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

Bobbie J.Alexander

and

Joseph Lipscomb

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?

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.

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.

• 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.

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

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.

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.

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

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.

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:

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

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

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%).

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).

• For the CRNA, the majority of physician supervision (62.4%) relates to the performance of medical procedures. But for the PA and NP, the most common activity is checking with the physician regarding orders. For the CNS, about two-thirds of all supervision pertains to neither of these two major functions but occurs in “other” formats.

From Table 3 we infer that:

• Both the absolute amount of time and the fraction of all direct care time that the physician spends supervising the nonphysician practitioner vary significantly with the type of NPP supervised.

For the CNS and NP, the physician devotes only about 5.3 and 9.2 hrs/wk, respectively, to supervision; this corresponds to roughly 19% and 31% of the time the physician, in each case, allocates to direct care. For the PA, the physician engages in supervision for about half of the reported 33 hrs/wk spent in direct care. Physicians supervising CRNAs allocate about 39 hrs/wk to patient care, and about two-thirds of that also involves supervising the CRNA. Physicians working with various combinations of NPPs (e.g., PAs and NPs) are engaged in supervision for roughly 90% of their direct care time (24.2 hrs/wk).

• These surveyed physicians report their NPPs take first call (when on call) much more frequently than the surveyed NPPs report, on average, that they in fact take first call. (It is possible this discrepancy arises from varying interpretations of the pertinent questions from the two survey instruments.)

• Similarly, there was (at best) only a rough correspondence between how the NPPs apportioned direct supervision time among medical procedures, checking order, and other activities and how the supervising physicians reported this breakout. For some estimates, such as supervision of the CRNA in direct procedures, the results are quite close; for other estimates, including those pertaining to the CNS, there was little agreement. (The reasons for these differences are not directly inferable.)

In what follows we summarize the comments contributed by various chiefs of staff, NPPs, their supervisors, and individual members of this panel regarding four issues of central importance to the functioning of nonphysician practitioners in the VA. These issues are in fact framed by the four main questions included in the COS Questionnaire (see Exhibit 3 of Appendix B). Consequently, many of the responses presented below are from chiefs of staff; however, in responding to their own questionnaires, a number of NPPs (see Exhibit 1) and supervisors (see Exhibit 2) offered comments germane to the four questions. Moreover, in preparation for their final meeting (in December 1990), several panel members submitted written comments that bear directly on the issues examined here.

Many of the 34 surveyed COS responded briefly, sometimes vaguely, to the questions of how NPP policies were established at their VAMC. Specific

answers included: following pertinent VA circular; attempting to adhere to state medical practice acts (although in several cases it was specifically stated that these acts were generally confusing and failed to clarify whether and how they applied to a federal health system like that run by the VA); following what was loosely termed “VA guidelines,” which were often out of date or noninformative; using “scope of practice” information circulated by VA Central Office; and following local area/community standards for NPP use.

The majority of COS implied that the state practice acts play little, if any, role in the individual VAMC's policies on the utilization of these four practitioners. Many COS said the state acts were too restrictive and confusing. Specific responses included: “state practice acts play no role,” “state practice acts play very little role,” “state practice acts only used for licensing requirements and guidance on development of facility's functional statements,” “state practice acts are too generic,” “state practice acts are too restrictive,” “while facility is aware of the state practice acts, they do not play a role in any policy,” and “VA facility is a federal agency and therefore does not have to follow state practice acts.” Several COS were careful to note that their NPP policies violate neither the letter nor the intent of the practice acts.

Many COS implied that they worked jointly with the medical director, facility medical board, the individual facility service in which the NPP will be working, the physician supervisor, and the individual NPP to develop specific functional role statements and guidelines for practice.

A clear majority (21) of chiefs of staff responded that the VA Central Office should develop a national policy for these four NPPs. The VA should do more on a national level to support and encourage the appropriate utilization of NPPs, and this requires that Central Office clarify the scope of activities recommended for these practitioners, many COS implied. They urged that such policies clearly delineate the functional roles and responsibilities of NPPs and their physician supervisors. They favored a policy that would clarify the relationship between the provisions of the state practice acts, the practice standards of each NPP, and what is permissible inside a VAMC.

The majority view was well articulated by the COS of one facility: “The VA should develop a national policy which allows each individual facility to develop local protocols and privileges within the guidelines of the national directive—as different facilities have different needs. A national policy is needed that will

empower and encourage the use of these NPPs, with guidelines as to supervision.”

