Physician Staffing for the VA Volume II, Supplementary Papers (1992) / Chapter Skim
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Psychiatry Panel Report
Psychiatry Panel Report
Pages 161-206
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From page 161... ...
As a prelude to these analyses, the panel wishes to command its views about the current state of psychiatry staffing in the VA. The panel believes these perceptions constitute important desiderata for interpreting the panel's subsequent recommendations about physician requirements in psychiatry.
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From page 162... ...
· Role of VA staff psychiatrist: The role of the VA staff physician in psychiatry is substantially different than that of his or her counterpart on a medical or surgical service. Typically, staff psychiatrists must spend substantial amounts of time on the unit, in direct patient care, and thus have little time available either for the preparation of research proposals or for conducting research.
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From page 163... ...
Further, the percentage of veterans whose psychiatric problems are service-connected is higher than the percentage of service-connected problems for other specialties. The panel sasses that the role of the staff physician on an inpatient psychiatric unit is substantially different from that of his or her counterpart on a medical or surgical service.
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From page 164... ...
(WWUs) in producing esb:ma~c of physician requirements from die Empirically Based Physician Staffing Models.
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From page 165... ...
than do Acute psychiatric patients in the system. Specific analyses of the characteristics of the current VA psychiatric patient population must be conducted to examine assumptions regarding the average age and acuity of He patients, as well as to explore patterns of transfer between facilities, rehospitalization, and outpatient care.
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From page 166... ...
Panel members concluded that policies to encourage greater participation by psychiatrists in research would serve to enhance retention rates in Me short term, and the quality of psychiatry care over Me long term. EXPERT JUDGMENT APPROACHED S TO DE~G PHYSICIAN REQUIREMENTS IN PSYCHIATRY The DSE Approach Initial Efforts A central purpose of the panel's first meeting, held in April 1990, was to help determine whether the expert judgment approach to staffing being developed by the study committee could be applied validly to psychiatry.
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From page 167... ...
These are important care providers; although they do not fully substitute for psychiatrists, they have an impact on the quality of care and should be taken into consideration in estimating physician requirements on psychiatric units and for ambulatory care. For example, psychologists with skills in rehabilitation and behavior modification may affect the number of psychiatrists that would otherwise be required on a unit serving patients with chronic conditions.
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From page 168... ...
Progress to date on both the expert judgment and empirical model approaches was evaluated. After reviewing the reports submitted by each panel, the study committee recommended that work pry on developing a more in~naRy consistent and comprehensive instant for determining physician requirements by expert judgment.
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From page 169... ...
In general, the underlying concept behind the DSE is to provide information in sufficient detail about the VAMC that the respondent can assess physician staffing requirements almost as if he/she were reviewing data at the facility. Resections and Assumptions To illustrate how the DSE works, a completed version of the instrument is presented as Exhibit 1 of the ~Overview.
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From page 170... ...
Approach SADI: OveraU Rationale Following the second round of panel meetings, the study committee initiated a set of ~postmeeting. activities to assist the specialty and clinical program panels in amving at consensus positions regarding the most appropriate methodology for VA physician staffing.
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From page 171... ...
, . , EMPIRICALLY BASED APPROACHES TO DETAINING PHYSICIAN STAFFING IN PSYCHIATRY As discussed at length in chapter 4 of Volume I, Here are two variants of the EBPSM: the production function (PF)
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From page 172... ...
HIYSICIAN STARING RESULTS FROM APPLICATION OF EMPIRICALLY BASED AND EXPERT JUDGMENT APPROACHES In Table l are alternative estimates of physician requirements in psychiatry at VAMCs I, II, m, and IV in FY 1989 as derived from: the VA's cost distribution report (CDR) , the PF and IPF variants of the EBPSM, the DSE (from He second panel meeting)
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From page 173... ...
The panel also acknowledges that if these apparent staffing deficiencies were eliminated in aggregate, it might well become appropriate to consider deriving VA physician requirements in psychiatry largely from empirically based models.) As Table 1 indicates, there were two variants of the Staffing Algorithm Development Instrument, which emerged in the following way.
