REHABILITATION MEDICINE PANEL REPORT1

INTRODUCTION

To assist the study committee in incorporating informed professional judgments in the development of a methodology for VA physician staffing in rehabilitation medicine, this panel was constituted during the early months of 1990. Comprised of five physiatrists and one orthopedic surgeon, the panel met twice during the year and participated in other efforts to advise the study committee on appropriate staffing for rehabilitation medicine. The chairman of the panel was also a member of the study committee. The panel roster is attached.

The panel's principal focus was on physiatrist requirements for the rehabilitation medicine service (RMS) at the VAMC. But it was also asked to recommend a methodology for calculating physician requirements for the spinal cord injury (SCI) service, a special program (currently available at 21 VAMCs) in which the physiatrist has traditionally played a major role. A detailed description of the process of analyses followed by this and the other seven specialty and clinical program panels is presented in the “Overview” to this section of Volume II.

The analyses arising from the panel's deliberations, along with its recommendations and conclusions, are described in this report.

1  

The initial draft of this report was prepared by Nancy Kader, Staff Officer to the Rehabilitation Medicine Panel during the conduct of the study. This final report was prepared by the editors of this Volume.



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Physician Staffing for the VA: VOLUME II REHABILITATION MEDICINE PANEL REPORT1 INTRODUCTION To assist the study committee in incorporating informed professional judgments in the development of a methodology for VA physician staffing in rehabilitation medicine, this panel was constituted during the early months of 1990. Comprised of five physiatrists and one orthopedic surgeon, the panel met twice during the year and participated in other efforts to advise the study committee on appropriate staffing for rehabilitation medicine. The chairman of the panel was also a member of the study committee. The panel roster is attached. The panel's principal focus was on physiatrist requirements for the rehabilitation medicine service (RMS) at the VAMC. But it was also asked to recommend a methodology for calculating physician requirements for the spinal cord injury (SCI) service, a special program (currently available at 21 VAMCs) in which the physiatrist has traditionally played a major role. A detailed description of the process of analyses followed by this and the other seven specialty and clinical program panels is presented in the “Overview” to this section of Volume II. The analyses arising from the panel's deliberations, along with its recommendations and conclusions, are described in this report. 1   The initial draft of this report was prepared by Nancy Kader, Staff Officer to the Rehabilitation Medicine Panel during the conduct of the study. This final report was prepared by the editors of this Volume.

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Physician Staffing for the VA: VOLUME II EXPERT JUDGMENT APPROACHES TO DETERMINING PHYSICIAN REQUIREMENTS IN REHABILITATION MEDICINE The Detailed Staffing Exercise (DSE) Approach Initial Efforts The first meeting of the rehabilitation medicine panel was conducted in the spring of 1990. The primary purpose was to examine whether the expert judgment panel process, as the study committee first envisioned it, could be applied to rehabilitation medicine. 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 physiatrists to render patient care, work with residents, and perform other tasks at the VA medical center. 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 was, how much physiatrist time is 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 physiatrist 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 would undergird the development of subsequent physician staffing instruments: The education of staff and residents is carried out mostly in the clinical setting and occurs as part of daily rounds. However, education time is not always documented properly in the VA's cost distribution report (CDR) for RMS. It is often allocated under the cost center for medicine. Insufficient numbers of rehab professionals (including nurses) reduce the efficiency of the physiatrist and may also compromise the quality of care, but probably will not alter physician FTEE requirements. Full-time physiatrists in the VA typically work substantially more than 40 hours a week. However, the 40-hour work week will be be used in estimating requirements in order to be consistent across panels.

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Physician Staffing for the VA: VOLUME II The amount of research varies by the individual physician and sometimes is obscured by university exchanges. Research per physician is unrelated to the direct patient care requirements. Vacation, leave, and sick time are not currently considered in physician requirements, and could be derived (for example) via a “multiplier ” determined by VA regulations and then applied to the direct care requirements. Considerable discussion centered on night and weekend coverage. Panelists generally agreed that although it is sometimes provided by “house officers” whose time may or may not be purchased specifically by the RMS, it is usually provided by resident/attending teams on a rotational schedule as part of their regular jobs. Therefore, no extra staff physician FTEE would be allocated specifically for these off-hours. The number of patients currently receiving rehabilitation medicine care is not an indicator of need, because the shortage of physiatrists results in obstacles and delays in scheduling, thus discouraging patients from seeking treatment. Nonetheless, the panel agreed to continue estimating physician requirements for the actual volume of workload anticipated, in keeping with the overall philosophy of the larger study. 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 whether the VA's CDR properly captured the productive contributions of physiatrists at the VAMCs. 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 empirically based modeling approaches was evaluated. After reviewing the reports submitted by each panel, the study committee recommended that work continue on developing a valid and measurable 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.