The majority of these COS favoring a national VA standard also advocated meaningful flexibility at the local level. That is, the national policy would specify basic requirements and general expectations, but each facility would tailor policies and procedures sensitive to specific local needs.

Overall, the seven chiefs of staff clearly not favoring a national VA standard contended that the local facility should be allowed to create the policies by which their respective NPPs practice.

In fact, all responding COS explicitly advocated flexibility in the application of any VA national policy at the facility level. It can be inferred that those COS expressing concern over a strong national policy were in fact concluding that it is unlikely such policies could be established while ensuring adequate local autonomy. Representative comments from the dissenting COS included: “The VA should not have a national policy because a VAMC needs it own flexibility, as the focus for utilization of each NPP differs from other facilities” and “The VA should not have a national policy because requirements and level of need are so varied from facility to facility.”

The NPP panel as a whole also stressed the need for a national policy on the use of these practitioners. Several panel members felt that appropriate responsibilities are not clearly delineated for either the NPP or the NPP physician supervisor, thereby affecting the appropriate utilization of these practitioners in a variety of ways within the VA system. Developing standard policies and practices across the system would benefit physicians, patients, the VAMCs, and NPPs as well.

Panel commentary included the following: “Different interpretations of regulations affect utilization and performance. The legal confusion over state laws and federal regulations deters effective utilization and management of these NPPs.” (Zampieri)

“Quite often these NPPs are used below their potential because of tenets of the various practice acts within the state in which the VAMC is located. Development of a national policy would help provide new insights about innovative ways that physicians and NPPs could work together. Currently, there is a lack of clarity about the scope of NPP use and practice across facilities.” (Woodson)

“The VA system does not clearly and uniformly define the roles of NPPs. It is not clear how much the physician's specialty area influences selection and use. There may be some local area norms for employment or non-employment.” (Woodson)

“There is wide variation in the interpretation of the role of NPPs, and a national policy would help to clarify scope of practice and supervision requirements. Current state regulations and licensing arrangements create wide differences in the use of NPPs within the VA system.” (Visotsky)

Two other panel members (Byers and Rhyne) also commented that a national policy is needed because quite often the decision to utilize these practitioners is based on the will of the local physician leadership (which may not have extensive experience with NPPs) or the state practice acts (which are often not understood). The former factor is frequently influenced by the medical practice “culture” of the local geographic area, as well as the proximity of facilities with strong (or weak) NPP programs. (Byers) It is important to note that some of the variability in physician use of NPPs can likely be explained by real differences in the experience and training of NPPs across sites. (Johnson)

But several panel members emphasized that, while a national VA policy for these four NPPs is needed, each facility should also encourage the physician supervisor to further train and assist the NPP in the development of his/her practice skills, thereby establishing a better understanding and level of trust between the NPP and his/her supervisor. Within a national policy, it is important that the individual VAMC have the flexibility to tailor the use of NPPs in response to the skill levels of the NPP and physician supervisors, as well as to local patient care needs. (Musser)

The majority of responding COS felt that they, as well as their staff physicians, needed education about the appropriate use of NPPs. A number of approaches were suggested, but a dominant response was that a facility should develop an ongoing in-service program. Several COS suggested that all new staff physicians be formally oriented to the role and utilization of NPPs at that facility. A few COS noted that some nonphysician staff also needed educational sessions on this topic.

The majority view was well summarized by the COS at one RAM Group 5 VAMC: “Physicians do need more education as to the use of these NPPs.

Initially, this education should begin with the COS, medical center directors, and those responsible for policy development. Service chiefs and supervising physicians should also be included. Eventually, educational sessions should be provided for all staff.”

Several chiefs of staff noted that education about NPPs would be especially useful to the more senior COS who had never worked directly with these practitioners and whose viewpoints, therefore, were based more on assumption and hearsay than on first-hand experience.

A few chiefs of staff who did not employ many of these NPPs at the time of the survey stated nonetheless that they wanted their physicians to have the chance to work with these practitioners so that the physicians could learn first-hand about the skills and potential roles of the NPP.

A few of the COS who responded that formal education was not needed contended that those physicians involved in the training of the NPPs had a clear idea of the skill and competence level of each practitioner.

Interestingly, two COS asserted that the four NPPs being studied here could perform only nursing practice methods and therefore should be involved solely in nursing practice assignments. Neither of these COS appeared to be familiar with the various current roles played by PAs, NPs, CRNAs, and CNSs.

Several of the responding COS did indicate that physician education regarding the use of the CRNA was probably less critical than for the other four categories of NPP. That is, they felt that many surgeons and anesthesiologists are already well acquainted with the CRNA.

