SECTION III

NONPHYSICIAN PRACTITIONERS PANEL REPORT



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Physician Staffing for the VA: VOLUME II SECTION III NONPHYSICIAN PRACTITIONERS PANEL REPORT

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Physician Staffing for the VA: VOLUME II This page in the original is blank.

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Physician Staffing for the VA: VOLUME II NONPHYSICIAN PRACTITIONERS PANEL REPORT Bobbie J.Alexander and Joseph Lipscomb INTRODUCTION Over the past quarter century there has emerged a substantial body of research indicating that certain nonphysician practitioners (NPPs) can boost physician productivity without adversely affecting the quality of care (see Appendix A). Among these NPPs are physician assistants (PAs), nurse practitioners (NPs), and other categories of providers, each of whom performs specified diagnostic and therapeutic patient care tasks under the supervision of a physician. Hence, the level of physician FTEE required by the VA could well depend directly on the extent to which NPPs are used in the system 's 172 hospitals, 68 satellite outpatient units, and 127 nursing homes. Broadly speaking, NPPs would influence VA physician requirements if these practitioners (1) can substitute for physicians in selected tasks (thus freeing the latter to perform additional services per unit time) or (2) can work jointly with physicians in ways that boost net productivity. The potential importance of the nonphysician practitioner within the VA system has been magnified, in effect, by the changing demographic structure of the VA patient population. In the years ahead, an increasing proportion of patients will be over age 65, chronically ill, and will require care that may be appropriately delivered in ambulatory and long-term care settings. These are precisely the type of primary care settings where the research literature (reviewed in the next section) indicates that NPPs can have the greatest productivity impact —and even enhancing the overall quality of patient care. Does it therefore follow that if the VA significantly expanded its use of NPPs in ambulatory care and long-term care, the system's physician requirements would be substantially influenced? And what would be the likely influence on the quality of care?

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Physician Staffing for the VA: VOLUME II To investigate these and a number of related issues, the IOM committee established the “physician extenders panel” in September 1988, a few weeks after the committee 's inaugural meeting. Subsequently, this new advisory group was renamed the “nonphysician practitioner panel.” It comprised 10 members, 5 from the VA and 5 non-VA; the chair was also a member of the IOM committee. The panel roster is attached. In response to the IOM committee's charge, the panel developed a framework for defining and studying a broad range of NPPs, completed an extensive literature review, and conducted three field surveys (by mail) to collect new information about the present and possible future roles of NPPs in the VA, as well as recommendations about policies the VA should adopt in this regard. Separate surveys were completed by NPPs (four particular types discussed below), their supervisors, and the chiefs of staff at 34 selected VA medical centers from around the nation. In the sections that follow, the panel presents a topology for studying nonphysician practitioners in the VA, discusses the potential role of the NPP in the overall physician staffing methodology developed by the IOM committee, analyzes both the empirical findings and policy recommendations from the three field surveys, and concludes with its own recommendations to the IOM committee. The literature review on nonphysician practitioners is summarized in an annotated bibliography in Appendix A, and the survey questionnaires are reproduced in Appendix B. From the beginning, the panel's basic charge was to advise the IOM committee. The committee's own views about nonphysician practitioners are found in chapter 10 of Volume I of its report to the VA. DEFINING THE NONPHYSICIAN PRACTITIONER The panel has developed a topology to differentiate nonphysician providers according to the nature of their interaction with physicians in the patient care areas of the VA medical center. The topology encompasses all providers who potentially have a direct impact on physician productivity; three categories of providers have been defined: Category I—Administrative/Operational Support Personnel, which includes clerical support, medical records clerks, patient transporters, and related workers.

