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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