SECTION I

SPECIALTY AND CLINICAL PROGRAM PANEL REPORTS



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Physician Staffing for the VA: VOLUME II SECTION I SPECIALTY AND CLINICAL PROGRAM PANEL REPORTS

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Physician Staffing for the VA: VOLUME II This page in the original is blank.

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Physician Staffing for the VA: VOLUME II OVERVIEW OF THE SPECIALTY AND CLINICAL PROGRAM PANELS1 INTRODUCTION Since the study's inception, it has been clear that expert judgment would be important in the formal development of a VA physician requirements methodology. The original statement of work noted that, “Because the available empirical data base alone is not adequate for driving the development effort or generating quantifiable estimates by purely mechanical numerical exercises, relevant informed professional judgments will be required throughout…and may well be an integral component of the physicians' requirements methodologies itself” (Institute of Medicine, 1987). To implement this mandate, the IOM committee was to appoint “advisory panels to broaden the base and range of experience and competence” brought to bear in the development of the methodology. In response, the committee established 11 advisory panels, eight of which were “specialty and clinical program” panels to serve as sources of medical professional judgment in the methodology's development.2 The six specialty panels were medicine, surgery (including anesthesiology), psychiatry, neurology, rehabilitation medicine (including spinal cord injury), and other physician specialties (including laboratory medicine, diagnostic radiology, nuclear medicine, and radiation oncology). The committee appointed two multidisciplinary clinical program panels in the areas of ambulatory care and long-term care. All panels were composed of VA as well as non-VA representatives, with the VA members never constituting a majority. 1   Adapted from material presented in chapter 5 of Volume I. 2   Also established were panels on data and methodology, affiliations, and nonphysician practitioners, whose activities are summarized elsewhere in these Supplementary Papers and in Volume I.

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Physician Staffing for the VA: VOLUME II A central issue for the committee was determining the scope of the charge given to the specialty and clinical panels. Two general approaches were considered. In a physician requirements methodology relying primarily on the empirically based physician staffing models (EBPSM), the panels would be asked to react to the estimated statistical models presented to them, evaluating their specification from a clinical perspective, and possibly modifying either the models themselves or their staffing recommendations. In a physician requirements methodology calling for a more balanced reliance on statistically based and expert judgment approaches, the panels would serve as the principal source of independently derived quantitative assessments of appropriate physician staffing. Under this second approach, the panels would not simply critique and modify statistical models, but render their own professional judgments about physician staffing levels consistent with good-quality medical care in particular clinical settings. These FTEE levels could then be compared with those emerging from the EBPSM for those same clinical settings. Under either interpretation, the panels would seek to develop external (to the VA) physician staffing norms, which would aid in the interpretation of empirically based as well as expert judgment-based results. The committee decided that the second, more expansive, interpretation of the panels' charge was the more appropriate (see chapter 5 of Volume I). Thus, each of the eight panels—in the course of two meetings in Washington, D.C., an extended conference call, and numerous mail and telephone communications with study staff —accomplished the following: Critiqued the empirically based models, offering recommendations about the choice of variables, data sets, and mathematical specification of the equations; Developed and evaluated external (to the VA) physician staffing norms; Derived its own independent estimations of appropriate physician staffing in specific VA medical centers. In accomplishing this, each panel used its own tailored variant of two alternative expert judgment approaches to estimating physician requirements: the Detailed Staffing Exercise (DSE) and the Staffing Algorithm Development Instrument (SADI); and

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Physician Staffing for the VA: VOLUME II In light of all these analyses, made recommendations to the study committee about how the VA should determine its physician requirements (for the physician categories within the panel's domain). COMMITTEE'S APPROACH TO ELICITING EXPERT JUDGMENTS AND REACHING CONSENSUS In designing a process by which the six specialty and two clinical program panels would operate, the committee faced two major methodological questions. By what means and in what form would expert judgments be elicited? How would the judgments of individual panel members be combined to reach consensus positions? In chapter 5 of Volume I, the recent literature pertaining to each of these questions is reviewed. In light of these studies and policy applications, the study committee initially determined that the specialty and clinical panels' own estimates of appropriate physician staffing levels would be obtained through a process with the following operating characteristics. A modified Delphi approach would be developed in which panel members would independently estimate appropriate physician staffing levels (in the applicable specialty or program area only) at a selected set of actual VA facilities. These estimates would be tabulated by study staff and displayed anonymously to panel members when they next convened. In the course of discussions, it might become natural, or necessary, for individuals to become identified with their estimates but this should evolve only as needed. Following discussion of the first round of estimates, the panel would be asked to reassess physician requirements (in its specialty or program area only). These results likewise would be tabulated and displayed. In principle, the reassessments would continue until the members' physician FTEE estimates had—by some criterion—stabilized sufficiently that a panel consensus estimate could be declared. But how should a consensus be defined? Following each iteration of physician FTEE assessments by the panel, the median value would be computed and the high and the low values noted. By one reasonable definition, a consensus emerges when the median stabilizes. More formally, a consensus would be declared on the ith iteration if the resulting median is within an acceptable range of the median obtained at the (i–1)st iteration (the previous one).