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Physician Staffing for the VA: VOLUME II Category II—Clinical Complementary Service Personnel, which includes nurses, podiatrists, optometrists, and such health professionals as occupational therapists, physical therapists, and speech therapists, among many other service personnel in the allied health technologies. Category III—Direct Medical Service Personnel, which includes PAs, NPs, clinical nurse specialists (CNSs), certified registered nurse anesthetists (CRNAs), clinical psychologists, and clinical social workers. This delineation of categories was motivated, in part, by the panel 's perceptions about the role of each provider vis à vis the physician. It was hypothesized that personnel in Categories I and II boost productivity by functioning as “complementary” inputs to the physician in the delivery of care in the PCAs. Personnel in Category III boost productivity by either directly “substituting” for physicians in certain designated patient care tasks or working collaboratively with physicians to improve productivity. Although these tasks are performed under the supervision of a physician, the latter need not be physically present with the Category III provider and, hence, can concentrate on other patient care services. From the beginning, the panel hypothesized that in a VA health care system of the future that gave increasing emphasis to ambulatory and long-term care, Category III providers—particularly PAs and NPs —could function satisfactorily in expanded roles in ways that could increase physician productivity while not diminishing the quality of patient care. Much of the panel's analyses and deliberations were devoted, directly or indirectly, to investigating this hypothesis. The panel notes that, because the IOM committee's charge focuses almost exclusively on physician productivity issues, the panel has examined NPPs largely in relationship to physician requirements. It should be emphasized that most NPs, CRNAs, and CNSs perform additionally in an expanded-nurse capacity (and not under physician supervision). In light of this, and with approval from the study committee, the panel focused almost entirely on Category III providers, designating this group as “nonphysician practitioners.” Throughout the remainder of this report, the term NPP refers specifically to these Category III providers.

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Physician Staffing for the VA: VOLUME II THE NPP AND THE PHYSICIAN STAFFING METHODOLOGY In order to evaluate the future role of the NPP in the VA health care system, it is critical that these providers be formally represented and fully integrated into the overall physician staffing methodology. In the panel's view, the study committee (in consultation with its data and methodology panel) has largely achieved this goal—in principle —though much practical work remains to be completed before NPPs are satisfactorily accounted for in the staffing methodology. First, with respect to the empirically based physician staffing models (EBPSM), variables representing the interaction between each type of NPP and each type of physician (by specialty) should be included in the production function estimated for each patient care area of the VAMC (see chapter 4 of Volume I). The algebraic sign and statistical significance of each such NPP and NPP-physician interaction variable would provide direct evidence about the degree to which the NPP boosts productivity and also whether the interaction of these inputs is consistent with a complementary or substitution relationship in the production process. Second, with respect to the committee's expert judgment approaches to physician staffing, a similar strategy can be pursued. That is, assumptions about the number and type of each NPP can be built into the Detailed Staffing Exercise (DSE), so that when the expert judge is estimating physician requirements for a given ward or clinic, the patient care role that each NPP might play can be taken directly into account. Similarly, in the Staffing Algorithm Development Instrument (SADI), each physician task time can be estimated as a function of (among other things) the number and type of NPPs available in that patient care area. But, in the short run, several factors have limited the extent to which NPPs are reflected in the overall methodology. With respect to the expert judgment approaches, there remains only the task of ensuring that every NPP relevant to a given patient care area is explicitly included in subsequent versions of the SADIs (or DSEs) that may be produced by the VA as it refines this portion of the methodology. The existing versions of the SADIs and DSEs well illustrate how this should be done. With regard to the EBPSM, this panel and the committee recognized early on that there are significant roadblocks to achieving a satisfactory integration of NPPs into the statistical staffing equations. Hence, a major task would be to

