10,249.16 2,806.05 82.27
April 13 13,538.80 2,633.07 91.56
May 13 14,750.87 3,357.62 102.59
June 13 17,005.75 4,672.77 118.68
July 13 8,859.22 4,294.28 62.84
August 13 15,391.65 5,045.25 109.11
September 13 19,912.80 5,137.09 132.27
October 13 21,180.07 9,075.32 148.43
November 13 21,146.17 5,395.14 148.92
December 13 30,799.82 5,401.61 205.98
Total 190,985.56 53,372.16 1,327.33
APC 5 Advance Practice Clinician; RVU 5 relative value units.

up clinic time to accommodate the new APC clinic, the trend
in the monthly total number of new patients seen was
unchanged. Financially, the new APC clinic was a success
with respect to increased capacity to charge for delivered
care, reflected by the dramatic increase in charges and
collections for clinic care. Coincidentally, the supervising
surgeon was able to devote more time to revenue production
in the operating room and academic pursuits in teaching and
research. Because of the positive financial effects of this
collaborative model, this APC clinic model is now our goal
for other APCs employed by our division. Additionally, the
breast APC now feels more clinically empowered to manage
patients independently while still having the reassurance of
direct physician back up if needed. The surgeon report
increased satisfaction based on the ability to best use her time
and abilities for research, teaching, and clinical problems that
require specific expertise. Perhaps most importantly, largely
based on the timeliness and quality of the APC appointments,
patient satisfaction scores remained high or improved for
both providers.
The implementation of physician extenders is variable
across specialties and across settings (academic vs private).
No single, perfect model can be adopted by all, and
improving the quality and delivery of health care will
require each institution or practice to examine their own
structure, needs, and limitations.
Parameters to evaluate improvement in care are also
difficult to measure. The objective of this study was to
evaluate changes in revenue, patient and provider satisfac-
tion, and overall efficiency secondary to initiating an
independent APC breast clinic. Based on the results of
this experience, we conclude that efficiency can comple-
ment quality when surgeons take the opportunity to
delegate responsibility so that all team members are
working at the top of their license. We believe this study
has shown that in a surgical breast practice, the develop-
ment of an independent APC-directed clinic can result in
‘‘change for the better.’’
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Discussion
Discussant: Dr Emily K. Robinson (Houston, TX). The
use of physician extenders in a breast clinic is a very inter-
esting topic, and very timely, given the number of Baby
Boomers that we have now and the number of patients
who are going to have breast cancer, to develop a model
like this. I congratulate you.
I do have several questions, though.
When I initially read the paper, it seemed obvious that
time for appointments would go down if you added a clinic,
but now it’s clarified that actually you have the same
number of clinic days. I’m wondering how you had met that
particular goal.
Additionally, as you said in the very beginning, value is
quality divided by cost. You give us a lot of information
about revenue, but have you actually decreased the cost per
episode of care for the patients that you are seeing?
Also, since you are decreasing the time to your
appointments, are you actually increasing the timeliness
of your care for your cancer patients?
1058 The American Journal of Surgery, Vol 208, No 6, December 2014

Along that line, is there any triage done of these patients
prior to them coming to clinic? Are all the cancer patients
sent to an attending surgeon, or is it just first come, first
serve, everybody gets put into a clinic based on the
appointment time?
Dr Katie Russell: The first question is, we did lose time
with one of our physicians. Our APC had more clinic spots
initially than the attending physician, so we opened up
more spots on that day and actually since, our M.D. origi-
nally completely was out of clinic and then, since, she’s
come back a little bit and sees a couple of appointments,
which goes along with your next question about the cancer.
We do triage these patients. The original idea was that this
would be a benign breast disease clinic. So we wanted to
make sure that the physician saw the cancer patients on
their initial visit, and then, our APC would see all of the
benign disease. And that was initially the plan, and still
how it goes most of the time. Every now and then, we’ll
catch a cancer that was kind of triaged as being benign,
and then we will have to get them in to see the physician
at another time, but we do triage the patients.
As far as decreasing the cost per patient, I think the
biggest thing that we have seen is just by increasing the
billing of our APC. So we have increased our revenue by
using her, because she was being used in the same situation
as a resident, just go going to clinic and having to present to
the attending, just like we do as residents. But now our time
is better utilized because she no longer has to staff with an
attending. And then she also is able to bill for her services,
which she couldn’t do before when she was being overseen
by a physician.
Dr Daniel Dent (San Antonio, TX). How has this
impacted the resident experience? If I understood
correctly, Dr. Neumayer has won more teaching awards
that you can count on two hands and now the residents
are not getting the opportunity to do breast clinic with
her, at least on the days that the advanced practice clini-
cian is doing it.
Dr Katie Russell: I think, as was alluded to in the lunch-
time session, at the University of Utah we have doubled our
faculty members, and we still only have five chief residents.
As far as Dr. Neumayer’s clinic, she still has a Tuesday
clinic that our resident goes to for the entire day. So we
have a full day of Neumayer clinic, which is a great clinic.
We actually have more autonomy in that clinic and less
nurse practitioner time in that clinic, and then her Thursday
clinic is primarily just a nurse practitioner clinic now. So
it’s been good for the residents.

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