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Physician Staffing for the VA: VOLUME II DSE: Overall Rationale For the panel's second meeting, held in June 1990, three additional VAMCs (denoted here and in the committee report (see Volume I) as VAMCs I, II, and III) 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 its 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 depicted 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 now described more comprehensively, as well. In general, the underlying concept behind the DSE is to provide information about the VAMC in sufficient detail 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. This DSE, designed specifically for calculating physician requirements in internal medicine, is nearly identical structurally to the one developed for rehabilitation medicine. 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 high-quality care and train residents in the patient care areas (PCAs) of the hospital. 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, and leaves of absence.

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Physician Staffing for the VA: VOLUME II The Panel Responds 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 the same assumptions and to allow panel members to justify their staffing judgments. Following this, the panelists were asked to reassess physician requirements in medicine at VAMCs I and II, again working independently. Then the actual level of physiatrist staffing at each VAMC, as reported in the CDR, was displayed for comparison. After discussion of actual versus DSE-based staffing, a new exercise depicting another actual facility, VAMC III, was distributed, 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 discussion, the panel was asked to develop a consensus on the actual process used to quantify 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. (Obviously, if this 40-hour-per-week equivalency assumption is replaced by one reflecting the average workweek of VA staff physicians, the SADI-derived FTEE estimates would change accordingly; this is true also for the DSE estimates.) Presented in Exhibit 1 of this report is the rehabilitation medicine SADI, complete with 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 Ehxibit 3 of the “Overview” to this section of Volume II. This example happens to focus on internist requirements at VAMC I; the application of SADI to determining physiatrist 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 its two meetings, a subsequent conference call, and follow-up communications with the study staff, the panel evaluated alternative specifications of the empirically based physician staffing models (EBPSM) that pertained expressly to rehabilitation medicine and spinal cord injury. The former encompass all physicians assigned to the rehabilitation medicine cost center (242) in the VA's cost distribution report. The latter pertain to all physicians, both physiatrist and other specialists, assigned to the spinal cord

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Physician Staffing for the VA: VOLUME II injury cost center (233) in the CDR. As noted in chapter 4 of the study committee's report (Volume I), there are two variants of the EBPSM: the production function (PF) and inverse production function (IPF). Production Functions Among the 14 VAMC patient care areas (PCAs) defined for analysis in this study, three were of particular concern to the panel: inpatient rehabilitation medicine, ambulatory rehabilitation medicine, and spinal cord injury. For these three PCAs, the final PF models, as developed in conjunction with the study's data and methodology panel, are presented in Table 2.A. Inverse Production Function Separate IPF models for RMS and SCI were estimated in the fall of 1990; the final versions of these models are shown in Table 2.B. EBPSM Assessment Neither the PF nor IPF variant of the EBPSM is acceptable for determining physiatrist requirements at present because the VA data used in their estimation is flawed in at least two significant respects. First, these data (of necessity) reflect current physiatrist staffing in relation to workload and these staffing ratios simply are not adequate, the panel feels, at a number of VAMCs. Second, in more than half of all VAMCs, there is no rehabilitation medicine service; when this occurs, the existing physiatrist FTEE is likely attributed to the medicine service, leading to biased observations for both the RMS_MD and MED_MD variables. PHYSICIAN STAFFING RESULTS FROM APPLICATION OF EMPIRICALLY BASED AND EXPERT JUDGMENT APPROACHES In Table 1 are alternative estimates of physiatrist requirements for the rehabilitation medicine service at VAMCs I, II, and III in FY 1989 as derived

