Reading Health System’s Respiratory Care Department recently instituted a clinical ladder for professional advancement among its respiratory therapists. 

By Denise Sauer BS, RRT, RPFT; Jolen Miller BS, RRT-NPS; Nadine Falatko BA, RRT; Kimberly Wann BS, RRT-SDS, RPSGT; and Stephen Kohler MBA, BS, RRT

Reading Health System’s (West Reading, Pa) Respiratory Care Department recently instituted a clinical ladder for professional advancement among its respiratory therapists. This article will provide an overview of the department’s model for promoting clinical career advancement for its full-time and part-time RTs, its incentive and advancement structure, and an assessment of the model’s success and challenges thus far.


Clinical ladder programs were first developed in 1972 as a framework of recognition and reward for progressive and effective nursing practices.1 The opportunities for advancement and promotion have been utilized primarily in nursing for many years. Reading Hospital System Nursing’s Career Advancement Program (CAP) is based on the synergy model, which provides a functional framework to organize the delivery of patient care throughout the healthcare system, which can be applied in various ways to promote quality care, patient satisfaction, and professional growth.2  Respiratory Therapy is an essential part of the healthcare team at Reading Health System. The Respiratory Care Director determined that the department needed an innovative method to promote full-time and part-time Respiratory Therapists in a clinical role involving direct patient care, who consistently provide advanced clinical knowledge and skills through clinical career advancement.


The Reading Health System includes The Reading Hospital and The Reading Health Rehabilitation Hospital.  The Reading Hospital is a 647-bed not-for-profit, non-unionized facility located in West Reading, Pennsylvania.  The Hospital includes a Level II trauma center, a Level III NICU, and an emergency department with more than 100 treatment areas. The Reading Health Rehabilitation Hospital, a facility in Spring Township, PA, features a 50-bed skilled nursing unit and a 62-bed inpatient rehabilitation unit.


The Respiratory Care director enlisted the help from the Reading Respiratory Care Council (a unit-based shared government council). They were appointed to develop a Professional Development Program specific to Respiratory Care, based loosely on the existing nursing Career Advancement Program (CAP). The goal was to provide Respiratory Therapists who wish to remain active in direct, bedside patient care with the opportunity for advancement and promotion.

The Reading Respiratory Care Council was established in November 2012.  The purpose of this council was to unify the department and to make effective decisions on the overall quality of care and function of the Respiratory Care Department and Neurodiagnostic Center.  The “geography” of this council is to adequately represent every member of the Respiratory Care Department and Neurodiagnostic Center.  The Respiratory Care Department consists of 88 total Respiratory therapists: 71 Therapists in the inpatient area, 11 in the Sleep Center, 2 Pulmonary Function Therapists, 2 in Pulmonary Rehabilitation, and 2 at The Reading Health Rehabilitation Hospital.

The objectives of the respiratory professional development programs at Reading Health System are:

  • To improve the quality of patient care and organizational outcomes.
  • To provide career opportunities for the therapist who demonstrates advanced clinical knowledge and skills.
  • To provide the therapist increased opportunity to achieve autonomy and accountability while remaining in a direct patient care role.
  • To promote the recruitment and retention of clinical therapists by increasing job satisfaction, opportunities for expanding clinical roles, and recognition for advanced education, clinical proficiency, and expertise.
  • To nurture future leaders within the Respiratory Care profession.

The opportunities for advancement and promotion are provided through a series of five levels of increasingly advanced skill and proficiency. The role of the respiratory therapist is defined within five sequential practice levels: Progression through these levels will be determined by successfully demonstrating criteria for advancement, which includes education and certifications, clinical expertise, professional contributions, professional accomplishments, and organizational contributions. Advancement through a series of challenges are determined initially by the Therapist’s direct supervisor and then reviewed by The Respiratory Professional Development Program Board (RPDP). The Respiratory Care Council assumed the duties as the RPDP Board.