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Physician Staffing for the VA: VOLUME II develop recommendations for how VA data collection procedures could be modified to facilitate this integration. The main problem is that current VA data systems do not permit one to obtain Full-Time-Equivalent Employees (FTEE) allocated to PCAs for most of the nonphysician providers listed above. Only for nurses (based on the VAMC nursing service), psychologists, and social workers are data on FTEE by PCA available presently on a national basis. For these three, the VA has designated direct cost centers in its Cost Distribution Report (CDR) (see chapter 4 of Volume I). For all others, including PAs and NPs, one can obtain total FTEE by VAMC but not by PCA. Since the production functions are PCA specific, all variables used in them must likewise be PCA specific. Instead, the study committee adopted a much more indirect route for studying the effect of NPPs in the empirically based models. In particular, SUPPORT/MD, a PCA-specific variable appearing in a number of PF equations, includes (among the components of its numerator) the total PA and CRNA FTEE in the PCA; depending on the policies at a given VAMC, it may also include NP and CNS FTEE. Similarly, the PCA-specific variable NURSE/MD may include (in its numerator) both NP and CNS FTEE. However, the numerators of both variables will also contain much FTEE not pertaining to these four NPPs. Hence, the statistical performance of SUPPORT/MD and NURSE/MD can provide some very broad indications of the impact of NPPs. However, these variables can yield no direct insights into the specific productivity contributions of PAs, NPs, CNSs, or CRNAs. SURVEYS ON THE CURRENT AND FUTURE ROLES OF NONPHYSICIAN PRACTITIONERS IN THE VA This panel concluded that, while many observers of and participants in the VA health care system held strong views about the current and future roles of NPPs, there had been little systematic analysis of data bearing on this issue. In response, the study committee directed the panel to conduct, in addition to the literature review, one or more field surveys to explore the issue directly.

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Physician Staffing for the VA: VOLUME II Sample Design The first two surveys, conducted in late summer of 1990, were of selected NPPs and their supervisors in a stratified random sample of VAMCs. The NPPs examined were PAs, NPs, CNSs, and CRNAs. The latter three NPPs are all trained registered nurses with advanced nursing preparation; their survey responses report the allocation of time to services performed under physician supervision and (by implication) the allocation to advanced nursing functinos. Because the VA cost distribution report already shows the allocation of psychologist and social worker FTEE across patient care areas in the VAMC, these two provider types were not included in the surveys. To select the sample of sites to be surveyed, we stratified the universe of VAMCs by VA region and type of hospital, where the latter was defined in terms of RAM group membership. Specifically, we created a sample frame consisting of 16 distinct cells defined by the four current VA regions (Eastern, Central, Southern, and Western) and by four hospital groups constructed as follows: I=RAM groups 1 and 2; II=RAM groups 3 and 5; III=RAM group 4; and IV=RAM group 6. Within cells, each VAMC was classified (judgmentally) as either a “high” or “low” user of NPPs or as neither, depending on the total number of PAs, NPs, and CNSs employed there (as reported in VA payroll records). Then within each cell at least one high-use site and at least one low-use site was chosen randomly—that is, without reference to the VAMC's identity. This process yielded a total sample of 40 VAMCs. NPPs and supervisors from 36 of these facilities elected to participate in the surveys, producing the following total usable sample of respondents: PAs, 138; NPs, 67; CNSs, 57; CRNAs, 26; and supervising physicians, 169. Following an analysis of these responses—particularly the commentary related to VA policies on the use of NPPs—the panel recommended to the committee a third survey that would focus on the NPP in relation to clinical decision making and policy at the VAMC. The committee concurred, and in January 1991 questionnaires were mailed to the chiefs of staff (COS) at the 40 VAMCs in the original sample; 34 COS responded satisfactorily. In the remainder of this section we first examine findings from the NPP survey on how these four types of providers allocate their time across patient care and non-patient-care activities. This is precisely the type of information needed to compute NPP FTEE by patient care area—as required by the production function models but not now available in the VA data systems. Also

