Physician Staffing for the VA Volume I (1991) / Chapter Skim
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6 - CHOOSING AMONG ALTERNATIVE APPROACHES TO DETERMINING PHYSICIAN STAFFING
6 - CHOOSING AMONG ALTERNATIVE APPROACHES TO DETERMINING PHYSICIAN STAFFING
Pages 221-298
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From page 221... ...
. A third approach also discussed in that chapter would involve using non-VA physician staffing criteria, or external norms, for guiding the decision about physician requirements in the VA.
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From page 222... ...
For example, the core of the methodology could be an empirically based model, but expert panels would be appointed to evaluate results. Or, the core of the methodology could be an expert judgment approach, for example, based on the SADI, but these judgments would be tempered by reference to external norms and the results from the EBPSM.
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From page 223... ...
TO RECONCILIATION STRATEGY Committee's Recommended Approach As an overall framework for determining VA physician requirements (given workload and other factors) , the committee endorses Strategy D.2, the "disaggregated weighted-average" variant of D
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From page 224... ...
It is the component for which there is the greatest amount of empirically based and expert judgment information. However, for completeness, it is important that all FTEE components be reflected in Equation 6.1.
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From page 225... ...
At the extremes, the Modifier can dominate entirely or have no influence at all, as discussed shortly. This articulation of the Reconciliation Strategy reflects the committee's view that there are clear advantages, organizational and methodological, to building a physician requirements methodology around the EBPSM if the important statistical and clinical assumptions are met.
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From page 226... ...
That is, it is possible for the Empirically Driven Baseline FTEE recommendation to be either greater or less than the current FTEE allocation, and likewise for the Modifier's recommended level. An underlying assumption is that EBPSM, expert judgment-based models, and external norms are all ~advisory" to the VA decision maker.
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From page 227... ...
As the analyses by the specialty and clinical Note that the physician FTEE levels emerging at any moment from the EBPSM and the expert judgment models are contigent on assumptions about the prevailing FTEE levels for nurses and other nonphysician personnel. If the FTEE levels for these nonphysicians are assumed to change, for whatever reason, calculated physician requirements may change accordingly.
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From page 228... ...
In such instances, a policy of phasing in these FTEE targets permits the decision maker to achieve feasible, incremental changes in physician staffing. For example, if there are now 8 FTEE physicians in a specialty and the Reconciliation Strategy target level is 12, the VA decision maker might judge that an appropriate intermediate target is 10 FTEE, to be achieved (say)
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From page 229... ...
Such evidence is critical in the development of a dynamic VA physician requirements methodology one that evolves and improves over time. Using the Reconciliation Strategy to Calculate Physician FIEE Among the responsibilities assigned by the committee to each of its eight specialty and clinical program panels, the final and arguably most difficult was to render advice on three related issues: · From the perspective of the specialties or VA program areas represented by the panel, is the committees proposed Reconciliation Strategy a viable and appropriate mechanism for determining physician requirements?
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From page 230... ...
Thus, when determining physician requirements under PF, the resident education FTEE applicable to a given specialty at a given facility must be added in separately; a reasonable approach is to use the most recently available estimate from the facility's CDR (see chapter 4~.
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From page 231... ...
is estimated separately; there is an effort to keep these FTEE distinct from those devoted to patient care and resident education. Miscellaneous Other Staff Physician Activities There are a few CDR line items (e.g., District, Regional, or National Support)
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From page 232... ...
The procedure for upwardly adjusting expert judgment-derived FTEE to allow for annual leave is as follows: Suppose the derived total for all missionrelated activities is T and thatf is defined as above. The adjusted total FTEE for full-time physicians isJT/~1 - 0.12~.
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From page 233... ...
The patient care and resident education FTEE estimates from the expert judgment models are intended to be comprehensive assessments of physician requirements, irrespective of the particular mix of VA staff and contract physicians. (In fact, the SADI and DSE instruments purposely never distinguish between these two.)
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From page 234... ...
under either expert judgment approach refer expressly to physician support desired, as a quality enhancement, over and above that required to meet day-to-day patient care and teaching responsibilities. Given the logic of the staffing exercises, to add these desired non-VA FTEE to the quantity already asserted as the total for patient care and resident education may serve to overstate physician requirements.
