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

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.

• 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.

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.

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

“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

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.

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.

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

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.

• 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

panel, but the instrument for each specialty or program area should be tailored to its specific characteristics.

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.

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.

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.

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.

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.

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.

The panel focused on equations estimated for the patient care areas of inpatient psychiatry and ambulatory psychiatry, two of 14 PCAs defined by the study committee. (In developing the concept of a PCA, the committee sought to divide the VAMC into a set of mutually exclusive and exhaustive locus-of-care areas to facilitate the calculation of physician requirements.) Although the derivation of total physician FTEE in psychiatry at a VAMC via the PF variant requires the calculation of psychiatrist requirements across all PCAs, this panel (like the others) restricted its critique to those PCAs where the psychiatrist is the “dominant” physician specialty.

The final versions of these two PF models, as developed in conjunction with the study's data and methodology panel, are presented in Table 2.A.

In early fall 1990, following its two meetings, the panel was asked to examine IPF equations, in which total psychiatrist FTEE for direct care and resident education was modeled as a function of workload (by type) and other variables. The final version of the psychiatry IPF is presented in Table 2.B.

In Table 1 are alternative estimates of physician requirements in psychiatry at VAMCs I, II, III, and IV in FY 1989 as derived from: the VA's cost distribution report (CDR), the PF and IPF variants of the EBPSM, the DSE (from the second panel meeting), the SADI (in both its initial and revised forms), and a mail survey of panel members just prior to Joint Meeting II (held September 7–9, 1990).

At the study committee's behest, these four facilities served essentially as “laboratories” for the development of a physician requirements methodology; consequently, the panel urges caution in using the staffing results in Table 1 to make quantitative inferences about the degree of understaffing in psychiatry across the VA system. With this caveat, several general conclusions are suggested in the table; these conclusions follow.

The level of total psychiatrist FTEE derived from either expert judgment approach significantly exceeds the levels from either empirically based model. As indicated in Table 1.A., this is clearly the case for all four facilities. Both the DSE and either variant of the SADI (the distinction will be discussed momentarily) yield FTEE totals that are closer to the panel's overall recommended level—as indexed by the median panel response to the Survey—than either the PF or the IPF.

When the focus shifts to FTEE for direct care and resident education only (Table 1.B.), the expert judgment methods continue to yield substantially higher estimates than either the PF or the IPF for VAMCs III and IV—two unaffiliated facilities. But the gap is much less pronounced now for VAMC II and basically disappears for VAMC I; the latter two facilities are both heavily affiliated.

The panel is not surprised at the overall trends above. Both empirically based models, no matter how carefully conceptualized and estimated, can at best indicate how the current aggregate level of psychiatry FTEE can be more efficiently distributed across VAMCs. These models are not capable of addressing the question of whether psychiatry, as a whole, is understaffed in the VA. (The panel also acknowledges that if these apparent staffing deficiencies were eliminated in aggregate, it might well become appropriate to consider deriving VA physician requirements in psychiatry largely from empirically based models.)

As Table 1 indicates, there were two variants of the Staffing Algorithm Development Instrument, which emerged in the following way. The first variant, simply labeled SADI in the table, sought estimates of the time required by physicians to perform a number of tasks and functions for patients assumed (implicitly) to represent an “average” level of difficulty; differences in case severity were not explicitly recognized. Both the panel and staff noted that application of this SADI resulted in substantially larger FTEE estimates for direct care and resident education FTEE at VAMCs III and IV than did the PF, IPF, and the DSE. As Table 1.B. shows, this trend was not evident for VAMCs I and II.

Thus, it was natural to test the hypothesis that one factor in the higher estimates for VAMCs III and IV was that the physician task times reflected in the (initial) SADI were in fact for acute care patients. Hence, if acute and chronic psychiatric patients were explicitly differentiated in the SADI, and if task times for the latter type of patient were applied to VAMCs III and IV, would these facilities' revised FTEE estimates be less than those based on the initial SADI?

The revised SADI, as reflected in Figure 1, does indeed distinguish between acute and chronic patients. The net impact of this modification on total FTEE and on FTEE allocated only to patient care and resident education is generally in the expected direction, but not quantitatively large. As seen in Table 1.A., total psychiatrist FTEE at both affiliated facilities is higher under SADI Revised; for both unaffiliated facilities, total FTEE is lower under SADI Revised. With the exception of VAMC IV (a psychiatric hospital), these trends continue in Table 1.B.

