oversight

Review of the Medical School Affiliation Program at the Veterans Administration Hospital, Washington, D.C.

Published by the Government Accountability Office on 1977-04-14.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

                                                                    /Oz 2,2-2



                          DOCBZIST lNSUSE
02222 - [Al452442 1
[Review of the Hedical School Affiliation Program at the
Veterans Adainistration Hospital, ashington, 'D.C. ]*. pril 14,
1977.. 3 pp. * enclosure (1I pp.!).
Report to A. A. Gavazzi, Director, Teterans Administration: VA
dospital, Washington, DC; by George D. ,Peck, Assistant Director,
Human Resources and Development Div.
Issue Area: Health Programs (t200).
Contact: Human Resources and Development Div.
 aud;et Function: Veterans Denefits and Services: Hospital and
     Hedical Care for Veterans (703).
Organization Concerned: Veterans Administration.
           The responses to a questionnaire sent to most
physicians employed at the Washington, D.C., -Veterans
 5 Iainistration (VA) Hospital identified certain deficiencies at
tLe hospital which could have an adverse impact on the quality
of the care that patioets receive. Findings/rConclusio s: The
medical school affiliation plays a large part in attracting
physicians to the hospital. Host of the physicians were
satisfied with the inpat-ient facilities; however, they were not
satisfied with the outFAtient facilities. Overall, many
physicians were satisfied with the availability of- edical
equipaent for inpatient and outpatient care. Eany physicians
were unsatisfied with all aspects of the radiology service,
iocluding availability, timeliness of delivery, and quality.
many narrative rusponses complained that the ancillary service
staff members were inefficient. In general, the physicians were
satisfied with the training, experience, and competency of the
nursing staff, although many tbought that the number of nurses
was'inadequate to upport the practice of good medi-ine and
provide good health care. They also balieved that the clerical
and secretarial support was inadequate. Overall, the-physicians
were satisfied with the quality of medical records and with the
availability of medical references, research facilities, and
egquipent. linety percent of the-physicians claimed that the
amount of tine they spend with patients was adequate for the
practice of good medicine. (SC)
                           UNITD STATES GENERAL ACCOUNING OFFICE
ta      ' \                        WASHINGTON.   D.C. 205A
 'J,

                     -       ^J     ~~APR                       1 4 1977

       Ir. A.A. Gavazzi, Director
       Veterans Administration Hospital
       Washington, D.C. 20422
       Dear Hr. Gavazzi:
             During our recent review of the medical school affiliation program
       at the Veterans Administration (VA) Hospital, Washington, D.C., we sent
       a questionnaire to most VA physicians (including interns and residents)
       employed at the hospital. The questionnaire was designed to obtain
       the views of the physicians regarding the quality of care being
       provided at the hospital, including, to the extent possible, the
       impact of the affiliation program.
             As you know, our review was made pursuant to a request from the
       Chairman, Senate Appropriations Subcommittee on HUD-Independent Agencies.
       Briefly, the Chairman asked us to assess the impact of medical school
       affiliations on the VA hospital system.. Our review i.t the Washington,
       D.C., VA Hospital was made primarily to obtain a better understanding of
       a VA hospital-pedical school affiliation prior to undertaking a more
       comprehensive review of selected VA hospital-medical school affiliations
       throughout the VA system.
            In our February 28, 1977, meeting with you, we discussed the results
       of responses to our questionnaire and stated that a more complete presen-
       tation of the results would be provided to you. The results presented are
       those froij the three largest services in the hospital--medicine, surgery,
       and psychiatry. Due to the low response rate (46 percent overall; 42
       percent among physicians in medicine, surgery, and psychiatry), we believe
       it would be inapprop, :ate to make definitive statements regarding the
       quality of care at this hospital. However, the responses received did
        identify certain deficiencies at the hospital which could have an adverse
       impact on the quality of patient care. Our overall findings, by category,
       i;e discussed below.
       STAFF I6/PHYSICIANS
            The medical school affiliation plays a large part in attracting
       physicians to the hospital. Seventy-eight percent of the staff physicians
       said the opportunity to teach at the hospital was an important factor in
       their decision to join the hospital staff. Furthermore, two physicians
       claimed that they and nearly 11 their colleagues would not work at the
       hospital without the affiliation.
     A VA official claims that affiliation arrangements help to attract
better qualified physicians who have graduated from U.S. medical schools.
This appears to be the case at the Washington, D.C., VA Hospital since
98 percent of the responding staff physicians were board certified or
board eligible and 74 percent had graduated from a U.S. .edical school.
FACILITIES' DESIGN AND LAYOUT

