Physician Staffing for the VA: Volume II, Supplementary Papers (1992)

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.

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.

1. 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.

2. 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

• 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).

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).

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.

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-

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.

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.)

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:

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).

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

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).

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.

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

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.

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.

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

Next, the panel was asked to assess physician requirements at a VAMC, hereafter known as VAMC III, using a DSE prepared for the task. (The psychiatry panel also analyzed a fourth facility, VAMC IV.) For all panels except surgery, the assessments were again completed independently, the results were tabulated, and the mean and median were found. The surgery panel again elected to reach consensus directly through structured group discussion.

Following these assessments, staff revealed the identity of VAMC III (and, for Psychiatry, VAMC IV), its CDR-recorded physician FTEE level in FY 1989, and the corresponding FTEE calculation derived from the PF model. As time permitted, there was general discussion about determining physician requirements through the DSE approach.

The best way to gain a clear understanding of how the DSE works is to examine a completed instrument in some depth. In Exhibit 1 below,⁵ the medicine DSE constructed expressly for VAMC II is shown in its entirety. The physician time estimates used to illustrate the process are the initial “homework” assessments of a medicine panel member who was particularly conscientious about documenting his assumptions and reasoning. This panel member's calculations and accompanying commentary serve to make Exhibit 1 reasonably self-explanatory. Because, with minor exceptions, the DSEs developed for all eight panels are structurally similar, only one will be shown here; the choice of medicine is entirely arbitrary.

In pursuit of a less cumbersome expert judgment approach to physician staffing, the committee began work in August 1990 on an alternative approach for each panel. The committee wanted to build upon, formalize, and strengthen some of the rules of thumb for staffing evident during the second panel meetings. Ideally, this new approach would retain much of the DSE's specificity, while being more streamlined and less labor intensive in application.

By late August, first-generation versions of the SADI had been developed for experimental application by each of the eight panels. By early September, the members of each panel, working separately and independently, had completed and returned their SADIs by mail to study staff. The results were processed, and first-generation SADI-based estimates of physician requirements were computed for VAMCs I, II, III, and (for Psychiatry) IV.

Several specific steps were involved in applying this new expert judgment approach within each panel.

The SADI (like the DSE) has two sections, A and B, focusing on patient care and non-patient-care physician activities, respectively. In section A, panel members were asked to estimate the amount of physician time required to perform each of an array of functions and tasks in a way consistent with achieving good-quality care. Patient workload categories for which physician time estimates (typically expressed in hours) were sought include: inpatient admission workup, routine daily care on the wards of that specialty's or program's “dominant” PCA (if applicable), consultations on all other PCAs, certain diagnostic and therapeutic procedures, and outpatient visits. In each category, physician time can be estimated as a function of the availability of residents by type, nonphysician practitioners by type, and other context factors.

In Section B, panelists were asked to determine the total amount of physician time (again, for physicians in the panel's domain) that ought to be devoted to the following non-patient-care activities: research, education of residents in the classroom, continuing education, administration, other hospital-related activities, and leaves of absence. The format in section B of the SADI is virtually identical to that used in the final version of the DSE.

In deriving group-consensus SADI estimates from individual member estimates, each physician task or function in section A was considered in turn: the individual estimates were arrayed, and the median was designated as the panel's consensus estimate. Likewise, for each FTEE component of section B, the panel median was declared the consensus estimate.

To determine physician requirements at a given VAMC, the panel median for each type of patient care activity was applied, in turn, to the volume of such activities associated with the facility's projected workload, and the results were summed across activities to derive total physician hours for patient care. Physician times for all non-patient-care activities were assessed separately using the relevant median estimates. The sum of physician hours estimated from

Sections A and B was then converted into FTEE using the 40-hour/week equivalence assumption.

As with the DSE, the best way to understand the SADI is to examine a completed instrument, then study how it can be applied to determine physician requirements at some VAMC.

Exhibit 2 below is a slightly compact version of the SADI completed by the members of the medicine panel; it is intended to be self-explanatory. ⁶ For each function or task, the medicine panel's high, low, mean, and median estimates of the amount of physician time required for good-quality care are shown.

Each panel report (other than medicine) contains the unabridged SADIs developed for the specialties or clinical program area under that panel's purview. Although each SADI is tailored specifically to the main activities associated with that specialty or program area, all are basically similar both in structure and the logic of application; hence, to understand the medicine instrument and how it is applied is to understand the SADI approach.

The application of this medicine SADI to determine physician requirements at VAMC I is summarized in Exhibit 3.⁷ This is intended to be a relatively self-contained walk-through of how the SADI works. However, several general points deserve emphasis.