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Physician Staffing for the VA: VOLUME II presented in this section are data on the functioning and allocation of time by NPP supervisors. In the next section we continue the analysis of these surveys, with an extended summary and discussion of the various commentaries offered by NPPs, their supervisors, and the chiefs of staff regarding the present and future roles of NPPs in the VA health care system. How NPPs and Supervisors Allocate Their Time at the VAMC Each sampled nonphysician practitioner completed the questionnaire reproduced as Exhibit 1 in Appendix B. Each sampled NPP supervisor completed the questionnaire shown in Exhibit 2. Table 1 below summarizes the responses to that part of the NPP questionnaire focusing on how each practitioner allocates his/her time across the various patient care units/activities of the VAMC (that is, the responses to question 2 of Exhibit 1). Shown in Table 1 are the mean percentage allocations of time across units/activities, by type of NPP. Similarly, Table 2 summarizes the responses to the remaining items on the NPP questionnaire (that is, to questions 3–9 of Exhibit 1). In Table 3, the mean responses of supervisors to the questions posed in Exhibit 2 (of Appendix B) are reported, by type of NPP supervised. The conclusions reported below are based on these survey sample means. For compactness, results will be stated without the repeated reminder that they constitute central tendencies, not certain truth about the entire population of these NPPs at VAMCs. Among the many inferences possible from Tables 1–3, the panel specifically notes the following: Allocation of NPP Time to Patient Care Units/Activities From Table 1 we infer that: In general, nonphysician practitioners were successfully able to partition their time across patient care areas, subcomponents of PCAs, and to various non-patient-care units/activities. This strongly supports the feasibility of adding cost centers to the VA's CDR for the PA, NP, CNS, and CRNA, thus enabling

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Physician Staffing for the VA: VOLUME II these providers to be included as inputs in the production function variants of the EBPSM, as discussed earlier. Regarding the PA, about half of all hours are devoted to inpatient care, with the largest components being psychiatry (18.7% of total time), medicine (9.8%), and surgery (8.9%). More than a third of all PA time is allocated to outpatient care, with the majority of that (20.9% of total time) devoted to the category of “Other” activities that includes: emergency room, admitting & screening, compensation & pension exams, employee health, hospital-based home care, satellite outpatient clinics, hemodialysis, domiciliary, and other outpatient settings. About 10% of the PA's day is allocated to the outpatient medicine clinics. Only about 7.6 % of PA time is spent in the nursing home and other extended care settings. If one adds to that the 4.0% of time allocated to inpatient intermediate care units, the total time devoted to what the study committee has termed “long-term care” PCAs is 11.6%. Regarding the NP, the largest allocation of time is to outpatient care (46.2%), with nearly two-thirds of that in the “Other” category that includes ER, admitting & screening, and the other activities noted just above. NPs also make a noteworthy contribution to delivering care in the outpatient medicine clinics (12.6% of total time). About 30% of NP time is devoted to inpatient care, and two-thirds of that is allocated to intermediate care. Only about 9 % of NP time is devoted altogether to the inpatient medicine and psychiatry units. The NP devotes nearly twice as much time as the PA to nursing home and other extended care (14.5% vs. 7.6%). But this still means that only a modest fraction of all NP time is being allocated to this potentially important part of the patient care spectrum. It is interesting to speculate about factors accounting for this result. It is possible that traditional patterns of NPP use persist (rather inflexibly) even as workload patterns have begun shifting toward extended care. It is also possible that present workload levels simply do not require (yet) a high percentage of NPP time allocated to extended care—but that this might change in future years as the veteran population continues to age. It should be noted, too, that if one adds the time the NP devotes to both nursing home and other extended care (14.5%) to the time devoted to intermediate care (18.0%) —consistent with the committee 's definition of long-term care—then roughly a third of all NP time is allocated to “long-term care.” Regarding the CNS, about 34% of all time is allocated to inpatient care and 43.1 to outpatient care—roughly similar to the way the NP divides time

