Physician Staffing for the VA Volume II, Supplementary Papers (1992) / Chapter Skim
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Ambulatory Care Panel Report
Ambulatory Care Panel Report
Pages 311-350
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From page 311... ...
EXPERT JUDGMENT APPROACHES TO DETERM~G HIYSICIAN REQUIREMENTS IN THE ADULATORY CARE PROGRAM The Detailed Staffing Exercise (I)
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From page 312... ...
· the administrative structure of the ambulatory care program should be defined: i.e., is it institutional administration or patient-focused administration? · the physician manpower required for direct patient contact and resident education should be distinguished from that required for research, continuing medical education, classroom teaching, administration, and leaves.
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From page 313... ...
, participants reviewed and evaluated the key concepts and assumptions underlying both the empirically based and expert judgment based approaches to determining VA physician requirements. The study staff emerged from Joint Meeting I with a set of recommendations from the committee on how to proceed with the panel process.
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From page 314... ...
In Section A of each exercise, the basic question was the same for each ambulatory patient care area: How much time (in hours) must be contributed by physicians in this VAMC's ambulatory care program to meet a specified workload level during an average weekday, under certain assumptions about patient Marc, residents, and support staff availability.
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From page 315... ...
To derive physician requirements for a given VAMC, the estimated physician hours for patient care and non-patient care activities are bummed, then converted to P-1EE under the assumption Hat 4S) hours per week translates into one t-1 BE.
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From page 316... ...
A carefi~1 study of the example reveals the Me of facility-specific data needed to implement any SADI. EMPIRICALLY BASED APPROAC~:S TO DETERMINING PHYSICIAN SIA~NG FOR THE AMBULATORY CARE PROGRAM Six of the 14 VAMC patient care areas defined by the study committee are for ambulatory care: medicine, surgery, psychiatry, neurology, rehabilitation medicine, and other physician services.
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From page 317... ...
variations in physician VlEE devoted to direct care and resident education across the VAMC. PHYSICIAN STAFFING RESULTS FROM APPLICATION OF EMPIRICALLY BASED AND EXPERT JUDGMENT APPROACHES In Table 1 are alternative estimates of physician requirements for the ambulatory care program at VAMCs I, II, and m in FY 1989, as derived from: the VA's cost distribution report (CDR)
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From page 318... ...
This, in Am, may have a dampening effect in many facilities on the amount of staff physician t-1tE that can be usefully allocated to ambulatory care. (This, in tum, may account for some of the discrepancy between CDR-recorded physician t-1tE for ambulatory care and the t-1~E levels derived from the expert judgment models.)
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From page 319... ...
Table 3 illustrates the computational approach, via dimensional analysis, used to derive each of these staffing standards. Summarized in Table 4 are the results from applying these norms to calculate the implied levels of physician staffing for the ambulatory care programs at VAMC I, II, and m.
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From page 320... ...
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 has problems at present.
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From page 321... ...
Rue 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 worldoad on physician requirements is recognize in each IPF.)
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From page 322... ...
~ur~ased Coverage for Nights and Weekends When emergency, admitting & screening, and related ambulatory care clinic stops are open, one or more staff physicians should be available either to provide patient care or to supervise the provision of patient care by residents or others. When availability cannot be provided by existing staff physicians-for example, when extensive coverage is needed in smaller institutions with few staff physicians then additional physician availability should be arranged for nights and weekends by purchasing coverage from other physicians.
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From page 323... ...
was applied, in turn, to VAMC I, II, and III to calculate Me physician staffing level in ambulatory care consistent with the norm. The implied physician staffing level of each VAMC could then be compared with its actual staffing.
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From page 324... ...
Ifaphysiciaorequirementsmethodologybuiltaround He SADI were to be applied to ambulatory care programs across the system, a quantitative assessment would be possibly and the panel's present judgment on staffing adequacy could be checked directly. 0~ Pbm Whatever physician staffing methodology the VA adopts should be reevaluated and updated on an ongoing basis.
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From page 325... ...