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Physician Staffing for the VA: VOLUME II A stronger definition of consensus would require that both the median and the mean absolute deviation (MAD) statistic, measuring here the average dispersion of physician FTEE responses around the median, 3 not change appreciably between assessment iterations. All else equal, this more stringent definition—requiring stability in the dispersion of assessments as well as their central tendency—would be preferred. The concepts underlying both the committee's preferred scheme for eliciting expert judgment and its preferred definition of consensus undergird the operations of the eight panels. However, given this study's developmental nature and time constraints, the panels' consensus assessments of appropriate physician staffing —via both the DSE and the SADI—must be regarded as approximations to what would have been obtained had these expert judgment processes been able to proceed through several iterations. Again, the panels' charge in this regard was to help the committee develop methods for staffing, not to render the final numbers on VA physician requirements. THE PANEL PROCESS—IN PRACTICE In this section the operation of the six specialty and two clinical program panels is described in terms of their major functional responsibilities: evaluating the empirically based physician staffing models, developing and testing the DSE, developing and testing the SADI, and evaluating external (non-VA) norms to guide physician staffing decisions. The primary focus here will be on the DSE and SADI because they are new vehicles for deriving expert judgment estimates of appropriate physician staffing; as such, they played central roles in most of the panels' recommendations for how the VA ought to determine physician requirements. Although the planning for panel operations began early in the study and their interactions with the committee and the staff continued through the first three months of 1991, the bulk of the activities described below occurred during the first 10 months of 1990. For expository purposes, it is useful to divide this period roughly into three phases: preparation for and conduct of the first panel meetings (January through April); preparation for and conduct of the second panel meetings (May through mid-August); and post-meeting activities (mid- 3   Formally, the MAD statistic is defined here as ∑|Xi–Xmad|/N, where Xi is the score of the ith panel member, Xmad is the panel median score, and N is the number of panel scores used in the decision process.

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Physician Staffing for the VA: VOLUME II August through October), culminating in a Panel Chairs' Session at the November 1–2, 1990, meeting of the committee. Before the panels' accomplishments are discussed, the procedures for appointing panel members are reviewed briefly. Appointment of Specialty and Clinical Program Panels The committee intended that the membership of each panel reflect a broad spectrum of clinical knowledge, professional judgment, and special technical expertise. Collectively, the physicians on each panel were selected to bring perspectives spanning a variety of clinical practice settings. It was understood from the beginning that the study would focus on the major specialty and program areas prominent in the VA; hence, the committee was constituted so as to have representation in these areas. It was natural that the chairs of the eight specialty and clinical panels be drawn directly from the committee membership. The study's workplan called for each panel to consist of VA as well as non-VA members, with the latter constituting a voting majority in each case. In response, the committee asked the Department of Veterans Affairs to nominate VA staff candidates for panel membership. The VA Liaison Committee proposed candidates for each panel, and a list of nominees was subsequently submitted to the IOM by the VA chief medical director. Non-VA panel nominees were initially solicited from members of the study committee. Additional nominees were drawn from the IOM membership, in consultation with the director of the Division of Health Care Services and the IOM executive office. After all nominations were received, a tentative panel roster (of non-VA and VA candidates) was submitted to each panel chair for review. Each chair could propose additional nominees. The final selection of VA and non-VA members was made by the panel chairs in consultation with the chair of the study committee. (Each panel's roster is included within its report.) Evaluating the EBPSM The specialty and clinical program panels provided important critical advice to the data and methodology panel and the study committee about several aspects of the EBPSM:

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Physician Staffing for the VA: VOLUME II Selection of Variables for Multivariate Regression Equations At its first and second meetings and during the postmeeting period, each panel was shown various specifications of empirically based models pertinent to its specialty domain or program area. Each was asked to address several questions: Is workload defined appropriately? Are the physician FTEE variables properly constituted? Do the variables included in the equations make clinical and organizational sense? Did the variables perform as expected statistically? For coefficient estimates that are not statistically significant, or that are significant but with the “wrong” algebraic sign (indicating perverse causality), what factors might be at work? Are there variables currently omitted from the equations that should be tested on clinical or organizational grounds? During the first and second panel meetings, the panels' empirically based model critique focused entirely on the production function (PF) variant. The inverse production functions (IPFs) did not begin emerging until the post-meeting period and were then evaluated by the panels at two junctures: first, via mail communications with study staff during late August (1990); and, second, during the conference calls with staff in late October. In the course of these meetings, written communications, and phone calls, panel members contributed numerous suggestions on improving the empirically based models (including the sentiment, expressed on occasion by some panels, that the models be discarded entirely in favor of an expert judgment approach). Plausibility and Desirability of Physician Requirement Estimates from Empirically Based Models During both its first and its second meetings, each panel examined the model-derived physician FTEE level and the corresponding level for three selected VAMCs (four for psychiatry in its second meeting), as recorded in their cost distribution reports (CDRs). The panel could compare these estimates with those it derived for the same facilities using the DSE. During the postmeeting

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Physician Staffing for the VA: VOLUME II period, panel members were also shown the physician requirement estimates for these facilities as derived from both the IPF and the SADI. Given this array of alternative FTEE estimates, each panel member was asked to state (during the postmeeting period via mail survey) what he/she regarded as the most appropriate physician FTEE level for each facility. Among other questions posed was whether the VA should adopt a physician requirements methodology whose centerpiece is an empirically based approach (either the PF or the IPF). The Detailed Staffing Exercise An “Ideal” Mechanism for Expert Judgment Staffing Suppose an expert panel is charged with determining physician requirements for a given specialty or program area at some VAMC. An ideal expert judgment mechanism is one that yields the same staff physician FTEE levels that would be derived if the panel had made the assessment with “complete information” about the volume and the severity of patient workload, the number and the type of residents and nonphysician personnel, other facility-specific data, and the relationship between staffing patterns and indicators of the quality of care. Search for a Practical Response In preparation for the first round of specialty and clinical panel meetings, study staff developed first-generation versions of the physician staffing instruments that would evolve into the DSEs. For each panel, three distinct (though generically similar) instruments were constructed for each of three VAMCs; the VAMCs were selected to reflect diversity in geographic location and affiliation status (as indexed by number of beds, residents, and scope of services offered). Each panel analyzed the same three VAMCs. Prior to the first panel meeting, members were mailed the instrument for one of the facilities and asked to complete it as a “homework exercise.” The identity of the facility was not revealed. At the first meeting, staff presented a summary of these homework results, they were discussed, and the panel completed the other two exercises. For one of the latter, the panel was divided into small groups of two to three

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Physician Staffing for the VA: VOLUME II members each; for the other, the panel worked together as a single group. In neither case was the identity of the VAMC revealed until the exercises were completed. Because these first-generation instruments turned out to be transitional documents, soon to be revised (into what later became the DSE), they are not discussed in depth in the panel reports that follow. Similarly, because the panels' staffing analyses during the first meeting were entirely exploratory, the resulting physician FTEE estimates are sufficiently experimental that policy inferences are not meaningful. At the May 1–2, 1990, meeting of the committee (termed Joint Meeting I), each panel presented a brief progress report. After discussions, the committee concluded two things: First, determining physician requirements by an expert judgment process was feasible, from a cognitive as well as a group-dynamics standpoint. Second, the initial instruments needed revision, aimed primarily at providing enough context-specific information that panel members could assess, with confidence, physician requirements for any given ward, clinic, or program at any given VAMC. Revised Instrument for Second-Round Panel Meetings Specifically, at the May 1–2 meeting, the committee directed each panel to work with staff to develop and test a revised instrument, subsequently termed the DSE. Each DSE consists of an A and a B section. Section A provides a ward-by-ward, clinic-by-clinic description of the patient care environment at an actual VAMC. For each patient care area (PCA, as defined in chapter 4 of Volume I), information is provided on the volume and diagnosis-related groups (DRG) mix of workload, number of residents by specialty and postgraduate year (PGY), number of nonphysician practitioners by type, general information about the adequacy of nursing and support staff, and other context details. For each ward, clinic, and procedure, the expert is asked to assess the amount of physician time—in hours—required per day, per visit, or per unit, respectively, to produce good-quality care. The B Section contains questions on the amount of physician time required for night and weekend coverage in the PCAs, educational activities not occurring in the PCAs, research, administration, other facility-related activities, and leaves of absence. For each panel member, time estimates for all patient care and non-patient-care activities are summed and converted to FTEE—assuming one FTEE translates into a 40-hour/week commitment.