A few of the COS responded that funds for continuing education are needed to allow these practitioners to maintain competence and up-to-date knowledge. Not only should funds be established, but these practitioners should be supported and encouraged in this effort, it was argued.

Roughly speaking, most of the COS responding negatively to this question implied that the appropriate use of NPPs was dependent upon the particular VA setting.

A persistent theme in both the NPP and the supervisor responses was that all staff need to be better educated about the present and potential roles of these NPPs.

Three panel member commented that, quite often, the medical staff is conservative in their use of NPPs because they are unfamiliar with the training, experience, and skill level of the practitioner. (Visotsky, Woodson, and Beyers) That VAMCs tend to be conservative in their employment and development of NPPs was a theme sounded by several other panel members, as well. In many facilities, the COS is unfamiliar with these practitioners—and the training and skills required of each—which leads to their underemployment and stifles opportunities for their innovative use in nontraditional settings.

“Education of medical center directors and chiefs of staff on the utilization of these practitioners is greatly needed throughout the VA system.” (Zampieri)

One panel member noted that, “if the episodes of care and treatment regimens are clearly delineated, specific roles and patterns of care can be defined. Specific roles, once defined, can lead to progressive training curricula and training programs, supporting the appropriate utilization and even innovative utilization of these NPPs.” (Visotsky)

Another member suggested that the VA examine the current use of these NPPs in order to decide what is working and why. A system should be designed to better relate continuity of care and quality of care. A process should be established for evaluating NPP matters in ways that can lead to generalizable findings and new designs. This panel member also recommended that VAMCs work with educational institutions to design a better fit between the education of these practitioners and the practice opportunities. (Visotsky)

One panel member (Ventura) offered specific recommendations on how to close the “knowledge gap” about NPPs: (1) key staff at each VAMC should be educated about the preparation and utilization of NPPs; (2) Central Office should issue a circular describing the role, responsibilities, and utilization of each of these NPPs in the system; (3) individual VAMCs should be creative in looking for effective methods to provide health care to VA patients by utilizing the different NPPs in innovative roles; and (4) each category of NPP should be included in an established staffing guidelines system that is updated regularly, so that these practitioners do not fall between the cracks in the system.

Most COS responded specifically to these questions for three of the four NPPs (PAs, NPS, and CRNAs). Several respondents noted that the PA and NP are often interchangeable in any of these three settings and function most of the time as physician extenders. The COS at one VAMC facility stated that these two types of practitioners could provide follow-up care on stable chronic patients in both inpatient and ambulatory care settings. Six COS also noted that these two types of practitioners, with appropriate physician supervision, could readily take over the patient history and physical examinations in any of the three settings. The PA or NP could provide follow-up and daily care after initial assessments, the COS at one VAMC facility said.

As the COS at another VAMC facility wrote: “These NPPs are a valuable resource and are underutilized. With the increased VA patient population and the demand for care, NPPs could be utilized in many of the ambulatory care settings, as clinical resources for specialty areas, and more extensively in extended care settings.”

Virtually all responding COS supported the use of NPPs in inpatient settings, and a number gave detailed responses about routine as well as innovative ways these practitioners could be further deployed in ambulatory and long-term care settings.

Quite a few NPPs said they feel underutilized in the VA system, given their training and task potential. Many also feel the medical staff does not really understand what services they could provide—physicians hire them, but then seem unwilling to allow them to practice their profession. The NPPs noted that the VA should take advantage of their training and experience rather than being so restrictive. Many PAs also urged the VA to allow them to write perscriptions, under properly defined circumstances. These PAs noted it is very frustrating and inefficient for the patients to wait for a physician's signature on routine prescriptions (as they now must do).

Supervisors were generally pleased with the quality of care rendered by NPPs and urged the VA to consider expanding their use, particularly in long-term care. Most indicated that competent physician supervision is essential. Some supervisors noted that these practitioners could be utilized more frequently in mental health, ambulatory care, and long-term care than at present.

There should be, and likely will be, an expansion of the NPP's role in the VA of the future, most panel members noted. “In the future there will be consideration given to increasing utilization of these individuals as health care reorganizes to provide more efficient and effective patient care services. All four of these practitioners (as well as other NPPs) could play a unique and valuable role in providing health care to veterans and to the public as a whole. In some cases, physicians depend a great deal on the judgment and activities of these NPPs and if they are not available there is a great void. ” (Visotsky) It is important, however, that the impact of NPPs on process and outcome measures on the quality of care be continuously monitored. (Johnson)

The research literature supports the claim that NPPs, particularly PAs and NPs, can be used effectively and productively in outpatient and long-term care (as well as inpatient) settings in a wide variety of functions, especially in primary care. (Zampieri and Beyers)

To pave the way for promoting the innovative use of NPPs, the VA should communicate openly and actively with state practice groups and legislative bodies.