To provide a context for the response, each panel member was presented a summary of the physician P 1 HE level emerging, alternatively, from the CDR, from both empirically based approaches (as applicable, and from both expert judgment approaches. 2Based on systemwide averages for medicine services in RAM Group 3, these figures assume that 74 percent of total education -ME in ambulatory care is for resident education.
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From page 326... ...
(2.292) with R: = 0.647 and N = 168 where W MED_MD RMS MD OTHER MD RESIDENTS the natural logarithm of total CAPWWUs, plus 1, produced in the ambulatory medicine PCA dig the fiscal year; VA staff physician t-lEE from the medicine service allocated to direct care in this PCA; VA staff physician blue from the rehabilitation medicine service allocated to direct care in this PCA; total P-lEE allocated to this PCA by VA staff physicians Lot in medicine, surgery, psychiatry, neurology, and rehabilitation medicine; second- and third-year resident Al BE allocated to this PCA;
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From page 327... ...
Ambulatory Surgery Patient Care Area W = 12.549 + 0.694 SUR MD + 0.069 SUPPORT/MD (7.261)
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From page 328... ...
328 SUR MD SUPPORT/MD FELLOWS HGROUP2 HGROUP(3 +4+5) Ambulatory Psychiatry Patient Care Area PHYSlCUN SI~FF1NG FOR TO VA-VOLUME 11 VA staff physician F1EE from surgery allocate to direct care in this PCA; support staff FREE per total physician P-1BE in this PCA (where the denonimator is defined Al total direct~are P-1EE allocated to this PCA by physicians in CDR cost centers pertaining to the following specialties: medicine, surgery, psychiatry, neurology, and rehabilitation medicines; V1 EE of residents PGY4 and above allocated to this PCA; categorical variable assuming a value of 1 if the facility is in RAM Group 2 (small, general unaffiliated VAMC)
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From page 329... ...
A2UBUI~TORY G{RE PINED REPORT where W PSY_MD PSYCH NURSE/MD Ambulatory Neurology Patient Care Area 329 withR2=0.814andN = 156 the nabual logarithm of total CAPWWUs, plus 1, produced in He ambulatory psychiatry PCA during the fiscal year; VA staff physician P-l~E from psychiatry allocated to direct care in this PCA; psychologist P-lliE allocated to direct care in this PCA; and nursing staff t-lEE per total physician [-l BE in this PCA (where the denominator is defined as total direct~are t-lEE allocated to this PCA by physicians in CDR cost centers pertaining to the following specialties: medicine, surgery, psychiatry, neurology, and rehabilitation medicines.
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From page 330... ...
Ambulator Rehabilitation Medicine Patient Care Area W = 11.892 + 1.390 R}4S_MD + 0.003 StIPPORTQdD (6.376)
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From page 331... ...
UBUI~TORY G4RE PINED REPORT where 331 W = the natural logarithm of total clinic stops, plus 1, produced in the ambulatory other physician services PCA during the fiscal year; RAD MD = VA staff physician -WE from radiology allocate to direct care activities in this PCA; and SOCW = social worker -WE allocated to this PCA.
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From page 332... ...
332 TABLE 3 External Norms-Ambulatory Care PHY5;1~UN Sl~FFlNG FOR THE Vat-VOLUME ~ l Source, Results9 and Derivations if any: VA INS AMA Core Survey Med = 2.5 visits/hour x 40 hour/week x 47.9 week/year x 54/60.1 eff factor - 4,300 visits/MD/year Sur = 3.33 visits/hour x 40 hour/week x 47.1 week/year x 52.6/58.1 off factor = 5,700 visits/MD/year Overall weighted 2:1 med:surg NYH&HC Med = visits/at/endings Sur = visits/at/endings. Overall weighted 2:1 med:surg Group Health Inc.
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From page 333... ...