For each physician activity (e.g., admission workup), the panel consensus estimate of the time required per unit (e.g., per workup) is multiplied by the projected number of units of the activity per day. One exception is the time required for routine daily patient care on the wards, which comes packaged as a total that varies with the average daily census (ADC) and other contextual factors.

Total physician hours required per day is the sum of hours required for all patient-care-related and non-patient-care-related activities. A final step is converting hours into FTEE.

In the SADI (as with the DSE), the whole is defined as the sum of the parts; hence, the parts must successfully encompass all physician activities at the VAMC.

To apply the SADI, in its current form, to determine physician requirements at a VAMC, the facility itself must generate certain workload and other data; the VA's central information systems do not generally supply information at the level of detail required by the SADI (or the DSE). These information requirements can be inferred from Exhibit 3, but are summarized here as well.

• Patient Care Activities—Inpatient:

1. Admissions/day in the specialty's dominant PCA (if applicable), with and without resident;

2. For each ward in the dominant PCA, the average daily census (ADC), the average length-of-stay (LOS), and the number and type of residents as a function of ADC;

3. For each special-care unit where the specialty is a major participant (e.g., ICU/CCU for medicine), the ADC, the LOS, and number and type of residents as a function of ADC;

4. For all other wards, including intermediate care and nursing home, the number of initial as well as follow-up consultations/day, with and without resident;

5. The number of special procedures (e.g., cardiac catheterizations in medicine) performed per day, with and without resident; for both surgery and anesthesiology, the number of operations/day distinguished, as the surgery panel has recommended, by level of complexity.

• Patient Care Activities—Ambulatory:

The number of patient visits/day by ambulatory PCA, with and without resident, and with and without physician assistant or nurse practitioner.

• Non-Patient-Care Activities

Sufficient information about total research funding at the VAMC that it can be classified as either a high-, medium-, or low-research facility—the overall proxy for affiliation status used in section B of all current SADIs.

As it turns out, all of this information (and then some) is required for constructing the DSE; thus, the facility-specific data for implementing the SADIs during the study were extracted directly from the existing DSEs.

The projected ADC for a given ward at a VAMC may not match exactly any of the ADC levels for which time estimates are available in the SADI, as evident in the Routine Daily Patient Care portion of Exhibit 2. For example, if the projected ADC is 35 and the highest ADC shown in the SADI is 30, an extrapolation is required to estimate physician time for 35. Similarly, if the projected ADC is 22 and the nearest ADC levels included are 20 and 25, physician time for 22 must be interpolated.

In both cases, the simplest approach would assume a linear relationship between ADC and physician time. This may or may not be warranted. For example, suppose the estimated median times for the ADCs of 20, 25, and 30 are 4, 5, and 5.5 hours, respectively. For an ADC of 22, an interpolated estimate of 4.4 hours—i.e., 4+[(22–20)/(25–20)] —seems reasonable. But given the nonlinear way physician time responds as ADC goes from 20 to 25 to 30, it seems unreasonable to calculate the time for an ADC of 35 as (35/30)5.5 =6.4 hours; rather, something less than this is more plausible.

If SADI estimates are directly available for a sufficiently dense set of ADC levels, the issue becomes moot. Clearly, there is a trade-off between the level of detail built into the SADI—and thus the resources required to produce and maintain the SADI—and the likelihood of having to estimate physician times based on those explicitly available in the instrument.

For example, at VAMC I there is a bone marrow transplant unit (BMTU), but the current medicine SADI includes no such activity category. Therefore, physician time estimates for the ICU/CCU unit were applied to the ADC levels

projected for the BMTU. As indicated in Exhibit 3, such approximations were required in several instances.

Again, if the SADI is constructed in great enough detail—if all relevant activity categories are included—such approximations are not needed.

One other major issue that the committee asked the specialty and clinical program panels to investigate was whether there exist non-VA physician staffing standards or patterns that could be usefully applied to help determine appropriate VA physician staffing.

Working with study staff, each panel developed over the course of its deliberations external norm information of two types:

• Explicit physician staffing standards, primarily from a few large organizations which, like the VA, plan and deliver health care through a centralized decision-making process. The prime examples in this study were the U.S. Department of Defense (DoD) and the Indian Health Service.

• Implicit physician staffing standards, as inferred from existing (secondary) data, that describe the ongoing relationship between workload and physician staffing in a health care organization selected for comparison with the VA, such as a large health maintenance organization or a public hospital system.

In addition, some panels were able to bring to bear existing (though sometimes dated) physician staffing guidelines developed within the VA. Where they existed, these internal norms provided a potentially useful basis for comparison.

All committee and panel members were asked to recommend health care organizations that might provide data relevant to the construction of norms. Several criteria were relevant: the perceived quality of care provided by the

organization; the comparability of the organization's patient population and patterns of care to the VA; and the quality and accessibility of its data on patient workload and physician FTEE. Guided by these factors, the study staff also pursued possible data sources.

