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

Chapter: Rehabilitation Medicine Panel Report

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Suggested Citation:"Rehabilitation Medicine Panel Report." Institute of Medicine. 1992. Physician Staffing for the VA: Volume II, Supplementary Papers. Washington, DC: The National Academies Press. doi: 10.17226/2076.
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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.

Suggested Citation:"Rehabilitation Medicine Panel Report." Institute of Medicine. 1992. Physician Staffing for the VA: Volume II, Supplementary Papers. Washington, DC: The National Academies Press. doi: 10.17226/2076.
×
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.

Suggested Citation:"Rehabilitation Medicine Panel Report." Institute of Medicine. 1992. Physician Staffing for the VA: Volume II, Supplementary Papers. Washington, DC: The National Academies Press. doi: 10.17226/2076.
×
  • 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.

Suggested Citation:"Rehabilitation Medicine Panel Report." Institute of Medicine. 1992. Physician Staffing for the VA: Volume II, Supplementary Papers. Washington, DC: The National Academies Press. doi: 10.17226/2076.
×
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.

Suggested Citation:"Rehabilitation Medicine Panel Report." Institute of Medicine. 1992. Physician Staffing for the VA: Volume II, Supplementary Papers. Washington, DC: The National Academies Press. doi: 10.17226/2076.
×
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.

Suggested Citation:"Rehabilitation Medicine Panel Report." Institute of Medicine. 1992. Physician Staffing for the VA: Volume II, Supplementary Papers. Washington, DC: The National Academies Press. doi: 10.17226/2076.
×
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

Suggested Citation:"Rehabilitation Medicine Panel Report." Institute of Medicine. 1992. Physician Staffing for the VA: Volume II, Supplementary Papers. Washington, DC: The National Academies Press. doi: 10.17226/2076.
×

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

Suggested Citation:"Rehabilitation Medicine Panel Report." Institute of Medicine. 1992. Physician Staffing for the VA: Volume II, Supplementary Papers. Washington, DC: The National Academies Press. doi: 10.17226/2076.
×

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.

Suggested Citation:"Rehabilitation Medicine Panel Report." Institute of Medicine. 1992. Physician Staffing for the VA: Volume II, Supplementary Papers. Washington, DC: The National Academies Press. doi: 10.17226/2076.
×
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

Suggested Citation:"Rehabilitation Medicine Panel Report." Institute of Medicine. 1992. Physician Staffing for the VA: Volume II, Supplementary Papers. Washington, DC: The National Academies Press. doi: 10.17226/2076.
×

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.

Suggested Citation:"Rehabilitation Medicine Panel Report." Institute of Medicine. 1992. Physician Staffing for the VA: Volume II, Supplementary Papers. Washington, DC: The National Academies Press. doi: 10.17226/2076.
×

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.

Suggested Citation:"Rehabilitation Medicine Panel Report." Institute of Medicine. 1992. Physician Staffing for the VA: Volume II, Supplementary Papers. Washington, DC: The National Academies Press. doi: 10.17226/2076.
×
Leaves of Absence

The percentage of total FTEE earmarked for vacation, sick leave, administrative leave, and other authorized absences should be consistent with the VAMC's policy.

Purchased Coverage for Nights and Weekends

Assuming an adequate availability of residents, none is required.

Consulting & Attending and Without-Compensation Coverage

In rehabilitation medicine, this category is primarily for education purposes.

External Norms

The panel pursued this topic with both enthusiasm and some ambivalence; it now concludes that there is much difficulty in applying non-VA staffing standards to determine the appropriate number of rehabilitation medicine and SCI physicians for the VA. Staffing levels in private, freestanding hospitals are frequently influenced by the profit motive. In affiliated university hospitals, there are technically more complex procedures done with a different group of patients; physiatrist FTEE in these settings are not measured comparably to the comprehensive approach taken by the VA. Furthermore, the education of residents and allied health workers is more intensive at university hospitals, necessitating a more intensive involvement of attending physicians in the training process. Some other organizations examined (e.g., Department of Defense) treat a substantially different patient mix than do VAMCs; hence, their patient populations present different management problems than in most VA facilities.

