b'unit in which APPs work to the top of their licensecompetency,forexample,anAPPsafelyandefficientlyin collaboration with the intensivist vs. one in whichplacing a central line, are the surest and most powerful intensivists provide all or most of the care, many areway to change minds quickly.intrigued. The surgeon at the hospital eventually walked into The argument for increasing APP responsibility extendsthe ICU as a highly trained APP was doing just that. As beyondthefinancialimperatives.NotonlycanAPPs hewasintheunit,thesurgeonsurprisinglyofferedtowork within appropriate quality safeguards, but, in theproctortheprocedure,andwhenshewasfinished,henew paradigm, APP involvement is critical to increasingwrote down the remarks excellent on her proctoring quality in the ICU. When intensivist-managed care andform. oversight are in place, supplemental care provided by APPs is safe, high-quality, and not associated withIncidents like these are small but important steps anegativedifferenceinmortality,lengthofstayor towards gaining trust and credibility with the medical ventilator days. 2APPs can also positively impact carestaffinthisnewparadigm.on improving infections and prophylaxis rates as well as increaseearlyidentificationofsepsis. 3When consideringB. Updating Hospital BylawsthecostdifferencebetweenanintensivistandanAPP, The challenge of utilizing APPs to the top of their license APPs provide a decrease in costs per visit and percan feel like a chicken and egg situation. Specialists consumerattypically1/3toofthesalarycost. 4sittingonahospitalsboardmayresistthechangeuntilthey can see evidence of APP competency, but they have The new way of thinking about the top-of-licenseno opportunity to see evidence of APP competency until question is to tackle both the high-level changes and thethe bylaws have been updated to allow APPs to practice on-the-ground impediments with a systematic approachto the top of their license.that allows the use of an expanded team (including APPs), while ensuring safe, consistent, and high-qualityNavigating these complex dynamics requires operational care. This approach has three components: leaders skilled in the art of relationship-building. The C-suite,thehospitalsmedicalboard,thecredentialingA. Culture change within the organization committee, and other stakeholders all have an invested B. Updates to hospital bylaws, if required interest in putting their stamp on questions of scope of C. Navigation of individual state regulatory regimes practice. A. Culture Change Clinical and operational leaders must work There is no doubt that some specialists will resist acollaboratively to demonstrate APP competency through greater role for APPs within the critical care space.procedurallogsandreferrals.Itmaylookdifferentlyat each facility, but the end goal is always the same: I once encountered a hospital where the chief operatingprovide exceptional care to patients that utilizes an officer(COO)andchiefmedicalofficer(CMO)agreed evidence-based approach. on greater APP involvement. However, they warned me about internal politics, and before long, one ofThe other key point to communicate is that from a themedicalboardslong-timemembers,asurgeon, critical care perspective, APPs are not there to replace approached me. He said he would never allow ourintensivists. They are there to partner, collaborate and group to care for his patients and would not assist in theutilize their procedural skills to support critically ill APP proctoring of procedures as required by the facilitypatients under the direct oversight of the intensivist.bylaws.C. Navigating state-by-state regulationThis kind of response is not uncommon. Culture changeEnsuring that APPs can work to the top of their license isdifficult,andnothingchangesmindslikebeingshownmeans supporting individual providers and the that current or antiquated thinking may be inaccurateorganization to navigate the local regulations which may and that there are opportunities to address mutualprohibit or restrict APP practice.goals another way. Active demonstrations of skill and Together, we healTogether, we heal 5Together, we heal SCP HEALTHIBRINGING THE C-SUITE TO THE BEDSIDE IN CRITICAL CARE MEDICINE'