One inference from these comparisons, supported by the physician time estimates in Figure 1, is that both acute and chronic patients should receive substantial attention from the psychiatrist —if high-quality care is to prevail in the VA.

Following the first meeting, a memo was sent to the members of the psychiatry panel requesting recommendations for specific non-VA psychiatric facilities that could provide an appropriate “yardstick” for staffing. Private facilities suggested by panel members and contacted by staff included:

• New York Hospital, Westchester Division

• Menninger Clinic (Topeka, KS)

• McLean Hospital (Boston, MA)

• Timberlawn Psychiatric Hospital (Dallas, TX)

• Sheppard and Enoch Pratt Hospital (Towson, MD)

• Langley Porter Psychiatric Institute (UCSF, San Francisco)

• University of Texas, San Antonio

• University of Colorado, Denver

• Yale Psychiatric Institute (New Haven, CT)

Although the information provided by these facilities was not always complete, and although the units of analysis (e.g., outpatient visits, outpatients assigned per psychiatrist, beds, and average daily census) were not always comparable, certain patterns nevertheless emerged from these data. As indicated in Table 3, for four private psychiatric hospitals, the average daily census (ADC) per psychiatrist varied only from 4.0 to 6.0. One additional private

hospital, Sheppard and Enoch Pratt, reported an average of 6.3 beds per psychiatrist. These hospitals range in size from 164 to 322 beds; their average length of stay is from 1.5 to 3 months.

Data obtained from inpatient psychiatric units in university hospitals, which had an average of 28 beds and an average length of stay of between 10 and 20 days, is displayed in Table 4. The ADC per psychiatric FTEE on these inpatient units ranged from 6.2 to 12.0. Two of these units had 4 psychiatric residents, the other, 2–3.

In order to obtain staffing information on large, longer-term public psychiatric facilities, staff also contacted the District of Columbia Commission on Mental Health Services (St. Elizabeth's Hospital). In addition, a 1987 report by Abt Associates, “A Study of Casemix, Facilities, and Staffing at the Regional Psychiatric Hospitals,” which examines four state hospitals in Maryland, was used as an indicator of staffing in public psychiatric facilities. Data from these facilities are displayed in Table 5. The number of inpatients (ADC) per psychiatrist FTEE in the Maryland state hospitals ranged from 17.4 to 21.0; at St. Elizabeth's Hospital (which was a federal facility for most of its 130-year history and was transferred to the jurisdiction of the District of Columbia government in 1987), the number of inpatients per psychiatrist FTEE was reported as 8.6 in 1990.

The panel reproduces these data merely to underscore its deep reservations about any effort to derive VA physician staffing standards on the basis of current staffing at public psychiatric facilities. Many state hospitals do not represent a “norm”; on the contrary, they are generally viewed as poorly staffed and providing an inadequate level of care. These Maryland state hospitals, for example, have had difficulty maintaining HCFA certification and JCAHO accreditation, partially due to insufficient staffing.

The Detailed Staffing Exercises (DSEs) completed by panel members in conjunction with the two meetings of the psychiatry panel served to highlight the fact that, in addition to possible differences in staffing patterns between the VA and private sector hospitals, there are important differences among VA facilities with regard to their psychiatry staffing. For example, for the four facilities used in the staffing exercises at the second panel meeting, a simple comparison of

inpatients per psychiatrist FTEE allocated to patient care and resident education in the inpatient psychiatry PCA indicated the following:

These observations prompted staff to conduct additional analyses, using data from the 1989 VA Cost Distribution Report (CDR), to compare the staffing levels for each of the six Resource Allocation Model (RAM) groups. Ratios within each of these groups were calculated for: inpatients per psychiatrist FTEE devoted to direct care and resident education in the inpatient psychiatry PCA; inpatients per inpatient social work FTEE allocated to psychiatry; and inpatients per inpatient nursing FTEE devoted to psychiatry.