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Physician Staffing for the VA: VOLUME II 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 “pure” and modified application formats), and a mail survey of panel members conducted just prior to Joint Meeting II (held September 7–9, 1990). The estimates in Table 1 do reflect consultations by physiatrists in the rehabilitation medicine service to the spinal cord injury unit; however, they do not include physiatrists who are assigned to the SCI unit (and its cost center) as primary providers of patient care there. For both affiliated facilities (VAMCs I and II), the existing physiatrist FTEE, as recorded in the CDR, is below that prescribed by every approach except the PF. This conclusion applies to total FTEE (Table 1.A) and to FTEE for direct care and resident education only (Table 1.B). For these two VAMCs, both expert judgment approaches yield recommendations for total physiatrist FTEE that substantially exceed those from either empirically based approach, with the DSE leading to the largest estimates. For direct care and resident education only, the DSE estimates are still the largest, but now there is little difference between the IPF and SADI numbers. For VAMC III, a somewhat different pattern emerges: the DSE estimates exceed the empirically based, while the SADI estimates are below both the PF and IPF figures; this result holds for both total physiatrist FTEE and that part allocated to direct care and resident education. Although physician staffing requirements for the spinal cord injury service were not analyzed as intensively as for RMS, the PF and IPF models for SCI reported in Table 2 can be applied to calculate physician requirements for VA facilities that have such a service. The panel notes that both Rehabilitation Medicine's and SCI's requirements are interdependent (e.g., physiatrists covering SCI as staff physicians). Among the three facilities above, both VAMCs I and II have an SCI service. The calculations reported below pertain to direct care and resident education only, the FTEE components that are the principal focus of chapter 4 of the study committee report (Volume I), where these results are presented in their proper context. For VAMC I (where physiatrists perform primary patient care on the SCI unit), the CDR-recorded level of physician FTEE for direct care and resident education assigned to the SCI cost center, namely SCI_MD, was 2.52 in FY 1989. The PF model projects that 2.27 FTEE would be required, while the IPF model yields a prediction of 1.99. For VAMC II (where physiatrists act as consultants only), the CDR reports 0.76 FTEE; the PF projects 0.65; and the IPF predicts 1.61.

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Physician Staffing for the VA: VOLUME II EXTERNAL NORMS Data on physician staffing in rehabilitation medicine were collected from external (to the VA) health care organizations in order to determine whether methodologies or productivity performance norms that may exist elsewhere in the public and private sectors could be applied validly to RMS staffing in the VA. Initially, study staff also obtained some “internal” VA guidelines on physician staffing in RMS. These guidelines, published in 1965, related RMS physician requirements to the total number of beds at the VAMC, regardless of specific services available. Although the recommended number of physical therapists and other support staff increased with bed size, the RMS physician staffing recommendation was fairly constant—at 1.0 FTEE per hospital until the size exceeded 600 beds. A hospital had to be large (601–750 beds) to be entitled to 2.0 FTEE, and very large (751–1000) to rate 3.0. Regarding external norms, the Department of Defense (DoD) provided perhaps the most useful specific criteria since it utilizes full-time physician equivalents much like the VA; however, its patient population is generally younger and includes a higher percentage of women and children. DoD defines physician performance levels by the number of outpatient and inpatient visits; the standard varies from 120 to 160 visits per month depending on the availability of teaching staff. A different criterion applies if there are a significant number of residents, since it is assumed that residents need supervision regardless of workload. The Indian Health Service (IHS) provided some staffing criteria for other services, but did not quantify physician requirements for RMS. A large national health maintenance organization could provide medical and surgical but not workload data for rehabilitation medicine; hence, workload norms could not be derived for RMS. At the request of the study staff, panel members suggested private, freestanding, rehabilitation and physical medicine facilities that were judged to offer quality care and presumably were reasonably well staffed with physicians. These facilities were the Rehabilitation Institute of Chicago; Craig Rehabilitation Center, Denver; and a hospital in Braintree, MA. Physiatrists are hired in FTEE at these facilities, and each was able to provide its annual rehabilitation medicine workload expressed in admissions, discharges, or outpatient visits. Similar information was obtained from two well-known rehabilitation programs, Bellevue and Beth Israel hospitals, which are part of comprehensive medical-surgical medical centers in New York City. Although these hospitals