     Most of the physicians were satisfied with the inpatient facilities;
however, they were not satisfied with the outpatient facilities. Many
claimed the outpatient services do not get the needed support (i.e.;
staffing, facilities, and supplies). They cited an increasing patient
load and changes in veteran eligibility for outpatient services as
causes of the overcrowding and inadequacy in the outpatient area.
MEDICAL EQUIPMENT AND SUPPLIES
     Overall many physicians were satisfied with the availability of
medical equipment for inpatient and outpatient care. However, regarding
inpatient medical equipment, the residents indicated experiencing a
shortage of equipment much more frequently- than- did the staff physicians.
ANCILLARY CLINICAL SERVICES
(RADIOLOGY AND LABORATORY)
     Many physicians were unsatisfied with all aspects of the radiology
service--availability, timeliness of delivery, and quality. This was
true for both inpatient and outpatient radiology services.
     In general most physicians were satisfied with the inpatient and
outpatient laboratory services. However, in the category of timeliness
of delivery, opinions were equally divided among those who were very or
generally satisfied and those who were very or generally unsatisfied.
     We received many narrative responses complaining about the ancillary
service staff. Many physicians claimed that staff members were
inefficient, but that It was extremely difficult to fire these employees
due to civil service regulations. Another frequent complaint was that
the physicians could not get prompt service and that it was almost
impossible' to get x-rays or laboratory work done during 'off-hours".
STAFFING/NURSES AND CLERICAL
     In general the physicians were satisfied with the t-aining,
experience, and competency of the nursing staff. However, they were
more satisfied with the registered nurses than with the licensed
practical nurses or the nursing assistants.




                                    -2-
     Many ptysicians thought that the number of nurses wds inadequate
to support the practice of good medicine and provide good health care.
They also believed the. clerical and secretarial support was inadequate.
     A in the castof the ancillary servficestaff, many physicians
claimed- the licensed practical nurses,. nursing' assistants. and
secretaries' had, lbad attitudes', were. inefficient, and took little
initiative or pride in their work. Many. coaolained that civil service
regulations made it "impossible' to fire these employees.
MEDICAL RECORDS MEDICAL
LIBRARY. AND RESEARCH -
    -Overall,.the physicians were satisfied with the quality of medical
records and the availability of medical references and research
facilities and equipment. However, many were unsatisfied with the
availability of medical records.
ADMISSIONS AND PATIENT LOAD
     Based on the questionnaire responses, the medical school affiliation
does not appear to influence admissions at the Hashington, D.C., VA
Hospital. Admissiors are rarely, if ever, hindered'oy either disinterest
in the case or the case not meeting teaching or rese3rch needs.
     Regarding patient load, 90 percent of the physicians claimed that
the amount of time they spent with patients was adequate for the practice
of good medicine. In the area of outpatient services, most physicians
felt that few patients were taking unnecessary advantage of the VA system
of providing free medical care.


     A more detailed analysis of the responses to our questionnaire is
enclosed for your information.
     We appreciate the assistance you and your staff provided to our
representatives during our review at the Washington hospital. Copies
of this report are being sent to the Chief Medical Director and the
Director, Internal Audit Service, at the VA central office.
                                     Sincerely yours,



                                      ~
                                      eorge    Peck
                                     Assistant Director
Enclosure
                                   - 3 -
              ENCLOSURE                                                        ENCLOSURE

                                   PHYSICIAN QUESTIOMNAIRE ANALYSIS
                                     WASHINGTON, D.C.. VA HOSPITAL
           PURPOSE OF THE QUESTIONNAIRE

                The SubcomIittee requested that we assess whether.the quality of-
           care in VA hospitals had; increased or decreased as a result of the VA
           hospital-medical school affiliation program, -In order to make this.
           assessment, we developed a physician questionnaire for use during our
           pilot study at the Washington, D.C., VA Hospital. The questionnaire is
           designed to obtain the views of VA physicians regarding the quality of
           care being provided at the hospital, including, to the extent possible,
           the impact of the affiliation program.
           QUESTIONNAIRE DISTRIBUTION AND RESPONSE
                We attempted to distribute the questionnaire to all the physicians
           at this hospital. However, due to resident rotations, vacations, etc.,
           several physicians did not receive the questionnaire. In total, we
           distributed the questionnaire to 111 of 116 employed staff physicians
           and 153 of 157 residents.
                Overall we received a 46 percent response from these physicians;
           67 staff physicians (60 percent) and 55 residents (36 percent) completed
           and returned the questionnaire. In evaluating the questionnaire results,
           we focused on the responses from the three largest services in the
           hospital--medicine, surgery, and psychiatry. The numbers and rates of response
           from these services are shown in table 1 below.
                                                 Table 1
                                        QUESTIONINAIRE RESPONSES
                                           BY MAJOR SERVICES
                       STAFF PHYSICIANS                               RES IDENTS
                Number       Nbmber Percent              Number        Number    Percent
              distributed returned response            distributed    returned response
Medicine        41            24           59             101           28         28
Surgery          22           10           45              26           12         46
Psy.-     -     22            16           73               7            3         43
   Total        85            50          59              134           43         32



                      NOTE:   Percentages throughout this summary may
                              not add to 100 percent due to rounding.
        ENCLOSURE                                                              ENCLOSURE

        QUESTIONNAIRE RESULTS
        Staff/Physicians

            :'Of the 50 responding staff physicians fronm the three larIest services,
        98.percent were board certified or board eligible and 74 percent graduated
        from U-;S.'iedicaTs  sctools .:Aong :the. 43: responding residentsi, 51; percent
                             'or. board eligibi'e and 95 percent graduated from U.S.
        werebt'o'ard certified
        medica1-schools;: : :.;-    :-;-.'

