Issues and Solutions in Accurately Measuring Clinical Full-Time Equivalents

Article Outline

• Assessing the Problem
• Current Proposed Enhancements
• Perfect is the Enemy of Good
• A New Definition of CFTE
• Future Challenges to a More Perfect Survey
• The Brave New World
• Acknowledgment
• Figure. 
• Table I. 
• Table II. 
• Table III. 
• Acknowledgments
• Copyright

AAAP, Association of Administrators in Academic Pediatrics, AMSPDC, American Medical School Pediatric Department Chairs, CFTE, Clinical full-time equivalent, WRVU, Work relative value unit

As with private practices, measuring, assessing, and rewarding clinical productivity are critical to successful management of academic practices. Academic practices have the added challenge of simultaneous research and educational activities.

Determining the proportion of effort devoted to clinical, research, and teaching activity for every faculty member allows pediatric department chairs to clarify roles and expectations for faculty. This clarity also benefits faculty, increasing the likelihood of improved productivity and professional satisfaction.

Like other clinical practices, academic pediatric practices benefit from external benchmarks that allow assessment of clinical productivity. Work relative value units (wRVUs) have long served as a common currency for productivity. The effort required to produce wRVUs is measured in clinical full-time equivalents (CFTEs), which do not have a commonly accepted definition.

In support of the AMSPDC, the Association of Administrators in Academic Pediatrics (AAAP) annually produces a comprehensive survey of pediatric faculty compensation and productivity. Chairs and their administrators use this survey to guide decisions regarding faculty compensation and expectations for faculty clinical productivity. To provide maximally reliable survey data, the AAAP has recently focused on reducing inconsistencies in measuring CFTEs among participating institutions.

This article summarizes our journey in minimizing variability in reporting of faculty CFTEs, in order to yield an accurate and optimally useful measure of clinical productivity.

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Assessing the Problem 

To validate the perception that survey respondents have been using different criteria to set CFTEs, we charted survey data of wRVUs against CFTE. Review of data for neonatologists demonstrated a lack of correlation between wRVUs and CFTEs (Figure; available at www.jpeds.com).

Work group discussions among interested volunteer members of the AAAP revealed that some institutions have defined CFTE on the basis of proportion of maximum clinical effort, and others have defined CFTE on the basis of proportion of 40 hours. Table I (available at www.jpeds.com) highlights the variability in productivity as measured by wRVU per CFTE between these two methods.

The work group also discovered examples in which some respondents have included nonbillable time in their measure of clinical effort, which has an effect on the calculation of productivity (Table II; available at www.jpeds.com).

Finally, the work group assessed the impact of the use of different relative value unit reference years and observed significant variability (Table III; available at www.jpeds.com). Fortunately, this concern is easily addressed. Future surveys will ask respondents to verify that their wRVU data apply to the particular year requested.

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Current Proposed Enhancements 

The work group has identified a handful of questions designed to explore other potential factors that might be associated with variability in clinical productivity and, in any event, would allow for closer comparison with like institutions. The group will propose to the AAAP membership that each survey respondent address the following general questions: type of organization (eg, free-standing children's hospital, hospital within a hospital, pediatric services within general hospital, etc.); number of inpatient beds; number of faculty in the department; and number of CFTEs in the department. These measures will be stratified into thirds, with the levels for each third determined by the data received for each particular criterion.

We will also seek consent from the AAAP membership to request responses to 3 more queries that may be valuable in further clarifying productivity expectations: Is nonphysician provider activity included in the reported wRVUs billed under a given physician's name? The most clinical effort a physician in this role would be expected to perform is ___ outpatient sessions per week (sessions defined as equivalent to 4 hours). The maximum effort that providers in 24-hour services (eg, emergency medicine, neonatology, pediatric critical care, cardiac critical care, hospitalist care) would be expected to attend is ___weeks of clinical service per year.

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Perfect is the Enemy of Good 

Increasing the length of the survey and the number of factors on which the data are stratified create challenges. The work group is also sensitive to requiring too much detail from members, thereby dissuading participation. A lower response rate would fundamentally reduce the reliability of the data and defeat the purpose of requests for more detailed information. We cannot control for all variables, including some valid factors such as service mix (eg, inpatient, outpatient, procedures) and patient acuity.

The AAAP will continue to balance ease of completion for survey respondents with the desire for more exact data and categories. Administrators and chairs must be comfortable that the data represent an effective tool to suggest further inquiry, as much as to lead to conclusions and provide guidance. The data cannot provide definitive answers to what are reasonable productivity expectations for a given institution, division, or faculty member.

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A New Definition of CFTE 

The critical issue in calculating CFTEs remains creating a standard approach to the numerator and the denominator in the calculation. We settled on the following proposed definition as guidance for current survey respondents to measure CFTEs for each of their faculty:

In general, the calculation of faculty clinical effort is universal: total billable clinical effort divided by total effort. It is understood that institutions have different expectations for total effort. It is also understood that particular specialties within a given institution have different expectations for total effort. For this survey, members should use their institution's accepted standard for each full-time position. For example, a physician who spends thirty hours per week, on average, on billable clinical activities and typically works sixty hours per week would be considered a 0.5 CFTE.

