Physician Staffing for the VA Volume II, Supplementary Papers (1992) / Chapter Skim
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Section I: Specialty and Clinical Program Panel ReportsOverview of the Specialty and Clinical Program Panels
Section I: Specialty and Clinical Program Panel ReportsOverview of the Specialty and Clinical Program Panels
Pages 15-74
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SECT- I S=C~ ~ Cal ~ IS
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. The committee appointed two multidisciplinary clinical program panels in the areas of ambulatory care and long-term care.
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physician staffing norms; · Derived its own independent estimations of appropriate physician staffing in specific VA medical centers. In accomplishing this, each panel used its own tailored variant of two alternative expert judgment approaches to estimating physician requirements: the Detailed Staffing Exercise (DSE)
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. COMMll~E'S APPROACH TO ELIClllNG EXPERT JUDGMENTS AND REACHING CONSENSUS In designing a process by which the six specialty and two clinical program panels would operate, the committee faced two major methodological questions.
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~ ~ am ~ A~of~_~` dim ~) art Hag ~ ~ ~~ _ of aft= ~ ~ _ ~ ~3 ~ _ grimy it.
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(Each panel's roster is included within its report.) Evaluating the EBPSM The specialty and clinical program panels provided important critical advice to the data and methodology panel and the study committee about several aspects of the EBPSM:
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In Me course of these meetings, written comn~un;ications, and phone calls, panel members contributed numerous suggestions on improving the empirically based models (including the sentiment, expressed on occasion by some panels, Mat the models be discarded entirely in favor of an expert judgment approach)
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. The Detailed Staffing Exercise An "Ideal" Mechanism for Expert Judgment Staffing Suppose an expert panel is charged with determining physician requirements for a given specialty or program area at some VAMC.
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For each ward, clinic, and procedure, the expert is ask to assess the amount of physician time in hours required per day, per visit, or per unit, respectively, to produce good-quality care. The B Section contains questions on the amount of physician time required for night and weekend coverage in the PCAs, educational activities not occurring in the PCAs, research, administration, other facility-related activities, and leaves of absence.
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~ _ ~= ~ is _ ~ ~ ~= of ~ it' ma.
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The Staffing Algorithm Development abstinent In pursuit of a less cumbersome expert judgment approach to physician staffing, the committee began work in August 1990 on an alternative approach for each panel. The committee want~xl to build upon, formalize, and strengthen some of Be rules of thumb for staffing evident during the second panel meetings.
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To determine physician requirements at a given VAMC, the panel median for each Me of patient care activity was applied, in turn, to the volume of such activities associated with the facility's projected workload, and the results were summed across activities to derive total physician hours for patient care. Physician times for all non-patient~are activities were assessed separately using Me relevant median estimates.
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A Closer Look As with the DSE, the best way to understand the SADI is to examine a completed instrument, then study how it can be applied to determine physician requirements at some VAMC. Exhibit 2 below is a slightly compact version of the SADI completed by the members of We medicine panel; it is intended to be self-e~cplanatory.6 For each fimction or tack, the medicine panel's high, low, mean, and median estimate of the amount of physician time required for good~uality care are shown.
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In the SADI (as with the DSE3, the whole is defined as the sum of the park; hence, the parts must successfully encompass all physician activities at the VAMC. Data Required from the VAMC To apply the SADI, in its current form, to determine physician requirements at a VAMC, the facility itself must generate certain workload and other data; the VA's central information systems do not generally supply information at the level of detail required by the SADI (or the DSE)
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, but the current medicine SADI includes no such activity category. Therefore, physician time estimates for the ICU/CCU unit were applied to the ADC levels
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Again, if the SADI is constructed in great enough detail if all relevant activity categories are included such approximations are not needed. External Nonns One other major issue that the committee asked tibe specialty and clinical program panels to investigate was whether there exist non-VA physician staffing standards or patterns that could be usefully applied to help determine appropriate VA physician staffing.
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On the basis of data supplied by He New York Health and Hospitals Corporation (NYH&HC, 1989) , stusly staff derived He following implicit physician staffing standards for medicine: 7.0 ADC/phy for inpatient and 4,270 visits/phy/yr for ambulatory care.