Overall Adequacy of Physician Staffing in the VA

From Table 1 it is evident that actual rehabilitation medicine staffing in FY 1989 at the three VAMCs examined in detail is below that recommended by any of the approaches to staffing, except the PF model; however, for VAMC III,

Suggested Citation:"Rehabilitation Medicine Panel Report." Institute of Medicine. 1992. Physician Staffing for the VA: Volume II, Supplementary Papers. Washington, DC: The National Academies Press. doi: 10.17226/2076.
×

only the DSE result is significantly greater than current RMS staffing, as reflected in the CDR. Because this is indeed a small sample, it would be premature to present a quantitative assessment of understaffing for the system.

Other Points

Regardless of whether the VA adopts an empirically based or expert-judgment-based approach (or some combination) to physician staffing, there would be much merit in developing models that distinguish sharply between VAMCs with a full RMS program, including a bed service, and those that offer only RMS consultation.

If the VA does adopt an empirically based approach, it is crucial that rehabilitation medicine physician FTEE allocations in the CDR represent more accurately how the physiatrists at a given VAMC spend their time.

Final Remarks

For rehabilitation medicine and SCI physician staffing, the panel endorses the modified version of the Reconciliation Strategy described above. For patient care, resident education, and administration, the centerpiece of the staffing model would be the SADI.

Suggested Citation:"Rehabilitation Medicine Panel Report." Institute of Medicine. 1992. Physician Staffing for the VA: Volume II, Supplementary Papers. Washington, DC: The National Academies Press. doi: 10.17226/2076.
×

TABLE 1 Estimates of Physician Requirements in Rehabilitation Medicine at Three VAMCs

A. Total FTEE

VAMC

CDR

PF

IPF

DSE

SADI

SADI-Modified1

Survey2

VAMC I

3.9

3.9

5.5

9.5

8.7

5.5

8.0

VAMC II

3.0

2.0

4.6

9.9

6.4

5.3

8.0

VAMC III

1.8

2.2

2.0

3.2

1.7

1.6

3.0

B. Direct Care Plus Resident Education FTEE Only

VAMC

CDR

PF

IPF

DSE

SADI

SADI-Modified1

Survey2

VAMC I

1.9

1.9

3.5

6.2

3.2

3.2

N.A.

VAMC II

2.7

1.5

4.1

6.8

3.0

3.0

N.A.

VAMC III

1.7

2.1

1.9

2.5

1.1

1.1

N.A.

1Derived by replacing the SADI-based estimates for non-patient-care activities with estimates based on the DSE; all FTEE for patient care and resident training in the PCAs continue to be derived from the SADI.

2Panel median response to the question, posed by mail survey in September 1990, of what is the overall preferred physician FTEE level at each VAMC. To provide a context for the response, each panel member was presented a summary of the physician FTEE level emerging, alternatively, from the CDR, from both empirically based approaches (as applicable), and from both expert judgment approaches.

Suggested Citation:"Rehabilitation Medicine Panel Report." Institute of Medicine. 1992. Physician Staffing for the VA: Volume II, Supplementary Papers. Washington, DC: The National Academies Press. doi: 10.17226/2076.
×

TABLE 2 Estimated Production Functions and Inverse Production Functions for Rehabilitation Medicine and Spinal Cord Injury

A. Production Functions

Inpatient Rehabilitation Medicine Patient Care Area

with =0.674 and N=79

where

W

=the natural logarithm of total WWUs, plus 1, produced in the inpatient rehabilitation medicine PCA during the fiscal year;

RMS_MD

=VA staff physician FTEE from the rehabilitation medicine service allocated to direct care in the inpatient rehabilitation medicine PCA;

MED_MD

=VA staff physician FTEE from the medicine service allocated to direct care in this PCA;

LAB_MD

=VA staff physician FTEE from laboratory medicine allocated to activities related to direct care in this PCA; and

ln(SUPPORT/MD)

=the natural logarithm of support-staff FTEE per physician FTEE in this PCA (where the denominator of the ratio is defined specifically as the sum of all direct care FTEE recorded for internists, surgeons, psychiatrists, neurologists, and rehabilitation medicine physicians); and

N

=the number of VAMCs in the sample, equivalent to the number showing nonzero physician FTEE allocated to inpatient rehabilitation medicine from the rehabilitation medicine cost center (242).