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From page 235... ...
The six specialty and two clinical program panels have demonstrated on a small scale the types of analyses that the VA decision maker ought to undertake to determine physician requirements across the system for this important component of FTEE. For each VAMC studied in depth, the current physician staffing level (including physician FTEE not in the CDR)
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From page 236... ...
A study of the panel analyses suggests the following technical points germane to future applications of the Reconciliation Strategy: · The PF and the IPF are potentially complementary variants of the EBPSM (see chapters 4 and 79, and either is a viable candidate for helping generate the Baseline estimate for patient care, resident education, administration, and leaves in Equatio'' 6.1. The PF allows physician FTEE to be derived by PCA within the VAMC, while taking explicit account of the productive contributions of residents and nonphysician personnel.
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From page 237... ...
Reevaluating and revising the SADIs periodically would also require data analyses involving experts, but the overall resource commitment by the VA would be far less than with the DSE approach (see chapter 5~. Consistent with the views of virtually all of its specialty and clinical program panels, the committee recommends the following: The VA, without delay, should apply the SADIs either across the board or to a representative sample of VAMCs; analyze the results; revise the instruments on the basis of what is learned; reapply the SADIs to VAMCs across the system; and, finally, integrate the resulting FTEE estimates into a Reconciliation Strategy-based assessment of physician requirements via Equation 6.1.
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From page 238... ...
Not all factors pertinent to staffing at a given VAMC will be incorporated, and there is no built-in safeguard to detect or correct many data measurement errors. Thus, it is important that the VA decision maker be alert to idiosyncratic factors affecting physician requirements.
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From page 239... ...
Staff Physician FIEE for Continuing Education Continuing education for staff physicians should be an important component of any VA quality assurance program. The committee therefore recommends that a certain minimum amount of FTEE for continuing education be expected for all- specialties at all VAMCs.
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From page 240... ...
If one regards these minimums as "expert judgment" driven, then it is as if d = 1 in Equation 6.1. EXTERNAL NORMS Without exception, the specialty and clinical program panels concluded that the non-VA staffing criteria developed in this study were of limited usefulness in determining VA physician requirements.
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From page 241... ...
Only for these facilities are there, via the panel analyses, estimates of physician requirements by all proposed empirically based and expert judgment approaches.
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From page 242... ...
(though an important issue, it is not one the committee was asked to address.) The proposed physician requirements methodology can, and should, be used to estimate physician staffing deficits (or surpluses)
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From page 243... ...
Hence, the SADI or the DSE becomes the means to help move the system away from the status quo; or (2) The empirically based models are either conceptually inadequate or estimated with flawed data, so that expert judgment approaches are preferred on technical grounds.
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From page 244... ...
from the facility CDR, and three variants of the Reconciliation Strategy. For simplicity only, the projected workload relevant to s is assumed to be the same in all years.
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From page 245... ...
At that point, these calculations will be analyzed from the perspective of Equation 6.1, which allows the VA decision maker to derive (if desired) a weighted-average calculation of physician requirements that balances the strengths and weaknesses of the individual empirically based and expert judgment approaches.
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From page 246... ...
Physician WEE for Continuing Education Suppose the VA decision maker concurs that FTEE for continuing education should be built into the physician requirement calculations at a rate of 80 hours/year per full-time physician. As noted earlier, this is equivalent to earmarking about 4 percent of total FTEE for this purpose.
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From page 247... ...
Physician F1EE for Patient Care, Resident Education, and Administration Suppose that by applying the SADI constructed for specialty s to VAMC i, the FTEE required for direct care, resident education, and administration on the inpatient, ambulatory, and long-term care PCAs is calculated to be 18.5. From the SADI, 0.5 FTEE from specialty s is estimated for resident education in the classroom (not PCAs)
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From page 248... ...
Consequently, Leaves2 and C2 depend, in part, on each other and must be jointly calculated in the final step leading to total physician requirements under this X2-oriented approach. The formula for carrying out this final step is as follows: Total FTEE = (X2 + Rat + C2)
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From page 249... ...
Strictly speaking, the leave adjustment should be performed only for VA staff physicians. The precise statement of total FTEE under this variant requires a somewhat more complicated fonnula: Total FTEE = 4(X2-Leaves2)
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From page 250... ...