The nonphysician practitioners panel's views are summarized below.

The panel believes that the degree to which these four types of NPPs are utilized has a direct effect on physician requirements. Therefore, the panel urges the VA to account more precisely for the influence of these NPPs, in both

the empirically based and the expert judgment approaches to physician staffing, by incorporating the following:

• For the empirically based models, the VA should establish CDR cost centers for each of these NPPs.

  At present, the total FTEE of each type of NPP is available at the facility level but is not allocated across PCAs. If each of these NPPs was given a designated CDR cost center—as is the case presently for physicians (by specialty), nurses, psychologists, and social workers—it would be possible to analyze them explicitly in the PF variants of the empirically based models. At present, these NPPs are reflected (indirectly) in the PF equations only through their inclusion in the SUPPORT/MD and NURSE/MD variables, as noted earlier.

• For the expert judgment models, NPPs are already explicitly included. However, in subsequent versions of the SADI and the DSE that the VA may choose to create, these NPPs should be recognized with greater specificity. In particular, the assumed number of each NPP in every patient care area of the VAMC should be specified in these staffing instruments.

From the analysis of the NPP survey data and commentary, the panel concludes that the utilization of these practitioners is more dependent on the attitudes and knowledge of individual physicians than on the training and the clinical skill level of the NPP. Before the VA can utilize NPPs in an efficient manner consistent with quality care, education programs for VA physicians must be established. The committee recommends that these be conducted on an ongoing basis, first with a centralized program for senior VA management staff, then with programs established at every VAMC. These programs would be most effective in conjunction with a national policy for appropriate NPP use, as recommended below.

To support this recommendation for continuing education, the panel recommends that the VA also

• Pursue and establish, wherever possible, academic affiliations with NPP training programs. Not only would this provide physicians with first-hand experience with the strengths and limitations of these practitioners, it would stimulate NPP recruitment.

• Require and actively support the participation by NPPs in their own continuing education. The panel feels that this would allow the NPP not only to maintain current skills, but to learn new techniques within any given specialty or setting. This would permit the NPP to continue to benefit from the clinical expertise within the VA, so that the quality of care they render will continue to improve. But by also encouraging the NPP to pursue education and training at outside sites, the VA would establish a mechanism that allows staff physicians to learn (indirectly) about innovative uses of NPPs. This will, over time, increase physician confidence in these practitioners.

The panel understands that such affiliation and continuing education programs now exist in various forms at some VAMCs. The panel recommends that the VA explore their expansion to all sites.

Because physician knowledge and attitudes regarding NPPs vary greatly across (and even within) VAMCs, there is wide variation in the activities actually performed by NPPs. This view was underscored by the survey results discussed earlier in this chapter.

From these, the panel concludes that much of this variation in NPP use is due to variations in a facility's or a physician's interpretation of the NPP role, response to various state regulations and licensing arrangements, and the quality of organized supervision. An underlying factor is the absence of a comprehensive VA national policy that establishes clear guidelines for all NPPs.

For PAs and CRNAs, national guidelines presently exist that serve to define their general scope of practice by listing specific permissible functions. The activities that may be delegated to the individual NPP are, in fact, determined entirely at the VAMC level by its clinical executive board. This board approves the specific terms of the clinical privileges held by each practicing NPP at the facility. The committee applauds the efforts undertaken thus far to establish national guidelines for these two NPPs, especially the relatively detailed policies developed for PAs.

The panel urges the VA to develop explicit national policies on the appropriate use of all NPPs through a careful evaluation of existing evidence on the efficiency and quality of their clinical practice and appropriate utilization according to national standards of practice. These policies should be reviewed

and revised periodically, should be consistent across the system, and should permit individual VAMCs the flexibility to tailor their use of NPPs to local conditions, including special patient groups, in ways that promote the quality and efficiency of VA health care.

National VA policies for each NPP should establish explicit guidelines for the practitioner's potential roles, responsibilities, and appropriate utilization in the VA system. The policies should encourage the appropriate use of NPPs by explicitly addressing, for each type of NPP, a range of expected requirements: training and skill level, continuing education for the NPP, physician supervision, peer review, continuing education for staff physicians, and administrative procedures for allowing certain practitioners with advanced training and experience to perform advanced functions under physician supervision.

