PSYCHIATRY PANEL REPORT1

INTRODUCTION

This panel was established in early 1990 to assist the IOM study committee in developing a VA physician requirements methodology that successfully incorporated the specialty of psychiatry. The panel, consisting of seven psychiatrists, met twice during 1990 and participated in other efforts to advise the study committee on appropriate physician staffing for this specialty. The panel was led by a chairman and a co-chairman; the chairman of the panel was a member of the study committee; the panel roster is attached. Additional details describing the analysis process followed by this and the other seven specialty and clinical program panels are found in the “Overview” to this section of Volume II.

This report summarizes the analyses conducted by the panel and its recommendations to the study committee.

As a prelude to these analyses, the panel wishes to summarize its views about the current state of psychiatry staffing in the VA. The panel believes these perceptions constitute important desiderata for interpreting the panel's subsequent recommendations about physician requirements in psychiatry.

Concerns Regarding Psychiatry in the VA
  • Utilization of VA psychiatric services: A higher percentage of veterans utilize the VA system for psychiatric problems than for medical or surgical

    1  

    The initial draft of this report was prepared by Judith L.Teich, Staff Officer to the Psychiatry Panel during the conduct of the study. This final report, which retains a substantial amount of the panel commentary incorporated in the initial draft, was prepared by Joseph Lipscomb.



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Physician Staffing for the VA: VOLUME II PSYCHIATRY PANEL REPORT1 INTRODUCTION This panel was established in early 1990 to assist the IOM study committee in developing a VA physician requirements methodology that successfully incorporated the specialty of psychiatry. The panel, consisting of seven psychiatrists, met twice during 1990 and participated in other efforts to advise the study committee on appropriate physician staffing for this specialty. The panel was led by a chairman and a co-chairman; the chairman of the panel was a member of the study committee; the panel roster is attached. Additional details describing the analysis process followed by this and the other seven specialty and clinical program panels are found in the “Overview” to this section of Volume II. This report summarizes the analyses conducted by the panel and its recommendations to the study committee. As a prelude to these analyses, the panel wishes to summarize its views about the current state of psychiatry staffing in the VA. The panel believes these perceptions constitute important desiderata for interpreting the panel's subsequent recommendations about physician requirements in psychiatry. Concerns Regarding Psychiatry in the VA Utilization of VA psychiatric services: A higher percentage of veterans utilize the VA system for psychiatric problems than for medical or surgical 1   The initial draft of this report was prepared by Judith L.Teich, Staff Officer to the Psychiatry Panel during the conduct of the study. This final report, which retains a substantial amount of the panel commentary incorporated in the initial draft, was prepared by Joseph Lipscomb.

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Physician Staffing for the VA: VOLUME II problems, possibly because of limitations of private insurance coverage regarding psychiatric services; further, a higher percentage of psychiatric problems are service-connected. The panel feels that the allocation of resources for psychiatry in the VA does not reflect these facts. Vacancy rates and recruitment/retention of psychiatrists: The National Association of VA Chiefs of Psychiatry conducted a survey of VAMCs in early 1990 which documented an overall vacancy rate of 18 percent for psychiatrists. In unaffiliated VAMCs, the overall vacancy rate was 34 percent. This high vacancy rate exacerbates the shortage of staffing in psychiatry. Differences in staffing levels: There are three- to four-fold differences in the number of patients per psychiatrist in different types of VA facilities; VAMCs with large psychiatry bed sections tend to have fewer psychiatrists and more patients per psychiatric FTEE. In particular, in RAM Group 6 hospitals, VA psychiatrists are frequently responsible for the total care of 25–40 inpatients. At acute tertiary hospitals, a VA psychiatrist may be responsible for 25–26 inpatients (and often the teaching and supervision of residents). Such trends raise concerns, in particular, about the quality and intensity of care available to psychiatric patients in long-term settings. Furthermore, despite placement in “chronic settings,” many of these patients require acute levels of care for days, weeks, or years. Role of VA staff psychiatrist: The role of the VA staff physician in psychiatry is substantially different than that of his or her counterpart on a medical or surgical service. Typically, staff psychiatrists must spend substantial amounts of time on the unit, in direct patient care, and thus have little time available either for the preparation of research proposals or for conducting research. The nature of psychiatrists' day-to-day responsibilities must be taken into consideration in estimates of staffing requirements. Consultation/liaisonpsychiatry: The importance of psychiatric consultation on medical and surgical services needs to be recognized and acknowledged; recent studies indicate that a high percentage of patients on these services have undiagnosed psychiatric problems that contribute to their length of stay and to the possible overutilization of other services. Psychiatric residency training: The number of psychiatric residency positions funded by the VA appears disproportionately low; while 29.9% of the beds in the VA and 31% of the inpatients (average daily census) are in psychiatry, only 9.1 % of the base allocation of VA residency positions are in psychiatry.

