Physician Staffing for the VA Volume I (1991) / Chapter Skim
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11 - CONCLUSIONS AND RECOMMENDATIONS
11 - CONCLUSIONS AND RECOMMENDATIONS
Pages 373-400
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From page 373... ...
However, a question not addressed earlier concerns the steps the VA should take to ensure that the physician requirements methodology is further refined in the near term, then maintained and improved over time. This issue is discussed near the end of the chapter.
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From page 374... ...
The net effect on VA staff physician requirements of possible changes in the number, type, and intensity of VA-medical school affiliation relationships. In addition, there should be analyses of the potential effect of such changes on the VA's ability to accomplish the physician education component of its mission, both now and in the future.
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From page 375... ...
3. Another 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 376... ...
The formulation of the strategy presented there is reproduced below using (for illustration) internal medicine, the PF variant of the EBPSM, and the SADI variant of the expert judgment models: Physician FTEE Requirements ill Medicine = [X + b(X2-X~]
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From page 377... ...
. This configuration of the Reconciliation Strategy conveys a particular policy perspective: In determining physician requirements for each specialty or program area, the first step is to derive FTEE estimates from a variant of the EBPSM either the IPF or the PF.
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From page 378... ...
There are two responses to this. First, to determine physician requirements according to the version of the Reconciliation Strategy is to work within the FTEE boundaries established by the empirically based and expert judgment models, specifically the PF, IPF, SADI, and DSE approaches.
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From page 379... ...
USING TO RECONCILIATION STRATEGY TO CALCULATE PHYSICIAN FIEE Within the Umbrellas of the Reconciliation Strategy, how exactly (by specialty and program area) should VA physician FTEE levels be calculated?
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From page 380... ...
Only after the Reconciliation Strategy has been applied to a significantly larger sample of VAMCs will there exist the breadth of empirical information required to reach a generalizable conclusion about whether the PF, IPF, DSE, SADI, or some weighted combination of these is preferred for a given specialty or program area. On the basis of the analyses summarized in chapters 4 through 7, the committee reached the following conclusions regarding empirically based and expert judgment approaches to analyzing this major component of physician FTEE: The PF arid the IPF are potentially compleme'`tary variants of the EBPSM, and either is a viable candidate for helping generate the Baseline estimates for this component of physician FTEE.
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From page 381... ...
The specialty and clinical program panel analyses indicate, in sum, that it is feasible to develop SADIs for all specialties and VA program areas. Task time estimates were derived exhibiting strong face validity and yielding physician requirements for selected VAMCs that were generally plausible and acceptable to panel participants (see chapter 5 and the appendix to chapter 6~.
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From page 382... ...
Physicians. For staff physician FTEE devoted to direct care, to resident education, and to administration, the nature of the required calculation depends in each case on whether the Reconciliation Strategy is to be implemented using the PF, IPF, SADI, or DSE-or some weighted average of an empirically based and an expert judgment model.
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From page 383... ...
. When computing physician requirements through either the SADI or the DSE expert judgment approaches, additional FI EE for off-hour (eight and weekend)
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From page 384... ...
If these minimums are regarded as based on expert judgment, 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 the study were of limited usefulness in determining VA physician requirements.
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From page 385... ...
Although the estimated empirically based models were used to derive physician requirements for all VAMCs (see chapter 4) , such was not the case here for the expert judgment models.
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From page 386... ...
The empirically based models are either conceptually inadequate or estimated with flawed data, so that expert judgment approaches are preferred on technical grounds. Note that the committee is not selecting among approaches here, but merely pointing out the logical implications of the relevant choices.
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From page 387... ...
VA CENTRAL OFFICE AND THE VAMC: PROMOTING A DIALOGUE In chapter 7, important issues related to the implementation and policy applications of the methodology were discussed. The committee's views can be summarized as follows: By its very structure and logic, the Reconciliation Strategy implies that the allocation of physician FTEE across the system would become more centrally directed; at present, each VAMC has broad discretion to establish physician FTEE levels, subject only to constraints involving its total budget and total assigned personnel ceiling.
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From page 388... ...
Second, good two-way communication will enhance the quality of the decision process itself, increasing the likelihood that the physician staffing levels adopted are indeed appropriate. Any broadly applicable methodology for determining VA physician requirements will necessarily use models that are simplifications of reality.
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From page 389... ...
They could be adapted readily to adjust also for changes in the distribution of the veteran population by gender or eligibility-for-care categories. · The workload projections from these models can be input directly into both the PF and the IPF variants of the empirically based models to derive future physician requirements, by VAMC and PCA within each VAMC.
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From page 390... ...
In other parts of this report, the committee has urged the VA to continue its work, being led by the VA Office of Quality Management, to develop quality-ofcare indicators. These indicators will be critical not only for the full development of the physician requirements methodology, but also for a more definitive evaluation of the effect of affiliations.
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From page 391... ...
The committee believes that this type of extension represents an exciting opportunity that could help the VA meet its physician requirements, especially for primary care, in the years ahead. NONEHYSICIAN PRACTITIONERS Early in the study the committee hypothesized that VA physician requirements at present, but especially in the future-may be influenced by the availability of certain nonphysician practitioners (NPPs)
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From page 392... ...
, nurses, psychologists, and social workers it would be possible to analyze them explicitly in the PF and the IPF variants of the empirically based models. At present, these NPPs are reflected in the PF and IPF equations only through their inclusion in the SUPPORT/MD and NURSE/MD variables (see chapter 10~.
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From page 393... ...
; and this action also should be communicated promptly. The outcome of these studies should influence not only the specific functions that NPPs perform, but their overall roles vis a vis physicians in the patient care process.
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From page 394... ...
These would serve to test the validity of the statistical and expert judgment models as well as the overall appropriateness of staffing recommendations from clinical and economic perspectives. In the course of this report, the committee has presented a number of proposals for testing, refining, and extending the current methodology.
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From page 395... ...
The CDR should be amended so that physician FTEE for resident education, research, and administration riot occurring in the PCAs can be clearly distinguished. · It is also not possible at present to distinguish physicians by subspecialty in the national CDR accounts.
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From page 396... ...
Evaluating and ReEning the SADI The committee has recommended that the expert judgment component of the physician requirements methodology be built around application of the SADI. However, the committee does regard the SADIs developed in this study as firstgeneration instn~ments, requiring additional evaluation and refinement.
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From page 397... ...
data from which to derive alternative estimates of these physician activity times; · The subsequent integration of expert judgment and empirically derived activity time estimates through Bayesian statistical analysis (see Volume II, Supplementary Papers)
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From page 398... ...
This staffing estimate could then be compared with physician requirements for the facility as derived from the SADI and with the actual level of physician FTEE there. The VA should explore this and other scenarios for applying norms to all specialties and program areas.
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From page 399... ...
With the veteran population aging, with technology ever changing, with practice patterns evolving in the non-VA sector, it is crucial that the physician requirements methodology be reexamined on a regular basis. The committee estimates that Phase I could be completed within 24 months; Phase II would represent an ongoing commitment by the VA to ensure the continuing quality of its physician staffing policies.
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