For each type of NPP, the national guidelines could include a specific list of functions for which there is evidence, in each case, that a well-trained and supervised practitioner can render care of appropriate quality. The national guidelines would also provide each facility with the autonomy to determine additional functions, such as drug prescribing, which could be performed by NPPs with specific levels of training and experience. These additional functions would be performed under physician supervision and could, in addition, require the establishment of a specific supervisory structure (e.g., team conferences, protocols) to monitor the quality of care. The credentialing and privileging mechanism at each VAMC would be structured to accommodate this national guidelines policy.

The aim here is to promote a strong, explicit, and coherent VA national policy on NPP use, while preserving the concept that individual VAMCs have both the autonomy to explore innovative uses of NPPs and the responsibility to ensure that the quality of care is assured through appropriate supervision.

In the course of establishing these policies, the VA should seek to clarify whether the “federal enclave” doctrine exempts the individual VAMC from the clinical provisions of its state medical practice act, so that each may establish unambiguously its own NPP practice policies under guidance from VA Central Office. Once this principle is ruled upon, the VA will be in a stronger position to promulgate its own positions on advanced uses of NPPs that are currently forbidden by many states.

As knowledge about the appropriate and effective use of NPPs continues to grow, the VA should periodically and thoroughly review its national policies on the use of these practitioners.

As analyses emerge indicating that specified functions can be performed efficiently by NPPs with anticipated loss in quality (and perhaps even an improvement, as some literature suggests), the VA should incorporate these

functions in its guidelines. This information should be communicated promptly to chiefs of staff, service chiefs, and clinicians (to the latter through the continuing education programs recommended above). Similarly, when the weight of evidence indicates that the NPP's performance of a function does not promote efficiency or quality, the function should be removed from the guidelines.

The importance of this recommendation is that these guidelines (as they are updated over time) are expected to be a major factor in the determination of the privileges accorded by the VAMC to each practitioner.

The panel concludes that much was learned from the NPP surveys. A number of particular research questions have been suggested, and these should be pursued by the VA in broader-scale analyses.

The panel recommends that the VA establish research projects to examine extensively the different systemwide uses of nonphysician practitioners. These projects should focus particularly on the NPPs impact on cost and the quality of care. These future studies need not be limited to VA NPPs and supervisors as was this initial effort. There is much to be learned from the extensive use of NPPs in both the public and private sectors, in the United States and abroad. This will be all the more the case in the years ahead as innovative managed care models are adopted.

At present, there are numerous opportunities to observe NPPs in various settings, for various functions, in varying degrees both inside and outside the VA. The VA should take advantage of these “natural experiments ” to evaluate the appropriate (and inappropriate) uses of NPPs under a variety of practice conditions.

As evidence from these evaluations accumulates over time, the VA's ability to establish appropriate NPP policies will be greatly enhanced.

Alexander, R., Bartee, L., Brown, N., Forbes, L.A., Grier, C., Leclair, J., Lee, J., Portt, J., Stewart, C.T., Walters, P., and Ward, S.June 1984. PAs: Stitching the seams of the hospital system. VA Practitioner 1(6):81–83. Identifies and evaluates responsibilities assigned to PAs at the AugustaVAMC; concludes that PAs have become a “pervasive” and “indispensable” factor in the delivery of care there.

Becker, D.M., Fournier, A.M., and Gardner, L.B. 1982. A description of a means of improving ambulatory care in a large municipal teaching hospital: A new role for nurse practitioners. Medical Care 20:1046–1050.

Bissonette, D. 1989. Hospital privileges and PAs: Principles and practices. Journal of the American Academy of Physician Assistants 2(2):132–135. Although PAs are widely used in hospital settings, their roles are not always clearly and formally delineated; this should be done both for the legal protection of the facility and the PA and to enhance understanding of the appropriate use of these practitioners.

Breslau, N., Novack, A.H., and Wolf, G. 1978. Work settings and job satisfaction: A study of primary care physicians and paramedical personnel. Medical Care 16:850–862. In modern medical settings, satisfaction with work activity, coworkers, and income is generally lower than in traditional practice settings. Only with respect to income were primary care physicians more satisfied than paramedical personnel.