The program was introduced in October 2015. All nonexempt respiratory therapists were actively placed on the new ladder as a Level II Therapist with a choice to advance to Levels III, IV, or V.  The RPDP board and Respiratory Care director were charged with disseminating the information to staff members during annual department educational seminars. Development Program packets were made available to staff via the hospital intranet.


All regular full time and part time respiratory therapists in a clinical role (at least 51% of job responsibilities involve direct care of patients) are eligible for promotion with the Respiratory professional development program. Graduate therapists are hired at a Level I and are promoted to a Level II within 6 months and upon successful completion of the Level II RT minimal requirements. Experienced therapists are hired at a level I until completion of orientation.  Advancement to Levels III, IV, and V is voluntary and involves a challenge process.

Reading Health System’s respiratory professional development program provides respiratory therapists with opportunity and incentives for advancement through five levels of increasingly advanced expertise in providing care to patients. Each level requires a specific individual performance evaluation score, this is an annual score based on a Likert 5 point scale that the Reading Health System uses to evaluate employee performance and goal achievements. Each level is defined below with the minimal level requirements:

Respiratory Therapist I

Respiratory Therapist I has limited experience with the organizational practices and can apply clinical skills and experience while learning policies and procedures.

  • All applicants for Level I must be a graduate of an accredited school of respiratory therapy, and hold a Temporary Practice permit or a Pennsylvania State RT license.
  • RCP with less than 6 months of professional experience

Respiratory Therapist II

Respiratory Therapist II demonstrates competence in patient assessment, problem solving, and treatment implementation.  The therapist is able to prioritize tasks and responsibilities effectively but may need occasional assistance with advanced or specialized procedures.

  • Must be a licensed RT in the state of Pennsylvania
  • Successfully complete orientation
  • CRT or RRT
  • RCP with 6 months to 2 years of experience
  • Must have an individual performance rating of 3.0 or higher for promotion from RT I and 3.0 or higher for renewal
  • Participates in quality improvement or shared governance activities, assisting council or team member
  • Precepts students when assigned
  • Minimum 15 CEUs required
  • 20 matrix points required to challenge and maintain level

Respiratory Therapist III

Respiratory Therapist III demonstrates specialized experience, knowledge, and education. The therapist works with minimal supervision and increased scope of practice.  They actively work to improve practice through research and mentorship.

  • Must be a licensed RRT in the state of Pennsylvania
  • RRT with 2 years of experience
  • Bachelor Level Degree or 6 credits per year toward the bachelor degree completed annually
  • Specialty trained areas of Respiratory/Sleep/PFT/Post-acute/Pulmonary Rehab
  • Must have an individual performance rating of 3.7 or higher for promotion from RT II and 3.5 or higher for renewal
  • Member of an organizational team, council, or project team
  • Professional organization membership
  • Complete Preceptor course
  • Precepts for new hires or clinical care units
  • Teaching activities that includes education for respiratory professionals, patients, or community
  • Minimum 20 CEUs required
  • 35 matrix points required to challenge and maintain level

Respiratory Therapist IV

Respiratory Therapist IV combines advanced knowledge and experience to serve as a role model and resource person to the department, hospital, and community.  The therapist acts as trusted leader exemplifying the mission of the organization.

  • Must be a licensed RRT in the state of Pennsylvania
  • RRT with 5 years of experience
  • Bachelor Level Degree
  • Meet Level I through III requirements
  • Certification in specialty area by recognized accrediting agency
  • Must have an individual performance rating of 3.85 or higher for promotion from RT III and 3.5 or higher for renewal
  • Participates in organized staff education or completes a special project
  • Professional organization membership
  • Charge therapist or Council Membership or Community Health Advocate (Resource Therapist)
  • Minimum 30 CEUs required
  • 55 matrix points required to challenge and maintain level

Respiratory Therapist V

Respiratory Therapist V participates in ongoing research, interdisciplinary task forces, professional organizations, and performance improvements.