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Physician Staffing for the VA: VOLUME II Summary of Discussions at Panel Meetings During the panel's two meetings, the members strongly stated their feeling that the goal of a physician staffing methodology is to develop a picture of optimal staffing, without regard to resource constraints, particularly because psychiatry's historical staffing is markedly below the other services. They felt that staffing requirements for psychiatry should include future as well as present considerations, and should also take into account quality and productivity. Previous or existing staffing patterns in psychiatry should not be used as models for future staffing, since these have often proven inadequate. The erosion of financial resources allocated to psychiatry in the VA over the past decade, coupled with a very high vacancy rate for psychiatrists in the VA system, has contributed to an overall staffing pattern that is not adequate to meet VA requirements. The issue of the differential utilization of psychiatric services in the VA was raised on a number of occasions. A higher percentage of eligible veterans utilize the VA health care system for psychiatric problems than for medical/surgical problems; this may be due to the fact that private insurance coverage limits psychiatric services more than medical services, thus encouraging more veterans with psychiatric problems to turn to the VA for their care. Further, the percentage of veterans whose psychiatric problems are service-connected is higher than the percentage of service-connected problems for other specialties. The panel stresses that the role of the staff physician on an inpatient psychiatric unit is substantially different from that of his or her counterpart on a medical or surgical service. The primary responsibility of a staff physician on a medical unit may be to make rounds once a day, perhaps visiting with each patient for a few minutes, in the presence of other staff. On the psychiatric unit the staff physician allocates a major portion of his or her time to direct clinical care including admission workups and writing orders, progress notes, and discharge summaries. In addition, the staff psychiatrist must also attend daily meetings in which treatment plans and patient progress are discussed (psychiatric rounds), as well as daily “community” meetings and other activities related to the operation of the treatment milieu on the unit. Unlike VA physicians in some other specialties, the staff psychiatrist is typically “on-service” 12 months per year—rather than having, say, a 3–4 month commitment to inpatient care, with the care responsibilities in the remaining months consisting largely of consults and outpatient visits. Since psychiatric patients are generally ambulatory, and since their treatment depends on participation in the unit's daily activities, the

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Physician Staffing for the VA: VOLUME II “milieu” is an important concept in psychiatry that demands a high level of attention on an ongoing basis. In addition to these two concerns—the differential utilization of psychiatric services by veterans with respect to medical and surgical services, and the different role of physicians in psychiatry than on medical and surgical services —the psychiatry panel also points out the heterogeneity among psychiatric problems and diagnoses. They caution against overreliance on the concept of “Weighted Work Units” (WWUs) in producing estimates of physician requirements from the Empirically Based Physician Staffing Models. They point out that medicare and private insurers do not use DRGs for psychiatry, since there is little correlation betwen psychiatric diagnosis and resource utilization, a prerequisite for establishment of any valid DRG. While the VA has developed its own system of DRGs, which do include psychiatric diagnoses, the panel felt there is reason to question their validity, and suggested that some other measure, such as bed days of care, might be a more appropriate workload measure for psychiatry. Still another concern emerging in the panel's meetings is that the VA system encompasses many different types of psychiatric settings, services, and programs, and the information provided in the staffing exercises used at the panel meetings did not adequately reflect this diversity. As a consequence, major outpatient programs such as chemical dependency (methadone maintenance), day treatment, day hospital, posttraumatic stress disorder, geropsychiatry, and dual-diagnosis clinics did not receive specific consideration by the panel. To the extent these programs represent a significant factor in estimating future workload for psychiatrists, the fact that they were not explicitly considered may lead to underestimation. While it is true that some psychiatric outpatient programs may legitimately depend heavily on nonphysician staff as administrators and therapists, this issue nevertheless needs to be addressed if reasonable assumptions regarding psychiatrists' responsibilities in the VA system are to be made. The panel also discussed the importance of psychiatric consultation on other services, and the impact of undiagnosed psychiatric problems in patients presenting with medical complaints. The literature in this area suggests that for some medical symptoms, e.g., chronic back problems, as many as 50 percent of the cases presenting may actually be based on psychiatric problems. In view of the emerging body of literature on psychiatric illness in primary care, there is need to take into account the adequacy of staffing for consulting/liaison psychiatry in the VA. An important theme woven throughout the panel's discussions was physician requirements in “acute” facilities versus “chronic” facilities. Discussion in the