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Physician Staffing for the VA: VOLUME II between these two categories. But compared with the NP, the CNS allocates much more time to psychiatry; about 11 % of total time is devoted to inpatient psychiatry and 25% of total time to outpatient psychiatry. Only about 5% of CNS time is devoted to extended care, while more than three times that amount (17.7% of total time) is spent on a variety of tasks (including teaching and administration) collected under the heading, Other (Nonclinical) Settings. Regarding the CRNA, the great majority of all time (not surprisingly) is allocated to inpatient surgery (87%). CRNAs rarely participate in outpatient care (1.6% of total time) or extended care (1.9%). Additional Perspectives on NPP Activities at the VAMC From Table 2 we infer that: Nonphysician practitioners are able to devote only a modest amount of time to teaching and research. The time allocated to teaching residents and other nonphysician personnel ranges from 6.2% for NPs to 9.4% for CRNAs. Research allocations are from 0.7 % for CRNAs to 6.7 % for CNSs. Altogether, the time devoted to both activities ranges from 7.0% for PAs to about twice that for CNSs. These answers do not distinguish time devloted to physician-sponsored and nurse-sponsored research. The latter may well comprise a significant portion of the total. With the exception of CRNAs, NPPs report little on-call duty, either at the VAMC or off site. CRNAs report spending about 8 hrs/wk on-call at the VAMC and an additional 30 hrs/wk on “stand by” call away from the VAMC. In a majority of the instances (60%) that the CRNA is on call, he/she is serving as first alternate to the physician. This is not the case for the other three categories on NPPs. PAs and CNSs report serving as first alternate for about 10% of on-call assignments, while NPs rarely perform this role. PAs and CRNAs are under direct supervision for about 15 hrs/wk; NPs, about 10 hrs/wk; and CNSs, about 4 hrs/wk.1 1   For the PA and CNS, these estimates square closely with the percentage of time under direct physician supervision that can be calculated, in a number of steps, from the responses to that portion of the NPP Questionnaire that allocates practitioner time across units/activities; and, within each, to the fraction of time devoted to physician-delivered services; and, within the latter, to the fraction of time the NPP is directly supervised by the physician (see Exhibit 1 of Appendix B).

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Physician Staffing for the VA: VOLUME II Ventura, M.R., Feldman, M.J., and Crosby, F. 1985. Nurse practitioners' perceptions of facilitators and constraints to practice. Report from Veterans Affairs Medical Center at Buffalo, NY. Identifies and explains conditions that serve either to constrain orfacilitate the use of NPs in the VA. Concludes that, on the whole, VA NPs experience more facilitation than constraint.

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Physician Staffing for the VA: VOLUME II APPENDIX B EXHIBITS EXHIBIT 1 Questionnaire for VA Nonphysician Practitioners (Physician Assistants, Nurse Practitioners, Certified Registered Nurse Anesthetists, and Clinical Nurse Specialists) Please Identify Your VAMC:____________________ In which of the following professions do you currently practice: Physician Assistant (PA) ____ Nurse Practitioner (NP) ____ Certified Registered Nurse Anesthetist (CRNA) ____ Clinical Nurse Specialist (CNS) ____ If you are currently practicing within a Veterans Affairs Medical Center as a PA, NP, CNS, or CRNA (nonphysician practitioner), please complete the remainder of this form. If not, please leave the rest of the form blank and return it to your Chief of Staff. For each of the service units or areas listed below, we are interested in three pieces of information: the percentage of your total work time spent there; for the time spent there, the percentage involved in physician-delivered direct care activities; and for the time spent in these direct care activities, the percentage of time under direct physician supervision:

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Physician Staffing for the VA: VOLUME II   Percentage of total work time (1) For the time spent in each unit or area below, please estimate the percentage of time in activities usually considered to be physician-delivered direct care (2) For the time spent in “physician-delivered direct care activities,” please estimate the percentage of time under “direct” (as opposed to indirect) supervision by a physician (3) Inpatient Care   Medical Service   Medical Ward _____% _____% _____% Intensive Care Unit _____% _____% _____% Coronary Care Unit _____% _____% _____% Neurology Service   Neurology Ward ____% ____% ____% Rehabilitation Medicine   Rehab Service Ward ____% ____% ____% Intermediate Care Unit ____% ____ % ____% Spinal Cord Injury Service ____% ____% ____% Surgery Service   Surgical Ward ____% _____% ____% Surgical Intensive Care Unit ____% ____% ____% Operating Room ____% ____% ____% Post Anesthesia   Recovery Room ____% ____% ____% Psychiatry Service   Psychiatry Ward ____% ____% ____% Alcohol/Drug Treatment Ward ____% ____% ____% Other Inpatient Care   Settings (please specify)   ___________ ____% ____% ____%

