Before these questions are introduced and the suggestions for their resolution in the chapters ahead are discussed, the main product that is to emerge from this study is commented upon briefly. The VA physician requirements methodology involves statistical formulas that use existing VA data. It involves the use of expert judgment approaches to derive appropriate physician staffing. It can accommodate physician staffing guidelines emerging from outside the VA health care system (external norms).

However, the overall methodology will not consist simply of statistical formulas, or expert judgment procedures, or external norm-based staffing ratios. Rather, it is best characterized as a decision-making process —a process for using these approaches, in concert, to establish physician staffing recommendations that are defensible by definable criteria.

In what follows and in chapters 4 through 7, the choice among alternative analytical approaches, and of desirable physician Full-Time-Equivalent Employee (FTEE) levels, is assumed to rest in the hands of a stylized actor called the VA decision maker. It is recognized that decisions within a system as complex and diverse as the VA require the interaction and consultation of multiple individuals with a variety of perspectives at various sites throughout the system. In many cases there is no one individual either in the field or in the VA Central Office that can be identified as the decision maker on a particular issue. Recognizing that interactions among multiple actors are typical of decision making in large organizations, it is nonetheless a useful shorthand (which simplifies exposition) to personify this set of relationships and processes in a single "VA decision maker."

The VA decision maker will alternatively appear to reside in Central Office or at a particular VAMC. In no case should this characterization suggest that the locus of decision making is assumed to reside exclusively in either site or that the decision maker is a pure type. Particularly in chapter 7, the importance of a strong, two-way communication link between the individual VAMCs and Central Office is emphasized. For the physician requirements methodology to function properly, and improve over time, certain kinds of information must flow freely between Central Office and the VAMCs.

With this as background, the major methodological questions facing the committee are discussed below.

A CENTRAL PROBLEM: DETERMINING PHYSICIAN FTEE REQUIRED FOR PATIENT CARE AND RESIDENT EDUCATION

By far the most important and difficult question (within this study's purview) facing the VA decision maker is how to determine the number of physicians, by specialty, required to meet a VAMC's commitment to high-quality patient care and resident education.



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