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Physician Staffing for the VA: VOLUME II The panel consensus estimate is defined as the median of the members' estimates. The format for the second panel meetings was as follows: Staffing instruments for two VAMCs, hereafter identified as I and II, were mailed to panel members in advance. Neither facility was identified by name at this point. As before, each panel assessed physician requirements for its specialty or program area only. With few exceptions, panel members did complete and return both instruments to staff prior to the meeting. The results were tabulated, checked for arithmetic errors, and presented by staff at the panel meeting in a way that kept the members' assessments anonymous. (During subsequent group discussions, however, members typically revealed their assessments.) For VAMC I and II, in turn, the panel was shown each member's estimates of physician time for the component parts of Sections A and B of the DSE and of total physician FTEE required at the facility. Also presented were some summary statistics: the panel's high, low, mean, and median estimates of total physician FTEE. Following discussion of these results, the panels reassessed physician requirements for VAMCs I and II, working from copies of the staffing exercises they originally submitted. For seven of the eight panels, members reassessed independently; the results were tabulated, then discussed. The surgery panel determined that it could derive consensus time estimates most efficiently through a group-interactive process, in which the panel as a whole discussed each FTEE component of the DSE, arriving in each instance at an estimate agreeable to the group. Such an approach leads directly to consensus estimates for total surgeon and anesthesiologist FTEE required at facilities I and II; the panel's high, low, mean, and median converge to a single FTEE estimate. At this point in the assessment process, each panel was shown the names of VAMCs I and II; their actual, CDR-recorded physician FTEE levels for FY 1989 for the specialties or programs within the panel 's domain; and the corresponding calculation of physician requirements derived from the PF variant of the empirically based model.4 4   However, PF estimates were derived only for those specialties assumed to play the dominant role in one or more specific PCAs. Hence, no PF estimates were available for laboratory medicine, diagnostic radiology, nuclear medicine, radiation oncology, and anesthesiology. Physician FTEE for these specialties can be derived via the IPF model, but this empirically based variant was not adequately developed until after the second panel meeting. For a discussion of these points, see chapter 4 of Volume I.

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Physician Staffing for the VA: VOLUME II AMBULATORY CARE Please fill in the average time in hours required by a staff physician in your service for the average ambulatory care clinic visit by a typical patient to one of your specialty program clinics, noting the presence or absence of residents and nonphysician practitioners (e.g., a physician assistant [PA] or a nurse practitioner [NP]), and whether the visit is by a new or returning patient. Chart 8   Physician Time per Visit Type of Visit High Low Mean Median New Patient Visit No Resident 1.00 0.67 0.92 1.00 New Patient Visit with Resident 1.00 0.25 0.53 0.50 New Patient Visit with NP or PA 1.00 0.33 0.67 0.70 Follow-Up Visit No Resident 0.33 0.25 0.30 0.33 Follow-Up Visit with Resident 0.33 0.08 0.22 0.25 Follow-Up Visit with NP or PA 0.33 0.08 0.25 0.25

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Physician Staffing for the VA: VOLUME II SECTION B: NON-PATIENT-CARE ACTIVITIES Part 1. The activities listed below generally do not occur every day, but may be time-consuming when looked at over a longer period, such as a week or month. List the time in hours that you would add to each physician's average workday to allow for the types of work other than direct patient care listed below. Chart 9 Assume the amount amount of research accomplished at this VAMC is: High1 Medium1 Low1 Physician Hours/Workday: High Low Mean Median High Low Mean Median High Low Mean Median Education of residents (didactic, classroom, not on the PCA): 1.00 0.30 0.42 0.45 1.00 0.30 0.42 0.45 1.00 0.12 0.32 0.45 Administration by Chief (time required to manage your whole service by a Chief and/or Assistant Chief): 7.00 3.00 4.00 3.30 7.00 2.30 3.55 3.30 7.00 1.00 3.25 3.30