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From page 174... ...
were not always comparable, certain patterns nevertheless emerged from these data. As indicated in Table 3, for four private psychiatric hospitals, the average daily cedes (ADC)
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From page 175... ...
The panel reproduces these data merely to underscore its deep reservations about any effort to derive VA physician staffing standards on the basis of current staffing at public psychiatric facilities. Many state hospitals do not represent a ~norm.; on the contrary, they are generally viewed as poorly staffed and providing an inadequate level of care.
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From page 176... ...
groups. Ratios within each of these groups were calculated for: inpatients per psychiatrist [Julie devoted to direct care and resident education in the inpatient psychiatry PCA; inpatients per inpatient social work t-lEE allocated to psychiatry; and inpatients per inpatient nursing P-lEE devoted to psychiatry.
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From page 177... ...
The most striking result overall, however, is that psychiatry staffing in all RAM groups is w~batially Winner than ill Me private sector facilities reviewed in Tables 3 and 4 and is roughly comparable to staffing found in the Maryland state hospitals (Iable S - which this panel and others have found to be unacceptable. Limitations of External Norms While the results just reported, suggesting mat VA psychiatry is substantially understaffed, come as no surprise to this panel, several important caveats should be kept in mind when drawing conclusions from such external norm data.
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From page 178... ...
Regarding the [-I BE components of the Reconciliation Strategy, the panel recommends the following: Patient Care, Resident Education, and A~nirus~ation For these activities, the VAMC's target level of PTEE should be determined through an expert judgment process, not by one of the proposed empirically based models. Although the panel admires the rigor of the statistical models, at best they can indicate only how the current aggregate level of psychiatry t-1EE can be better distributed across VAMCs.
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From page 179... ...
To arrive at these psychiatry staffing targets, the panel experimented successfully with, and recommends to the VA, a weighted-average version of the Reconciliation Strategy. The IPF and the SADI served as the core approaches for establishing the P-1EE boundaries of staffing targets for patient care, resident education, and administration.
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From page 180... ...
R - earch The panel has serious concerns about adopting an empirically based approach for determining research [-IKE in psychiatry in Me absence of accompanying policies that recognize an important equity point. Psychiatrists at many VAMCs have been so pry to handle patient care demands that little time has been left for research.
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From page 181... ...
But these non-VA physicians can enhance tl~e overall quality of care at Me VAMC and play a valuable role in resident education and continuing education for the staff. External Nonns Efforts to uncover non-VA staffing criteria, or norms, that could be used to evaluate psychiatry staffing in the VA proved to be problematic.
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From page 182... ...
For private psychiatric hospitals, in particular, there is a question about what factors influence physician staffing levels. In some, a concern for profits and the accompanying desire to control cost likely influence the observed ratios at these facilities.
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From page 183... ...
were applied v" He proposed Reconciliation Strategy to a broader supple of VAMCs, the overall situation could be asset more precisely. Final Remarks ~ detelmmmg physician staffing in psychiatry, the panel recommends a variant of the Reconciliation Strategy in which F1EE targets are formally established and evaluated, as indicated above.
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From page 184... ...
To provide a context for the response, each panel member was presented a summary of the physician FTEE level emerging, alternatively, from the CAR, from both empirically based approaches (as applicable) , and from both expert judgment approaches.
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From page 185... ...
(-5.342) with R2 = 0.874 and N= 141 where W = the natural loganthm of total bed days of care, plus 1, produced in the inpatient psychiatry PCA during the fiscal year; PSY MD = VA staff physician t-1EE from psychiatry allocated to direct care in this PCA; RESIDENTS = second- and third-year resident t-1EE allocated to this PCA; SOCW = social worker t-1EE allocated to this PCA;
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From page 186... ...
(3.484) where W OTHER_MD with R2 = 0.814 and N = 156 = the natural logarithm of total CAPWWUs, plus 1, proudly in the ambulatory psychiatry PCA during the fiscal year; = total blEE allocated to ambulatory psychiatry PCA by VA staff physicians not in medicine, surgery, psychiatry, neurology, rehabiltation medicine, laboratory medicine, radiology, nuclear medicine, radiation oncology, or anesthesiology;
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From page 187... ...
