Physician Staffing for the VA -- Preface -- Acknowledgments -- Contents -- Executive Summary -- OVERVIEW OF THE STUDY -- Purpose and Scope -- Organization and Conduct of the Study -- Some Undergirding Assumptions -- DEFINING, BUILDING, AND RECONCILING ALTERNATIVE APPROACHES TO PHYSICIAN STAFFING -- Three General Approaches to Determining Physician Requirements -- The Empirically Based Physician Staffing Models -- Expert Judgment Models -- Reconciling the Approaches -- Using the Reconciliation Strategy to Calculate Physician FTEE -- External Norms -- OVERALL ADEQUACY OF PHYSICIAN STAFFING IN THE VA: COMMITTEE PERSPECTIVE -- VA CENTRAL OFFICE AND THE VAMC: PROMOTING A DIALOGUE -- AFFILIATIONS WITH MEDICAL SCHOOLS -- NONPHYSICIAN PRACTITIONERS -- FURTHER DEVELOPMENT OF THE METHODOLOGY -- CONCLUDING REMARKS -- 1 Overview of the Study -- PURPOSE AND SCOPE -- ORGANIZATION AND CONDUCT OF THE STUDY -- THE COMMITTEE PERSPECTIVE -- REFERENCES -- 2 Background -- CURRENT ALLOCATION OF PHYSICIANS IN THE VA -- Total Physicians, By Specialty -- How Physician FTEE Levels Currently Are Determined -- SOME UNDERGIRDING ASSUMPTIONS -- The Methodology Focuses on Physician FTEE for VAMCs -- This Is Not a Needs-Based Approach -- Assuring the Quality of Care -- The Methodology Must Be Relevant to the Present, Flexible for the Future -- REFERENCES -- 3 Overview of the Analysis -- A CENTRAL PROBLEM: DETERMINING PHYSICIAN FTEE REQUIRED FOR PATIENT CARE AND RESIDENT EDUCATION -- DETERMINING PHYSICIAN REQUIREMENTS FOR OTHER MISSION-RELATED ACTIVITIES -- RECONCILING THE APPROACHES -- MANAGEMENT USES OF PHYSICIAN STAFFING MODELS -- PROJECTING FUTURE VA PATIENT WORKLOAD -- THE VAMC-MEDICAL SCHOOL AFFILIATION RELATIONSHIP -- NONPHYSICIAN PRACTITIONERS AND VA PHYSICIAN REQUIREMENTS -- COMMITTEE CONCLUSIONS AND RECOMMENDATIONS -- REFERENCE.

4 The Empirically Based Physician Staffing Models -- HOW THE EMPIRICALLY BASED MODELS WORK -- Anatomy of the PF Variant -- Anatomy of the IPF Variant -- FORMAL PRESENTATION OF THE EBPSM -- Production Function -- Inverse Production Function -- USING VA DATA TO ASSIGN VALUES TO VARIABLES -- Workload -- Inpatient Care -- Ambulatory Care -- Long-Term Care -- VA Staff Physician FTEE -- Nurse FTEE -- Support-Staff FTEE -- Contract Physician FTEE -- Resident FTEE -- Nonpersonnel Factors Influencing Physician Productivity -- ESTIMATED PF AND IPF EQUATIONS -- PF Estimates -- Inpatient Medicine -- Inpatient Surgery -- Inpatient Psychiatry -- Inpatient Neurology -- Inpatient Rehabilitation Medicine -- Spinal Cord Injury -- Ambulatory Medicine -- Ambulatory Surgery -- Ambulatory Psychiatry -- Ambulatory Neurology -- Ambulatory Rehabilitation Medicine -- Ambulatory Other Physician Services -- Nursing Home Care -- Intermediate Care -- IPF Estimates -- Medicine -- Surgery -- Psychiatry -- Neurology -- Rehabilitation Medicine -- Spinal Cord Injury -- Anesthesiology -- Laboratory Medicine -- Diagnostic Radiology -- Nuclear Medicine -- Radiation Oncology -- EBPSM APPLICATION 1: USING THE MODELS TO ASSESS PHYSICIAN STAFFING LEVELS AND WORKLOAD PRODUCTIVITY ... -- Using the IPF to Compare Predicted and Actual Physician FTEE Devoted to Direct Patient Care and Resi ... -- Using the PF to Compare Projected and Actual Physician FTEE Devoted to Direct Patient Care -- Using the PF to Compare Predicted and Actual Rates of Workload Productivity -- EBPSM APPLICATION 2: DERIVATION OF FUTURE PHYSICIAN REQUIREMENTS, BY SPECIALTY, FOR VAMCS -- Using the IPF to Derive Future Physician Requirements For Direct Patient Care and Resident Education -- Using the PF to Derive Future Physician Requirements For Direct Patient Care -- PROPOSALS FOR REFINING AND EXTENDING THE EBPSM.