Suggested Citation:"Rehabilitation Medicine Panel Report." Institute of Medicine. 1992. Physician Staffing for the VA: Volume II, Supplementary Papers. Washington, DC: The National Academies Press. doi: 10.17226/2076.
×

Ambulatory Rehabilitation Medicine Patient Care Area

with =0.583 and N=140

where

W

=the natural logarithm of total CAPWWUs, plus 1, produced in the ambulatory rehabilitation medicine PCA during the fiscal year;

HGROUP3

=a categorical variable assuming a value of 1 if the facility is in RAM Group 3 (midsize affiliated);

HGROUP4

=a categorical variable assuming a value of 1 if the facility is in RAM Group 4 (midsize general unaffiliated);

HGROUP5

=a categorical variable assuming a value of 1 if the facility is in RAM Group 5 (metro affiliated);

HGROUP6

=a categorical variable assuming a value of 1 if the facility is in RAM Group 6 (psych-iatric);

(RMS_MD×HGROUP5)

=interaction term for the joint influence on production of VA staff physicians in rehabilitation medicine and the VAMC's status as a metro affiliated facility; and

N

=the number of VAMCs in the sample, equivalent to the number showing nonzero visits to the rehabilitation medicine ambulatory clinic stops.

Suggested Citation:"Rehabilitation Medicine Panel Report." Institute of Medicine. 1992. Physician Staffing for the VA: Volume II, Supplementary Papers. Washington, DC: The National Academies Press. doi: 10.17226/2076.
×

Spinal Cord Injury Patient Care Area

with =0.915 and N=21

where

W

=the natural logarithm of the sum of all medicine, surgery, psychiatry, neurology, and rehabilitation medicine WWUs, plus 1, generated in the SCI PCA;

SCI_MD

=VA staff physician FTEE from the SCI service allocated to direct care in the SCI PCA;

NURSE/MD

=nursing staff FTEE per VA staff physician FTEE in the SCI PCA (where the denominator of the ratio is defined specifically as the sum of all direct care FTEE recorded for internists, surgeons, psychiatrists, neurologists, rehabilitation medicine physicians, and physicians assigned expressly to the SCI cost center at the facility); and

N

=the number of VAMCs in the sample, equivalent to the number with a designated spinal cord injury service.

Suggested Citation:"Rehabilitation Medicine Panel Report." Institute of Medicine. 1992. Physician Staffing for the VA: Volume II, Supplementary Papers. Washington, DC: The National Academies Press. doi: 10.17226/2076.
×

B. Inverse Production Functions

Rehabilitation Medicine

with =0.605 and N=136

where

RMS_MD'

=the natural logarithm of the sum of VA rehabilitation medicine physician FTEE devoted to direct care (i.e., the sum of all RMS MD variables) across PCAs, plus total RMS FTEE allocated to resident training, plus 1;

RMSWWU

=total RMSWWUs produced during the fiscal year across the inpatient PCAs;

RMSCAPWWU

=total CAPWWUs produced during the fiscal year in the ambulatory rehabilitation medicine PCA;

RMSRUGWWU

=total rehabilitation medicine RUGWWUs produced during the fiscal year in the LTC PCAs of nursing home care and intermediate care;

RESIDENTS

=total FTEE of RMS residents PGY1-PGY3 at the VAMC;

FELLOWS

=total FTEE of RMS residents PGY4 and above at the VAMC; and

N

=the number of VAMCs in the sample, equivalent to the number with nonzero physician FTEE allocated to direct care or resident education from the rehabilitation medicine cost center.

Suggested Citation:"Rehabilitation Medicine Panel Report." Institute of Medicine. 1992. Physician Staffing for the VA: Volume II, Supplementary Papers. Washington, DC: The National Academies Press. doi: 10.17226/2076.
×

Spinal Cord Injury

with =0.808 and N=21

where

SCI_MD'

=the natural logarithm of the total FTEE devoted by physicians in the SCI cost center to direct care and resident education in the SCI PCA, plus 1; and

SCIWWU

=the sum of all medicine, surgery, psychiatry, neurology, and rehabilitation medicine WWUs generated during the fiscal year in the SCI PCA.