The major organizations contacted are listed in Table 5.4 of Volume I; in addition, data were obtained from a number of individual hospitals, long-term-care units, and clinics. The particular set of organizations analyzed by each panel is discussed in its report to the committee.

Given the nature of (a) explicit staffing guidelines at organizations such as DoD or IHS and (b) secondary data on staffing available from other types of providers, the process for calculating VA physician requirements on the basis of external norms was technically straightforward and basically similar for all panels.

Specifically, an organization's staffing standard for inpatient or long-term care was generally defined in terms of its ADC per physician FTEE (ADC/phy) —either as posited by the organization or as observed there. An organization 's standard for ambulatory care was based on either its posited or its observed ratio of patient visits per physician FTEE per year (visits/phy/yr).

As one example, consider the DoD, where explicit standards for workload per physician per year are specified separately by specialty category and by type of hospital (teaching versus nonteaching). For a facility with an ADC of 100 and 60,000 ambulatory visits per year, the physician staffing standards in medicine for inpatient and ambulatory care are, respectively, 10.3 ADC/phy and 5,808 visits/phy/yr (DoD, 1989). Applying these staffing ratios to the assumed workload data, it can be calculated that

Inpatient FTEE=100 ADC/(10.3 ADC/phy)=9.7

Ambulatory Care FTEE=(60,000 visits/yr)/(5,808 visits/phy/yr)=10.3

Total FTEE Required=9.7+10.3=20.0.

On the basis of data supplied by the New York Health and Hospitals Corporation (NYH&HC, 1989), study staff derived the following implicit physician staffing standards for medicine: 7.0 ADC/phy for inpatient and 4,270 visits/phy/yr for ambulatory care. When these ratios are applied to the fictitious workload data above, the physician FTEE required for inpatient and ambulatory care are 14.3 and 14.1, respectively, for a total FTEE requirement of 28.4.

When the DoD and NYH&HC ratios were in fact applied to the FY 1989 workload data (suitably aggregated) at VAMC II, the implied physician staffing in medicine was 53.0 and 56.0 FTEE, respectively. These estimates can be compared with physician requirements in medicine at VAMC II as assessed through the SADI (54.0), the DSE (49.9), as well as with the medicine staffing actually there (45.7, as recorded in its CDR); see the medicine panel report that follows for further discussion.

DoD (U.S. Department of Defense). 1989. Joint Health Manpower Standards. DoD #6025.12-STD, Washington, D.C., November.

IHS (Indian Health Service, U.S. Public Health Service, Department of Health and Human Services). 1988. Allocation of Resources in the Indian Health Service. A handbook on the Resource Allocation Methodology (RAM), April.

Institute of Medicine. 1987. Study Workplan (Statement of Work) for a Study to Develop Methods Useful to the Veterans Administration in Estimating its Physician Needs. Washington, D.C. Unpublished.

New York City Health and Hospitals Corporation. 1989. Report of the New York City Health and Hospitals Corporation. In: The Mayor's Management Report to the City of New York. February. Unpublished.

What follows is the medicine panel's DSE, slightly compressed to focus illustratively on the physician requirement estimates of one panel member. All of the panel member 's responses, numerical and narrative, appear in italic type.

In the previous meeting of the medicine panel, we asked you to estimate physician staff requirements in your specialty, for a real VA Medical Center (VAMC), in a number consistent with good quality of care. This new staffing exercise repeats the process, but we have provided a more specific description of the facility including the type of patients, number of admissions, and length of stay. We have also provided more details on the number and types of residents (including level of experience and specialty) available, and the numbers of any nonphysician practitioners (NPP) that may be present. While obtaining your numerical estimates for this facility, we also will be probing the thought processes used in determining physician staffing.

This highly affiliated VAMC participates in a moderate amount of research and is large with total operating beds of 978 and an average daily census of 772.

Your task in Section A is to calculate the physician hours required from the Medicine Service for each Patient Care Area (PCA) for an average weekday.

Do include in Section A:

• Physician time spent on direct patient care

• Physician time spent on patient-care-related activities such as:

  • chart documentation

  • related telephone communication

  • patient and family teaching and counseling

  • time spent interactively with residents in patient care and/or teaching on the PCA

Do NOT include in section A:

• Night call and weekend coverage.

• Physician time spent in non-patient-care-related activities such as:

  • research off the PCA

  • educational activities that are not related to direct patient care (such as teaching residents, or delivering lectures off the PCA)

  • quality assurance

  • mortality and morbidity meetings or studies

  • administrative activities

  • any other function that is not directly related to the care of the patients on the PCA.