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These estimates can be compare with physician requirements in medicine at VAMC II as assessed through the SADI (54.0)
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This highly affiliated VAMC participates in a moderate amount of research and is large with total operating beds of 978 and an average daily census of 772. Your task in Section A is to calculate the physician hours required from the Medicine Service for each Patient Care Area (PCA)
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In the first part of Section A, you must estimate the physician hours spent by medicine service physicians for an average weekday. Next, you must estimate time spent by physicians from the Medicine Service on other PCAs in the hospital, usually as a consultant.
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UNIT DESCRIPTIONS PHYSICIAN HOURS REQUIRED (Wok)
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ADC 27 x 16 min = 432 An ADC 26 X 16 min = 416 me IDA 14 x 16 nun = 224 An ADC 25 x 16 nun = 4() 0 nun DC 16 x 16min = 256 ADC S x 20 nuns = 100 min ADC 9 x 20 nun = 180 nun ADCIl X3min=33nun New Admissions: 15/day x 38 min/patia~t = 570 mitt 0.9 caths/day x 50 mitt = 45 mu' 0.4 PTG`s/d~ x 70 mitt = 28 mitt 13 prOCCdUKS/d~ X 30 nun = 390 nun 2 bronchos/d~y x 45 mitt = 90 main TOTAL MEDICINE PHYSICIAN HOURS REQUIRED FOR PCA 1: 4,492 nun/60 miner = 74.87 he Staff physician time/critical patient/day (Mon-Pn)
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38 PilYSICUN STAFFING FOR TIE VA-VOLUME 11 QUES~iON: PCA 1 We are interested in exactly bow you used the available information to derive intent requirements for this PCA. Please explain in this worlupacc any Nile of thumb you used or any Gumption that will help us to understand your _.
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Resident Specialties: 40% 27 0.2 General Surgery 13 Neurosurgery 2 Ophthalmology 5 Orthopedics 5 Otolaryagology s = 38 11 Plastic Surgeryl Thoracic Surgety2 Vascular Surgeryl Uro10gy4 UNIT DESCRIPTIONS PHYSICIAN HOURS REQUIRED (Won) Consults/Da~r WARD 1: GENERAL SURG, PLASTIC, GYN Beds 31, ADC 31 WARD 2: GENERAL SURG Bede30,ADC17 WARD 3: CARDIAC SURG Monitored step~own unit Beds 18, ADC 15 WARD 4: UROLOGY Beds 28, ADC 22 WARD 5: OTOLARYNGOLOGY Beds 14, ADC 7 WARD 6: OPHTHALMOLOGY Beds 15, ADC 5 2.0 1.0 3.0 2.0 0.2 0.1
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Consults/DaY 2.0 3.0 0.2 0.1 Total Consults: 13.6 Assam 30 sum Total men = 13.6 x 30 = 408nun TOTAL MEDICINE PHYSICIAN WEIRDLY HOURS REQUIRED FOR PCA 2: 408 nun/60 = 6.8hr
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Total Operating Neurology I: Average Daily Ce~u (ADC) : 23 Occupancy Rate: 87.3 % Length of Stay: Daily Admissions: UNIT DESCRlPllONS PHYSICIAN HOURS REQUIRED - ..
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UNIT DESCRIPI1ONS PHYSICIAN HOURS REQUIRED (VVorlc~heet) Consults/DaY WARD 1: CLOSED; PSYCHOTIC, SCHIZ, BIPOLAR, ORGANIC Beds 42, ADC 31, plus 2-Bed Psych Evaluation and Admission Unit, ADC 2 WARD 2: CLOSED; This ward is identical to Ward 1.