, where R2, representing an expert judgment-based estimate of research FTEE requirements, was not formally considered (by assumption) ; Cat, representing an empirically driven estimate of FTEE required for continuing education, was not formally considered (by assumption)
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From page 251... ...
1986. Information Booklet on the Physician Recognition Award.
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From page 252... ...
252 PHYSIC~N STAFFING FOR ~ VA APPENDIX SPECIALTY AND CLINICAL PROGRAM PANEL CONCLUSIONS The following appendix comprises the concluding sections of the reports of the six specialty and two clinical program panels, whose full reports are contained in Volume II, Supplementary Papers. Each panel's conclusions are presented here as a distinct entity for ease of reproduction and use.
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From page 253... ...
Included in the latter are FTEE representing contract physicians and C&A and WOC physicians. The panel believes that expert judgment approaches for determining physician requirements are also valid, but, compared with statistically based approaches, they are relatively expensive and cumbersome to operate.
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From page 254... ...
or a merit award from the VA. In a given VA medicine service, if 10 FTEE are listed for research in the CDR, but only three investigators have independent grant support, then the amount of FTEE assumed for research in the execution of the Reconciliation Strategy should not be 10 but a much smaller number.
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From page 255... ...
Hence, the panel found the external norms analysis interesting but not very useful for determining VA requirements in internal medicine. Overall Adequacy of Physician Staffing in the VA With a sample of but three VAMCs examined in detail, the panel feels that it is not possible to produce a defensible quantitative assessment of whether the VA is understaffed or overstaffed in internal medicine.
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From page 256... ...
In this regard, the panel urges the VA to continue efforts to improve the accuracy of the FTEE data in the Cost Distribution Report. Final Remarks For determining VA physician requirements in internal medicine, the medicine panel endorses a variant of the Reconciliation Strategy that relies upon the PF for deriving FTEE for patient care, resident education, and administration.
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From page 257... ...
, and from both expert judgment approaches. Gibe panel's original median (26.0)
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From page 258... ...
For anesthesiology, the panel recommends a variant of the Reconciliation Strategy that allows (but does not require) the VA decision maker to place due weight on both expert judgment and empirically based approaches in calculating
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From page 259... ...
If other VAM:Cs had been examined, different b values would likely have emerged. In general, the Reconciliation Strategy should be executed on a facility-specific basis, so that relevant local data and circumstances can befactored into the staffing decision process.
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From page 260... ...
External Norms Developing non-VA physician staffing standards to which the VA's own staffing could be validly compared proved difficult for several reasons. First, most non-VA facilities do not measure physician time in terms of an FTEE.
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From page 261... ...
of its estimates of physician requirements for three actual VAMCs, based on applications of the empirically based and expert judgment approaches discussed above. [Note: A more complete discussion of these results is found in the panel's report to the study committee; see Volume II, Supplementary Papers.]
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From page 262... ...
To provide a context for the response, each panel member was presented with a summary of the physician FTEE level emerging, alternatively, from the CDR, from both empirically based approaches (as applicable) , and from both expert judgment approaches.
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From page 263... ...
B Direct Care Plus Resident Education FTEE Only VAMC CDR IPF DSE SADI Survey .
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From page 264... ...
(The panel acknowledges that if these staffing deficiencies are reduced, then eliminated, it may well become appropriate to consider deriving psychiatry staffing requirements largely from empirically based models.) Given projected workload and other factors, what is the appropriate target level of psychiatry FTEE required for patient care, resident education, and administration?
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From page 265... ...
The IPF and the SADI served as the core approaches for establishing the FTEE boundaries of staffing targets for patient care, resident education, and administration. In the current terminology of the Reconciliation Strategy, a value of 0.35 for the weighting parameter b (see Equation 6.1)
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From page 266... ...
Consulting & Attending and Without-Compensation Coverage Assuming the VAMC is adequately staffed with VA physicians, there is no need for C&A and WOC FTEE to meet basic patient care demands. But these non-VA physicians can enhance the overall quality of care at the VAMC and play a valuable role in resident education and continuing education for the staff.
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From page 267... ...