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Physician Staffing for the VA: VOLUME II are affiliated with major universities, they were still able to provide physician staffing in terms of FTEE, making it possible to infer a staffing pattern that can be applied (roughly) to VA facilities. Finally, staffing information was extracted from an article published in the Archives of Physical Medicine and Rehabilitation.2 The authors published the results of a nationwide survey of physiatrists in which information was collected about a typical work week for both office-based and hospital-based physiatrists. The number of patient visits (both inpatient and outpatient, new patients and follow-up patients) are provided in this article, thus allowing the calculation of a staffing norm that can then be applied to derive the implied FTEE level for any VAMC. Summarized in Table 3 are the results from applying these norms to calculate the implied levels of physiatrist FTEE at VAMCs I, II, and III. The logic behind these calculations is presented and illustrated in the Overview to this section of Volume II. CONCLUSIONS As a framework for determining VA physician requirements in both rehabilitation medicine and spinal cord injury (SCI), the panel endorses a variant of the study committee's Reconciliation Strategy (the “disaggregated weighted-average” approach). With respect to the FTEE components of the strategy, the panel recommends the following: Patient Care, Resident Education, and Administration For these activities, FTEE should be derived from the expert judgment model rather than the EBPSM. Both the SADI and the DSE represent acceptable expert judgment models, but the SADI is preferred because it will be easier and more efficient to apply across the system. Although application of the rehabilitation medicine SADI to VAMCs I, II, and III resulted generally in 2   Volume 69, January 1988. This article, entitled “Physiatric Practice Characteristics: Report of a Membership Survey, ” was written by Erwin G.Gonzalez, MD, from Columbia University; Joseph C.Honet, MD, from Sinai Hospital of Detroit, Michigan; and Myron M.LaBan, MD, from William Beaumont Hospital, Royal Oak, Michigan.

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Physician Staffing for the VA: VOLUME II reasonable physician FTEE estimates, its acceptability and reasonableness should be assessed on a systemwide basis soon, and reevaluated periodically. Neither the PF nor the IPF variant of the EBPSM is fully acceptable because the VA data used in their estimation have potential errors in two major areas. First, these data (of necessity) reflect current input-output relationships, which are skewed because rehabilitation medicine is seriously understaffed in many VAMCs; thus these data reflect the status quo, clearly an inappropriate basis for estimating appropriate physician staffing for high-quality rehabilitation medicine and SCI patient care. Second, in over half of all VAMCs there is no inpatient rehabilitation medicine service (RMS), though one or more physiatrists at such a facility could consult on other services. In these cases, there is a likelihood that the existing RMS FTEE will be attributed, in all or in part, to the medicine service. If this occurs, both the RMS_MD and the MED_MD variables in the PF and the IPF models will reflect measurement error. The panel believes that this could result in a substantial underestimation of physician requirements in rehabilitation medicine. Research An empirically based, rather than expert-judgment-based, approach should be adopted for determining FTEE allowances for research. One method is to assign each RMS and SCI service (or consultant service) the research FTEE allocated on the facility's CDR in the previous fiscal year. Another approach is to base research FTEE on indicators of research productivity, such as the amount of grant funding. The panel prefers the latter approach. Continuing Education Physician FTEE for continuing education should be based on the individual VAMC's recommended level; this can be easily determined as the amount of FTEE allocated to continuing education on the previous fiscal year's CDR.

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Physician Staffing for the VA: VOLUME II SECTION A: PATIENT CARE ACTIVITIES 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. Chart 1 Time per Admission Work-Up without Resident Time per Admission Work-Up with Resident High Low Mean Median High Low Mean Median 2.00 1.00 1.42 1.42 1.33 0.25 0.72 0.67

