Physician Staffing for the VA Volume II, Supplementary Papers (1992) / Chapter Skim
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Rehabilitation Medicine Panel Report
Rehabilitation Medicine Panel Report
Pages 237-268
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From page 237... ...
at Me VAMC. But it was also asked to recommend a methodology for calculating physician requirements for the spinal cord injury (SCI)
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From page 238... ...
The primary purpose was to examine whether the expert judgment panel process, as the study committee first envisioned it, could be applied to rehabilitation medicine. The focus of this analysis was the initial draft of a physician staffing instrument, which required the expert to assess the time (and hence t-1EE)
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From page 239... ...
Nonetheless, the panel age to continue estimating physician requirements for the actual volume of workload anticipated, in keeping with the overall philosophy of the larger study. 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 240... ...
In general, the underlying concept behind the DSE is to provide information about the VAMC in sufficient detail that the respondent can assess physician staffing requirements almost as if he/she were reviewing data at the facility. Instructions and Assumptions To illustrate how the DSE works, a completed version of the instrument is presented as Exhibit 1 of the Overview to this section of Volume II.
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From page 241... ...
activities to assist the specialty and clinical program panels in arriving at consensus positions regarding the most appropriate methodology for VA physician staffing. These recommendations would be regarded as advisory to the committee.
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From page 242... ...
Although Me information requirements of the DSE are greater, both of these expert judgment approaches require data (e.g., on frequency of consults across PCAs3 not presently collected in Me VA system. EMPIRICALLY BASED APPROACHES TO DE1~G I~IYSICIAN SrA"ING In its two meetings, a subsequent conference call, and follow-up communications with the study staff, He panel evaluated alternative specifications of the empirically based physician staffing models (EBPSM)
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From page 243... ...
Second, ~ more than half of all VAMCs, there is no rehabilitation medicine service; when this occurs, the existing physiatrist t-lEE is likely attributed to the medicine ~vice, leading to biased observations for both the RMS_MD and MED_MD variables. PHYSICIAN STAFFING RESUlLTS FROM APPLICATION OF EMPIRICALLY BASED AND EXPERT JUDGMENT APPROACHES In Table 1 are alternative estimates of physiatnst requirements for He rehabilitation medicine service at VAMCs I, II, and III in FY 1989 as derived
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From page 244... ...
Although physician staffing requirements for the spinal cord injury service were not analyzed as intensively as for RMS, the PF and IPF models for SCI reported in Table 2 can be applied to calculate physician requirements for VA facilities Hat have such a service. The panel notes that both Rehabilitation Medicine's and SCI's requirements are interdependent (e.g., physiatrists covering SCI as staff physicians)
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From page 245... ...
Ihitially, study staff also obtained some Internal VA guidelines OD physician staffing in RMS. Ibese guidelin-, published in 1965, related RMS physician requirements to the total number of beds at the VAMC, regarded of specific services available.
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From page 246... ...
CONCLUSIONS As a framework for determining VA physician requirements in both rehabilitation medicine and spinal cord injury (SCI) , the panel endorses a variant of the study committee's Reconciliation Strategy (the Disaggregate weightedaverage.
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From page 247... ...
reflect current input-output relationships, which are skewed because rehabilitation medicine is seriously understaffed in many VAMCs; thus these data reflect the status quo, clearly an inappropriate basis for estimating appropriate physician staffing for high~uality rehabilitation medicine and SCI patient care. Second, in over half of all VAMCs there is no inpatient rehabilitation medicine service (RMS)
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From page 248... ...
Overall Adequacy of Physician Staffing in the VA From Table 1 it is evident that actual rehabilitation medicine staffing in FY 1989 at the three VAMCs examined in detail is below that recommendW by any of the approaches to staffing, except the PF model; however, for VAMC m,
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From page 249... ...
If the VA does adopt an empirically based approach, it is crucial mat rehabilitation medicine physician t-1 BE allocations in the CDR represent more accurately how the physiatrists at a given VAMC spend their time. Final Remarks For rehabilitation medicine and SCI physician staffing, the panel endorses the modified version of the Reconciliation Strategy described above.
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From page 250... ...
Direct Care Plus Resident Education P-1EE Only SADI VAMC CDR PF IPF DSE SADI Modified1 Survey2 ~ VAMC I -1.9 1.9 3.5 6.2 3.2 3.2 N.A.
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From page 251... ...
