Physician Staffing for the VA Volume II, Supplementary Papers (1992) / Chapter Skim
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Neurology Panel Report
Neurology Panel Report
Pages 207-236
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From page 207... ...
EXPERT JUDGMENT APPROACHES TO DETERMINING PHYSICIAN REQUIREMENTS IN NEUROLOGY The Detailed StafRulg Exercise (I)
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From page 208... ...
· Vacation, leave, and sick time are not currently considered in physician requirements, and might be derived via a Multiplier applied to the direct care requirements. Although there was a great deal of debate about the issue of night and weekend coverage, panelists generally agreed that it is usually provided by House officers.
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From page 209... ...
Hence, it would be s~ that neurologists would serve largely as consultants in the delivery of SCI and EMG procedures. At this first meeting the panel also reviewed and evaluated the initial versions of the empirically based physician staffing model.
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From page 210... ...
Then the actual level of neurologist staffing at each VAMC, as reported in the CDR, was displayed for comparison. After discussion of actual versus DSE-based staffing, a third exercise was distributed pertaining now to VAMC III (another actual facility)
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From page 211... ...
NEUROLOGY PANEL REPORT 211 the group discussion, Me panel was ablced to reflect on whether certain Rules of thumb. were used (0aps implicitly)
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From page 212... ...
212 ~ ~ -I T~ ~ _~- _ (I gap_ I: Fog_ ~ of ~ ~s, ~ _ of eat ~ ~ ^~ ~ Aims ~ IS ~ ~ ~ ~ ~ ~ ~ ~ Act _~^^~.
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From page 213... ...
EMPIRICALLY BASED APPROACHES TO DE~G HIYSICLAN SrA~NG IN NEUROLOGY In its two meetings and a subsequent conference call, the panel evaluated alternative specifications of the empirically based physician staffing models (EBPSM) that pertained expressly to neurology.
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From page 214... ...
, all empirically based and expert opinion approaches lead to total t-1~E estimates for neurologists that exceed He levels recorded in the CDR. The latter is not likely to undercount actual neurologist FAME at these facilities, since VAMCs I and II have a neurology cost cuter, and the study staff ascertained by direct communication win VAMC m that the most appropriate neurologist count there for FY 1989 was, on balance, 1.0 t-1~;E.)
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From page 215... ...
health care organizations in order to determine whether productivity performance norms that may exist elsewhere in the public and private sectors could be applied usefully to determine appropriate neurologist staffing in the VA. In addition, the study staff attempted to obtain Intel VA guidelines on physician staffing in neurology.
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From page 216... ...
The panel also investigated data from several other sources that had proven useful in developing staffing norms for internal medicine: The Indian Health Service, the American Medical Association, the New York Health and Hospitals Corporation, and a large health maintenance organization. However, none of these organizations had explicit criteria, or available data, relating neurologist [-I BE to patient worldoad.
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From page 217... ...
as a fiamewodc for computing physician requirements in neurology. Regarding the [-I HE components of this strategy, the panel recommends the following: Patient Cam, Resident Education, and A.ninistration Neurology F-lliE for these activities should be calculated from an expertjudgment-based staffing model, not from an empirically based model that relies on current VA staffing data.
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From page 218... ...
The most straightforward reasonable procedure is to assign each neurology service (or consultant serviced the amount of research WEE allocated on the facility's CDR in the previous fiscal year. An alternative approach deserving investigation is to make these t-1EE allowances dependent on quantitative measures of research productivity, such as grant funding levels.
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From page 219... ...
University medical centers generally deliver high-quality care, but serve a patient population quite different that the VA's. Overall Adequacy of Physician Staffing in the VA From Table 1 it is evident that actual neurology staffing in FY 1989 at all three VAMCs examined in detail by He panel is below that recommended by any of the proposed approaches to staffing.
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From page 220... ...
to physician staffing, the models should distinguish ibs~ply between VAMCs that have a full neurology service and those that offer only neurology consultation. If the VA does adopt an empirically based approach, it is crucial that neurologist t-1hE allocations in the CDR be made more accurately.
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From page 221... ...
2Panel median responec to the question, posed by mail survey in September 1990, of what is the overall preferred physician FTEE lover at each VAMC. To provide a context for the response, each panel member was presented a summary of the physician ~-~ level emerging, alternatively, from the CDR, from both empirically based approaches (as applicable)
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From page 222... ...
(-5.621) where W NEU MD MIlD MD SUR MD SUPPORT/MD SOCW with R2 = 0.722 and N = 80 the natural logarithm of total WWUs, plus 1, produced in the inpatient neurology PCA during the fiscal year; VA staff physician FLEE in neurology allocated to direct care in the neurology PCA; VA staff physician Al Ire from the medicine service allocated to direct care in this PCA; VA staff physician Al ~E from the surgery service allocated to direct care in this PCA; support staff Oral]
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From page 223... ...
(6.733) where withR2 = 0.591 end N = 72 W = the natural logarithm of total CAPWWUs, plus 1, produced in the ambulatory neurology PCA during the fiscal year; RESIDENTS = second- and third-year neurology resident Al HE allocated to the ambulatory neurology PCA; HGROUP3 = a categorical variable assuming a value of 1 if the facility ~ in RAM Group 3 (midsize affiliated)
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From page 224... ...
; NEUCAPWWU = total CAPWWUs produced during the fiscal year in the ambulatory neurology PCA (divided by 10,000) ; HGROUP4 = a categorical variable assuming a value of 1 if the facility is in RAM Group 4 (midsize general unaffiliated)
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From page 225... ...