Overall Adequacy of Physician Staffing in the VA For the four VAMCs studied in depth, psychiatry staffing was not adequate in FY 1989. In all four, the current FTEE level was significantly below the FTEE level derived using the SADI.
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From page 268... ...
were applied via the proposed Reconciliation Strategy to a broader sample of VAMCs, the overall situation could be assessed more precisely. Final Remarks In determining physician staffing in psychiatry, the panel recommends a variant of the Reconciliation Strategy in which FTEE targets are formally established and evaluated, as indicated above.
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From page 269... ...
To provide a context for the response, each panel member was presented with a summary of the physician FTEE level emerging, alternatively, from the CDR, from both empirically based approaches (as applicable) , and from both expert judgment approaches.
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From page 270... ...
Regarding the FTEE components of this strategy, the panel recommends the following: Patient Care, Resident Education, and Administration Neurology FTEE for these activities should be calculated from an expert judgment-based staffing model, not from an empirically based model that relies on current VA staffing data. Both the SADI and the DSE are acceptable expert judgment models.
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From page 271... ...
Continuing Education Like the research allocation, physician FTEE for continuing education should be based on what the individual VAMC has deemed to be an appropriate level; the most straightforward indicator of this is the amount of FTEE allocated to continuing education on the facility's CDR in the previous fiscal year. Leaves of Absence The percentage of total FTEE earmarked for vacation, sick leave, administrative leave, and other authorized absences should be based on existing VA policies.
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From page 272... ...
Other Points - Regardless of whether the VA adopts an empirically based or expert judgment-based approach (or some combination) to physician staffing, the models should distinguish sharply between VAMCs that have a full neurology service and those that offer only neurology consultation.
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From page 273... ...
The panel's estimate of physician requirements for three actual VAMCs, based on applications of the empirically based and expert judgment approaches discussed above, are summarized in Table 6A.4. [Note: A more complete discussion of these results is found in the panel's report to the study committee; see Volume II, Supplementary Papers.]
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From page 274... ...
, and from both expert judgment approaches. Because there is no separate CDR cost center for neurology at VAMC III, the CDR submitted by that facility indicates (of necessity)
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From page 275... ...
. With respect to the FTEE components of the strategy, the panel recommends: Patient Care, Resident Education, and Administration For these activities, FTEE should be derived from an expert judgment model rather than the EBPSM.
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From page 276... ...
Continuing Education Physician FTEE for continuing education should be based on the individual VAMC's recommended level; this can be easily determined as the amount of FTEE allocated to continuing education on the previous fiscal year's CDR. Leaves of Absence The percentage of total FTEE earmarked for vacation, sick leave, administrative leave, and other authorized absences should be consistent with the VA's policies.
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From page 277... ...
If the VA does adopt an empirically based approach, it is crucial that rehabilitation medicine physician FTEE allocations in the CDR represent more accurately how the physiatrists at a given VAMC spend their time. Final Remarks For rehabilitation medicine and SCI physician staffing, the panel endorses the modified version of the Reconciliation Strategy described above.
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From page 278... ...
2Panel median response to the question, posed by mail survey in September 1990, of what is the overall preferred physician FTEE level at each VAMC. To provide a context for the response, each panel member was presented with a summary of the physician FTEE level emerging, alternatively, from the CDR, from both empirically based approaches (as applicable)
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From page 279... ...
. Regarding the components of the strategy, the panel recommends the following: Patient Care, Resident Education, and Administration For these activities, FTEE should be derived from expert judgment methodologies.
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From page 280... ...
The VA could base these FTEE allocations on standards established by the specialty boards for recertification, by the states for maintaining licensure, or by the American Medical Association for its Physician Recognition Award for Continuing Medical Education. Leaves of Absence The percentage of total FTEE earmarked for vacation, sick leave, administrative leave, and other authorized absences should be set globally, perhaps equated to an overall average computed across the VA system.
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From page 281... ...
But the validity of these comparisons is threatened by some fundamental problems. For each of the four specialties, there are national guidelines relating workload to physician staffing, but it is not clear whether these make proper allowance for all of the patient care and non-patient-care duties expected of the VA staff physician.
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From page 282... ...