(9.872) where W RMS MD = MElD_MD = with R2 = 0.674 and N = 79 = the natural logarithm of total WWUs, plus 1, produced in the inpatient "l~abiL;tation medicine PCA during the fiscal year; VA staff physician Alum Tom the Debilitation medicine service allocate to direct care in the inpatient rehabilitation medicine PCA; VA staff physician Al HE Tom the medicine service allocated to direct care in Ail PCA; LAB MD= VA staff physician Pl~E from laboratory medicine allocate to activities related to direct care in this PCA; and ln(SUPPORT/MD)
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From page 252... ...
; a categorical variable assuming a value of 1 if the facility is in RAM Group 6 ~sych-iatric) ; interaction tenn for the joint influence on production of VA staff physicians in rehabilitation medicine and the VAMC's status as a metm affiliated facility; and the number of VAMCs in the sample, equivalent to the number showing nonzero visits to the rehabilitation medicine ambulatory clinic stops.
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From page 253... ...
PCA; NURSE/MD = nursing staff P-l ~E per VA staff physician Al ~E in the SCI PCA (where the denominator of the ratio is defined specifically as the sum of all direct care Al ~E recorded for internists, surgeons, psychiatrists, neurologists, rehabilitation medicine physicians, and physicians assigned expressly to the SCI cost center at the facility) ; and N = the number of VAMCs in the sample, equivalent to the number with a designated spinal cord injury service.
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From page 254... ...
of RMS residents PGY4 and above at the VAMC; and N the number of VAMCs in the sample equivalent to the number with nonzero physician Al ~E allocate to direct care or resident education from the rehabilitation medicine cost center.
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From page 255... ...
~ o~ 1~ scans = 0.~2 + go.= SCAM - 56.418 ~C~) 2 .~ (-2 ~ = Act= scans = ~ ~ am of ~ ~ ACHE ~- by Trysts SC1 -~ ~ dim ~ ~ ~ man ~ ~ SC1 at, ~ 1; ~ SCAM = ~e sum of ~ mate, sum, pa, no, ad ~n~s~ ~ ~^ -~' ~ an,
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From page 256... ...
256 TABLE 3 RMS External Norm Compansons P~YSICI'IN SNIFFING FOR TIE VA-VOLUME IT Source of Norm VAMC I VAMC II VAMC m Actual Staffing From Pacilit~r's CDR 3.9 3.0 1.8 1965 VA 1.0 3.0 4.0 DoD 8.8 4.4 2.0 Braintree 1.0 1.0 0.5 Rehab Institute of Chicago 1.0 2.8 0.8 Craig, Denver 2.0 3.2 1.1 Bellevue 2.0 3.0 1.0 Beth Israel ~ 2.0 2.9 1.0 Survey of Literature (derived from Gonzalez et al., 1988) Solo University 3.2 2.9 1.6 4.0 2.5 2.0 Rehabilitation Center 2.5 4.0 1.3
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From page 257... ...
Section B seeks responses to a series of questions for He 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 Rehabilitation Medicine Service to deliver good~uality care under the Specified circumstances.
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From page 258... ...
258 PHYSIC SIFTING FOR T7IE Via-VOLUME ~ SECTION A: PATIENT CARE ACTIV1T ADMISSIONS Please fill in the average time ~ hours required by a staff physician in your service to accomplish an admission wo~-up, either with or without the assistance of a resident in your service. Cart 1 Time per Admission Work-Up without Resident High Low Mean Median Time per Admission Work-Up with Resident High Low Mean Median 2.00 1.00 1.42 1.42 1.33 0.25 0.72 0.67
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From page 259... ...
RE~B~ITHIION H=1~~ Pi ART ROI] TINE DAILY PA'l~NT CARE 259 For each workload factor and alternative average daily census (ADC3 level below, please fill in He average number of physician hours required from the rehabilitation medicine service.
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From page 260... ...