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Physician Staffing for the VA: VOLUME II panel meetings, in psychiatry as well as in other specialties, tended to center on highly affiliated tertiary care hospitals with strong research and education components. However, the VA system also encompasses a number of large hospitals (including all RAM Group 6 hospitals) that are primarily psychiatric in nature, or that may have large numbers of intermediate medical beds in addition to their psychiatric units. These “old” intermediate medicine beds are long-term beds (as opposed to the “new intermediate medicine beds,” limited to 90 days) and have a patient population of which 60 percent have either only psychiatric diagnoses or have at least one secondary psychiatric diagnosis. But the units typically have no psychiatrists on staff. Such facilities tend to have longer average lengths of stay than do the affiliated general hospitals; for intermediate medical patients, the apparent assumption is that they need a less intensive (and therefore less physician-intensive) type of care. For this reason, as well as a number of other factors such as the geographic location of many of these facilities, physician staffing at the Group 6 hospitals tends to be substantially lower than staffing at affiliated tertiary facilities. However, it is not valid to assume that psychiatric patients in longer-term facilities, like intermediate medical patients, also need a less intensive level of care. Contrary to the antiquated notion of chronic psychiatric patients being unable to respond to treatment and therefore needing only “custodial” care (e.g., the state hospital “back ward”), newer developments in psychiatry indicate that patient improvement is often related to the intensity of services provided, and that many patients have a strong potential for rehabilitation. Moreover, the nature of the psychiatric patients referred to these “chronic” facilities over the past few years has changed dramatically: the average age of patients in the VA's psychiatric facilities has decreased, and their problems have become more acute. Additionally, patients with problems of a violent nature, who cannot be managed on open units in tertiary care hospitals and who may need a high level of attention, are often transferred to these longer-term Group 6 facilities. Bearing in mind these factors, it cannot then simply be assumed that “chronic” psychiatric patients in the VA system need less treatment (i.e., from psychiatrists) than do “acute” psychiatric patients in the system. Specific analyses of the characteristics of the current VA psychiatric patient population must be conducted to examine assumptions regarding the average age and acuity of the patients, as well as to explore patterns of transfer between facilities, rehospitalization, and outpatient care. Such analyses are beyond the scope of the current study, but future assessment of physician requirements for psychiatry in the VA system should examine these factors.

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Physician Staffing for the VA: VOLUME II Regarding the Group 6 hospitals, in June 1989 the VA Office of Quality Assurance issued a 500-page report entitled, “Review of Mortality in VA Medical Centers.” The report stated that of the 12 hospitals having the highest rates of “excess” mortality, six are psychiatric facilities. The executive summary concludes that quality of care was more likely to be assessed as problematic for patients who died in the acute medical and surgical wards of primarily psychiatric VA medical centers than for patients whose death occurred in primarily medical and surgical facilities. Predominantly psychiatric facilities were also overrepresented among facilities with significantly elevated overall mortality rates. These statements must, of course, be examined with caution, since 1) the study excluded from consideration patients discharged from rehabilitation, psychiatric, substance abuse, halfway house, intermediate medicine, nursing home, respite care, and domiciliary bed sections; and 2) the reasons for this “excess mortality” have not been explored. However, it is certainly possible that inadequate staffing levels contribute to the overall quality of care problems in these RAM Group 6 facilities. Finally, the panel was unanimous in its view that VA psychiatrists should be permitted, and encouraged, to conduct more research than at present. At many VAMCs, psychiatrists have been so pressed to handle patient care demands that little time has been left for research. This is evident both from the meager amounts of physician FTEE allocated to “research” by psychiatrists in the VA's cost distribution report and also from daily observation of the patterns of care on VA psychiatry units. Most of the VA psychiatrist 's workday is devoted to managing a burgeoning case load. Panel members concluded that policies to encourage greater participation by psychiatrists in research would serve to enhance retention rates in the short term, and the quality of psychiatry care over the long term. EXPERT JUDGMENT APPROACHES TO DETERMINING PHYSICIAN REQUIREMENTS IN PSYCHIATRY The DSE Approach Initial Efforts A central purpose of the panel's first meeting, held in April 1990, was to help determine whether the expert judgment approach to staffing being developed by the study committee could be applied validly to psychiatry. The focus of this