The definition further clarifies: “Clinical effort should be restricted to that portion of effort for which a billable professional charge may be generated for the service provided.” Thus, clinical administrative effort is not included in the numerator.

The concept of clinical effort as a proportion of total effort lessens the possibility of individual or inconsistent definitions of total expectations (eg, maximum clinical effort, 40 hours, etc) serving as a source of confusion. This approach to clinical effort respects the individuality of institutions and specifically acknowledges the factor of higher work standards for a given physician as a legitimate variable in measuring clinical productivity. Inclusion of only those elements of clinical effort that relate to billable activity is an equally important aspect of the definition.

Additional guidance, including specific examples of activities that should be included as billable time and activities that should be excluded, will also be provided to members. Excluded activities that are nonclinical (eg, research, on-call time outside the hospital) are straightforward.

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Future Challenges to a More Perfect Survey 

The exclusion of certain clinical activities provides more reliable data by matching measurable work to the effort associated with it. However, this approach will lead to exclusion of a portion of clinical work for some faculty. For example, the survey will exclude any work that has no wRVU associated with it, such as contracted work whereby another party bills, capitation contracts, or global or bundled billing arrangements. To the extent that faculty participate in clinical activities that are not billable, we will no longer measure the totality of their clinical effort or productivity.

Exclusion of a portion of clinical work is problematic on two fronts. First, it leads to confusion for chairs if budgeted faculty full-time equivalents differ from CFTEs, as submitted in the survey. To the extent that these numbers are reviewed by third parties such as deans, clarifying such data may be confusing at best and troublesome at worst. Second, the prevalence of faculty who provide clinical services that are not directly billed is significant and is growing. The proportion of nonbillable activities will increase further as we move into the era of health care reform. Finding a means to apply wRVUs to such nonbillable activities would allow their inclusion in future surveys. The AAAP will need to explore how best to guide respondents in consistently applying wRVUs to activities that do not use wRVUs to generate revenue. The association will need to only include what we can define accurately, to retain the integrity of matching productivity (wRVUs) with effort (CFTE).

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The Brave New World 

The introduction of Accountable Care Organizations and the attendant payment and care delivery reforms have the potential to not only challenge the wRVU as the gold standard of clinical productivity, but even to challenge the validity of the wRVU as a measure of successful clinical productivity.

The authors of this survey presented a report to AMSPDC, on behalf of the work group and the AAAP, to solicit comments and feedback on the progress of this effort. Our future direction reflects this feedback. Members of the work group, together with Alan Stiles, MD of AMSPDC, presented a report to the AAAP in a post-health care reform legislation passage world.

The challenge of accurately measuring provider productivity is clearly a journey, not a destination, for chairs, administrators, faculty, and each of our organizations. The AAAP will continue to work diligently to diagnose and address problems. We are confident that the AAAP will continue to provide the most comprehensive and authoritative resource for benchmarking pediatric subspecialty compensation and productivity in the future, regardless of the magnitude of challenges that we face. We will continue to seek feedback as we advance our work in this arena.

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Acknowledgments available at www.jpeds.com.

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Figure. 

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• Clinical productivity—neonatologists.

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Table I. 

Effect of alternate measures of total effort

CFTE, clinical full-time equivalent; WRVU, work relative value unit.

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Table II. 

Effect of inclusion of nonbillable time

CFTE, clinical full-time equivalent; WRVU, work relative value unit.

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Table III. 

Differing relative value unit reference years

CFTE, clinical full-time equivalent; NPV, net present value; RBRVS, resource-based relative value scale; wRVU, work relative value unit.

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Acknowledgments 

The authors would like to recognize current and past workgroup members who have contributed to this progress:

Mark Amox, University of Arkansas for Medical Sciences; Denny Bardeau, Alberta Children's Hospital; Gail Cohen, University of Colorado Children's Hospital; Mary Corcoran, Stanford University School of Medicine; Marcene Dickes, The Children's Mercy Hospital; Dennis Harris, University of Miami Miller School of Medicine; Jon Hayes, University of Oklahoma Health Sciences Center; Anna Carol Herman-Giddens, University of North Carolina School of Medicine; Elizabeth Hickle, MetroHealth Medical Center; Jackie Jew, University of California, San Francisco; Lori Mackey, University of Cincinnati College of Medicine; Tom Malin, Medical College of Wisconsin; Constance Marr, University of Maryland School of Medicine; Jim Morgridge, Northwestern University, Feinberg School of Medicine; Billy Newton, Duke University School of Medicine; Gwen Pfeifer, Duke University Medical Center; Chuck Rydzy, Johns Hopkins University School of Medicine; Patrick Shumaker, Wayne State University School of Medicine; Marsha Wendt, University of Wisconsin School of Medicine and Public Health; Lisa Wohlert, Yale University