Suggested Citation:"Rehabilitation Medicine Panel Report." Institute of Medicine. 1992. Physician Staffing for the VA: Volume II, Supplementary Papers. Washington, DC: The National Academies Press. doi: 10.17226/2076.
×

TABLE 3 RMS External Norm Comparisons

Source of Norm

VAMC I

VAMC II

VAMC III

Actual Staffing From Facility's CDR

3.9

3.0

1.8

1965 VA

1.0

3.0

4.0

DoD

8.8

4.4

2.0

Braintree

1.0

1.0

0.5

Rehab Institute of Chicago

1.0

2.8

0.8

Craig, Denver

2.0

3.2

1.1

Bellevue

2.0

3.0

1.0

Beth Israel

2.0

2.9

1.0

Survey of Literature (derived from Gonzalez et al., 1988)

 

Solo

3.2

2.9

1.6

University

4.0

2.5

2.0

Rehabilitation Center

2.5

4.0

1.3

Suggested Citation:"Rehabilitation Medicine Panel Report." Institute of Medicine. 1992. Physician Staffing for the VA: Volume II, Supplementary Papers. Washington, DC: The National Academies Press. doi: 10.17226/2076.
×

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

INTRODUCTION AND INSTRUCTIONS

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 to estimate staffing requirements at VA medical centers (VAMCs), presumably duplicating the results specialty and clinical program panelists themselves would have derived.

Section A of the SADI requests time estimates, in some cases by workload unit. In other cases, it requests time estimates by major job elements (tasks). These elements had previously been indicated by some panel members as accounting for the bulk of the work of VA physiatrists. 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 responses to a series of questions for the time spent in activities other than direct patient care.

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

Suggested Citation:"Rehabilitation Medicine Panel Report." Institute of Medicine. 1992. Physician Staffing for the VA: Volume II, Supplementary Papers. Washington, DC: The National Academies Press. doi: 10.17226/2076.
×
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

Suggested Citation:"Rehabilitation Medicine Panel Report." Institute of Medicine. 1992. Physician Staffing for the VA: Volume II, Supplementary Papers. Washington, DC: The National Academies Press. doi: 10.17226/2076.
×

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

Suggested Citation:"Rehabilitation Medicine Panel Report." Institute of Medicine. 1992. Physician Staffing for the VA: Volume II, Supplementary Papers. Washington, DC: The National Academies Press. doi: 10.17226/2076.
×

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

Suggested Citation:"Rehabilitation Medicine Panel Report." Institute of Medicine. 1992. Physician Staffing for the VA: Volume II, Supplementary Papers. Washington, DC: The National Academies Press. doi: 10.17226/2076.
×

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

Suggested Citation:"Rehabilitation Medicine Panel Report." Institute of Medicine. 1992. Physician Staffing for the VA: Volume II, Supplementary Papers. Washington, DC: The National Academies Press. doi: 10.17226/2076.
×

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

Suggested Citation:"Rehabilitation Medicine Panel Report." Institute of Medicine. 1992. Physician Staffing for the VA: Volume II, Supplementary Papers. Washington, DC: The National Academies Press. doi: 10.17226/2076.
×

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

Suggested Citation:"Rehabilitation Medicine Panel Report." Institute of Medicine. 1992. Physician Staffing for the VA: Volume II, Supplementary Papers. Washington, DC: The National Academies Press. doi: 10.17226/2076.
×
 

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

Suggested Citation:"Rehabilitation Medicine Panel Report." Institute of Medicine. 1992. Physician Staffing for the VA: Volume II, Supplementary Papers. Washington, DC: The National Academies Press. doi: 10.17226/2076.
×
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.

Suggested Citation:"Rehabilitation Medicine Panel Report." Institute of Medicine. 1992. Physician Staffing for the VA: Volume II, Supplementary Papers. Washington, DC: The National Academies Press. doi: 10.17226/2076.
×

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.

Suggested Citation:"Rehabilitation Medicine Panel Report." Institute of Medicine. 1992. Physician Staffing for the VA: Volume II, Supplementary Papers. Washington, DC: The National Academies Press. doi: 10.17226/2076.
×

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.

Suggested Citation:"Rehabilitation Medicine Panel Report." Institute of Medicine. 1992. Physician Staffing for the VA: Volume II, Supplementary Papers. Washington, DC: The National Academies Press. doi: 10.17226/2076.
×
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.

Suggested Citation:"Rehabilitation Medicine Panel Report." Institute of Medicine. 1992. Physician Staffing for the VA: Volume II, Supplementary Papers. Washington, DC: The National Academies Press. doi: 10.17226/2076.
×
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×
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×
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