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Physician Staffing for the VA: VOLUME II analysis was the initial draft of a physician staffing instrument, which required the expert to assess the time (and hence FTEE) required by psychiatrists to render patient care, work with residents, and perform other tasks at the VA medical center (VAMC). To test this approach, staffing instruments were constructed for three actual VAMCs. Each facility was portrayed as consisting of a set of patient care areas (PCAs), where direct patient care and resident training occur. For each PCA, data were presented on the volume of patient workload expected, the number of residents available, and the overall availability of nursing and support staff. The critical question with respect to each PCA centered on the amount of psychiatrist time required, in total, to meet these VA mission-related demands in the course of a typical workday. Each PCA was analyzed, in turn, and total psychiatrist FTEE for the facility was computed. Additional questions at the end of the instrument elicited FTEE requirements for weekend coverage, special procedures, and non-VA physician consultants. In the course of this first meeting the panel reached several initial conclusions about the assumptions that should underlie the development of subsequent physician staffing instruments: The amount of psychologist and social worker FTEE available in each PCA should be made explicit. These are important care providers; although they do not fully substitute for psychiatrists, they have an impact on the quality of care and should be taken into consideration in estimating physician requirements on psychiatric units and for ambulatory care. For example, psychologists with skills in rehabilitation and behavior modification may affect the number of psychiatrists that would otherwise be required on a unit serving patients with chronic conditions. Neuropsychologists may make critical contributions to the care of patients with mixed neurological and psychiatric conditions. The description “sufficient” for nursing staff may be too ambiguous—the notion of “sufficiency” is very subjective, and individual interpretations of this may vary widely. Educational and research issues should be addressed more specifically; for example, how many medical students might be present on a given unit? What percentage of physician's time should research represent? Differences between specialties with regard to physician staffing should be recognized explicitly. For example, full-time physicians on the psychiatric service in the VA generally spend most of their time on direct clinical care on the unit, while in other specialties “attending” responsibilities may not require physicians to be present on the unit nearly as much.

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Physician Staffing for the VA: VOLUME II It would be useful to develop a profile of a typical hospital that would help to delineate and define how much consultation is given to psychiatry units by other services. Further, it would be useful to have more specific information on particular hospitals regarding the age distribution of their patients, the percentage of their patients who have drug and alcohol problems, who are IV drug users, etc. A number of special outpatient programs in psychiatry need to be given consideration. These include chemical dependency; day treatment; day hospital; rehabilitation; posttraumatic stress disorder programs; psychiatric triage and emergency; geropsychiatry; programs for mixed-diagnosis patients; and medication/maintenance clinics. Staff involved in the provision of such services may include psychiatrists as well as psychologists, social workers, nurses, counselors, occupational therapists, recreational therapists, clerks, and secretarial staff. The acute unit model in psychiatry includes the capacity for seclusion and restraints; this is sometimes referred to as psychiatric intensive care. The special needs of detoxification units must also be taken into account. Changes in recent years regarding the type of patients cared for in VA psychiatric units may also need to be considered. Assumptions regarding psychiatric staffing in the VA have been built upon the image of chronic patients with long lengths of stay. But this has changed dramatically in recent years. Many more patients are now younger, more acute, and stay for shorter periods of time in VA psychiatric units. Since admissions and discharges are recognized to generate a large proportion of physician workload, the impact of shorter lengths of stay and higher turnover on needs for physicians should be assessed. At this first meeting the panel also reviewed and evaluated the initial versions of the empirically based physician staffing model. A special concern, identified early on, was that currently observed psychiatrist FTEE-workload relationships are sufficiently skewed by inadequate staffing that models based on these data would not reflect good-quality care. Following the first round of meetings for all eight specialty and clinical program panels, there was convened (in May 1990) Joint Meeting I, involving the study committee, data and methodology panel, and VA liaison committee. Progress to date on both the expert judgment and empirical model approaches was evaluated. After reviewing the reports submitted by each panel, the study committee recommended that work proceed on developing a more internally consistent and comprehensive instrument for determining physician requirements by expert judgment. A broadly similar approach should be adopted by each