(-5.264) with R2 = where 0.887 and N = 164 PSY_MD' = the natural logarithm of He sum of VA psychiatrist t-lhE devoted to direct care (i.e., He sum of all PSY_MD variables)
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From page 188... ...
188 PRYSl~N MIFFING FOR THE Vat-VOLUME PSYCAPWWU = total CAPWWUs dunug the fiscal year in the ambulatory psychiatry PCA; and INSOCW = total inpatient social worker t-1~E.
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From page 189... ...
1,64S.00 230.00322.00 338.00177.00285.00 73.00 8,867.0036,919.00 500.0.0 164.00 145.00 2 wlc to 10mo Dial hospital ADC = 120 pts) Psychiatrists 68.77 33.00 71.00 24.00 Other MDs 4.00 Residents 37.20 Psychologists 39.24 15,00 Social Workers 47.81 49.00 ADC Per Psychiatrist 4.90 5.30 4.00 6.00 Outpatients Per Psychiatrist 56.50 268.70 520.00 30.00 (visits/ (visits/ (patients/ year)
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From page 190... ...
190 P~CUN Sr=Fl~G FOR nIE Vat-VOLUME TABLE 4 E'cte~ (Non-VA) Staffing PatielDs: University Hospitals Psychiatric Inpatient Units U
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From page 191... ...
restudy of Casemix, Facilities, and Staffing at the Regional Psychiatric Hospitals,n 1987, Abt Associates.
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From page 192... ...
192 P~lYSICUN SI,IFFfNG FOR TTIE Vat-VOLUME TABLE 6 VA Staffing Averages for apparent Psychiatry Units, by RAM Hospital Groups ADcmsychi~ I'VE for Direct Care and Resident Education in the Inpatient Psychiatry PCA ADC/Social Worker ADC/Nurs~g FREE Allocated Pl~E Allocated to Inpatient Psychiatry PCA to Inpatient Psychiatry PCA HGroup 1 17.7 24.2 2.1 small affil HGroup2 71.0 30.4 3.4 small unaff~1 HGroup3 17.2 22.6 2.5 mid-size affil HGroup 4 28.1 27.2 4.0 mid-size unaffil HGroupS 19.2 23.4 3.0 metro affil HGroup 6 32.2 28.2 4.3 large psych
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From page 193... ...
Your responses to the SADI will allow us not only to develop these algorithms but also to compare the relative efficacy of estimating physician requirements by disaggregated job activity versus estimating them more globally, e.g., by ward or Patient Care Area, as used in the original Detailed Staffing Exercises. Section A of the SADI requests time estimates in some cases by workload unit.
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From page 194... ...
Time per Admission Work-up with Resident (includes old record review) High Low Mean Med_ 111 ~1 ~11 ~14~1^ 4.00 2.00 2.70 2.50 2.00 0.75 1.25 1.00 PREADMISSIONS Please fill in the average time in hours required by a staff physician in your service to accomplish a preadmission assessment, either with or without the assistance of a resident in your service.
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From page 195... ...
Keep in mind that the Daily Rounds do not include admission workups, since they are covered ~ Char 1 and 2. Chart 3 Assume No Residents Psychiatry Ward ADC ADC ADC ADC ADC ADC Average LOS = 25 1 10 20 30 40 50 Daily Patient Care High 2.00 12.00 24.00 36.00 48.Q0 60.00 (direct: group and Low 0.50 4.00 5.00 7.00 10.00 20.00 individual tx)
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From page 196... ...
196 Mart 4 P~Y~lCIAN SI~FFING FOR TRE Vet-VOLUME ~ For ADC of 10 or less, assume one PGY3 or 4 resident; for ADC gamer Man 10 - 1 led tban or equal to 40, Plume two PGY3 or 4 residents; sold for ADC greaten than 40, assume three PGY3 or 4 residents. Psychia~y Ward Average LOS = IS ADC ADC ADC 1 10 20 ADC ADC ADC 30 40 SO Daily Patient Care High 2.00 S.OO S.OO 11.00 17.S0 20.00 (direct: Coup and Low 0.2S 1.50 3.00 2.SO S.OO 6.00 individual Mean 0.88 2.70 4.10 6.20 9.90 13.25 treatment)
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From page 197... ...
