AMBULATORY CARE PANEL REPORT1

INTRODUCTION

The ambulatory care panel, organized by the study committee in the winter of 1989, was charged with examining physician manpower requirements for the ambulatory care program at VA medical centers. The panel was composed of eight physicians—four with specialties in internal medicine, one in surgery, one in rehabilitation medicine, one in neurology, and one in psychiatry. The chairman of the panel was also a member of the study committee. The panel roster is attached.

This report will describe the ambulatory care panel's analyses, conducted in the framework of the “panel process” described in the “Overview” to this section of Volume II. Reported here will be the results of these analyses, along with the panel's commentary and conclusions.

EXPERT JUDGMENT APPROACHES TO DETERMINING PHYSICIAN REQUIREMENTS IN THE AMBULATORY CARE PROGRAM
The Detailed Staffing Exercise (DSE) Approach
Initial Efforts

The first meeting of the ambulatory care panel was convened in April 1990. The primary purpose was to determine whether the expert judgment panel process, as the study committee first conceived it, represented a viable means

1  

The initial draft of this report was prepared by Bobbie J.Alexander, Staff Associate to the Ambulatory Care 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 AMBULATORY CARE PANEL REPORT1 INTRODUCTION The ambulatory care panel, organized by the study committee in the winter of 1989, was charged with examining physician manpower requirements for the ambulatory care program at VA medical centers. The panel was composed of eight physicians—four with specialties in internal medicine, one in surgery, one in rehabilitation medicine, one in neurology, and one in psychiatry. The chairman of the panel was also a member of the study committee. The panel roster is attached. This report will describe the ambulatory care panel's analyses, conducted in the framework of the “panel process” described in the “Overview” to this section of Volume II. Reported here will be the results of these analyses, along with the panel's commentary and conclusions. EXPERT JUDGMENT APPROACHES TO DETERMINING PHYSICIAN REQUIREMENTS IN THE AMBULATORY CARE PROGRAM The Detailed Staffing Exercise (DSE) Approach Initial Efforts The first meeting of the ambulatory care panel was convened in April 1990. The primary purpose was to determine whether the expert judgment panel process, as the study committee first conceived it, represented a viable means 1   The initial draft of this report was prepared by Bobbie J.Alexander, Staff Associate to the Ambulatory Care 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 for determining physician staffing for the entire ambulatory care program at individual VAMCs. This process required the development of staffing instruments that would provide the panel with information about workload, about various nonphysician personnel that might be available to deliver care, and then—given that conditional information —that would elicit judgments about the appropriate levels of physician FTEE to meet that workload. In preparation for the first panel meetings, staffing instruments were constructed for three actual VAMCs. Focusing on the analysis of these instruments, study staff tested the feasibility of this process at the first meeting and found that it was generally acceptable, that panel members could render physician staffing judgments, but that they wished to have more detailed information about workload and other factors. The panel concluded that study staff should proceed with the expert judgment process, but that many of the underlying assumptions within the initial staffing exercises should be better defined in the next generation of the staffing instrument. In particular, more detail was needed on clinic configuration and scheduling, defining the scope of each clinic listed—to include how frequently each is held, its length (in hours), and the number of patients seen. emergency room activities should be treated separately from admitting and screening. more specific detail was needed for psychiatry and surgery clinics. the input of psychologists and psychiatric social workers should be acknowledged where appropriate, and the number of residents should be adjusted accordingly. the postgraduate year of residents should be indicated. compensation and pension exams need to be included—focusing on fee-for-service contracts as well as in-house services. the administrative structure of the ambulatory care program should be defined: i.e., is it institutional administration or patient-focused administration? the physician manpower required for direct patient contact and resident education should be distinguished from that required for research, continuing medical education, classroom teaching, administration, and leaves. the next instruments should better separate out and define ambulatory surgery. the next instruments should include at least one satellite clinic. the length of the assumed workweek—30 hours, 40 hours, 50 hours or 60 hours—should be noted explicitly.