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Physician Staffing for the VA: VOLUME II Assume the amount amount of research accomplished at this VAMC is: High1 Medium1 Low1 Physician Hours/Workday: High Low Mean Median High Low Mean Median High Low Mean Median Administration by Others (time required for individual physicians): 1.00 0.05 0.25 0.40 1.00 0.05 0.25 0.40 1.00 0.05 0.25 0.40 Hospital-Related Activities (mortality and morbidity, quality assurance, staff meetings): 1.00 0.35 0.40 0.35 1.00 0.25 0.40 0.35 1.00 0.25 0.35 0.30 Total Hours per Average Workday: For Chief2   For Non-Chief   For Chief   For Non-Chief   For Chief   For Non-Chief   Overall Mean 4.0   1.8   3.9   1.9   3.4   1.6   Overall Median 3.3   1.5   3.3   1.8   3.3   1.5   1Examples of research level by total amount of funding (VA plus non-VA) in fiscal year 1988: High—VAMC I with $8.8 million in total funding; Medium—VAMC II with $2.75 million in total funding; Low—VAMC III with about $176,000 in total funding. 2Assume that Chief does not participate significantly in the Education of Residents and Hospital-Related Activities; SADI users may casuly modify this assumption.

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Physician Staffing for the VA: VOLUME II Part 2. In order to determine the actual staffing in this hospital, the number of FTEE must be adjusted to allow for continuing medical education, research, and leaves of absence. What do you believe to be the appropriate percentage of time the “average” (typical) member of your service should devote to each of the following categories of non-patient-care-related activities? Chart 10 Assume the amount amount of research accomplished at this VAMC is: High1 Medium1 Low1 Percentage of Physician Time: High Low Mean Median High Low Mean Median High Low Mean Median Continuing Education: 15.0 1.5 7.4 8.0 15.0 1.5 7.4 8.0 10.0 1.5 6.2 6.0 Research (off the PCA): 50.0 30.0 36.3 34.0 30.0 20.0 23.3 23.0 15.0 0.0 7.5 7.5 Vacation, Administrative Leave, Sick Leave, Other: 15.0 8.0 12.5 13.0 15.0 8.0 12.5 13.0 25.0 8.0 14.0 13.0 Total Percentage of Time:   Mean 55.6 43.3 27.9 Median 54.0 44.3 26.8 1Examples of research level by total amount of funding (VA plus non-VA) in fiscal year 1988: High—VAMC I with $8.8 million in total funding; Medium—VAMC II with $2.75 million in total funding; Low—VAMC III with about $ 176,000 in total funding.

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Physician Staffing for the VA: VOLUME II EXHIBIT 3 Application of the SADI to Compute Physician Requirements in Medicine at VAMC I1 FOR SECTION A: PATIENT CARE ACTIVITIES Medicine Inpatient PCA Admissions Physician hours is the product of admissions per day and the panel 's median estimate of physician time per admission, given resident availability. The former is supplied by the VAMC; the latter is from Chart 1 of Figure 5.2. 15 Adm/day×0.50 hr/Adm=7.50 hr (Wards) 1 Adm/day×0.50 hr/Adm=0.50 hr2 (Intensive Care) Subtotal for Admissions=8.00 hr Routine Care Based on the overall median estimates from Charts 3 and 4 of Figure 5.2. In each instance below, the required physician time estimate could not be read directly from the charts, but had to be derived by interpolation, extrapolation, or some other mapping process. 1   Since VAMC I is a highly affiliated, research-intensive facility, all physician time estimates assume resident availability. All workload-related data are taken from the medicine DSE developed for VAMC I and are based on information reported to study staff by officials at the facility. 2   Assumes admission work-up time same as for medicine wards. Admission times taken from Chart 1 of Figure 5.2.