The results, displayed in Table 6, indicate that the affiliated hospitals (RAM Groups 1, 3 and 5) have the lowest ratios of inpatients per inpatient psychiatrist

FTEE, while the unaffiliated hospitals (RAM Groups 2, 4, and 6) are staffed much less intensively. In particular, the (19) small, unaffiliated facilities in RAM Group 2 have patient-to-psychiatrist ratios well in excess of the other hospital groups. The most striking result overall, however, is that psychiatry staffing in all RAM groups is substantially thinner than in the private sector facilities reviewed in Tables 3 and 4 and is roughly comparable to staffing found in the Maryland state hospitals (Table 5) —which this panel and others have found to be unacceptable.

While the results just reported, suggesting that VA psychiatry is substantially understaffed, come as no surprise to this panel, several important caveats should be kept in mind when drawing conclusions from such external norm data. First, these numbers and the ratios derived from them might be better regarded as patterns rather than norms; that is, they do not represent explicit standards consciously developed by any organization or agency, but rather reflect existing staffing as it has evolved in a number of facilities around the country.

Second, since there is no universally accepted operational definition of an FTEE, these staffing numbers should not be taken to represent “hard” data, but rather rough approximations of levels of staffing. It is not clear, for example, to what extent psychiatrists in a given facility may have other, outside responsibilities (e.g., the medical director of the Menninger clinic specifically stated that each full-time psychiatrist on staff is assigned 6 patients, is expected to spend 20–30 hours/week seeing those patients, and has approximately 10 hours/week to do psychotherapy with staff members or outside private patients.) Further, while statistics on admissions, beds, outpatient visits, etc., are usually readily available, staffing data rarely seem to exist at any of these facilities in a comprehensive, standardized form. Rather, most of these data were derived from telephone conversations with one or more persons at each facility. For this reason, these data are subject to certain inaccuracies or ambiguities.

Third, while all of the facilities offer some form of outpatient treatment in addition to their inpatient units, there is generally no straightforward way of delineating psychiatrists' responsibilities for inpatient vs. outpatient areas, or of differentiating the psychiatric staffing of outpatient programs. Full-time psychiatrists may have substantial responsibilities for outpatient treatment as well as for inpatients; but numbers obtained regarding outpatients were often vague (sometimes given as number of patients, sometimes given as number of visits),

and their comparability from facility to facility cannot necessarily be assumed. Similarly, while the VA's Cost Distribution Report attempts to capture all of the FTEE allocated to outpatient care by the psychiatry service (Cost Center 203), the FTEE contributions from psychiatrists who may be assigned to other cost centers are not easily derived; this may be a particular problem in those VAMCs, such as VAMC IV, which now have a separate cost center (204) for “Ambulatory Care.”

Finally, most psychiatric facilities (including VAMCs) offer substantial partial hospitalization programs: day hospital and day treatment centers, halfway houses, community support systems. The extent to which psychiatrists are routinely involved in the functioning of these programs was not explored (neither for the VAMCs nor the private sector facilities). Thus, it is difficult to make assumptions regarding the amount of psychiatrist FTEE which may, in fact, be allocated to programs of this type at any given facility. This is an important area deserving much closer scrutiny in future attempts to examine physician requirements for psychiatry.

For determining VA physician requirements in psychiatry, the panel endorses a variant of the Reconciliation Strategy that offers the flexibility to use expert judgment approaches as a corrective to statistical staffing models. Regarding the FTEE components of the Reconciliation Strategy, the panel recommends the following:

For these activities, the VAMC's target level of FTEE should be determined through an expert judgment process, not by one of the proposed empirically based models. Although the panel admires the rigor of the statistical models, at best they can indicate only how the current aggregate level of psychiatry FTEE can be better distributed across VAMCs. It appears unlikely that these models, alone, can address an issue the panel feels is paramount: The VA, as a whole, is now understaffed in psychiatry. (The panel acknowledges that if these staffing deficiencies are reduced, then eliminated, it may well become appropriate to consider deriving psychiatry staffing requirements largely from empirically based models.)