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Physician Staffing for the VA: VOLUME II The proper role of the chief of the ambulatory care program was a significant topic of discussion at the first panel meeting. At some VAMCs, the chief may have direct control of a number of physicians, similar to the chief of a specialty service (e.g., medicine). At other VAMCs, the chief is primarily a program manager and oversees all aspects of ambulatory care across all disciplines, but does not directly supervise staff physicians from the specialty services. On balance, the panel thought that the second model is more appropriate, since it is consistent with the philosophy that each physician in the institution is assigned to a discipline (service) and the distribution of patient care workload determines the location of practice. Subsequent staffing exercises should be compatible with this viewpoint, the panel indicated. At the conclusion of the first round of all eight specialty and clinical program panel meetings, there was convened a major meeting (Joint Meeting I) involving the study committee (which includes all eight panel chairmen), the data and methodology panel, and the VA liaison committee. At this meeting (held in May 1990), participants reviewed and evaluated the key concepts and assumptions underlying both the empirically based and expert judgment based approaches to determining VA physician requirements. The study staff emerged from Joint Meeting I with a set of recommendations from the committee on how to proceed with the panel process. Staff began to implement these recommendations on a panel-specific basis. DSE: Overall Rationale The next stage in the development of expert judgment staffing methodology centered on the preparation for, and conduct of, the second panel meeting, held in August, 1990. Again, three actual VAMCs were selected for intensive analysis—in essence, to serve as “laboratories” for methodology development. They were chosen to represent a range of geographic locations, bed sizes, staffing intensities, available services/programs, and affiliation status. A revised staffing instrument, later termed the Detailed Staffing Exercise (DSE), was developed in response to the panel's recommendations. It provided a more specific description of the VAMC, including the number of admissions, length of stay, and DRG mix of patients in each PCA. It was intended that all three VAMCs would be presented “in context” and described in sufficient detail that the respondent could assess physician staffing requirements almost as if he/she were reviewing data at the facility.

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Physician Staffing for the VA: VOLUME II Panel members were asked to complete DSEs for two of the VAMCs prior to the meeting. These results were tabulated and distributed at the meeting, along with information on both the actual staffing and the statistically derived staffing at these facilities. After review and discussion, each panel member was given the opportunity to reevaluate his initial staffing estimates. Then the panel, as a group, worked through a third DSE constructed for VAMC III; the members subsequently reflected on these results in light of the actual and statistically derived staffing for ambulatory care at VAMC III. 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 is nearly identical structurally to the one constructed for ambulatory care (although the latter does focus only on physician requirements for the ambulatory care program per se). In Section A of each exercise, the basic question was the same for each ambulatory patient care area: How much time (in hours) must be contributed by physicians in this VAMC's ambulatory care program to meet a specified workload level during an average weekday, under certain assumptions about patient mix, residents, and support staff availability. These hours were then converted to FTEE, using the 40-hour-per-week equivalency assumption. In Section B of each DSE, panel members were asked to estimate the number of hours (and then to covert into FTEE) required from ambulatory care physicians for night call and weekend coverage, and for physician time spent in non-patient-care-related activities: research off the patient care area, educational activities not related to direct patient care, quality assurance, mortality and morbidity meetings or studies, administrative activities, and any other function not directly related to patient care areas. Also, panel members were asked to estimate how many consulting and attending (C&A) and without-compensation (WOC) physicians would be desired from the community or neighboring medical school (given the member's prior assessment of VA staff physician requirements). In general, the second meeting focused on the assumptions, thought processes, and algorithms underlying the panel's staffing estimates. From these discussions, the panel worked toward a consensus about the appropriate data, assumptions, and methodology required for expert judgment assessments of physician requirements. Strategies were discussed for reconciling the alternative