PSYC~U"Y PI REPORT Chad 5 197 Assume No Residents Substance Abuse Unit Average LOS = 25 ADC ADC ADC ADC ADC ADC 1 5 10 15 20 25 Daily Patient Care High 2.00 10.00 20.00 30.00 40.0 50.00 (direct: group and Low 0.S0 2.00 4.00 4.50 S.0 7.50 individual to) Mean 1.22 4.25 8.30 12.00 lS.25 19.37 (indirect: staff, Median 1.20 2.50 4.75 6.75 8.0 10.00 community mtgs.)
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From page 198... ...
ADC ADC ADC ADC ADC ADC 1 5 10 15 20 25 Daily Patient Care High 2.00 2.00 3.50 4.00 5.50 8.00 (direct: group and Low 0.15 1.00 2.30 3.50 3.90 5.75 individual to) Mean 0.96 1.54 2.95 3.80 4.85 6.40 (indirect: staff, Median 0.85 1.58 3.00 3.90 5.00 6.00 community mtgs.)
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From page 199... ...
PSYC~U"Y PANEL REPORT TIME PER INITIAL CONSULTATION OFF YOUR PCA 199 Fill in the average time in hours required by a staff physician in your service for each initial (new) consult on another service, noting the presence or absence of a resident in your own service.
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From page 200... ...
17 0.39 0.40 0.66 O 17 0.39 0.40 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.
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From page 201... ...
PSYC~U~Y PANEL REPORT 201 OUTPATIENT VISITS Please fill in the average time in hours required by a staff physician in your service for the average ambulatory care clinic visit by a typical patient to one of your specialty clinics, noting the presence or absence of the residents and nonphysician practitioners, and whether the visit is by a new or returning patient. Chart 10 Physician Time per Visit Type of Visit High Low Mean Median New Patient Visit Mental Hygiene No Resident New Patient Visit Mental Hygiene With Resident New Patient Visit Mental Hygiene With NP or PA New Patient Visit Substance Abuse No Resident New Patient Visit Substance Abuse With Resident New Patient Visit Substance Abuse With NP or PA 2.00 1.00 1.60 1.50 1.50 0.50 0.80 0.50 1.50 0.50 0.85 0.75 2.00 1.00 1.37 1.25 1.50 0.50 0.87 0.75 1.00 0.50 0.81 0.87
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From page 202... ...
202 Cart 10 (continued) P~CUN SHIFTING FOR TRE Vat-VOGUE ~ Physician Time per Visit Type of Visit High Low Mean Median Return Visit Mental Hygiene Return Visit Medicine Clack Return Visit Substance Abuse 1.00 0.62 0.50 0.30 1.00 0.50 0.92 1.00 0.44 0.50 0.72 0.70 Group Therapy Session 2.00 1.50 1.62 1.50 _ ..
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From page 203... ...
ICON B: N~CT ~ Cam T~ ~3 Pa 1.
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From page 204... ...
204 Chart 11 (continued) P~YSlCUN SNIFFING FOR TRE Vie-VOLUME ~ Assume the amount of research accomplished at Is VAMC is: Highi ~ Mediums Low!
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From page 205... ...
member of your service should devote to each of the following categories of non-patient~related activities? Chart 12 205 Assume the amount of research accomplished at this VAMC is: High Mediums Lows Continuing Education High 15.00 10.00 10.00 Low 5.00 5.00 3.00 Mean 10.00 6.60 6.00 Median 10.00 5.00 5.00 Research (off the - High 50.00 30.00 10.00 PCA)
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From page 206... ...
ROBERT FOWLER, Chief, Psychiatry Service, Dallas VA Medical Center, Dallas, Texas DAVID J KNESPER, Director, Division of General Hospital Services, Department of Psychiatry, University of Michigan, Ann Arbor JOHN O
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