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Physician Staffing for the VA: VOLUME II 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 rehabilitation medicine service. Keep in mind that the Daily Rounds do not include new admission work-ups, since they are covered in Chart 1. Chart 2 Assume No Residents Rehabilitation Ward Average LOS=7   ADC 1 ADC 5 ADC 10 ADC 15 ADC 20 ADC 25 Daily Rounds High 0.33 1.42 2.50 3.00 5.00 6.00   Low 0.08 0.50 0.75 1.00 1.50 1.50   Mean 0.22 0.82 1.33 1.75 2.47 3.08   Median 0.25 0.67 0.83 1.25 1.67 3.00 Charting, Phone, and Paperwork High 0.25 2.00 2.50 3.50 5.00 6.00   Low 0.17 0.42 0.50 1.00 1.00 1.50   Mean 0.23 1.00 1.50 2.33 3.05 3.83   Median 0.25 1.00 1.67 2.50 3.50 4.50 Patient and Family Contacts plus Teaching High 0.25 1.00 2.00 3.00 4.00 5.00   Low 0.08 0.25 0.50 0.75 1.00 1.25   Mean 0.20 0.67 1.25 1.80 2.33 2.92   Median 0.25 0.50 1.00 1.25 1.50 1.75 Supervision and Teaching (Residents/Staff) High 1.00 1.00 1.00 1.00 1.00 1.50   Low 0.00 0.50 0.50 0.50 1.00 1.00   Mean 0.48 0.70 0.78 0.75 1.08 1.08   Median 0.25 0.50 0.67 1.00 1.00 1.00 Overall Mean Time 1.12 3.08 4.48 6.66 8.85 10.90 Overall Median Time 0.83 3.00 4.50 6.25 8.25 9.75

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Physician Staffing for the VA: VOLUME II Chart 3   For ADC of 10 or less, assume one PGY 2 or 3 resident; for ADC greater than 10, assume two PGY 2 or 3 residents. Rehabilitation Ward Average LOS=7   ADC 1 ADC 5 ADC 10 ADC 15 ADC 20 ADC 25 Daily Rounds High 0.33 1.00 1.33 2.50 3.00 4.00   Low 0.08 0.25 1.00 1.25 2.67 2.00   Mean 0.20 0.58 1.07 1.67 2.08 2.67   Median 0.17 0.50 1.00 1.50 2.00 2.50 Charting, Phone, and Paperwork High 0.25 0.50 1.00 1.50 2.00 4.00   Low 0.08 0.25 0.42 0.67 0.83 1.00   Mean 0.15 0.42 0.67 0.97 1.25 1.83   Median 0.17 0.50 0.50 1.00 1.00 1.42 Patient and Family Contacts plus Teaching High 0.25 1.00 2.00 3.00 4.00 5.00   Low 0.08 0.17 0.25 0.25 0.25 0.25   Mean 0.18 0.43 0.67 1.08 1.42 1.75   Median 0.25 0.25 0.33 0.50 0.67 0.83 Supervision and Teaching (Residents/Staff) High 4.00 4.00 4.00 4.00 4.00 4.50   Low 0.17 0.25 0.25 0.50 0.50 0.50   Mean 1.17 1.50 1.75 2.08 2.08 2.50   Median 0.33 1.00 1.00 1.00 1.00 1.00 Overall Mean Time 0.89 2.93 4.22 5.43 6.82 8.43 Overall Median Time 0.83 2.00 2.75 3.75 4.25 5.25

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Physician Staffing for the VA: VOLUME II TIME PER INITIAL CONSULTATION OFF YOUR PCA Please 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 4   Time per Consult without Resident Time per Consult with Resident Consultation off your PCA High Low Mean Median High Low Mean Median Medicine 1.00 0.50 0.70 0.58 1.00 0.25 0.67 0.63 Surgery 1.00 0.50 0.57 0.58 1.00 0.25 0.52 0.58 Nursing Home 1.00 0.25 0.53 0.50 1.00 0.08 0.52 0.50 Intermediate Care 1.00 0.25 0.53 0.50 1.00 0.08 0.52 0.50 Neurology 1.50 0.50 0.87 0.70 1.50 0.25 0.78 0.75 Psychiatry 1.00 0.33 0.63 0.50 1.00 0.25 0.63 0.63

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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 5   Time per Visit without Resident Time per Visit with Resident Follow-Up Visit (Post-consult) High Low Mean Median High Low Mean Median Medicine 0.50 0.17 0.28 0.25 0.50 0.08 0.27 0.25 Surgery 0.50 0.17 0.28 0.25 0.50 0.08 0.23 0.20 Nursing Home 0.50 0.08 0.25 0.25 0.50 0.08 0.23 0.20 Intermediate Care 0.50 0.08 0.25 0.25 0.50 0.08 0.23 0.20 Neurology 0.50 0.17 0.33 0.28 0.50 0.17 0.33 0.28 Psychiatry 0.50 0.17 0.28 0.25 0.50 0.08 0.23 0.20