In the first part of Section A, you must estimate the physician hours spent by medicine service physicians for an average weekday. Next, you must estimate time spent by physicians from the Medicine Service on other PCAs in the hospital, usually as a consultant. You may assume that the Medicine Service receives adequate consultative support from all other services at this VAMC.

You may assume that the level of nursing staff and support staff is adequate for this VAMC.

Appendix 1 [not included here] provides you with a list of the top DRGs and frequency of their occurrence for each individual PCA at this hospital, so that you may get a sense of the facility's case mix.

In Section B, you will assess the amount of physician time that is not addressed in Section A, such as non-patient-care-related activities off the PCA, night and weekend coverage, and administrative functions.

PATIENT CARE AREA 1: MEDICINE SERVICE

We are interested in exactly how you used the available information to derive internist requirements for this PCA. Please explain in this workspace any rule of thumb you used or any assumptions that will help us to understand your reasoning. Feel free to illustrate your response with sample calculations showing how you arrived at one or more of your estimates on the previous page.

Patients are primarily cared for by house officer teams (attending staff are consultants and teachers).

All patients are seen daily Monday through Saturday (Sunday for critical ones) by attending staff.

New patients are examined within 24 hours of admission.

New patients require longer examination and more documentation.

1. New patients average 38 minutes

   10 min for care, 6 min for documentation and communication…

2. Old patients average 16 minutes

   7 min for care, 5 min for documentation and communication, 4 min for teaching

All procedures are performed or staffed by the attending physician (all require the presence of the attending staff).

Consults are seen by residents and staffed by attendings:

1. 30 minutes on the PCA

   20 min for care, 10 min for teaching

2. 30 minutes off the PCA

   teaching and didactic activity

PATIENT CARE AREA 2: SURGERY SERVICE

PATIENT CARE AREA 3: NEUROLOGY SERVICE

PATIENT CARE AREA 4: PSYCHIATRY SERVICE

PATIENT CARE AREA 5: REHABILITATION MEDICINE SERVICE

PATIENT CARE AREA 6: SPINAL CORD INJURY SERVICE

PATIENT CARE AREA 7: LONG-TERM CARE SERVICE

PATIENT CARE AREA 8: AMBULATORY CARE PROGRAM

The purpose of the SADI is to gather the data needed to construct, test, formalize, and enhance the algorithms and rules of thumb for staffing that emerged from prior meetings of each specialty and clinical program panel. The ultimate intention is to develop algorithms that could be applied to estimate staffing requirements at VA medical centers (VAMCs), presumably duplicating the results that specialty panelists themselves would have derived.

Section A of the SADI requests time estimates in some cases by workload unit. In other cases, it requests time estimates by major job elements (tasks). These elements had previously been indicated by some panel members as accounting for the bulk of the work of VA internists. For the latter cases, we seek your estimates of how physician requirements vary with respect to such variables as the volume of patients and the availability of residents and nonphysician practitioners. By systematically varying the levels of workload and nonphysician personnel, we hope to infer from your numerical responses the implicit formulas you used to relate physician time to these variables as well as the nature of the relationship between workload and staffing, e.g., linear or nonlinear.

Section B requests your response to a series of questions for the time spent in activities other than direct patient care.

Instructions: Section A: For each cell of each table, please estimate the number of physician hours required from the Medicine Service to deliver good-quality care under the specified circumstances. Section B is self-explanatory.

ADMISSIONS

Please fill in the average time in hours required by a staff physician in your service to accomplish an admission work-up, either with or without a resident in your service.

ROUTINE DAILY PATIENT CARE

For each workload factor and alternative average daily census (ADC) level below, please fill in the average number of physician hours required from the Medicine Service. Keep in mind that the daily rounds do not include new admission work-ups, since they are covered in Chart 1.

Assume No Residents

For ADC of 15 or less, assume one PGY 1 resident and one PGY 2 or 3 resident. For ADC greater than 15, assume two PGY 1 residents and two PGY 2 or 3 residents.

Assume One PGY 1 and One PGY 2 or 3 Resident per ICU/CCU

TIME PER INITIAL CONSULTATION OFF YOUR PCA

Fill in the average time in hours required by a staff physician in your service for each initial (new) consult on another service, noting the presence or absence of a resident in your own service. (When the resident is present, assume that he/she is performing the consult under the supervision of an attending physician.)

TIME PER FOLLOW-UP CONSULTATION OFF YOUR PCA

Fill in the average time in hours required by a staff physician in your service for each follow-up consultation visit on another service, noting the presence or absence of a resident from your service.

SPECIAL PROCEDURES

Please fill in the average time in hours required by a staff physician in your service for each of the special procedures listed on the left, noting the presence or absence of a resident.

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.

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.

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?