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Physician Staffing for the VA: VOLUME II panel, but the instrument for each specialty or program area should be tailored to its specific characteristics. DSE: Overall Rationale For the psychiatry panel's second meeting, held in August 1990, four additional VAMCs (denoted here and in the committee report as VAMCs I, II, III, and IV) were analyzed using a revised version of the initial staffing instrument. This new instrument—later termed the Detailed Staffing Exercise (DSE) —was developed on the basis of the panel's critique delivered at the first meeting, plus general instructions from the study committee at the conclusion of Joint Meeting I. As before, each DSE was specific to an actual VAMC. This revised instrument described each PCA in greater detail than before, including more specific information on the VA patient population (e.g., admission rate, length of stay, and DRG mix). The ambulatory care clinics at each VAMC were described in much greater detail. In general, the underlying concept behind the DSE is to provide information in sufficient detail about the VAMC that the respondent can assess physician staffing requirements almost as if he/she were reviewing data at the facility. Instructions and Assumptions To illustrate how the DSE works, a completed version of the instrument is presented as Exhibit 1 of the “Overview” to this section of Volume II. Structurally this DSE is nearly identical to the one constructed for psychiatry. As indicated in that Exhibit 1, each DSE has an A and B section. Section A elicits the amount of time, in hours, required to provide quality care for individual PCAs of the VAMC. For each PCA, information is provided on the volume and DRG mix of workload, number of residents by postgraduate year, number of nonphysician practitioners (e.g., nurse practitioners, physician assistants), and general information about the adequacy of nursing and support staff. Section B focuses on physician activities not addressed in Section A, such as night and weekend coverage, non-patient-care-related activities off the PCA, administrative functions, and leaves of absence.

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Physician Staffing for the VA: VOLUME II Nature of Panel Consensus Before the second meeting, panelists were mailed DSEs for VAMCs I and II; these were completed independently and returned prior to the meeting. The staff compiled these results on a spreadsheet showing the high, low, mean, and median responses. At the second panel meeting, these DSEs were discussed thoroughly to determine whether panelists were using similar assumptions and to allow members to discuss the underlying reasoning behind these calculations. Following this, the panelists were asked to reassess physician requirements in psychiatry at VAMCs I and II, again working independently. Then the actual level of psychiatrist staffing at each VAMC, as reported in the facility's cost distribution report (CDR), was displayed for comparison. After discussion comparing the actual and DSE-based staffing, a third exercise was distributed for VAMC III (another actual facility), and the panel worked as a group to estimate staffing requirements. Following the assessment, the actual CDR numbers for VAMC III were displayed for comparison. During the group discussions, the panel was asked to reflect on whether certain “rules of thumb” were used (perhaps implicitly) to help quantify staffing requirements. Finally, a DSE was distributed for VAMC IV, a large psychiatric hospital, and the panel again worked as a group to estimate appropriate psychiatry staffing. The Staffing Algorithm Development Instrument (SADI) Approach SADI: Overall Rationale Following the second round of panel meetings, the study committee initiated a set of “postmeeting” activities to assist the specialty and clinical program panels in arriving at consensus positions regarding the most appropriate methodology for VA physician staffing. These recommendations would be regarded as advisory to the committee. A central feature of these activities was the introduction of the Staffing Algorithm Development Instrument (SADI). The overall purpose of the SADI was to help test, build upon, and ultimately strengthen the rules of thumb for staffing that emerged from the second meetings of all eight panels. It represents an alternative, more compact means to derive physician requirements, by specialty or program, for any given VAMC.

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Physician Staffing for the VA: VOLUME II Instructions and Assumptions Like the DSE, the SADI has two sections, A and B, which focus on patient care and non-patient-care activities, respectively. In Section A, the respondent is asked to estimate the amount of physician time required to complete a number of patient care functions and tasks under varying assumptions about the availability of residents and nonphysician practitioners. In Section B, the respondent must determine the amount of physician time that should be allocated to research, classroom instruction, continuing education, administration, and leaves of absence. To derive physician requirements for a given VAMC, the estimated physician hours for patient care and non-patient-care activities are summed, then converted to FTEE under the assumption that 40 hours per week translates into one FTEE. Presented in Figure 1 of this report is the psychiatry SADI, as revised to distinguish “chronic” from “acute” inpatients; also shown in Figure 1 are the panel's median estimates for physician task times. A detailed, self-contained, illustration of how the SADI can be applied to determine the number of physicians required at a given VAMC is found in Exhibit 3 of the “Overview” to this section of Volume II. This example happens to focus on internist requirements at VAMC I; the application of the SADI to determine psychiatry FTEE at a given facility proceeds in a virtually identical fashion. A careful study of the example reveals the type of facility-specific data needed to implement any SADI. Although the information requirements of the DSE are greater, both of these expert judgment approaches require data (e.g., on frequency of consults across PCAs) not presently collected in the VA system. EMPIRICALLY BASED APPROACHES TO DETERMINING PHYSICIAN STAFFING IN PSYCHIATRY As discussed at length in chapter 4 of Volume I, there are two variants of the EBPSM: the production function (PF) and the inverse production function (IPF). In the course of its two meetings, the panel examined alternative specifications of the PF equations, and in the postmeeting period it evaluated IPF equations.