  • Must be a licensed RRT in the state of Pennsylvania
  • RRT with 7 years of experience
  • Master Level Degree
  • Meet Level I through IV requirements
  • Certification in specialty area by recognized accrediting agency
  • Must have an individual performance rating of 4.0 or higher for promotion from RT IV and 3.5 or higher for renewal
  • Leads or facilitates councils or teams that improve patient outcomes
  • Complex project that improves clinical practice through research, develops educational programs or improves operational efficiency
  • Publication, presentation, or Leadership for professional organization
  • Specialized certification instructor or Preceptor educator
  • Professional organization membership
  • Minimum 40 CEU’s required
  • 75 matrix points required to challenge and maintain level


A key element is that the clinical ladder system is an all-encompassing structure that starts with the annual performance evaluation score, point matrix score and educational contributions are all combined in order to help promote the therapist.  The point matrix score is a value given by demonstrating expertise and accomplishments associated with point values varying by activities associated with each attribute.

Examples of the point matrix for each of the five attributes include:

Clinical Expertise (RT years of experience)

  • 1 to 2 years = 3 points
  • 2+ to 5 years = 5 points
  • 5+ to 10 years = 7 points
  • 10+ to 15 years = 9 points
  • 15+ years = 10 points

Professional Accomplishments

  • Member of a healthcare professional organization = 1 points (max 2)
  • Author for professional publication: journal or book = 4 points (max 8)

Professional Contributions

  • Case study review with peers = 1 point
  • Develops patient education materials = 2 points

Education / Certification

  • Bachelor’s degree = 7 points
  • Master’s level degree = 15 points

Organizational Contributions

  • Charge therapist = 4 points
  • Preceptor instructor = 2 points

This system is designed to help motivate and reward the respiratory therapists at Reading Health System to maximize their achievements and goals.

Observations and Potential Outcomes

At first glance, staff seemed skeptical that this was created as an unachievable accomplishment. Upon further review, it was realized that the point matrix is a comprehensive structure that includes contributions of clinical expertise, professional accomplishments, professional contributions, educational accomplishments, certifications, and organizational contributions. A portfolio example could include a respiratory therapist with 10-15 years of experience, who is a member of a professional organization, serves as a member of a council within the hospital system, is a PALS and NRP provider, instructs ACLS, holds a bachelor’s degree, serves as a preceptor, works in adult ICU and neonatal ICU, fulfills the role as a charge therapist, and works at the institution for 15 years would have a score of 47 points in the matrix which would qualify them to challenge for a level 3 advancement making them eligible for an increase in salary.

Our vision is that the professional development program will improve staff satisfaction, accountability, retention, recruitment, and quantity of accomplished, advanced respiratory therapists.

In the model of the 2015-2020 AARC strategic plan, the objective is to refine and expand the scope of practice for respiratory therapists in all care settings. This professional development program supports the vision of the AARC to encourage and promote professional excellence, advance the science and practice of respiratory care, and serve as an advocate of patients, their families, the public, the profession, and the respiratory therapist.3


Denise Sauer BS, RRT, RPFT is a Respiratory Care staff therapist – Pulmonary Function at Reading Health System;
Jolen Miller BS, RRT-NPS is a Respiratory Care staff therapist at Reading Health System;
Nadine Falatko BA, RRT is a Respiratory Care evening shift supervisor at Reading Health System;
Kimberly Wann BS, RRT-SDS, RPSGT is a Respiratory Care staff therapist–Sleep Center at Reading Health System;
Stephen Kohler MBA, BS, RRT is a Respiratory Care supervisor and Adult Critical Care clinical specialist at Reading Health System.
For further information, contact [email protected].


  1. Winslow SA, Fickley S, Knight D, et al. Staff nurses revitalize a clinical ladder program through shared governance. Journal for Nurses in Staff Development. 2011;27(1):13-17.
  2. Czerwinski S, Blastic L, Rice B. The synergy model: building a clinical advancement program. Critical Care Nurse. 1999;19(4):72-77.
  3. Cathcart Marsha, ed. AARC strategic plan 2015-2020. AARC Times. 2015;38(2):20-23.