Given projected workload and other factors, what is the appropriate target level of psychiatry FTEE required for patient care, resident education, and administration? To address this question, the panel recommends a form of the Reconciliation Strategy in which the expert judgment component is built around the SADI. Although the DSE is an excellent vehicle for examining staffing at an individual VAMC in depth, to apply this instrument across the system would be very labor intensive—possibly requiring a “permanent” expert panel to interpret and update the data. The SADI methodology, on the other hand, could be applied comparatively rapidly to compute psychiatry staffing levels for all VAMCs.

The current SADI instrument, although promising, is an experimental construct. The VA should apply it across the system, revise it on the basis of what is learned, and then periodically reevaluate and update it. This would require some form of expert panel, but the overall manpower commitment would be less than for a DSE-based approach.

When the panel applied the SADI (and also the DSE) at four selected VAMCs, all were found to be understaffed. One facility (VAMC III) was seriously short of psychiatrists by any standard.

Reflecting on these results, the panel feels that it is not feasible to immediately achieve the several-fold increase in psychiatry staffing that is derived from this initial version of the SADI for facilities such as VAMC III. Rather, the panel endorses a variant of the Reconciliation Strategy in which psychiatrist FTEE at a VAMC is incremented initially by some appropriately chosen fraction of the total difference between the SADI-derived level and the current level.

To arrive at these psychiatry staffing targets, the panel experimented successfully with, and recommends to the VA, a weighted-average version of the Reconciliation Strategy. The IPF and the SADI served as the core approaches for establishing the FTEE boundaries of staffing targets for patient care, resident education, and administration. In the current terminology of the Reconciliation Strategy, a value of 0.35 for the weighting parameter b (see Equation 6.1 in chapter 6 of Volume I) seemed reasonable to the panel—given the four VAMCs evaluated.

The panel emphasizes that had a different group of facilities been analyzed, the ratio might have been different. Indeed there is a strong case that the parameter b should be determined on a facility-specific basis, in response to relevant information about current staffing at the VAMC and other factors.

The panel urges the VA to refine the SADI further, then perform these calculations across the board to derive psychiatry staffing targets for all VAMCs in the system. The most seriously understaffed facilities should have top priority

in acquiring the resources necessary to boost staffing up to computed target levels, and the implications for patient care should be evaluated over time. Average length of stay, treatment outcomes, rates of rehospitalization, and other indicators of the quality and effectiveness of care should be monitored at these selected facilities.

If these indicators improve significantly over time, subsequent iterations of the Reconciliation Strategy should indicate, in response, that additional psychiatrists are appropriate. Thus, what the panel anticipates, if the Reconciliation Strategy is implemented properly, is a type of “transition” or “phasing in” policy, in which psychiatrist FTEE are initially incremented at a number of VAMCs, then further increased over time as the supporting data emerge.

It is important that the initially derived staffing targets be sufficiently different from the status quo FTEE levels that the anticipated resulting changes in the quality and effectiveness of care are observable and measurable.

The panel has serious concerns about adopting an empirically based approach for determining research FTEE in psychiatry in the absence of accompanying policies that recognize an important equity point. Psychiatrists at many VAMCs have been so pressed to handle patient care demands that little time has been left for research. Current FTEE allocations to research in the CDR are smaller than would be the case in a less strained system. To compensate for this inequity, the VA should consider providing “seed money” to stimulate research activities by VA physicians in specialties, such as psychiatry, where the opportunity to launch promising projects has been limited. The panel feels that research improves physician recruitment and retention, and the quality of care. It recommends that the amount of FTEE allocated to research be a conscious VA policy decision not tied to the status quo. This allocation should be determined on the basis of scholarly promise, but should reflect a genuine commitment to equal opportunity.

Allocations for research derived from existing data will only perpetuate existing inequities in psychiatric research.

Physician FTEE for continuing education should be based on what the individual VAMC has deemed to be an appropriate level. The most straightforward indicator of this is the amount of FTEE allocated to continuing education on the facility's CDR in the previous fiscal year.

The percentage of total FTEE earmarked for vacation, sick leave, administrative leave, and other authorized absences should be based on existing VA policies.

There is a need for continuous backup coverage (on-call coverage for nights and weekends) by staff psychiatrists. The extent to which the backup coverage amounts to actual hours put in on the wards will be a function of several factors including the allocation of resident staffing, case mix, and case acuity. The panel therefore supports a policy calling for additional (purchased) psychiatrist FTEE for nights and weekends. This additional staffing cannot be calculated globally through a formula, but must be determined on a facility-by-facility basis.