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Physician Staffing for the VA: VOLUME II Chart 4   For ADC of 10 or less, assume one PGY3 or 4 resident; for ADC greater than 10 and less than or equal to 40, assume two PGY3 or 4 residents; and for ADC greater than 40, assume three PGY3 or 4 residents. Psychiatry Ward Average LOS=25   ADC 1 ADC 10 ADC 20 ADC 30 ADC 40 ADC 50 Daily Patient Care (direct: group and individual treatment) (indirect: staff, community mtgs. High 2.00 5.00 5.00 11.00 17.50 20.00   Low 0.25 1.50 3.00 2.50 5.00 6.00   Mean 0.88 2.70 4.10 6.20 9.90 13.25   Median 0.50 2.00 4.00 5.00 6.50 13.50 Charting, Phone, Paperwork, Unit-Based QA High 1.00 2.00 2.00 4.00 6.00 10.00   Low 0.50 0.25 0.50 1.25 1.50 2.00   Mean 0.33 0.81 1.05 2.09 2.80 4.60   Median 0.25 0.50 1.00 1.50 2.00 3.35 Patient and Family Contacts and Teaching High 1.00 1.00 1.00 2.00 4.00 8.00   Low 0.10 0.10 0.20 0.50 1.00 1.00   Mean 0.39 0.57 0.69 1.10 2.10 3.37   Median 0.25 0.50 0.75 1.00 2.00 2.25 Supervision and Teaching (Residents/Staff) High 1.00 2.00 6.00 10.00 13.00 18.00   Low 0.25 0.50 1.00 1.50 2.00 3.00   Mean 0.85 1.50 3.20 3.70 5.40 7.75   Median 1.00 2.00 3.00 4.00 4.00 5.00   Median 2.00 5.00 8.25 11.25 14.00 25.10

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Physician Staffing for the VA: VOLUME II Chart 5   Assume No Residents Substance Abuse Unit Average LOS=25   ADC 1 ADC 5 ADC 10 ADC 15 ADC 20 ADC 25 Daily Patient Care (direct: group and individual tx) (indirect: staff, community mtgs.) High 2.00 10.00 20.00 30.00 40.0 50.00   Low 0.50 2.00 4.00 4.50 5.0 7.50   Mean 1.22 4.25 8.30 12.00 15.25 19.37   Median 1.20 2.50 4.75 6.75 8.0 10.00 Charting, Phone, Paperwork, Unit-Based QA High 1.00 5.00 5.00 7.00 10.0 12.00   Low 0.17 0.25 0.50 0.75 1.0 1.20   Mean 0.51 1.65 2.00 2.20 3.8 4.60   Median 0.45 0.70 1.30 1.65 2.25 2.75 Patient and Family Contacts and Teaching High 1.00 3.00 3.00 5.00 7.0 8.00   Low 0.25 0.50 0.50 1.00 1.0 1.40   Mean 0.47 1.15 1.31 2.25 2.6 3.10   Median 0.32 0.55 0.87 1.50 1.22 1.50 Supervision and Teaching (Residents/Staff) High 1.00 2.00 3.00 4.00 5.0 6.00   Low 0.20 0.20 0.20 0.20 0.5 0.50   Mean 0.67 1.05 1.42 1.67 1.87 2.25   Median 0.75 1.00 1.25 1.25 1.0 1.25   Median 2.72 4.75 8.05 10.40 11.35 15.05