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Physician Staffing for the VA: VOLUME II approaches to deriving physician requirements: the expert panel approach, statistical models, and the application of external (to the VA) staffing norms. The Staffing Algorithm Development Instrument (SADI) Approach SADI: Overall Rationale At the conclusion of the second panel meeting, the committee implemented a sequence of postmeeting activities designed to promote the development of consensus positions regarding the appropriate methodology and accompanying data for determining VA physician requirements. This postmeeting process was formally initiated with the development of the Staffing Algorithm Development Instrument (SADI). The purpose of this new instrument was to test, build upon, and ultimately strengthen the algorithms and rules of thumb for staffing that emerged from the meetings of all eight specialty and clinical program panels. The instrument was designed to determine whether panel members could be asked a set of generic staffing questions whose answers would be applied to selected data from individual VAMCs to derive appropriate staffing levels for these facilities. 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. Section A was divided into three parts. In the first, all panel members were asked to estimate the average time in hours required by an ambulatory care program staff physician for the typical emergency/walk-in patient, or the typical

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Physician Staffing for the VA: VOLUME II admitting & screening patient. In responding, panelists were requested to note the SADI's stated assumptions regarding the presence or absence of residents and nonphysician practitioners, and whether the visit was by a new or returning patient. In the second part, panel members were to estimate the average time in hours required by a staff physician in their service for a typical patient visit to one of their specialty clinics, noting the presence or absence of residents and nonphysician practitioners, and whether the visit is by a new or returning patient. The final part of Section A asked for estimates of the physician time (per test) required for ambulatory care-based special procedures, conditional on the presence or absence of a resident. The list of special procedures used was recommended by the panel during its second meeting. In Section B, panel members were asked to 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 ambulatory care SADI, complete with the the panel members' median estimates for physician task times. (Where multiple members estimated task time, the high, low, median, and mean are reported; where only one panel member estimated times, e.g., the neurology clinics, those numbers are simply reported.) 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 total internist requirements at VAMC I; the application of the ambulatory care SADI to determine physician FTEE at a given facility proceeds in a very similar fashion. A careful study of the example reveals the type of facility-specific data needed to implement any SADI. EMPIRICALLY BASED APPROACHES TO DETERMINING PHYSICIAN STAFFING FOR THE AMBULATORY CARE PROGRAM Six of the 14 VAMC patient care areas defined by the study committee are for ambulatory care: medicine, surgery, psychiatry, neurology, rehabilitation medicine, and other physician services. Each of the first five PCAs above is defined operationally as the set of clinic stops related to that specialty, e.g., the

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Physician Staffing for the VA: VOLUME II ambulatory surgery PCA consists of all the designated surgery clinic stops. The other physician services PCA consists of all the remaining physician-related clinic stops, including the emergency room and admitting & screening. (For further discussion of how ambulatory care clinic stops were mapped into ambulatory PCAs, see chapter 4 of Volume I.) Over the course of its two panel meetings and a follow-up conference call, the panel evaluated alternative specifications of production function models estimated for each of these six PCAs. The final versions of these equations, as derived in cooperation with the study's data and methodology panel, are presented in Table 2. No inverse production function models have been estimated. As specified in this study, the IPF is specialty specific, and the facility, not the PCA, is the basic unit of observation. On the other hand, the ambulatory care program is multidisciplinary and encompasses only a portion of the VAMC. Nonetheless, the influence of ambulatory care workload on physician requirements is reflected in the IPF—specifically, as an independent variable that may be (and frequently was) a statistically significant factor “explaining” variations in physician FTEE devoted to direct care and resident education across the VAMC. PHYSICIAN STAFFING RESULTS FROM APPLICATION OF EMPIRICALLY BASED AND EXPERT JUDGMENT APPROACHES In Table 1 are alternative estimates of physician requirements for the ambulatory care program at VAMCs I, II, and III in FY 1989, as derived from: the VA's cost distribution report (CDR), the PF variant of the empirically based models, the DSE (from the second panel meeting), the SADI, and a mail survey of panel members conducted just prior to Joint Meeting II (held September 7–9, 1990). Any conclusions drawn from the analysis of only three VAMCs must be treated cautiously, but several trends are suggested in Table 1. Both expert judgment approaches yield total FTEE estimates that noticeably exceed those derived from the PF and the actual physician count as inferred from the CDR. When the focus shifts to physician FTEE for direct care and resident education only, the DSE continues to yield the largest estimates but now there is no systematic tendency for the SADI results to exceed the PF. By all criteria, the ambulatory care program at VAMC III appears to be significantly understaffed, in terms of both total physician FTEE and that allocated to direct care and resident education only. The expert judgment