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tWo~) ConsultalDaY 0.8 0.1 a2 Assume 30 nun/consuk Total nun = 6.1 x 30 = 183 min TOTAL MEDICINE PHYSICIAN AVERAGE WEEKDAY HOURS REQUIRED FOR PCA 4: 183 m~n/60 = 3.05 Or
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: 23 Occupancy Rate: 62.3 % Length of Stay: 24 Daily Admissions: TOTAL RESIDENCY POSITIONS 3 PGY 1e for the RMS Ward 2 EGY 2e or as for Consults 1 PGY 4 for EMG Service = 6 UNIT DESCRIPTIONS PHYSICIAN HOURS REQUIRED (Wok) Con~lts/Da~r WARD 1: GENERAL REHAB; AMPUTEE, MUSCULAR DYSTROPHY, HEAD INJURY Beds 26, ADC 23 SPECIAL PROCEDURES: EMG SERVICE: 5/weekday 0.4 Assent 30 min/co~ Totalmir'=0.4x 30=12 TOTAL MEDICINE PHYSICIAN AVERAGE WEEKDAY HOURS REQUIRED FOR PCA S: 12m~n/60= 0.20 he
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. WARD 1: GENERAL SCI Beds 26, ADC 19 TOTAL MEDICINE PHYSICIAN AVERAGE WEEKDAY HOURS REQUIRED FOR PCA 6: 45 PHYSICIAN HOURS REQUIRED l (Worlc~t)
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= 20 nun DC 74 x 8 man = 592 man IDS 22 x 12 min = 264 min TOTAL MEDICINE PHYSICIAN AVERAGE WEEKDAY HOURS REQUIRED FOR PCA 7: 1,244 m~n/60 = 2a73 he distaff physician time/patient/day (Mon-Fri) = 3 mitt care + 3 mitt communication + 2 mitt documentation = 8 min.
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CLINIC DESCRIPrlONS PHYSICIAN HOURS REQUIRED trot) Individual Physicians Required at Clinics x Clinic Hr/Wlc GENERAL MEDICINE: 1,079 per weelc 5 days per week, all day 7 residents PULMONARY: 53 per weelc 1 halfway per weelc 1 fellow, 1 resident ENDOCRINE: 23 per weelc 1 half-day per week 1 fellow, 1 resident 4 staffphys x 40 hr/wk = 160 hr 2 sta~phys x 4hr/wk = 8hr I staf~phys x 4hr/wk = 4hr
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. CLINIC DESCRIPTIONS PHYSICIAN HOURS REQUIRED avow)
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Individual Physicians Required at Clinics x Clinic Hr IWk 1 staffp~ys x 8hr/wt = 8hr
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1 resident PSYCH DAY TREATMENT: 53 per day Day-care program with activities, low turnover. No residents ALCOHOL DEPENDENCY: 14 per day Daily No resident, 1 psychologist, 2 social workers, 3 techs, 1 nurse practitioner, 2 counselors DRUG DEPENDENCY: 114 per day Daily No resident, 1 psychologist, 1 social worker, 1 physician assistant, 1 nurse practitioner, 2 pharms, 1 policeperson COMP AND PENSIONS: 8 per day Daily (Wok)
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30 visits are scheduled (medicine follow-up referrals) 15 visits are psychiatric No specialty clinics are held No residents EMPLOYEE HEALTH: 29 per day Daily, all day No residents TOTAL MEDICINE PHYSICIAN AV=AGE WEEKDAY HOURS REQUIRED FOR PCA 8: 298 he per week ~ 5 days = 59.6()
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Estimate the number of hours that would be required from medicine service in order to cover this facility: Weclcnight Coverage (Physician present) Weeknight Connally Weekend Coverage (Physician present)
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Purchased Coverage Hours (question #2) PCA 1: Medicine PCA 2: Surgery PCA 3: Neurology PCA 4: Psychiatry PCA 5: Rehab Med PCA 6: SCI PCA 7: Long-Term Care PCA 8: Ambulatory Care TOTAL MEDICINE HOURS 4.
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How many hours of physician time would be required at this facility in an average month to fi,lfill these functions? Education of residents (didactic, classroom, not on the PCA)
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Subtotal Non-Patient-Care Related FTEE: 10. Now create your Grand Total Medicine FTEE: Subtotal Patient-Care-Related WEE: (from question #6)
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Section B requests your response to a series of questions for the time spent in activities other than direct patient care. Instructions: Section A: For each cell of each table, please estimate the number of physician hours required from the Medicine Service to deliver good~uality care under the Specified circumstances.
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Chart 1 Resident Time per Admission Work-Up Without Resident Time per Admission Work-Up With High 2.50 0.75 Low 0.75 0.33 Mean 2.13 0.50 Median 1.00 0.50 ROUTINE DAILY PAl I ANT CARE For each workload factor and alternative average daily census (ADC) level below, please fill in the average number of physician hours reqDd from the Medicine Service.