Buchanan, J.L., Kane, R.L., Garrard, J., Bell, R.M., Witsberger, C., Rosenfeld, A., Skay, C., and Gifford, D. 1989. Results from the Evaluation of the Massachusetts Nursing Home Connection Program. Rand/University of Minnesota School of Public Health/Boston University School of Public Health. Unpublished. To examine the cost and quality-of-care implications of using PAs and NPs in nursing homes, this study compares physician-only care to that provided by MD/NP/PA teams. Concludes there is no statistically significant difference in performance between the two staffing approaches, although the direction of results suggest a possible cost-effectiveness advantage for the MD/NP/PA provider groups. More than three-quarters of the nursing home directors interviewed favored the MD/NP/PA groups over the traditional physician-only approach.

Crandall, L.A., Santulli, W.P., Radelet, M.L., Kilpatrick, K.E., and Lewis, D.E. 1984. Physician assistants in primary care—patient assignment and task delegation. Medical Care 22(3):268–282From data on office encounters with physicians and PAs reported by 16 primary care private practices in Florida, analyzes the types of patients most frequently assigned to the PA, the tasks performed, and the supervision received.

Cawley, J.F. 1986. The cost effectiveness of physician assistants. Washington, D.C.: American Academy of Physician Assistants. Argues for increased delegation of tasks to PAs and better integration of PAs into physician practices.

Cawley, J.F. 1985. The physician assistant profession: Current status and future trends . Journal of Public Health Policy 6(1):78–99. After reviewing the development of the PA concept in the United States, examines existing policy barriers hindering the cost-effective use of PAs, including uneven and restrictive state medical practice acts.

Cromwell, J., and Rosenbach, M. 1980. The impact of nurse anesthetists on anesthesiologist productivity . Medical Care 18:609–623.

Cromwell, J., and Rosenbach, M. 1980. The impact of nurse anesthetists on anesthesiologist productivity . Medical Care 18:609–623. From original survey data on anesthesiologist productivity—defined in terms of patients, anesthesia hours, and revenues—concludes that supervising nurse anesthetists can raise practice productivity at least 20 percent, after allowing for downtime and scheduling problems. Extrapolates from findings to estimate that greater delegation to nurse anesthetists could save $500 million annually. These potential productivity gains have not been realized because of restrictive third-party reimbursement policies that discourage both hospitals and physicians from utilizing the nurse anesthetist.

Davidson, R.A., and Lander, D. 1984. Nurse practitioner and physician roles: Delineation and complementarity of practice. Research in Nursing and Health 7:3–9. The handwriting is on the wall: nurse practitioners are saying to U.S. physicians, “In your face!” Physicians respond that remarks are “off the wall.”

Draye, M.A. and Stetson, L.A. 1975. The nurse practitioner as an economic reality. Nurse Practitioner 1(2):60–63. Based on detailed examination of NPs in one clinic setting, concludes that greater use of these practitioners would improve quality of care and lower costs. Urges much broader study of this issue.

Fottler, M.D. 1982. Manpower utilization practices in physician offices: the role of physician extenders. Journal of Health and Human Resources Administration 5:159–185. Analyzes mechanisms by which greater use of physician assistants and nurse practitioners could improve access to primary medical care while dampening the rate of increase in costs.

Gambert, S.R., Rosenkranz, W.E., Basu, S.N., Jewell, K.E., and Winga, E.R. 1983. Role of the physician extender in long-term care settings. Wisconsin Medical Journal 82:30–32. Defines and contrasts the roles that may be played by physician assistants and nurse practitioners in providing patient care in nursing homes and other long-term care sites.

Glenn, J.K., and Goldman, J. 1975. Task delegation to physician extenders—some comparisons. American Journal of Public Health 66:64–66. Describes results from survey to investigate the ranges of appropriate task delegation to physician assistants and nurse practitioners, particularly in ambulatory care settings.

Goldberg, G.A., Jolly, K.M., Hosek, S., and Chu, D.S.C. 1981. Physician extenders' performance in Air Force clinics. Medical Care 19:951–965. Empirical analyses indicate that for a substantial portion of patients now treated by physicians in Air Force primary medicine clinics, care of comparable quality could be provided by physician assistants and nurse practitioners.

Golden, A.S., and Cawley, J.F. 1983. A national survey of performance objectives of physician's assistant training programs. Journal of the American Medical Association 58:418–424. Offers indepth picture of the particular tasks and overall performance levels expected of graduates of the nation's PA training programs, based on responses to a nationwide survey of these programs.

Hershey, J.C., and Kropp, D.H. 1979. A re-appraisal of the productivity potential and economic benefits of physician's assistants. Medical Care 17:592–606. From a critical review of earlier studies, concludes that the potential of the PA to boost medical practice productivity and net income may frequently be overestimated because physician supervisory requirements are underestimated.