260 Chart 3 PHYSI~IN SI~FFI~& FOR TIE Vim-VOLUME ~ For ADC of 10 or less, assume one PGY 2 or 3 resident; for ADC Or than 10, assume two PGY 2 or 3 red - te. ~ Rehabilitation Ward Average LOS = 7 ADC ADC ADC ADC ADC ADC 1 5 10 15 20 25 Daily Rounds High 0.33 1.00 1.33 2.50 3.00 4.00 Low 0.08 0.25 1.00 1.25 2.67 2.00 Mean 0.20 0.58 1.07 1.67 2.08 2.67 Median 0.17 0.50 1.00 1.50 2.00 2.50 Charting, Phone, High 0.25 0.50 1.00 1.50 2.00 4.00 and Paperboy Low 0.08 0.25 0.42 0.67 0.83 1.00 Mean 0.15 0.42 0.67 0.97 1.25 1.83 Median 0.17 0.50 0.50 1.00 1.00 1.42 Patient and Folly High 0.25 1.00 2.00 3.00 4.00 5.00 Contacts plus Low 0.08 0.17 0.25 0.25 0.25 0.25 Teaching Mean 0.18 0.43 0.67 1.08 1.42 1.75 Median 0.25 0.25 0.33 0.50 0.67 0.83 Supervision High 4.00 4.00 4.00 4.00 4.00 4.50 and Teaching Low 0.17 0.25 0.25 0.50 0.50 0.50 (Residents/Staff)
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From page 261... ...
(When lhe resident is present, assume that dine/he is performing the consult under the supervision of an adding physician.) Chat 4 Time per Consult without Resident Time per Consult with Resident Consultation off your PCA High Low Mean Median High Low Mean ME Medicine 1.00 0.50 0.70 0.58 1.00 0.25 0.67 0.63 Surgery 1.00 0.50 0.57 0.58 1.00 0.25 0.52 0.58 -Nursing Home -1.00 0.25 0.53 0.50 1.00 0.08 0.52 0.50 Intermediate Care 1.00 0.25 0.53 0.50 1.00 0.08 0.52 0.50 Neurology 1.50 0.50 0.87 0.70 1.50 0.25 0.78 0.75 Psychiatry 1.00 0.33 0.63 0.50 1.00 0.25 0.63 0.63
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From page 262... ...
262 P~IYSICUN SI~FPING FOR To Vat-VOLUME TIME PER FOLLOW-UP VISll (POST-CONSULTATION) OFF YOUR PCA Please fill in He average time in hours required by a staff physician in your service for each follow-up consultation visit (post-consultation)
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From page 263... ...
. EMG Evoked Potential Others (SpeciO 2.00 0.67 1.07 0.92 2.00 0.42 1.17 1.25 1.00 0.67 0.95 1.00 1.25 0.33 1.00 1.00 1.00 0.67 0.80 0.92 OUTPA'l~NT VISITS 1.00 0.75 0.87 0.92 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 residents and nonphysician practitioners, sad whether t},e visit in hv ~ now Or rPh~rnino patient.
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From page 264... ...
264 C:hart 7 (continued) PASSION STAFFING FOR ARE Vat-VOLUME n Physician Time per Visit Type of Visit High Low Mean Median New Patient Visit l.SO 0.42 0.70 0.58 With NP or PA Follow-Up Visit O.SO 0.25 0.35 0.33 No Resident Follow-Up Visit O.SO 0.08 0.28 0.2S With Resident Pollow-Up Visit 0.33 0.08 0.22 0.22 With NP or PA
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From page 265... ...
List the time in hours that you would add to each physician's average workday to allow for He types of non-patient care work listed below: Chart 8 . Assume He amount of research accomplished at this VAMC is: High Mediums Lows Education of High 2.50 1.50 0.83 Residents Low 1.00 O.SO 0.00 (didactic, Mean 1.57 1.00 0.45 classroom, not Median 1.50 1.00 0.50 on the PCA)
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From page 266... ...
266 Ant 9 (continued) PilYSIGI~ STAFFING; FOR TRE Vie-VOLUME ~ Assume He amount of research accomplished at this VAMC is: Highly Medium' Low' Hospital-Related High 2.50 1.50 1.00 Activities (mortality Low 0.50 0.50 0.25 and morbidity, Mean 1.05 0.77 0.57 Q.A., staff, Median 0.92 0.50 0.50 meetings)
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From page 267... ...
member of your service should devote to each of the following categories of non-patient~e related activities? Chart 9 Assume He amount of research accomplished at this VAMC is: High' Mediums Low l Continuing Education High 15.0 15.0 15.0 Low 5.0 5.0 2.0 Mean 10.0 8.0 6.0 Median 10.0 8.0 5.0 Research (off the PCA)
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From page 268... ...
BRITELL, Assistant Chief, Spinal Cord Injury Service, Seattle VA Medical Center, Seattle, Washington VALERY LANYI, Medical Director of Rehabilitation Service, Bellevue Hospital, New York, New York NICOLAS E WALSH, Professor and Chairman, Department of Rehabilitation Medicine, University of Texas Health Sciences Center, San Antonio Study Staff: Nancy Kader, Staff Officer tMember of the study committee.
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