BUI~TORY G4RE PANES REPOkT Lame HMO Med = 1,571 visits/k mem x 5,436 k mem x 1/2,412 MD /0.9 OF factor x 40 hour/week / 47 hour/week = 3,350 visits/MD/year Sur = 200 visits/mem x 5,436 k mem x 1/883.5 MD /0.6 OF factor x 40 hour/weik /47 hour/weik = Overall weighted 2:1 med:surg DoD 333 1,750 visits/MD/year 2,820 visits/MD/year Standards for the number of visits per MD per year are specified separately by DoD for each of a number of specialists, e.g., internists, neurologists, general surgeons, orthopedic surgeons, neurosurgeons, etc. Further, different standards are specified for teaching versus nonteaching hospitals.
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From page 334... ...
334 P! IY5;1GUN STRING FOR ME VA-VOLUME 1r TABIE 4 Ambulatory Care Ex~al Norms Applied to Selected VAMCs Computed F-lEE' at Source Statistic WoALload/MD VAMC I VAMC II VAMC m DoD visit/MD weighted 27.9 36.4 35.0 HMO visit/MD 2,800 48.2 72.9 36.4 IHS visit/MD 5,000 27.0 40.8 20.4 AMA visit/MD 4,800 28.1 42.5 21.3 NYH&HC visit/MD 5,000 27.0 40.8 20.4 GrHlthInc visit/MD 4,050 33.3 50.4 25.2 (St.
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From page 335... ...
Section B seeks responses to a series of questions about 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 the ambulatory care program to deliver good~uality care under the Specified circumstances.
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From page 336... ...
In responding, please note Me presence or absence of residents and no~hysician practitioners, and whether the visit is by a new or Turning patient. C:hart 1 Physician Time per Visit ~ Type of Visit High Low Mean Median New Patient Visit No Resident New Patient Visit Win Resident New Patient Visit With NP or PA 1.50 0.25 0.80 0.75 0.50 0.10 0.31 0.33 1.00 0.16 0.42 0.33
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From page 337... ...
AMBUI~TORY G`RE PANEL REPORT to 337 ADMITTING & RECEIVING Physician Time per Visit Type of Visit High Low Mean Median New Patient Visit 1.00 0.33 0.62 0.67 No Resident New Patient Visit 0.83 0.10 0.33 0.25 With Resident New Patient Visit 0.50 0.08 0.27 0.25 With NP or PA Follow-Up Visit 0.75 0.25 0.36 0.33 No Resident Follow-Up Visit 0.50 0.08 0.20 0.25 With Resident Follow-Up Visit 0.50 0.08 0.20 0.16 With NP or PA
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From page 338... ...
Note the presence or absence of residents and nonphysiciaD practitioners, and whether the visit is by a new or resuming patient. Chart 3 Physician Time per Visit Type of Visit High Low Mean Median New Patient Visit 1.50 0.67 0.98 0.88 No Resident New Patient Visit 0.50 0.08 0.25 0.22 Win Resident New Patient Visit 0.50 0.08 0.25 0.22 With NP or PA Follow-Up Visit 0.50 0.25 0.40 0.42 No Resident Follow-Up Visit With Resident Follow-Up Visit With NP or PA 0.16 0.08 0.16 0.08 0.11 0.09 0.11 0.09
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From page 339... ...
Chat 4 Type of Visit Physician Time per Visit New Patient Visit No Resident New Patient Visit With Resident New Patient Visit With NP or PA Follow-Up Visit No Resident Follow-Up Visit With Resident Follow-Up Visit With NP or PA 0.75 1.00 0.58 0-25 0.33 0.16
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From page 340... ...
Note He presence or absence of residents and nonphysician practitioners, and whether He visit is by a new or Waning patient. ~5 Type of Visit Physician Time per Visit l New Patient Visit No Resident New Patient Visit With Resident New Patient Visit With NP or PA Follow-Up Visit No Resident Follow-Up Visit Win Resident Follow-Up Visit With NP or PA 1.00 0.75 0.50 0-25 0.16 0.16
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From page 341... ...
Chant 6 Type of Visit Physician Time per Visit New Patient Visit Mental Hygiene No Resident New Patient Visit Mental Hygiene Win Resident New Patient Visit Mental Hygiene With NP or PA New Patient Visit Substance Abuse No Resident New Patient Visit Substance Abuse With Resident 1.00 0.50 0.50 1.00 0.50
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From page 342... ...