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Physician Staffing for the VA: VOLUME II approaches, but not the PF, indicate that VAMCs I and II have too few physicians in ambulatory care. The approach yielding total FTEE estimates that are the closest overall to the panel's recommended levels, as indexed by the median of their responses to the Survey, is the SADI. One possible explanation for these notable discrepancies between actual versus recommended physician staffing centers on the quality of the FTEE data available in the CDR for ambulatory care. In this FTEE accounting scheme, physicians in the different services (or their service chiefs) are asked to allocate their time across a range of activities that includes ambulatory care. But since a large component of physician time has traditionally been allocated to the inpatient side, these physicians may tend to underestimate the time spent in ambulatory care, as the latter has edged up in recent years. Reflecting on the state of ambulatory care in the VA generally (and not just at these three facilities), the panel notes that many VA hospitals are not equipped (or constructed) for ambulatory care programs or services. At many facilities, the number and quality of examining rooms, overall floor space, and support personnel are all inadequate. This, in turn, may have a dampening effect in many facilities on the amount of staff physician FTEE that can be usefully allocated to ambulatory care. (This, in turn, may account for some of the discrepancy between CDR-recorded physician FTEE for ambulatory care and the FTEE levels derived from the expert judgment models.) The issue of unmet patient need was a major concern at both panel meetings. Traditionally, queues are regarded as more tolerable in ambulatory than in acute patient care; in many medical centers, there is a significant queueing process, with some patients waiting months for specific types of ambulatory care. Moreover, current eligibility criteria create situations in which many patients may be accepted for care (initial access) but referral to other ambulatory care and inpatient programs is limited because of limited resources. EXTERNAL (NON-VA) PHYSICIAN STAFFING NORMS Data on physician staffing for ambulatory care were collected from external (to the VA) health care organizations to determine whether methodologies or productivity performance norms that may exist in the public and private sectors could be applied successfully to the VA ambulatory care program.

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Physician Staffing for the VA: VOLUME II Also acquired were some “internal” VA staffing guidelines, issued about 1965, which indicated it was appropriate to have one physician FTEE per 3500 visits per year. Regarding the external staffing criteria, the Department of Defense (DoD) provided perhaps the most useful data since it utilizes full-time physician equivalents much like the VA; however, the DoD patient population is generally younger and includes a significant percentage of women and children. DoD defines physician performance levels in terms of the annual number of outpatient and inpatient visits rendered (the standard varies widely depending on the specialty and whether the facility has a teaching program). A different criterion applies if there are a significant number of residents, since it is assumed they need supervision regardless of workload. From the Indian Health Service (IHS) came a simple staffing guideline: outpatient staffing is earned at the rate of 1.0 physician for every 5000 visits per year. An interesting application was based on a 1987 survey conducted by the American Medical Association, “1987 AMA Socioeconomic Monitoring System Core Survey.” Only active, nonfederal, patient care physicians were sampled. By analyzing the reported rates with which surveyed physicians generated hospital and office visits, comparisons to the VA could be made. The New York City Health and Hospitals Corporation (NYH&HC) provided data on physician FTEE per office visit. Finally, data were obtained from a large, nationwide HMO on physician staffing in relation to outpatient visits (as well as inpatient workload). However, the patient population served by this HMO is substantially younger and contains more females than the VA population, with considerably different disease patterns. Table 3 illustrates the computational approach, via dimensional analysis, used to derive each of these staffing standards. Summarized in Table 4 are the results from applying these norms to calculate the implied levels of physician staffing for the ambulatory care programs at VAMC I, II, and III. The logic behind these calculations is presented and illustrated in the “Overview” to this section of Volume II (see “External Norms”). CONCLUSIONS To determine the number of physicians required for the ambulatory care program at VAMCs, the panel endorses the study committee's proposed