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Physician Staffing for the VA: VOLUME II Chart 6   For ADC of 5 or less, assume one PGY3 or 4 resident; for ADC greater than 5, assume two PGY3 or 4 residents. Substance Abuse Unit Average LOS=25   ADC 1 ADC 5 ADC 10 ADC 15 ADC 20 ADC 25 Daily Patient Care (direct: group and individual tx) (indirect: staff, community mtgs.) High 2.00 2.00 3.50 4.00 5.50 8.00   Low 0.15 1.00 2.30 3.50 3.90 5.75   Mean 0.96 1.54 2.95 3.80 4.85 6.40   Median 0.85 1.58 3.00 3.90 5.00 6.00 Charting, Phone, Paperwork, Unit-Based QA High 1.00 1.00 2.00 2.00 2.00 2.00   Low 0.05 0.05 0.10 0.10 0.15 0.40   Mean 0.37 0.46 0.87 0.82 0.95 1.12   Median 0.22 0.40 0.70 0.60 0.82 1.05 Patient and Family Contacts and Teaching High 1.00 1.00 2.00 2.00 2.00 3.00   Low 0.00 0.05 0.05 0.10 0.10 0.40   Mean 0.36 0.46 0.88 0.76 0.82 1.37   Median 0.25 0.40 0.75 0.60 0.60 1.05 Supervision and Teaching (Residents/Staff) High 1.00 2.00 3.00 5.00 7.00 8.00   Low 0.50 0.40 1.00 1.50 1.50 1.50   Mean 0.87 1.35 1.75 2.60 3.37 3.75   Median 1.00 1.50 1.50 2.00 2.50 2.75   Median 2.30 3.80 6.20 6.87 8.92 11.50

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Physician Staffing for the VA: VOLUME II 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 she/he is performing the consult under the supervision of an attending physician.) Chart 7   Time per Consult without Resident Time per Consult with Resident Consultation off your PCA High Low Mean Median High Low Mean Median Neurology 1.75 1.00 1.35 1.25 1.50 0.30 0.73 0.50 Surgical 1.50 0.85 1.12 1.00 1.50 0.30 0.68 0.50 Nursing Home 1.75 1.00 1.35 1.25 1.75 0.30 0.73 0.50 Intermediate Care 1.75 1.00 1.25 1.00 1.50 0.30 0.68 0.50 Rehab Med 1.75 1.00 1.30 1.25 1.50 0.30 0.68 0.50 Medicine 1.35 1.00 1.27 1.25 1.50 0.30 0.73 0.50

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Physician Staffing for the VA: VOLUME II TIME PER FOLLOW-UP VISIT (POST-CONSULTATION) OFF YOUR PCA Please fill in the average time in hours required by a staff physician in your service for each follow-up consultation visit (post-consultation) on another service, noting the presence or absence of a resident from your service. Chart 8   Time per Visit without Resident Time per Visit with Resident Follow-Up Visit (Post-consult) High Low Mean Median High Low Mean Median Neurology 0.50 0.30 0.46 0.50 0.66 0.17 0.39 0.40 Surgical 0.50 0.25 0.41 0.50 0.66 0.15 0.37 0.40 Nursing Home 0.75 0.30 0.51 0.50 1.0 0.17 0.46 0.40 Intermediate Care 0.50 0.30 0.42 0.50 0.66 0.17 0.37 0.30 Rehab Med 0.50 0.30 0.46 0.50 0.66 0.17 0.39 0.40 Medicine 0.50 0.30 0.46 0.50 0.66 0.17 0.39 0.40 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. Chart 9   Time per Test without Resident Time per Test with Resident Special Procedure High Low Mean Median High Low Mean Median ECT Other? (Specify) 1.50 1.00 1.12 1.00 1.50 1.00 1.12 1.00

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Physician Staffing for the VA: VOLUME II OUTPATIENT VISITS 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 clinics, noting the presence or absence of the residents and nonphysician practitioners, and whether the visit is by a new or returning patient. Chart 10   Physician Time per Visit Type of Visit High Low Mean Median New Patient Visit Mental Hygiene No Resident 2.00 1.00 1.60 1.50 New Patient Visit Mental Hygiene With Resident 1.50 0.50 0.80 0.50 New Patient Visit Mental Hygiene With NP or PA 1.50 0.50 0.85 0.75 New Patient Visit Substance Abuse No Resident 2.00 1.00 1.37 1.25 New Patient Visit Substance Abuse With Resident 1.50 0.50 0.87 0.75 New Patient Visit Substance Abuse With NP or PA 1.00 0.50 0.81 0.87

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Physician Staffing for the VA: VOLUME II   Physician Time per Visit Type of Visit High Low Mean Median Return Visit Mental Hygiene 1.00 0.62 0.92 1.00 Return Visit Medicine Check 0.50 0.30 0.44 0.50 Return Visit Substance Abuse 1.00 0.50 0.72 0.70 Group Therapy Session 2.00 1.50 1.62 1.50

