Physician Staffing for the VA Volume II, Supplementary Papers (1992) / Chapter Skim
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Section III: Nonphysician Practitioners Panel ReportNonphysician Practitioners Panel Report
Section III: Nonphysician Practitioners Panel ReportNonphysician Practitioners Panel Report
Pages 419-466
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From page 421... ...
, nurse practitioners (NPs) , and other categories of providers, each of whom performs specified diagnostic and therapeutic patient care tasks under the supervision of · .
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From page 422... ...
, their supervisors, and the chiefs of staff at 34 selected VA medical centers from around the nation. In the sections that follow, the panel presents a topology for studying nonphysician practitioners in the VA, discusses the potential role of the NPP in the overall physician staffing methodology developed by the IOM committee, analyzes both the empirical findings and policy recommendations from the three field surveys, and concludes with its own recommendations to the IOM committee.
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From page 423... ...
. In light of this, and with approval from the study committee, the panel focused almost entirely on Category III providers, designating this group as ~nonphysician practitioners.
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Second, with respect to the committee's expert judgment approaches to physician staffing, a similar strategy can be pwsuml. That is, assumptions about the number and type of each NPP can be built into the Detailed Staffing Exercise (DSE)
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From page 425... ...
However, these variables can yield no direct insights into the specific productivity contributions of PAs, NPs, CNSs, or CRNAs. SURVEYS ON THE CURRENT AND FUTURE ROLES OF NONPHYSICIAN PRACTITIONERS IN THE VA This panel concluded that, while many observers of and participants in the VA health care system held strong views about the current and future roles of NPPs, there had been little systematic analysis of data bearing on this issue.
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From page 426... ...
Thelatter three NPPs are all trained registered nurses with advanced nursing preparation; their survey responses report the allocation of time to services performed under physician supervision and (by implication) the allocation to advanced nursing functinos.
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From page 427... ...
Among the many inferences possible from Tables 1-3, the panel specifically notes the following: Allocation of REP Time to Patient Care Units/Activities From Table 1 we infer that: · In general, nonphysician practitioners were successfully able to partition their time across patient care areas, subcomponents of PCAs, and to various non-patient~are units/activities. This strongly supports the feasibility of adding cost centers to He VA's CDR for the PA, NP, CNS, and CRNA, thus enabling
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From page 428... ...
Only about 7.6% of PA time is spent in the nursing home and other extended care settings. If one adds to that the 4.0% of time allocated to inpatient intermediate care units, the total time devoted to what the study committee has termed Long-term care.
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From page 429... ...
Additional Perspectives on NPP Activities at the VAMC From Table 2 we infer that: · Nonphysician practitioners are able to devote only a modest amount of time to teaching and research. The time allocated to teaching residents and other nonphysician personnel ranges from 6.2% for NPs to 9.4% for CRNAs.
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From page 430... ...
formats. Mom the Vantage of the NPP Supervisor From Table 3 we infer ~at: · Both the absolute amount of time and the fraction of all direct care time that the physician spends supervising the nonphysician practitioner vary significantly with We type of NPP supervised.
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From page 431... ...
How Does Your VAMC Set Its Policies Regarding the Use of Physician Assistants, Nurse Practitioners, Certified Registered Nurse Anesthetists, and Clinical Nurse Specialism? Many of the 34 surveyed COS responded briefly, sometimes vaguely, to the questions of how NPP policies were established at their VAMC.
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From page 432... ...
The majority of COS implied that the state practice acts play little, if any, role in the individual VAMC9s policies on the utilization of these four practitioners. Many COS said the state acts were too restrictive and confusing.
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From page 433... ...
(Zampieri) Quite often these NPPs are used below their potential because of tenets of the various practice acts within the state in which the VAMC is located.
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From page 434... ...
Leo other panel members (Byers and Rhyne3 also commented that a national policy is needed because quite oft" the decision to utilize these practitioners is based on the will of the local physician leadership (which may not have extensive experience with NPPs) or the state practice acts (which are often not understood)
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From page 435... ...