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Physician Staffing for the VA: VOLUME II Reconciliation Strategy. Regarding the components of the strategy, the panel recommends the following: Patient Care, Resident Education, and Administration To derive the level of physician FTEE required to care for a given patient workload, while residents are being trained and administrative duties are being handled, the panel recommends an expert-judgment-based methodology built around the SADI. The DSE is an acceptable alternative methodology, but the SADI is the better approach for ambulatory care for several reasons. The time (and hence, FTEE) required to deliver ambulatory care can be usefully conceptualized as the time to manage a sequence of patient visits, of varying complexities. Some will be initial visits, others followup. Some will be handled with residents and various nonphysician practitioners; others may involve primarily the physician. Some will be emergency; others routine. Depending on the patient's problem, different specialties (or mixes of them) will be involved. The degree of physician involvement in a given visit will be influenced by all of these factors. Because it focuses on the physician time required per visit or per procedure, the SADI methodology is thus well suited for computing physician requirements in ambulatory care. Unlike the DSE instrument, which is facility specific, the SADI is a generic construct that can be applied directly to any VAMC (assuming adequate information about outpatient workload, residents, and support personnel). The application of SADI to the ambulatory care program at VAMCs I, II, and III lead generally to plausible estimates of physician FTEE for patient care, resident education, and administration. The panel regards this as a fairly successful small-scale experiment; however, the validity and acceptability of the SADI methodology should be evaluated further through a much broader application involving a strategically chosen sample of VA ambulatory care programs. Either form of the empirically based physician staffing model has problems at present. Conceptually, the PF does offer an attractive approach for analyzing physician requirements in ambulatory care. All of the VA's clinic stops are mapped into six mutually exclusive and exhaustive PCAs; and one can calculate alternative combinations of provider types that are consistent with meeting patient workload in each PCA. Given certain assumptions, physician FTEE required by specialty can be deduced from these statistical analyses. But a major concern is that the FTEE data used in estimating these models may be

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Physician Staffing for the VA: VOLUME II significantly flawed at present. The panel believes that physician FTEE devoted to ambulatory care are consistently undercounted in the current data system. Despite efforts to improve data collection at many VAMCs, there is insufficient uniformity in the way facilities allocate physician FTEE between inpatient and ambulatory care and among activity categories within ambulatory care. Because the PF model requires FTEE broken out to this level of detail, the issue is important. Correspondingly, if CDR record keeping continues to improve over time, this objection to the PF model should dissipate. The IPF model is plagued by these same data difficulties, but it presents a more fundamental problem. Because the IPF equations presented to the panel do not allow physician FTEE to be analyzed by PCA, there is no appropriate IPF for ambulatory care. (However, the effect of outpatient workload on physician requirements is recognized in each IPF.) Research Physician FTEE allocated to research should reflect a deliberate VA policy decision—not something determined mechanically from CDR data. The panel recommends that this determination be made by each facility with guidance from VA Central Office. Although a good research program will enhance the overall quality of ambulatory care at any VAMC, the panel acknowledges that the amount of FTEE allocated to research will—and should—vary significantly across facilities. In determining these FTEE, VA policymakers should be guided by measurable indicators of research productivity such as the level of VA and non-VA research funding. The strength of the VAMC's affiliation with a scientifically productive medical school is another potential indicator. Continuing Education As with research, the commitment to continuing education should not be dictated by the status quo, but rather be the result of a conscious VA policy decision on what continuing education is required to promote high-quality care. At a minimum, the FTEE allocated to continuing education should be commensurate with the commitment required to maintain board certification in the specialties concentrated in ambulatory care. The panel strongly recommends that the continuing education allowance be greater than this minimum and applied to all VAMCs, affiliated or not. Further, each VAMC should develop