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Physician Staffing for the VA: VOLUME II 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 6   Time per Test without Resident Time per Test with Resident Special Procedure High Low Mean Median High Low Mean Median EMG 2.00 0.67 1.07 0.92 2.00 0.42 1.17 1.25 Evoked Potential 1.00 0.67 0.95 1.00 1.25 0.33 1.00 1.00 Others (Specify) 1.00 0.67 0.80 0.92 1.00 0.75 0.87 0.92 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 residents and nonphysician practitioners, and whether the visit is by a new or returning patient. Chart 7   Physician Time per Visit Type of Visit High Low Mean Median New Patient Visit No Resident 1.50 0.50 0.87 0.75 New Patient Visit With Resident 1.50 0.33 0.80 0.75

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Physician Staffing for the VA: VOLUME II   Physician Time per Visit Type of Visit High Low Mean Median New Patient Visit With NP or PA 1.50 0.42 0.70 0.58 Follow-Up Visit No Resident 0.50 0.25 0.35 0.33 Follow-Up Visit With Resident 0.50 0.08 0.28 0.25 Follow-Up Visit With NP or PA 0.33 0.08 0.22 0.22

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Physician Staffing for the VA: VOLUME II SECTION B: NON-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 non-patient-care work listed below: Chart 8 Assume the amount of research accomplished at this VAMC is:   High1 Medium1 Low1 Education of Residents (didactic, classroom, not on the PCA) High 2.50 1.50 0.83   Low 1.00 0.50 0.00   Mean 1.57 1.00 0.45   Median 1.50 1.00 0.50 Administration by by Chief (time required to manage whole service by a Chief and/or Assistant Chief) High 8.00 8.00 8.00   Low 1.00 1.00 0.50   Mean 4.00 3.75 3.00   Median 3.50 2.75 2.50 Administration by Others (time required for individual physicians) High 2.00 2.00 2.00   Low 0.25 0.25 0.25   Mean 1.12 0.93 0.77   Median 1.00 0.67 0.58 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 Hospital-Related Activities (mortality and morbidity, Q.A., staff, meetings) High 2.50 1.50 1.00   Low 0.50 0.50 0.25   Mean 1.05 0.77 0.57   Median 0.92 0.50 0.50 Total Hours per Average Weekday:   Overall Median   For Chief2 3.50 2.75 2.50 For Non-Chief Physician 3.38 2.25 1.96 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. 2Assume that Chief does not participate significantly in the Education of Residents 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 9 Assume the amount of research accomplished at this VAMC is:   High1 Medium1 Low1 Continuing Education High 15.0 15.0 15.0   Low 5.0 5.0 2.0   Mean 10.0 8.0 6.0   Median 10.0 8.0 5.0 Research (off the PCA) High 30.0 20.0 10.0   Low 5.0 5.0 0.0   Mean 21.0 14.0 5.0   Median 22.0 15.0 5.0 Vacation, Administrative Leave, Sick Leave, Other High 20.0 16.0 16.0   Low 8.0 8.0 3.0   Mean 14.0 12.0 10.0   Median 14.0 12.0 10.0 Total Percentage of Time:   Median 47.0 39.0 19.0 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 REHABILITATION MEDICINE PANEL ERNEST W.JOHNSON (Chair),† Professor of Physical Medicine and Rehabilitation and Associate Dean for External Affairs, Ohio State University College of Medicine, Columbus PETER C.ALTNER, Chief, Orthopaedic Surgery, and Chief, Rehabilitation Medicine Service, Northport VA Medical Center, Northport, New York ROBERT D.BAER, Associate Clinical Professor of Physical Medicine and Rehabilitation, University of Utah Medical School, Salt Lake City CATHERINE W.BRITELL, Assistant Chief, Spinal Cord Injury Service, Seattle VA Medical Center, Seattle, Washington VALERY LANYI, Medical Director of Rehabilitation Service, Bellevue Hospital, New York, New York NICOLAS E.WALSH, Professor and Chairman, Department of Rehabilitation Medicine, University of Texas Health Sciences Center, San Antonio Study Staff: Nancy Kader, Staff Officer †Member of the study committee.