VAMC I VAMC II VAMC m Actual Neurologist Staffing as Inferred from VA Cost Distribution Report 1.6 5.5 1.0 DoD 3.0 4.3 0.6 Private City Hospital Diana) 3.0 8.5 0.5 University Hospital (Indiana)
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From page 226... ...
Section B seeks responses to a series of questions for the time spent in activities other than direct patient care. Instructions: In Section A, for each cell of each table, please estimate the number of physician hours required from Be Neurology Service to deliver good~uality care under the specified circumstances.
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From page 227... ...
level below, please fill in the average number of physician hours required from the Neurology Service. Keep in mind that the daily rounds do not include new admission work-ups, since they are covered ~ Chart 1.
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From page 228... ...
228 Chart 2 (continued) PHYSICL~N STAFFING FOR To Vat-VOLUME ~ Neurology Ward Average LOS = 7 ADC ADC ADC ADC ADC ADC 1 5 10 15 20 25 Charting, Phone' High 0.25 0.75 1.00 1.50 2.00 2.50 and Paperwork Low 0.08 0.50 1.00 1.25 1.50 1.75 Mean 0.27 0.55 1.00 1.33 1.67 2.00 Median 0.25 0.50 1.00 1.25 1.50 1.87 Patient and Family High 0.50 0.75 1.00 1.25 1.50 1.50 Contacts plus Low 0.05 0.25 0.50 0.75 1.00 1.25 Teaching Mean 0.27 0.45 0.75 1.33 1.08 1.50 Median 0.27 0.42 0.73 1.00 1.08 1.38 Supervision High 0.50 0.50 0.75 1.00 1.00 1.25 and Teaching Low 0.00 0.00 0.00 0.00 0.00 0.00 (Residents/Staff3 Mean 0.12 0.28 0.38 0.55 0.57 0.67 Median 0.00 0.28 0.42 0.62 0.62 0.75 Overall Mean Time 1.00 2.07 3.45 5.00 6.00 7.20 Overall Median Time 0.50 2.27 4.00 5.12 6.05 7.15
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From page 229... ...
APOLOGY PANEL REPORT ~t3 229 For ADC of 10 or less, assume one PGY 2 or 3 resident. For ADC gamer Man 15, assume two PGY 2 or 3 residents.
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From page 230... ...
consult on "other service, noting the presence or absence of ~ resident in your own service. (When the resident is present, assume diet he/§he is performing the consult under the supervision of an attending physician.)
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From page 231... ...
Medicine 0.33 0.25 0.28 0.28 Surgery 0.33 0.25 0.28 0.28 Nursing Home 0.33 0.17 0.28 0.28 Intermediate Care 0.33 0.17 0.27 0.28 Rehab Medicine 0.33 0.17 0.27 0.28 Psychiatry 0.33 0.25 0.28 0.28 SPECIAL PROCEDURES 0.42 0.17 0.25 0.42 0.17 0.25 0.42 0.08 0.23 0.42 0.08 0.23 0.42 0.08 0.23 0.42 0.17 0.25 0.22 0.22 0.22 0.22 0.22 0.22 Please fill in the average time in hours required by a staff physician in your service for each of the special procedures listed on the left, noting the presence or absence of a resident. Chart 6 Time per Test without Resident Special Procedures Time per Test with Resident High Low Mean Median High Low Mean Median EEG 0.83 0.33 0.47 0.42 Evoked Potential 1.00 0.42 0.63, 0.62 EMG 2.00 1.00 1.37 1.50 Others (SpeciO 1.00 0.25 0.52 0.42 0.75 0.33 0.52 0.50 2.00 0.50 1.50 1.75 1.00 1.00
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From page 232... ...
232 P~Y~ICUN SZ~F7;lNG FOR WE Vie-V"~E ~ SE:CTION B: NON-PATIEN'T~ARE TIME Part 1. The activities listed below Ivy do not occur every day, but may be ti~onsum~ng when looked at over a longer period, such as a week or month.
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From page 233... ...
NEUROLOGY PEEL REPORT Chart 7 (continued) l 233 Assume the amount of research accomplished at this VAMC m: Total Hours per Average Wedlcdlay: Overall Mean Overall Median For Chief 2 High 1.75 t.75 Medium 1.S0 1.50 Low 1.25 1.33 For Non-Chief High 3.17 3.12 Physician Medium 2.42 2.42 Low 1.67 1.78 "Examples of research level by total amount of funding (VA plus non-VA)
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From page 234... ...
High 60.0 40.0 10.0 - Low 25.0 20.0 5.0 Mean 40.0 26.0 7.0 Median 33.0 23.0 10.0 Vacation, High 25.0 23.0 20.0 Administrative Leave, Low 8.0 8.0 8.0 Sick Leave, Other Mean 13.0 13.0 12.0 Median 10.0 10.0 10.0 Total Percentage of Time Overall Mean 60.0 46.0 26.0 Overall Median 62.0 46.0 23.0 Examples of research level by total amount of funding (VA plus non-VA)
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From page 235... ...
BROOKS, Chief, Neurology Service, Madison VA Medical Center, Madison, Wisconsin MARK DYKEN, Professor and Chairman, Department of Neurology, India a University Medical Center, Indianapolis JOSEPH GREEN, Cbai~, Department of Medical/Surgical Neurology, Texas Tech University, Lubbock JOHN F KURTZKE, Professor and Vice Chairman, Department of Neurology, Georgetown University Medical Center, Washington, D
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