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Physician Staffing for the VA: VOLUME II SPECIALTY CLINIC VISITS—REHABILITATION MEDICINE Please estimate the average time in hours required by a staff physician for the typical ambulatory care specialty clinic visit. Note the presence or absence of residents and nonphysician practitioners, and whether the visit is by a new or returning patient. Chart 5 Type of Visit Physician Time per Visit New Patient Visit No Resident 1.00 New Patient Visit With Resident 0.75 New Patient Visit With NP or PA 0.50 Follow-Up Visit No Resident 0.25 Follow-Up Visit With Resident 0.16 Follow-Up Visit With NP or PA 0.16

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Physician Staffing for the VA: VOLUME II SPECIALTY CLINIC VISITS—PSYCHIATRY Please estimate the average time in hours required by a staff physician for the typical ambulatory care specialty clinic visit. Note the presence or absence of residents and nonphysician practitioners, and whether the visit is by a new or returning patient. Chart 6 Type of Visit Physician Time per Visit New Patient Visit Mental Hygiene No Resident 1.00 New Patient Visit Mental Hygiene With Resident 0.50 New Patient Visit Mental Hygiene With NP or PA 0.50 New Patient Visit Substance Abuse No Resident 1.00 New Patient Visit Substance Abuse With Resident 0.50

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Physician Staffing for the VA: VOLUME II SPECIALTY CLINIC VISITS—PSYCHIATRY Type of Visit Physician Time per Visit New Patient Visit Substance Abuse With NP or PA 0.50   Return Visit Mental Hygiene 1.00   Return Visit Medicine Check 0.50   Return Visit Substance Abuse 1.00   Group Therapy Session 0.25 (per patient in 2-hour session w/group of 8 patients)

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Physician Staffing for the VA: VOLUME II SPECIALTY CLINIC VISITS—SURGERY Please estimate the average time in hours required by a staff physician for the typical ambulatory care specialty clinic visit. Note the presence or absence of residents and nonphysician practitioners, and whether the visit is by a new or returning patient. Chart 7 Type of Visit Physician Time per Visit New Patient Visit No Resident 0.33 New Patient Visit With Resident 0.33 New Patient Visit With NP or PA 0.25 Follow-Up Visit No Resident 0.16 Follow-Up Visit With Resident 0.16 Follow-Up Visit With NP or PA 0.16

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Physician Staffing for the VA: VOLUME II SPECIAL PROCEDURES—Within Medicine We have listed the ambulatory care-based special procedures identified during the panel meeting which should be considered in estimating a staff physician's daily workload. Please estimate the physician time required, in hours, noting the presence or absence of a resident. Chart 8 Special Procedure Time per Test Without Resident Time per Test with Resident   High Low Mean Median High Low Mean Median Endoscopies 1.00 0.33 0.67 0.67 1.00 0.50 0.75 0.75 Cardiac Stress Testing 0.75 0.08 0.53 0.75 0.75 0.08 0.47 0.58 Pulmonary Bronchs 0.33 0.30 0.32 0.32 0.58 0.42 0.50 0.50 Sigmoidoscopies 0.75 0.13 0.38 0.25 0.58 0.22 0.43 0.50 Gastroscopies 0.30 0.25 0.28 0.28 0.50 0.42 0.46 0.46 ECHOs 0.50 0.17 0.34 0.34 0.75 0.17 0.46 0.46 EMGs 0.75 0.75 0.75 0.75 1.00 1.00 1.00 1.00 Others: Bone Marrow 0.50 0.25 0.38 0.38 0.58 0.33 0.46 0.46 Arthrocentesis 0.58 0.58 0.58 0.58 0.33 0.33 0.33 0.33 Thoracenthesis 1.00 1.00 1.00 1.00 0.33 0.33 0.33 0.33 Lumbar Puncture 1.00 1.00 1.00 1.00 0.33 0.33 0.33 0.33 Skeletal Biopsy 0.50 0.50 0.50 0.50 0.25 0.25 0.25 0.25