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Physician Staffing for the VA: VOLUME II Ward 1: ADC=26: 5.08 hr3 Ward 2: ADC=31: 5.10 hr3 Ward 3: MICU w/ADC=6: 3.07 hr4 Ward 4: CCU w/ADC=6: 3.07 hr4 Ward 5: Bone Marrow Transplant Unit (BMTU) w/ADC=5: 2.63 hr5 Intermediate Care: ADC=1: 0.54 hr6 Geriatric Evaluation Unit (GEU): ADC=6: 3.07 hr5 Subtotal for Routine Care= 22.56 hr Special Procedures Physician hours is the product of procedures per day and the panel 's median estimate of physician time per procedure, given resident availability. The former is supplied by the VAMC; the latter is from Chart 7 of Figure 5.2. Cardiac Caths: 1.5 Caths/day×1.50 hr/cath= 2.25 hr Endoscopies: 6 Endos/day×0.70 hr/endo= 4.20 hr Bronchoscopies: 3.5 Bronchos/day×0.87 hr/broncho= 3.03 hr Subtotal for Special Procedures= 9.48 hr Subtotal for Medicine Inpatient PCA: 40.04 hr/day 3Estimate based on extrapolation of overall median values found in Chart 3 under Routine Daily Patient Care in Figure 5.2. 4Estimate based on linear interpolation of overall median values found in Chart 4 under Routine Daily Patient Care in Figure 5.2. 5Estimate derived from ICU/CCU times found in Chart 4 under Routine Daily Patient Care in Figure 5.2, since neither the BMTU nor the GEU is included in the current medicine SADI. 6Assumes Routine Daily Patient Care time same as for medicine wards in Chart 3 of Figure 5.2.

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Physician Staffing for the VA: VOLUME II Consultations Physician hours is the product of consults per day and the panel's median estimate of physician time per consult, given resident availability. The former is supplied by the facility; the latter is from either Chart 5 or Chart 6 of Figure 5.2, depending on whether the consult is “initial” or “follow-up.” Surgery Inpatient PCA: 18.50 consults/day7 Initial: 9.25 visit8×0.50 hr/visit =4.63 hr Follow-up: 9.25 visit×0.25 hr/visit =2.31 hr   Subtotal 6.94 hr/day Neurology Inpatient PCA: 1.85 consults/day7 Initial: 0.92 visit8×0.50 hr/visit =0.46 hr Follow-up: 0.92 visit×0.25 hr/visit =0.23 hr   Subtotal 0.69 hr/day Psychiatry Inpatient PCA: 5.54 consults/day7 Initial: 2.77 visit8×0.50 hr/visit =1.39 hr Follow-up: 2.77 visit×0.25 hr/visit =0.69 hr   Subtotal 2.08 hr/day Rehabilitation Medicine Inpatient PCA: 1.85 consults/day7 Initial: 0.92 visit8×0.37 hr/visit =0.34 hr Follow-up: 0.92 visit×0.25 hr/visit =0.23 hr   Subtotal 0.57 hr/day 7Average daily consult or visit rate by medicine service physicians, as reported by VAMC I. Consults or visits on a given day may be above or below this average figure. 8Assumes 50 percent of visits are “initial” consults and 50 percent are “follow-up.” Physician times per initial consult are found in Chart 5 and Chart 6, respectively, of Figure 5.2.

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Physician Staffing for the VA: VOLUME II Spinal Cord Injury PCA: 0.58 consults/day7 Initial: 0.29 visit8×0.50 hr/visit9 =0.15 hr Follow-up: 0.29 visit×0.25 hr/visit9 =0.07 hr   Subtotal 0.22hr/day Nursing Home PCA: VAMC I reports 0 consults Subtotal for Consultations: 10.50 hr/day Ambulatory Visits Physician hours is the product of visits per day and the panel's median estimate of physician time per visit. The former is supplied by the VAMC; the latter is from Chart 8, expressed as a function of whether the particular clinic operates with or without residents and with or without physician assistants and nurse practitioners. General Medicine: 100 visit/day7 Residents and NPs available. Initial: 20 visit10×0.50 hr/visit =10.00 hr Follow-up: 80 visit×0.25 hr/visit =20.00 hr   Subtotal 30.00 hr/day General Medicine Follow-up: 18 visit/day7 NPs available. Initial: 3.6 visit10×0.70 hr/visit =2.52 hr Follow-up 14.4 visit×0.25 hr/visit =3.60 hr   Subtotal 6.12 hr/day 9Based on median consult times to surgery service, since SCI not included in current medicine SADI. 10Assume 20 percent of ambulatory care visits involve new patients and 80 percent are for follow-up. Physician times per ambulatory visit are in Chart 8 of Figure 5.2.