A few of the COS responded that funds for continuing education are needed to allow these practitioners to maintain competence and up-to-date knowledge. Not only should funds be established, but these practitioners should be supported and encouraged in this effort, it was argued.
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From page 436... ...
Cen - 1 Of lice should issue a circular describing the role, responsibilities, and utilization of each of these NPPs in Me system; (3) individual VAMCs should be creative in lowing for effective methods to provide health care to VA patients by utilizing the different NPPs in innovative roles; and (4)
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From page 437... ...
The COS at one VAMC facility stated that these two types of practitioners could provide follow-up care on stable chronic patients in both inpatient and ambulatory care settings. Six COS also noted that these two types of practitioners, with appropriate physician supervision, could readily take over the patient history and physical examinations in any of He Tree settings.
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From page 438... ...
~. _ PANEL CONCLUSIONS AND RECOMMENDATIONS The nonphysician practitioners panel's views are shamans below.
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From page 439... ...
Continuing Education for Physicians and NPPs From the analysis of the NPP survey data and commentary, the panel concludes that the utilization of these practitioners is more dependent on the attitudes and knowledge of individual physicians than on the braining and the clinical skill level of He NPP. Before the VA can utilize NPPs in an efficient maimer consistent with quality care, education programs for VA physicians must be established.
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From page 440... ...
The committee applauds the efforts undertaken thus far to establish national guidelines for these two NPPs, especially the relatively detailed policies developed for PAs. The panel urges the VA to develop explicit national policies on the appropriate use of all NPPs through a careful evaluation of existing evidence on He efficiency and quality of their clinical practice and appropriate utilization according to national standards of practice.
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From page 441... ...
The policies should encourage the appropriate use of NPPs by explicitly Idling, for each type of NPP, a range of expected requirements: Gaining and skill level, continuing edition for the NPP, physician supervision, peer review, continuing education for staff physicians, and administrative procedures for allowing certain practitioners with advanced tanning and experience to perform advanced functions under physician supervision. For each type of NPP, the national guidelines could include a specific list of functions for which there is evidence, in each case, that a well-tra~ned and supervised practitioner can render care of appropriate quality.
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From page 442... ...
The panel recommends that the VA establish research projects to e~camme extensively the different systemwide uses of nonphysician practitioners. These projects should focus particularly on the NPPs impact on cost and the quality of care.
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From page 443... ...
: Emergency Room, Admitting/Scree~g Area, Compensation ~ Pension Exams, Employee Health, Ho~ital-Based Home Care, Satellite Outpatient Clinic, Hcmodialysis, Domiciliary, and Other Outpatient Settings.
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From page 444... ...
(N=57) (N=26 Extended Care (Nursing Home Plus Other Settings)
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From page 445... ...
Hours/Week Under Direct Physician Supervision % Time Physician Supervision Relates to Performing Medical Procedures (unclog Physician Orders Other Activities 35.7 36.1 4.6 2.4 42.8 0.6 6.2 6.6 38.8 0.2 1.8 0.0 10.0 0.0 7.5 6.7 38.8 3.0 0.3 10.0 9.4 0.7 40.1 8.2 28.5 60.0 14.2 9.7 4.1 15.0 20.5 18.1 43.8 45.8 5.6 62.4 27.0 18.8 67.4 18.8
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From page 446... ...
Hours/Week 33.0 29.7 27.9 39.0 24.2 Physician Spends in Direct Care Hours/We~k Physician Supervises NPP % Time NPP Takes First Call for Physician % Time Supervision Evolves: 16.1 9.2 5.3 25.7 21.6 20.2 26.4 25.7 47.1 7.4 Overseeing 23.7 27.2 41.3 68.6 20.7 Medical Procedures (checking 25.7 41.5 7.8 5.9 15.6 Orders with NPP Other Activities 50.6 31.3 50.9 25.5 63.7 lNuniber of responding physician in parentheses.