Final Remarks For determining physician requirements in laboratory medicine, diagnostic radiology, nuclear medicine, and radiation oncology, the panel endorses the variant of the Reconciliation Strategy described above. The panel's estimates of physician requirements for three actual VAMCs, based on applications of the empirically based and expert judgment approaches discussed above, are summarized in Table 6A.6.
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From page 283... ...
To provide a context for the response, each panel member was presented with a summary of the physician FTEE level emerging, alternatively, from the CDR, from both empirically based approaches (as applicable) , and from both expert judgment approaches.
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From page 284... ...
2Panel median response to the question, posed by mail survey in September 1990, of what is the overall preferred physician FTEE level at each VAMC. To provide a context for the response, each panel member was presented with a summary of the physician FTEE level emerging, alternatively, from the CDR, from both empirically based approaches (as applicable)
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From page 285... ...
The panel regards this as a fairly successful small-scale experiment; however, the validity and acceptability of the SADI methodology should be evaluated further through a much broader application involving a strategically chosen sample of VA ambulatory care programs. Either form of the empirically based physician staffing model presents problems at present.
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From page 286... ...
Because the IPF equations presented to the panel do not allow physician FTEE to be analyzed by PCA, there is no appropriate IPF for ambulatory care. (However, the effect of outpatient workload on physician requirements is recognized in each IPF.)
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From page 287... ...
In general, decisions about the purchase of additional coverage should be made by each VAMC following guidelines provided by VA Central Office. Consulting & Attending and Without-Compensation Coverage These non-VA physicians enhance the quality of both patient care and resident education.
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From page 288... ...
Other Points Whatever physician staffing methodology the VA adopts should be reevaluated and updated on an ongoing basis. Given the anticipated changes in patient demographics, the technology of care, and physician practice patterns in the private sector, determining physician requirements in the VA cannot be a
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From page 289... ...
Final Remarks For calculating physician requirements for the ambulatory care program at VAMCs, the panel supports the use of a Reconciliation Strategy whose FTEE components are analyzed as recommended above. The panel's estimates of physician requirements for three actual VAMCs, based on applications of the empirically based and expert judgment approaches discussed above, are summarized in Table 6A.7.
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From page 290... ...
To provide a context for the response, each panel member was presented with a summary of the physician FTEE level emerging, alternatively, from the CDR, from both empirically based approaches (as applicable) , and from both expert judgment approaches.
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From page 291... ...
First, the PF variant of the EBPSM allows one to infer physician requirements for the nursing home and intermediate PCAs, but those geriatric and extended care activities occurring on other PCAs are excluded from what the model calls "long-term care." For example, geriatric evaluation units (GEUs) are analyzed as part of the inpatient medicine PCA.
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From page 292... ...
Leaves of Absence As a baseline across the system, the percentage of total FTEE allocated to leaves of all types should be set at a uniform level; the panel concurs with the committee that a reasonable benchmark is the amount of annual leave. However, there should be a mechanism to allow for leave days beyond this baseline for facilities that participate heavily in external research and education activities.
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From page 293... ...
Physician staffing requirements were not reviewed for HBHC because, under the current VA system, the program is implemented by nursing with little direct physician involvement for patient care. In the non-VA home care field, the push toward decreasing utilization of higher cost inpatient services has shifted the care of many patients to the community.
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From page 294... ...
screening for enrollment into HBHC, (b) patient care planning, (c)
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From page 295... ...
Domiciliary care (VA, state home) State home hospital care Hospital-based home care Community residential care Adult day health care Hospice/palliative care Respite care Geriatric Research, Education, and Clinical Centers Geriatric Evaluation and Management Units Dementia and Alzheimer's disease initiatives Information and referral services or activities Hence, the scope of "long-term care" activities in the overall physician requirements methodology would be operationally defined in an appropriate fashion and could encompass the growing role of physicians in such programs as HBHC.
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From page 296... ...
The panel's estimates of physician requirements for three actual VAMCs, based on applications of the empirically based and expert judgment approaches discussed above, are summarized in Table 6A.
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From page 297... ...
, and from both expert judgment approaches. 3Does not include FTEE for consults by geriatricians to the non-LTC patient care areas, i.e., all PCAs except nursing home and intermediate care.
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