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Physician Staffing for the VA: VOLUME II Chart 9 SPECIAL PROCEDURES—Within Neurology Special Procedure Time per Test without Resident Time per Test with Resident EMGs 0.75 1.00 Lumbar Puncture 0.50 0.08 Chart 10 SPECIAL PROCEDURES—Within Surgery Special Procedure Time per Test without Resident Time per Test with Resident Endoscopies 0.67 0.50 Cardiac Stress Testing 0.33 0.25 Pulmonary Bronchs 0.67 0.50 Sigmoidoscopies 0.50 0.50 Gastroscopies 0.50 0.33 ECHOs 0.33 0.33 Chart 11 SPECIAL PROCEDURES—Within Psychiatry Special Procedure Time per Test without Resident Time per Test with Resident Hypnosis 1.50 1.50 Amytal Interview 1.50 1.50

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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 weekday to allow for the types of non-patient-care-related activities listed below: Chart 12 Assume the amount of research accomplished at this VAMC is:   High1 Medium1 Low1 Education of Residents (didactic, classroom, not on the PCA) High 1.00 0.50 0.50   Low 0.25 0.17 0.00   Mean 0.49 0.30 0.16   Median 0.44 0.25 0.12 Administration by Chief (time required to manage your whole service by a chief and/or assistant chief) High 4.00 4.00 4.00   Low 1.00 0.50 0.17   Mean 2.17 2.21 1.86   Median 2.00 2.00 2.00 Administration by Others (time required per individual— non-chief— physician) High 4.00 4.00 4.00   Low 0.33 0.17 0.00   Mean 1.10 0.87 0.88   Median 0.75 0.50 0.38 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 1.00 1.00 1.00   Low 0.10 0.10 0.10   Mean 0.60 0.63 0.55   Median 0.50 0.50 0.50 Total Hours per Average Workday   Chief2 High 4.00 4.00 4.00   Low 1.00 0.50 0.17   Mean 2.17 2.21 1.86   Median 2.00 2.00 2.00 Other High 6.00 5.25 5.15   Low 1.88 1.00 0.34   Mean 3.27 3.15 2.57   Median 3.18 3.00 2.43 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, 2Assumes 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) staff (nonresident) member of your service should devote to each of the following categories of non-patient-care-related activities? Chart 13 Assume the amount of research accomplished at this VAMC is:   High1 Medium1 Low1 Continuing Education High 10.0 10.0 15.0   Low 3.8 2.0 5.0   Mean 7.3 6.0 7.5   Median 7.5 5.0 5.0 Research (off the PCA) High 50.0 20.0 5.0   Low 10.0 2.0 0.0   Mean 23.3 10.6 1.8   Median 17.5 10.0 1.0 Vacation, Administrative Leave, Sick Time Other   10.02 10.02 10.02 Total Percentage of Time High 70.0 40.0 28.8   Low 28.8 17.0 15.0   Mean 40.6 26.6 19.3   Median 35.0 25.0 17.5 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. 2The percentages noted for vacation, administrative leave, sick time, and other are based on system guidelines.

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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 AMBULATORY CARE PANEL SANKEY V.WILLIAMS (Chair),† Professor of Medicine and Director of Clinical Scholars Program, University of Pennsylvania, Philadelphia C.RODNEY BAKER, Associate Chief of Staff for Ambulatory Care, Little Rock VA Medical Center, Little Rock, Arkansas JOHN R.CLARKE, Professor of Surgery and Director, Trauma Center, Medical College of Pennsylvania, Philadelphia JOHN W.GOLDSCHMIDT, Medical Director (retired), National Rehabilitation Hospital, Washington, D.C. ELWOOD J.HEADLEY, Deputy Associate Deputy Chief Medical Director for Ambulatory Care, Department of Veterans Affairs, Washington, D.C. GAETANO F.MOLINARI, Professor and Chairman, Department of Neurology, George Washington University Medical Center, Washington, D.C. DAVID A.NARDONE, Associate Chief of Staff for Ambulatory Care, Portland VA Medical Center, Portland, Oregon LOUIS JOLYON WEST, Professor of Psychiatry and Biobehavioral Sciences, School of Medicine, University of California at Los Angeles Staff: Bobbie J.Alexander, Staff Associate †Member of the study committee.

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