3 ~6 ~ ~ -I Saw ~ ~PSY~ ~ of Via ~^~- ~1 Movie So_ _ fiat Visit Via So_ _ 0.50 1.
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From page 343... ...
~t7 Type of Visit Physician Time per Visit New Patient Visit No Resident New Patient Visit Win Resident New Patient Visit With NP or PA Follow-Up Visit No Resident Follow-Up Visit Win Resident Follow-Up Visit With NP or PA 0.33 0.33 0-25 0.16 0.16 0.16
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From page 344... ...
344 P~YSIGlAN SIN ING FOR TIE Vie-VOLUME SPECIAL PROCEDURES-Within Medicine We have listed the ambulatory care based special procedures identified during the panel meeting which should be considered in estimating a staff physician's daily workload. Please estimate the physician time required, in hours, noting He presence or absence of a resident.
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From page 345... ...
BUI~1TORY CME PINED REPORT Chit 9 345 SPECIAL PROCEDURES Within Neurology Special Time per Test Time per Test Procedure without Resident with Resident EMGs 0.75 1.00 Lumbar Puncture 0.50 0.08 Chart 10 SPECIAL PROCEDURES Within Surgery Special Time per Test Time per Test Procedure without Resident with Resident Endoscopies 0.67 0.50 Cardiac Stress Testing 0.33 0.25 Nary Bronchs 0.67 0.50 Sigmoidoscopies 0.50 0.50 Gastroscopies 0.50 0.33 ECHOs 0.33 0.33 Chart 11 SPECIAL PROCEDURES Within Psychiatry Special Time per Test Time per Test Procedure without Resident with Resident Hypnosis 1.50 1.50 Amytal Interview 1.50 1.50
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From page 346... ...
List the time in hours that you would add to each physici~n's average weekday to allow for the types of non-patient care-related activities listed below: Chart 12 Assume the amount of r~smrch accomplished at this VAMC is: High' Mediumi Lows Education of High 1.00 0.50 0.50 Residents Low 0.25 0.17 0.00 (didactic, Mean 0.49 0.30 0.16 classroom, Median 0.44 0.25 0.12 not on the PCA) Administration by High 4.00 4.00 4.00 Thief (time Low 1.00 0.50 0.17 required to manage Mean 2.17 2.21 1.86 your whole service Median 2.00 2.00 2.00 by a chief and/or assistant chief)
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From page 347... ...
Total Hours per Average Workday Chiefs High 4.00 4.00 4.00 Low 1.00 0.50 0.17 Mean 2.17 2.21 1.86 Median 2.00 2.00 2.00 Over High 6.00 5.25 5.15 Low 1.88 1.00 0.34 Mean 3.27 3.15 2.57 Median 3.18 3.00 2.43 Examples of research level by total amount of funding (VA plus non-VA) in FY 1988: High: c.g., VAMC I with S8.8 million in total funding; Medium: e.g., VAMC II with S2.75 million in total fundu g; Low: e.g., VAMC m with about S176,000 in total funding, 2A"umes that Chief does not participate dgniScantly in the Education of Residents and HospitalRelated Activities; SADI were may easily modify this assumption.
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From page 348... ...
Low 10.0 2.0 0.0 Mean 23.3 10.6 1.8 Median 17.5 10.0 1.0 Vacation, Administrative Leave, Sick TO Other lo.o2 lo.o2 lo.o2 Total High 70.0 40.0 28.8 Percentage Low 28.8 17.0 15.0 of TO Mean 40.6 26.6 19.3 Median 35.0 25.0 17.5 "Examples of research level by total amount of funding (VA p1w non-VA) in FY 198B: High: e.g., VAMC I with S8.8 million in total funding' Medium: e.g., VAMC ~ with S2.75 million in total funding; Low: e.g., VAMC m with about S176,000 in total funding.
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From page 349... ...
ELWOOD J HEADLEY, Deputy Associate Deputy Chief Medical Director for Ambulatory Care, Department of Veterans Affairs, Washington, D.C.
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