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From page 447... ...
1982. A description of a means of improving ambulatory care in a large municipal teaching hospital: A new role for nurse practitioners.
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From page 448... ...
Journal of Public Health Policy 6~1~:78-99. After reviewing the development of the PA concept in the United States, examines existing policy barriers hindering the cost-effective use of PAs, including uneven and restrictive state medical practice acts.
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From page 449... ...
Journal of Health and Human Resources Administration 5:159-185. Analyzes mechanisms by which greater use of physician assistants and nurse practitioners could improve access to primary medical care while dampening the rate of increase in costs.
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From page 450... ...
American Journal of Public Wealth 66: 64-6~6. Descnbes results from survey to investigate the ranges of appropriate task delegation to physician assistants and nurse practitioners, particularly in ambulatory care settings.
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From page 451... ...
Cost analyses suggest that these practitioners nary lead to a net dollar savings; such production efficiencies would likely increase with the sustained use of these extenders in nursing homes. MendenhaH, M.C., Repicly, P.A., and Neville, R.E.
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From page 452... ...
1986. Nurse Practitioners, Physician Assistants, and Certified Nurse-Midwives: A Policy Analysis.
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From page 453... ...
1981. The current and future role of surgical physician assistants: Report of a national survey of surgical chairmen in large U.S.
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~4 ~ ~ -I ash J.C., ~ H.~., M~, G.S., ~ ~, J.F.
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1990. Improved quality of care and reduced house staff workload using trauma nurse practitioners.
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1985. Nurse practitioners' perceptions of facilitators and constraints to practice.
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From page 457... ...
2. For each of the service units or areas listed below, we are interested in three pieces of information: the percentage of your total work time spent there; for the time spent there, the percentage involved in physiciandelivered direct care activities; and for the time spent in these direct care activities, the percentage of time under direct physician supervision:
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From page 458... ...
a) 0 Inpatient Care Medical Service Medical Ward % % % Intensive Care Unit % % % Coronary Care Unit % % % Neurology Service Neurology Ward % _ % % Rehabilitation Medicine Rehab Service Ward % % Intermediate Care Unit % % Spinal Cord Injury Service % % % ar al or _" Surgery Service SurgicalWard % % % Surgical Intensive Care Unit % % % Operating Room % % % Post Anesthesia Recovery Room % % % Psychiatry Service Psychiatry Ward % % % Alcohol/Dmg Treatment Ward % % % Other Inpatient Care Settings (§lease specify)
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From page 459... ...
0 459 For the time spent in ~physiciandelivered direct care activities,. please estimate He percentage of time under ~direct.
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From page 460... ...
. Ended Care Nursing Home Care Unit % % % Over Extended Care Setting (§lease specify)
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From page 461... ...
IYSlCUN PMCIITIONERS Ply SPORT 3. Considering your work on all of the units or areas above, please estimate the percentage of your total time involved in: Teaching residents or other nonphysician practitioners.
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From page 462... ...
~2 ~ ~ ~-~Q 8. -~x~y ~ ~ ~= ~ ~ dad ~ ~sici~ dimly _i~ yea ^~ of H~= S~i~ By ~ysici~ 9.
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From page 463... ...
Hours Per Week 2. Which of the following Nonphysician Practitioners do you actively supervise: Physician Assistant Nurse Practitioner Certified Registered Nurse Anesthetist Clinical Nurse Specialist 3.
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From page 464... ...
: 5. For the physician supervision you provide, please estimate the percentage of time that it occurs in each of the following formats: Overseeing the Performance of Medical Procedures (please specify)
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From page 465... ...
4. What potential roles can you envision for nonphysician practitioners in: A
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From page 466... ...
WOODSON,~ Director, Fellowship Program in Geriatric Medicine, Pritzker School of Medicine, University of Chicago, Chicago, Illinois THOMAS A ZAMPIERI, Physician Assistant, Surgical Service, Richmond VA Medical Center, Richmond, Virginia Bobbie J
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