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Physician Staffing for the VA: VOLUME II Cardiology: 13.6 visit/day7 Initial: 2.72 visit10×0.50 hr/visit =1.36 hr Follow-up: 10.88 visit×0.25 hr/visit =2.72 hr   Subtotal 4.08 hr/day Dermatology: 17 visit/day7 Initial: 3.40 visit10×0.50 hr/visit =1.70 hr Follow-up: 13.60 visit×0.25 hr/visit =3.40 hr   Subtotal 5.10hr/day Endocrine: 6.4 visit/day7 Initial: 1.28 visit10×0.50 hr/visit =0.64 hr Follow-up: 5.12 visit×0.25 hr/visit =1.28 hr   Subtotal 1.92 hr/day Gastrointestinal: 8.4 visit/day7 Initial: 1.68 visit10×0.50 hr/visit =0.84 hr Follow-up: 6.72 visit×0.25 hr/visit =1.68 hr   Subtotal 2.52 hr/day Hypertension: 8.4 visit/day7 NPs available. Initial: 1.68 visit10×0.70 hr/visit =1.18 hr Follow-up: 6.72 visit×0.25 hr/visit =1.68 hr   Subtotal 2.86 hr/day Pulmonary: 12.6 visit/day7 Initial: 2.52 visit10×0.50 hr/visit =1.26 hr Follow-up: 10.08 visit×0.25 hr/visit =2.52 hr   Subtotal 3.78 hr/day

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Physician Staffing for the VA: VOLUME II Renal: 4.8 visit/day7 Initial: 0.91 visit10×0.50 hr/visit =0.48 hr Follow-up: 3.84 visit×0.25 hr/visit =0.96 hr   Subtotal 1.44 hr/day Dialysis: 10.6 visit/day7 Initial: 2.12 visit10×0.50 hr/visit =1.06 hr Follow-up: 8.48 visit×0.25 hr/visit =2.12 hr   Subtotal 3.18 hr/day Rheumatology: 7.6 visit/day7 Initial: 1.52 visit10×0.50 hr/visit =0.76 hr Follow-up: 6.08 visit×0.25 hr/visit =1.52 hr   Subtotal 2.28 hr/day Oncology: 8.6 visit/day7 Initial: 1.72 visit10×0.50 hr/visit =0.88 hr Follow-up: 6.88 visit×0.25 hr/visit =1.72 hr   Subtotal 2.60 hr/day   Subtotal for Ambulatory Visits (excluding Comp & Pensions Exams11): 65.88 hr/day Total Section A Hours: 116.42 hr/day Total Section A FTEE (assuming 40 hr/week equivalence): 116.42 hr/day ÷8 hr/day/FTEE 14.6 FTEE At its second meeting, the medicine panel agreed that no additional FTEE need be purchased for night and weekend coverage. 11At VAMC I, Compensation and Pension Examinations are not performed by VA staff physicians, but externally through contract arrangements.

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Physician Staffing for the VA: VOLUME II FOR SECTION B: NON-PATIENT-CARE ACTIVITIES Didactic instruction of residents (not on PCAs), administration, and other hospital-related, non-patient-care activities: For Service Chief12 For All Other Staff Physicians13 3.5 hr/day 1.5 hr/day×(14.6–1)=20.4 hr/day Subtotal=3.5+20.4=23.9, which implies 23.9/8=3.0 FTEE Total (to this point)=14.6+3.0=17.6 FTEE. Next, the panel's median estimates for percentage of time to be devoted to continuing education (8%), research (34%), and vacation, administrative leave, sick leave, and other (13%) lead to an overall median estimate of 54% for the percentage of total medicine service time allocated to these activities.14 Hence, total FTEE for the medicine service at VAMC I=17.6/(1–0.54)=38.3 This implies that about 38.3×0.34=13.0 FTEE would be devoted to research, and 38.3×0.08=3.1 FTEE to continuing education. At its second meeting, the panel's median estimate of additional FTEE desired from Consulting & Attending and Without-Compensation physicians was 1.5. If these are included, the desired FTEE total is 38.3+1.5=39.8. 12Estimate assumes that, among the three FTEE categories of administration, resident classroom instructions, and other hospital-related non-patient-care activities, the service chief s time is concentrated in administration and only minimally devoted to the other two. See Chart 9 in Part 1, under Non-Patient-Care Activities, in Figure 5.2. 13Estimate derived by multiplying the median estimate of total time for the three categories (i.e., 1.5 hr/day) by the number of patient-care-related FTEE, minus the assumed full-time service chief [i.e., by (14.6– 1)=13.6]. See Chart 9 in Section B, Part 1, under Non-Patient-Care Activities, in Figure 5.2. There are other plausible ways to compute this. 14See Chart 10 in Part 2 under Non-Patient-Care Activities in Figure 5.2.