Assuming the VAMC is adequately staffed with VA physicians, there is no need for C&A and WOC FTEE to meet basic patient care demands. But these non-VA physicians can enhance the overall quality of care at the VAMC and play a valuable role in resident education and continuing education for the staff.

Efforts to uncover non-VA staffing criteria, or norms, that could be used to evaluate psychiatry staffing in the VA proved to be problematic.

Workload-to-psychiatrist FTEE ratios were computed from data derived from a variety of non-VA sources, including private psychiatric facilities, university hospitals, and public treatment facilities. In the end, the panel concluded that it is simply inappropriate, and potentially misleading, to apply simple ratios of this type to infer appropriate staffing at VAMCs. There are both methodological and philosophical problems with such comparisons.

Methodologically, there were two major difficulties in comparing staffing ratios across facilities. First, there was no control, or adjustment, for possible differences in patient severity; thus, a patient day or a patient visit was assumed to be a relatively homogenous workload index. In fact, this may not be the case. Second, it was not possible to apply a standard definition of a psychiatrist FTEE, nor could the panel accurately split out a non-VA facility's FTEE into inpatient and outpatient components. (One can attempt to do this for VA psychiatrists via the CDR.) The net result is that the denominator in the staffing ratios could not be defined and computed uniformly.

Philosophically, a major caveat is that most of these non-VA ratios emerged not through some formal decision on optimal staffing, but rather as behavioral responses to patient demands in light of various incentives and constraints. For private psychiatric hospitals, in particular, there is a question about what factors influence physician staffing levels. In some, a concern for profits and the accompanying desire to control cost likely influence the observed ratios at these facilities. In others, many participating psychiatrists are community based and their FTEE are not well recorded (or counted at all) in the facility's personnel system; consequently, workload-to-psychiatrist ratios computed at such sites would tend to be inflated.

Future efforts to develop external staffing norms should focus largely on university hospitals and other selected facilities with a demonstrated concern for the quality of care. The analyses should be performed in detail, so that adjustments can be made for important differences between the non-VA sites and the VAMCs to which the norms would be applied.

For the four VAMCs studied in depth, psychiatry staffing was not adequate in FY 1989. In all four, the current FTEE level was significantly below the FTEE level derived using the SADI. At least two of the four (VAMCs III and IV) are severely understaffed.

The panel believes that the findings emerging from this small-sample study fairly reflect the state of psychiatry staffing in the VA, but it would be premature to draw conclusions about the overall extent of understaffing in each of the facilities across the system. If a version of the SADI (after further testing and development) were applied via the proposed Reconciliation Strategy to a broader sample of VAMCs, the overall situation could be assessed more precisely.

In determining physician staffing in psychiatry, the panel recommends a variant of the Reconciliation Strategy in which FTEE targets are formally established and evaluated, as indicated above.

A summary of alternative estimates of psychiatrist requirements for four actual VAMCs is provided in Table 1.

FIGURE 1 The Staffing Algorithm Development Instrument (SADI) for Psychiatry: The Complete Instrument with Statistical Summary of the Panel's Assessments.

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 which could be applied by the project staff to estimate staffing requirements at VA medical centers (VAMCs), presumably duplicating the results specialty panelists themselves would have derived.

Your responses to the SADI will allow us not only to develop these algorithms but also to compare the relative efficacy of estimating physician requirements by disaggregated job activity versus estimating them more globally, e.g., by ward or Patient Care Area, as used in the original Detailed Staffing Exercises.

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 in your specialty 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 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 seeks your responses to a series of questions designed to allow us to explicitly account for the time spent in non-patient-care activities.

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

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 the assistance of a resident in your service.

PREADMISSIONS

Please fill in the average time in hours required by a staff physician in your service to accomplish a preadmission assessment, either with or without the assistance of 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 Psychiatry Service. Keep in mind that the Daily Rounds do not include admission work-ups, since they are covered in Charts 1 and 2.

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.)

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.

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.

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.

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.

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?

Committee to Develop Methods Useful to the Department of Veterans Affairs in Estimating Its Physician Requirements

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