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Physician Staffing for the VA: VOLUME II SECTION B: NON-DIRECT PATIENT CARE TIME 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 nondirect patient care work listed below. Chart 11 Assume the amount of research accomplished at this VAMC is:   High1 Medium1 Low1 Education of residents (didactic, classroom, not on the PCA) High 4.00 3.00 2.00   Low 0.10 0.05 0.00   Mean 1.35 0.94 0.61   Median 0.50 0.50 0.40 Administration by Chief (time required to manage your whole service by a Chief and/or Assistant Chief) High 8.00 8.00 8.00   Low 3.00 2.00 1.00   Mean 5.00 4.00 3.75   Median 4.50 3.00 3.50 Administration by Others (time required for individual physicians) High 2.00 1.00 1.00   Low 1.00 0.50 0.50   Mean 1.30 0.90 0.70   Median 1.00 1.00 0.50 Hospital-Related Activities (Mortality and Morbidity, Q.A., Staff Meetings) High 2.00 1.00 0.50   Low 0.15 0.15 0.15   Mean 0.83 0.63 0.43   Median 0.50 0.50 0.50 1Examples of research level by total amount of funding (VA plus non-VA) in FY 1988: High: e.g.; VAMC I with $8.8 million in total funding; Medium: e.g.; VAMC II with $2.75 million in total funding; Low: e.g.; VAMC III with about $176,000 in total funding.

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Physician Staffing for the VA: VOLUME II Assume the amount of research accomplished at this VAMC is:   High1 Medium1 Low1 Total Hours per Average Weekday   For Chief2 High 8.00 8.00 8.00   Low 3.00 2.00 1.00   Median 4.50 3.00 3.00 For Others High 8.00 5.00 3.00   Low 1.30 1.30 1.00   Median 2.10 2.00 1.00 1Examples of research level by total amount of funding (VA plus non-VA) in FY 1988. 2Assume that Chief does not participate significantly in the Education of Resident and Hospital-Related Activities; SADI users may easily 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 CME, research, and any off-time required. 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 12 Assume the amount of research accomplished at this VAMC is:   High1 Medium1 Low1 Continuing Education High 15.00 10.00 10.00   Low 5.00 5.00 3.00   Mean 10.00 6.60 6.00   Median 10.00 5.00 5.00 Research (off the PCA) High 50.00 30.00 10.00   Low 10.00 5.00 0.00   Mean 28.00 15.00 4.40   Median 25.00 15.00 5.50 Vacation, Administrative Leave, Sick Time, Other High 18.00 15.00 12.00   Low 8.00 9.00 8.00   Mean 12.40 10.80 9.80   Median 12.00 10.00 9.00 Total Percentage of Time High 80.00 50.00 28.00   Low 40.00 19.00 14.00   Mean 50.40 33.40 20.20   Median 53.00 35.00 18.00 1Examples of research level by total amount of funding (VA plus non-VA) in FY 1988. High: e.g., VAMC I with $8.8 million in total funding; Medium: e.g., VAMC II with $2.75 million in total funding; Low: e.g., VAMC III with about $176,000 in total funding.

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Physician Staffing for the VA: VOLUME II INSTITUTE OF MEDICINE Committee to Develop Methods Useful to the Department of Veterans Affairs in Estimating Its Physician Requirements PSYCHIATRY PANEL HAROLD M.VISOTSKY (Chair),† Professor and Chairman, Department of Psychiatry and Behavioral Sciences, Northwestern University, and Director, Institute of Psychiatry, Northwestern Memorial Hospital, Chicago, Illinois ROBERT L.LEON (Co-Chair), Professor and Chairman, Department of Psychiatry, University of Texas Health Sciences Center, San Antonio D.ROBERT FOWLER, Chief, Psychiatry Service, Dallas VA Medical Center, Dallas, Texas DAVID J.KNESPER, Director, Division of General Hospital Services, Department of Psychiatry, University of Michigan, Ann Arbor JOHN O.LIPKIN, Chief of Staff, Perry Point VA Medical Center, Perry Point, Maryland JOHN A.TALBOTT, Professor and Chairman, Department of Psychiatry, University of Maryland at Baltimore ROBERT L.WILLIAMS, Professor and Chairman, Department of Psychiatry, Baylor College of Medicine, Houston, Texas Staff: Judith L.Teich, Staff Officer †Member of the study committee.