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Medicine Ward ADC ADC ADC ADC ADC ADC Average LOS = 71 5 10 15 20 25 l Charting,High 0.33 1.25 2.50 3.75 5.00 6.25 Phone, andLow 0.10 0.50 0.50 0.75 1.00 1.00 PaperworkMean 0.23 0.80 1.50 2.00 2.75 3.25 Median 0.25 1.00 1.50 2.00 3.00 3.00 Patient andHigh 0.25 1.25 2.50 3.75 5.00 6.25 Family Contacts, Low 0.00 0.17 0.67 0.25 0.33 0.33 plus Teaching Mean 0.13 0.82 0.92 1.42 1.75 2.18 Median 0.08 0.25 0.67 0.75 1.00 1.50 Supervision High 0.10 1.00 1.50 1.50 2.W Z.W and Teaching Low 0.00 0.00 0.00 0.00 0.00 0.00 (Residents/Staff) Mean 0.02 0.27 0.67 0.70 0.60 0.60 Median 0.00 0.05 0.25 0.25 0.30 0.50 Overall Mean Time 0.61 2.25 4.51 6.59 8.16 9.71 Overall Median Time 0.65 2.35 4.35 7.00 7.00 8.00 .
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Mean 0.52 0.67 0.75 0.80 1.00 1.00 Median 0.50 0.75 1.00 1.00 1.00 1.00 Overall Mean Time 0.85 1.78 2.66 3.45 4.41 4.92 Overall Median Time 0.54 1.50 2.75 3.38 4.44 4.89
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Mean 0.50 0.45 0.58 0.75 0.83 0.92 Median 0.50 0.50 0.83 0.75 0.75 1.00 Overall Mean Time 0.94 1.82 2.70 3.54 4.29 4.95 Overall Median Time 0.99 1.75 2.63 3.50 4.50 5.00
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Neurology 1.00 0.50 0.73 0.75 0.75 0.25 0.47 0.50 Surgery 1.00 0.75 0.83 0.75 0.75 0.50 0.53 0.50 Nursing Home 1.00 0.50 0.73 0.75 0.75 0.25 0.47 0.50 l~termediate 1.00 0.50 0.63 0.50 0.75 0.25 0.37 0.25 Rehab Medicine 1.00 0.50 0.70 0.67 0.75 0.25 0.40 0.37 Psychiatry 1.00 0.50 0.73 0.50 0.75 0.25 0.47 0.50
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Time per Consult With Resident Consultation off your PCA High Low Mean Median High Low Mean Median Neurology 0.50 0.13 0.25 0.25 0.50 0.12 0.40 0.25 Surgery 0.50 0.17 0.28 0.25 0.50 0.17 0.45 0.25 Nursing Home 0.33 0.08 0.23 0.25 0.25 0.08 0.20 0.25 Intermediate 0.25 0.08 0.20 0.25 0.25 0.08 0.20 0.25 Rehab Medicine 0.25 0.08 0.22 0.25 0.25 0.08 0.20 0.25 Psychiatry 0.25 0.08 0 ZD ~ 25 ~ 21 0 011 02Z 0 Z5
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O~R~W SPECIAL PROCEDURES 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. Chat 7 63 Time per Test Time per Test Without Resident With Resident Special Procedures High Low Mean Median High Low Mean Median l Cardiac Catheterization 2.00 0.42 1.25 1.00 3.00 0.50 1.67 1.50 Bronchoscopy 1.00 0.42 0.77 0.92 2.00 0.50 1.08 0.87 Endoscopy 1.00 0.42 0.62 0.30 2.00 0.33 0.92 0.70 Others (Specify)
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t8 Physician Time per Visit Type of Visit High Low Mean Median New Patient Visit No Resident 1.00 0.67 0.92 1.00 New Patient Visit with Resident 1.00 0.25 0.53 0.50 New Patient Visit with NP or PA 1.00 0.33 0.67 0.70 Follow-Up Visit No Resident 0.33 0.25 0.30 0.33 Follow-Up Visit with Resident 0.33 0.08 0.22 0.25 Follow-Up Visit with NP or PA 0.33 0.08 0.25 0.25
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In each instance below, the required physician time estimate could not be read directly from the charts, but had to be derived by interpolation, extrapolation, or some other mapping Pews. Since VAMC I is a highly affiliated, research-intensive facility, all physician time estimates assume resident availability.