Hooker, R.S., and Freeborn, D.K. 1989. The utilization of PAs in a managed health care system. Center for Health Research, Kaiser Permanente Northwest Region, Portland, OR. Unpublished. At Kaiser Permanente, PAs and NPs make up 20 percent of the primary care staff and write 25 percent of the prescriptions for members of this large health maintenance organization. The cost of a PA ranges from 25–53 percent of the equivalent cost of a primary care physician, depending on assumptions. PAs are capable of providing care for 86 percent of the diagnoses seen in Kaiser's outpatient primary care settings while maintaining high patient acceptance.

Kane, R.L., Garrard, J., Buchanan, J.L., Rosenfeld, A., Skay, C., and McDermott, S. 1991. Improving primary care in nursing homes. Journal of the American Geriatric Society 39:359–367. Examines the impact of NPs and PAs on the delivery of primary care to nursing home patients when the limits are removed on the number of reimbursable visits per month. Cost analyses suggest that these practitioners may lead to a net dollar savings; such production efficiencies would likely increase with the sustained use of these extenders in nursing homes.

Mendenhall, M.C., Repicky, P.A., and Neville, R.E. 1980. Assessing the utilization and productivity of nurse practitioners and physician's assistants: Methodology and findings on productivity . Medical Care 18:609–623.

McGrath, S. 1990. The cost-effectiveness of nurse practitioners. Nurse Practitioner 15:40–42. Summarizes ways in which NPs can be used to reduce the cost, increase the quality, and extend the availability of health care services.

Mezey, M.D., and Lynaugh, J.E. 1989. The teaching nursing home program: Outcomes of Care. Nurse Clinicians of North America 24:769–780. Analyzes the rationale and findings of an innovative demonstration project in which 11 schools of nursing collaborated with 12 nursing homes to upgrade the quality of clinical care through greater use of the NP.

Nelson, E.C., Jacobs, A.R., and Johnson, K.G. 1974. Patients' acceptance of physician's assistants. Journal of the American Medical Association 228:63–67. In a survey of patients from physician practices where PAs are used extensively, these practitioners were highly rated, in general; the most important determinants of individual patient ratings were the patient's age, socioeconomic class, and perceived access to medical care.

Office of Technology Assessment. 1986. Nurse Practitioners, Physician Assistants, and Certified Nurse-Midwives: A Policy Analysis. Health Technology Case Study No. 37. Washington, D.C.: U.S. Department ofCommerce, National Technical Information Service . Reviews the evolution of these NPPs and discusses how changes in the health care environment have altered the forces that spurred the development of these practitioners. Analyzes obstacles to the use of NPPs, including unsupportive physicians, restrictive state medical practice acts, costly and frequently inaccessible malpractice insurance, and the unwillingness of third-party payers to cover services performed by NPPs.

Perry, H.B., Detmer, D.E., and Redmond, E.L. 1981. The current and future role of surgical physician assistants: Report of a national survey of surgical chairmen in large U.S. hospitals . Annals of Surgery 193:132–137. Two-thirds of the surveyed surgical chairmen felt that the introduction of PAs had improved surgical care at their institution. Appropriately trained and supervised surgical PAs will play an increasingly important role in improving the quality of patient care and, by functioning as “junior” house staff, may make it possible to reduce the overall number of surgeons being trained.

Perry. H.B., and Breitner, B. 1982. Physician Assistants: Their Contribution to Health Care New York: Human Sciences Press. Reviews and assesses the physician assistant concept, the development of the PA in the United States, and policy issues affecting the future of these practitioners.

Prescott, P.A., and Driscoll, L. 1980. Evaluating nurse practitioner performance. Nurse Practitioner 5:28–32. The most common interpretation from a number of studies that evaluated NP performance is that, for a range of selected functions, there is little difference between these practitioners and the physician.

Record, J.C., and Greenlick, M.R. 1975. New health professionals and the physician role: An hypothesis from Kaiser experience. Public Health Reports 90:241–246. Physician attitude is the critical factor determining the extent to which, and the way in which, NPPs will be used. However, little attention has been given to a key influence on physician receptivity to PAs and NPs: whether the particular services they would perform are perceived by physicians as being role elevating or role threatening. Studies should be initiated to explore further this hypothesis.