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Physician Staffing for the VA: VOLUME II   Percentage of total work time (1) For the time spent in each unit or area below, please estimate the percentage of time in activities usually considered to be physician-delivered direct care (2) For the time spent in “physician-delivered direct care activities,” please estimate the percentage of time under “direct” (as opposed to indirect) supervision by a physician (3) Outpatient Care   Emergency Room ____ % ____% ____% Admitting/Screening Area ____% ____% ____% Specialty Clinics   Medicine ____% ____% ____% Neurology ____% ____% ____% Rehabilitation Medicine ____% ____% ____% Spinal Cord Injury ____% ____% ____% Surgery ____% ____% ____% Compensation & Pension   Exam ____% ____% ____% Employee Health ____% ____% ____% Hospital-Based Home Care ____% ____% ____% Satellite Outpatient Clinic ____% ____% ____% Hemodialysis ____% ____% ____% Domiciliary ____% ____% ____% Other Outpatient Setting (please specify)   ___________ ____% ____% ____% ___________ ____% ____% ____%

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Physician Staffing for the VA: VOLUME II   Percentage of total work time (1) For the time spent in each unit or area below, please estimate the percentage of time in activities usually considered to be physician-delivered direct care (2) For the time spent in “physician-delivered direct care activities,” please estimate the percentage of time under “direct” (as opposed to indirect) supervision by a physician 3 Extended Care   Nursing Home Care Unit ____% ____% ____ % Other Extended Care Setting (please specify)   __________ ____% ____% ____% __________ ____% ____% ____% Other (Nonclinical) Setting (e.g., administration or teaching role) (please specify)   __________ ____% ____% ____% __________ ____% ____% ____% TOTAL 100%   Please note: Percentages in column (1) must total to 100%; this is not true for the other two columns.

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Physician Staffing for the VA: VOLUME II Considering your work on all of the units or areas above, please estimate the percentage of your total time involved in: ____ Teaching residents or other nonphysician practitioners. ____ Research. What is the average number of hours per week you work at your VA facility during a typical work week (in all capacities, but excluding on-call hours)? ____ Average Total Weekly Hours What is the average number of hours a week you spend on-call at the VA facility? ____ Average Weekly Hours On-Call At Facility What is the average number of hours a week you spend on-call not at the VA facility? ____ Average Weekly Hours On-Call Not At Facility When you are on-call at the VA facility, do you usually function: As a first alternate for the physician ______ Or, in some other capacity (please specify): _____________________________ _____________________________ _____________________________

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Physician Staffing for the VA: VOLUME II Approximately how many hours per week does a physician directly supervise your work? ____ Number of Hours Supervised By Physician For the physician supervision you do receive, please estimate the percentage of time that it occurs in each of the following formats (the percentage should add to 100%): ____ Time Performing Medical Procedures (please specify): ______________________________ ______________________________ ______________________________ ____ Time Checking with Physician Regarding Orders ____ Time in Other Formats (please specify): ______________________________ ______________________________ ______________________________ General comments:

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Physician Staffing for the VA: VOLUME II EXHIBIT 2 Questionnaire for Supervisors of VA Nonphysician Practitioners Please Identify Your VAMC:___________________________ Please complete the remainder of this form if you are currently a VA Staff Physician practicing within a Veterans Affairs Medical Center supervising one (or more) of the following Nonphysician Practitioners: Physician Assistant, Nurse Practitioner, Certified Registered Nurse Anesthetist, or Clinical Nurse Specialist. If not, please leave the rest of this form blank and return it to your Chief of Staff. Please estimate the average number of hours per week you spend in activities usually considered to be physician-delivered direct care activities. ___ Hours Per Week Which of the following Nonphysician Practitioners do you actively supervise: ___ Physician Assistant ___ Nurse Practitioner ___ Certified Registered Nurse Anesthetist ___ Clinical Nurse Specialist Approximately how many hours per week do you spend directly supervising Nonphysician Practitioners in the following four categories: ___ Hours Per Week for Physician Assistant(s) ___ Hours Per Week for Nurse Practitioner(s) ___ Hours Per Week for Certified Registered Nurse Anesthetist(s) ___ Hours Per Week for Clinical Nurse Specialist(s)

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Physician Staffing for the VA: VOLUME II For each Nonphysician Practitioner you supervise who takes “call” at the VA facility, please indicate how he/she functions: ___ As a First Alternate For You Or, in some other capacity (please specify): _____________________________________ _____________________________________ _____________________________________ For the physician supervision you provide, please estimate the percentage of time that it occurs in each of the following formats: ___ Overseeing the Performance of Medical Procedures (please specify): ______________________________ ______________________________ ______________________________ ___ Checking with NPP Regarding Your Orders ___ Other Activities (please specify): ______________________________ ______________________________ ______________________________ ___ TOTAL (%) General Comments:

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Physician Staffing for the VA: VOLUME II EXHIBIT 3 Questionnaire for Chiefs of Staff1 Chief of Staff:___________________ VAMC:__________ How does your VAMC set its policy regarding the use of nonphysician practitioners? What role do the state practice acts play? Should there be a national VA standard on the use of nonphysician practitioners or should these policies be set at the facility level? Why? Do physicians need more education about the use of nonphysician practitioners? How could that be accomplished at your facility? What potential roles can you envision for nonphysician practitioners in: Inpatient Care? Ambulatory Care? Long-Term (Extended) Care? What policies could the VA adopt that would help this potential to be realized? In the NPP questionnaire data received, we note that some nonphysician practitioners are indicating they spend time on the psychiatry service. At your facility, what psychiatry tasks or services are being provided by these practitioners? General comments. 1   For compactness, the term “nonphysician practitioner” is used throughout this exhibit. In fact, each chief of staff received four such (six-item) questionnaires, one each applicable to PAs, NPs, CRNAs, and CNSs.

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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 Nonphysician Practitioners Panel Roster HAROLD M.VISOTSKY (Chair),† Professor and Chairman, Department of Psychiatry and Behavioral Sciences, Northwestern University, and Director, Institute of Psychiatry, Northwestern Memorial Hospital, Chicago, Illinois MARJORIE BEYERS,† Associate Vice President for Nursing and Allied Health Services, Mercy Health Services, Farmington Hills, Michigan PAUL F.FLETCHER, Chief of Staff, Chillicothe VA Medical Center, Chillicothe, Ohio ERNEST W.JOHNSON,† Professor of Physical Medicine and Rehabilitation and Associate Dean for External Affairs, Ohio State University College of Medicine, Columbus A.WENDELL MUSSER, Chief of Staff, Atlanta VA Medical Center, Atlanta, Georgia J.WARREN PERRY,*† Professor and Dean Emeritus, School of Health Related Professions, State University of New York at Buffalo ROBERT R.RHYNE, Medical Center Director, Grand Junction VA Medical Center, Grand Junction, Colorado MARLENE R.VENTURA, Associate Chief, Nursing Service/Research, Buffalo VA Medical Center, Buffalo, New York CHERYL E.WOODSON,† Director, Fellowship Program in Geriatric Medicine, Pritzker School of Medicine, University of Chicago, Chicago, Illinois THOMAS A.ZAMPIERI, Physician Assistant, Surgical Service, Richmond VA Medical Center, Richmond, Virginia Bobbie J.Alexander, Staff Associate *Member of the Institute of Medicine. †Member of the study committee.