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From page 69... ...
: Subtotal for Routine Care = 0.54 hr6 ADC = 6: 3.07 hr5 22.56 hr Special Procedures Physician hours is the product of procedures per day and the panel's median estimate of physician time per procedure, given resident availability. The former is supplied by the VAMC; the latter is from Chart 7 of Figure 5.2.
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Surgery Inpatient PCA: 18.50 consulte/day7 Initial: 9.25 visits x 0.50 hr/visit Follow-up: 9.25 visit x 0.25 hr/visit Subtotal Neurology Inpatient PCA: 1.85 consults/day7 Initial: 0.92 visits x 0.50 hr/visit Pollow-up: 0.92 visit x 0.25 hr/visit Subs Psychiatry Inpatient PCA: 5.54 consults/day7 Initial: 2.77 visits x 0.50 hr/visit Pollow-up: 2.77 visit x 0.25 hr/visit Subtotal Rehabilitation Medicine Inpatient PCA: 1.85 consults/day7 Initial: 0.92 visits x 0.37 hr/visit Pollow-up: 0.92 visit x 0.25 hr/visit Subtotal = 4.63 hr = 2.31 hr 6.94 ~/d~y = 0.46 hr = 0.23 hr 0.69 br/d~y = 1.39 hr = 0.69 hr 2.08 ~/d~y = 0.34 hr = 0.23 hr 0.57 b~/d~y 7Average daily consult or Unlit rate by medicine service physicians, as repotted by VAMC I Consults or visits on a given day may be above or below this average figure.
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reassume 20 percent of ambulatory care visits involve new patients sad 80 percent are for follow-up. Physician times per ambulatory visit arc in Chart 8 of Figure S.2.
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72 P}TYSICIAN ST~FPING FOR TRE VA-VOLUME 17 Cardiology: 13.6 visit/day7 Initial: 2.72 visitl° x O.SO hr/v~it Follow-up: 10.88 visit x 0.25 hr/visit Sub~al Dermatology: 17 visit/day7 Initial: 3.40 visitl° x O.SO hr/v~it Follow-up: 13.60 visit x 0.25 hr/v~it Subtotal Endocrine: 6.4 visit/day7 Initial: 1.28 visitl° x O.SO hr/visit Follow-up: 5.12 visit x 0.25 hr/visit Subtotal Gastrointestinal: 8.4 visit/day7 Initial: 1.68 visit'° x 0.50 hr/visit Follow-up: 6.72 visit xO.2Shr/visit Subiotal Hype~tension: 8.4 visit/day7 NPs available. Initial: 1.68 visitl° x 0.70 hr/visit Follow-up: 6.72 visit x 0.2S hr/visit Subtotal Pulmonary: 12.6 visit/day7 Initial: 2.52 visit~° x O.SO hr/visit Follow-up: 10.08 visit x 0.2S hr/visit Subtotal = 1.36 hr 2.72 hr 4.08 hr/day 1.70 hr 3.40 hr 5.10hr/day 0.64 hr 1.28 hr 1.92 hr/day 0.84 hr 1.68 hr 2.S2 hr/day 1.18 hr 1.68 hr 2.86 hr/day 1.26 hr 2.52 hr 3.78 hr/day
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: 116.42 hr/day-. 8 hr/day/FFEE = 0.48 hr 0.96 hr 1.44 hr/d`I' 1.06 hr = 2.12hr 3.18 hr/d~ly = 0.76 hr 1.52 hr 2.28 hr/dby 0.88 br 1.72 hr 2.60 hr/day 65.88 hr/d~ llG.42 hr/d~ly 14.6 t-I15E At its second meeting, the medicine panel ag~ that no additional ~l ~E need be purchased for night and weekend coverage.
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From page 74... ...
lead to an overall median estimate of 54% for the percentage of total medicine service time allocated to these activities.~4 Hence, total Alum for the medicine service at VAMC I = 17.6/~1 - 0.54) = 38.3 This implies that about 38.3 x 0.34 = 13.0 Flue would be devoted to research, and 38.3 x 0.08 = 3.1 Fll5E to continuing education.
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