Romeis, J.C., Schey, H.M., Marion, G.S., and Keith, J.F. 1985. Extending the extenders: Compromise for the geriatric specialization-manpower debate. Journal of the American Geriatrics Society 33:559–565. A significant portion of the tasks and services required by older adults in an urban clinic setting could be delegated to physician extenders with no adverse effect on the quality of care. Rather than developing a new physician specialty to handle such patients, policymakers should promote the use of appropriately trained and supervised physician extenders.

Sackett, D.L., Spitzer, W.O., Gent, M., and Roberts, R.S. 1974. The Burlington randomized trial of the nurse practitioner: Health outcomes of patients. Annals of Internal Medicine 80:137–142. NPs proved to be a safe and effective provider of primary clinical services.

Salkever, D.S., Skinner, E.A., Steinwachs, D.M., and Katz, H. 1982. Episode-based efficiency comparisons for physician and nurse practitioners . Medical Care 20:143–153. Introduces episode-based approach for comparing the efficiency of NPs and physicians in primary care. Episodes in which the NP was the initial provider were 20 percent less costly than those with the physician as initial provider. Based on a limited amount of patient-reported data on effectiveness, it appears that while NPs were less costly than physicians, they were not perceived as less effective.

Schuman, E. 1978. Physician assistant. Journal of the Kansas Medical Society 79:66–67. First-hand account of the training and primary care practice experiences of one PA, focusing on the perceptions and reactions of patients, staff, and physicians.

Simborg, D.W., Starfield, B.H., and Horn, S.D. 1978. Physicians and non-physician health practitioners: The characteristics of their practices and their relationships. American Journal of Public Health 68:44–48. The skills of physicians and NPPs are potentially complementary and not fully exploited.

Sonntag, V.K.H., Steiner, S., and Stein, B.M. 1977. Neurosurgery and the physician assistant. Surgical Neurology 8:207–208. Analyzes the potential role of PAs in policies to reduce the number of neurosurgeons being trained. Reviews evidence that surgical PAs can function effectively. If the number of residents are to be reduced, adequate staffing can be maintained by increased use of PAs, thus allowing each resident to spend more time training in the O.R.

Spisso, J., O'Callaghan, C., McKennan, M., and Holcroft, J.W. 1990. Improved quality of care and reduced house staff workload using trauma nurse practitioners. Journal of Trauma 30:660–665. Because of increasing burdens on surgical house staff, NPs were introduced into the trauma service at the University of California at Davis. In response, the average length of stay of seriously ill patients declined (while remaining the same for other patients), documented measures of the quality of care increased dramatically, house staff time was economized, and NPs were well received by the trauma team and staff.

Sturmann, K.M., Ehrenberg, K., and Salzberg, M.R. 1990. Physician assistants in emergency medicine. Annals of Emergency Medicine 19:304–308. Examines the concept of using PAs in the emergency room and the concerns of physicians in this regard, including fears of increased malpractice risk. Although the well-trained emergency physician remains the “gold standard” for quality patient care, the PA can provide cost-effective care for certain patient complaints.

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.

Please Identify Your VAMC:____________________

1. 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.

2. 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:

3. 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.

4. 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

5. What is the average number of hours a week you spend on-call at the VA facility?

   ____ Average Weekly Hours On-Call At Facility

6. 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

7. 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):

   _____________________________

   _____________________________

   _____________________________

8. Approximately how many hours per week does a physician directly supervise your work?

   ____ Number of Hours Supervised By Physician

9. 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):

   ______________________________

   ______________________________

   ______________________________

10. General comments:

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.

1. 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

2. Which of the following Nonphysician Practitioners do you actively supervise:

   ___ Physician Assistant

   ___ Nurse Practitioner

   ___ Certified Registered Nurse Anesthetist

   ___ Clinical Nurse Specialist

3. 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)

4. 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):

   _____________________________________

   _____________________________________

   _____________________________________

5. 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 (%)

7. General Comments:

Chief of Staff:___________________ VAMC:__________

1. How does your VAMC set its policy regarding the use of nonphysician practitioners?

   What role do the state practice acts play?

2. Should there be a national VA standard on the use of nonphysician practitioners or should these policies be set at the facility level?

   Why?

3. Do physicians need more education about the use of nonphysician practitioners?

   How could that be accomplished at your facility?

4. What potential roles can you envision for nonphysician practitioners in:

   1. Inpatient Care?

   2. Ambulatory Care?

   3. Long-Term (Extended) Care?

      What policies could the VA adopt that would help this potential to be realized?

5. 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?

6. General comments.

Committee to Develop Methods Useful to the Department of Veterans Affairs in Estimating Its Physician Requirements

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