Improving the Accuracy of Data From the CDR -- Developing Improved and New Variables For the Models -- Further Methodological Development -- REFERENCES -- 5 Expert Judgment Approaches to Physician Staffing -- INTRODUCTION -- THE PANEL PROCESS-IN THEORY -- Scheme For Eliciting Judgments -- "Pure" Delphi Method -- Group Interactive Methods -- Modified Delphi Approaches -- Reaching an Consensus -- Committee's Proposed Approach To Eliciting Expert Judgments and Reaching Consensus -- THE PANEL PROCESS-IN PRACTICE -- Appointment of Specialty and Clinical Program Panels -- Evaluating the EBPSM -- Selection of Variables For Multivariate Regression Equations -- Plausibility and Desirability of Physician Requirement Estimates from Empirically Based Models -- Development of the DSE -- An "Ideal" Mechanism -- Search For an Practical Response -- Revised Instrument For Second Round of Panel Meetings -- A Closer Look -- Application To an VAMC -- Committee Evaluation -- The SADI -- Overview -- A Closer Look -- Overall Idea -- Application To an VAMC -- Committee Evaluation -- External Norms -- Types of Staffing Standards -- Data Sources -- Application of External Norms: An Illustration -- REFERENCES -- INSTRUCTIONS FOR STAFFING EXERCISE TWO MEDICINE SECOND PANEL MEETING -- PATIENT CARE AREA 1: MEDICINE SERVICE -- PATIENT CARE AREA 3: NEUROLOGY SERVICE -- PATIENT CARE AREA 4: PSYCHIATRY SERVICE -- PATIENT CARE AREA 5: REHABILITATION MEDICINE SERVICE -- PATIENT CARE AREA 6: SPINAL CORD INJURY SERVICE -- PATIENT CARE AREA 7: LONG-TERM CARE SERVICE -- PATIENT CARE AREA 8: AMBULATORY CARE PROGRAM -- INTRODUCTION AND INSTRUCTIONS (APPREVIATED) -- SECTION A: PATIENT CARE ACTIVITIES -- Admissions -- Routine Daily Patient Care -- Assume No Residents -- Assume One PGY 1 and One PGY 2 or 3 Resident Per ICU/CCU -- Time Per Initial Consultation Off Your Pca.

Time Per Follow-Up Consultation Off Your Pca -- Special Procedures -- Ambulatory Care -- 6 Choosing Among Alternative Approaches to Determining Physician Staffing -- STRATEGIES FOR RECONCILING THE APPROACHES -- THE RECONCILIATION STRATEGY -- Committee's Recommended Approach -- Interpretation of the Strategy -- Establishing Appropriate FTEE Targets, by Specialty and Program Area -- Establishing a Transition Policy to Phase in New Physician Staffing Levels -- Using the Reconciliation Strategy to Calculate Physician FTEE -- Total Physician FTEE (VA and Non-VA) for Direct Care, Resident Education, Administration, and Leaves -- Staff Physician FTEE for Research -- Staff Physician FTEE for Continuing Education -- EXTERNAL NORMS -- OVERALL ADEQUACY OF PHYSICIAN STAFFING IN THE VA: COMMITTEE PERSPECTIVE -- ILLUSTRATION OF RECONCILIATION STRATEGY CALCULATIONS -- Current Staffing -- The Reconciliation Strategy -- Physician FTEE Calculations Oriented Around the Empirically Driven Baseline (X1) -- Physician FTEE For Patient Care, Resident Education, Administration, and Leaves of Absence -- Physician FTEE for Research -- Physician FTEE for Continuing Education -- Physician FTEE Calculations Oriented Around the Expert Judgment Element of the Modifier (X2) -- Physician FTEE For Patient Care, Resident Education, and Administration -- Physician FTEE for Research -- Physician FTEE for Continuing Education -- Physician FTEE for Leaves of Absence -- Physician FTEE Calculations from the Perspective of the Reconciliation Strategy -- REFERENCE -- APPENDIX -- SPECIALTY AND CLINICAL PROGRAM PANEL CONCLUSIONS -- MEDICINE PANEL -- Patient Care, Resident Education, and Administration -- Research -- Continuing Education -- Leaves of Absence -- Purchased Coverage for Nights and Weekends -- Consulting & Attending and Without-Compensation Coverage -- External Norms.

Overall Adequacy of Physician Staffing in the VA -- Other Points -- Final Remarks -- SURGERY PANEL -- Patient Care, Resident Education, and Administration -- Research -- Continuing Education -- Leaves of Absence -- Purchased Coverage for Nights and Weekends -- Consulting & Attending and Without-Compensation Coverage -- External Norms -- Overall Adequacy of Physician Staffing in the VA -- Other Points -- Final Remarks -- PSYCHIATRY PANEL -- Patient Care, Resident Education, and Administration -- Research -- Continuing Education -- Leaves of Absence -- Purchased Coverage for Nights and Weekends -- Consulting & Attending and Without-Compensation Coverage -- External Norms -- Overall Adequacy of Physician Staffing in the VA -- Final Remarks -- NEUROLOGY PANEL -- Patient Care, Resident Education, and Administration -- Research -- Continuing Education -- Leaves of Absence -- Purchased Coverage For Nights and Weekends -- Consulting & Attending and Without-Compensation Coverage -- External Norms -- Overall Adequacy of Physician Staffing in the VA -- Other Points -- Final Remarks -- REHABILITATION MEDICINE PANEL -- Patient Care, Resident Education, and Administration -- RESEARCH -- Continuing Education -- Leaves of Absence -- Purchased Coverage For Nights and Weekends -- Consulting & Attending and Without-Compensation Coverage -- External Norms -- Overall Adequacy of Physician Staffing in the VA -- Other Points -- Final Remarks -- OTHER PHYSICIAN SPECIALTIES PANEL -- Patient Care, Resident Education, and Administration -- Research -- Continuing Education -- Leaves of Absence -- Purchased Coverage for Nights and Weekends -- Consulting & Attending and Without-Compensation Coverage -- External Norms -- Overall Adequacy of Physician Staffing in the VA -- Other Points -- Final Remarks -- AMBULATORY CARE PANEL -- Patient Care, Resident Education, and Administration.

Research.