             The most important reasons given'by the staff physicians for deciding
        to work at the hospital follow.'
            . Opportunity for professional development - 86 percent
          ." Caliber of colleagues.                                 - 78 percent

             Opportunity to teach at hospital'                      - 78 percent
             Opportunity to participate in continuing
               education programs                                   - 76 percent

             Opportunity to participate in
               training programs                                    - 76 percent

             Of the reasons directly related to the medical school affiliation, most
        physicians cited the opportunity to teach and conduct research at the hospital
        and the medical school's reputation as being very important in their decision
        to join the hospital staff (see table 2).
                                             Table 2-
                           Reasons Associated With The Medical School
                            Affiliation For Staff Physicians' Joining
                                  Uashington VA Hospital Staff

                                   Of little or no                            Substantially
                                   importance or                 Moderately      or very         No
                                 somewhat important              important      important     response
                                                              -(Percent------------
                                              …------------------




1. Opportunity to teach
     at the hospital                      8                          14            78           0
2. Affiliated medical
    school's reputation                  16                          16            68           0
3. Opportunity for research
     at the hospital                     24                          22            54           0
4. Availability of con-
    sultants/attendings                  26                          26            46           2


                                                        -2-
         ENCLOSURE                                                          ENCLOSURE'
                                         Table 2 (cont.)

                                  Of little or no                        Substantially
                                  importance or            Mloderately     or very             No
                                somewhat important         important      important         response
                                …------------------_-
                                                    (Percent)--             .------------------
                                                                                         …
5. Opportunity to teach
     at the affiliated
     medical school                        28                   30           42                   0
6. Opportunity for research
     at the affiliated
     medical school                        58                   14           26                   2
       Facilities' Design and Layout
            Host of the staff physicians and residents in the three largest
       services were generally satisfied with the physical design of the hospital. for
       inpatients. Regarding the adequacy of the hospital inpatient care facilities, 78
       percent of the staff physicians and residents responded that they are more
       than or generally adequate, 13 percent responded they are marginally
       adequate, 5 percent responded they are generally or very inadequate, and
       3 percent did not respond or said they had no basis to judge. Fifty-
       eight percent were very or generally satisfied with the provisions for
       inpatient privacy, while 27 percent said they were. marginally satisfied,
       12 percent were generally or very unsatisfied, and 3 percent did not
       respond or said they had no basis to judge.
            However, the physicians were not satisfied with the outpatient facili-
       ties. Overall, 37 percent of the respondents believed that the facilities
       for outpatient diagnostic and treatment services. were generally or very
       inadequate. (See table 3 for a breakdown of the responses.)
                                           Table 3
                              Adequacy of Outpatient Facilities
                                   Staff
                                physicians               Residents                 Overall
                                ------------------- (Percent) --------------------------
       More than or generally       38                           19                         29
         adequate
      Marginally adequate           16                           35                         25
      Generally or very
        inadequate                  38                           35                         37
      No basis to judge
        or no response              8                            12                         10


                                                -3-
           ·
  ECOUEENCLOSURE                                                ENCLOSURE

Furthermore, 46 percent felt the outpatient waiting areas were frequently
or very. often overcrowded, while. 22 percent indicated that this was a rare
or-.occasional occurrence; 11. percent .indicated- that the, waiting areas were
overcrowded as often.as not, and 22' percent did not    resDond or said thPv
                                                     .              '
  d i,  .s as s t ude . ...-            .                             '


   :' .ealis.'recejved additronal. comments regarding outpatient facilities.
:For:exampl'e,:physicians indicated -that the facilities we'e inadequate to
 handle the "mushrooming" patient load. In another case, a physician
 commented. that outpatient medical services are treated as "step-children"
 and; need to be upgraded.,.' Also, a surgical' staff physician and a resident
 believed that there is a need for: outpatient surgical facilities.
  edical Equipment and Supplies.

      ; In general,.' the physicians. were..pleased with the medical equipment
.-available for inpatient care. Among..the surgeons (staff physicians and
  residents) responding to the questionnaire,:.95 percent were very or
  generally satisifed with the quality of the operating room equipment,
  while. 5 percent were generally or very unsatisfied. When asked how often
  they had. experienced a shortage of medical equipment needed for providing
  inpatient care, the responses were as shown in table 4.
                                     Table 4
                                    Sta ff
                                 physicians         Residents        Overall
                                 ---------------- (Percent)------------------
 In the last year,
 .how often have you
 experienced a shortage of
 inpatient medical equipment:
 1. Not: more than once, if ever     26                19                23

 2. Two or three times               20                19                19

 3. Four or five times                6                lb                11

 4. Six to nine times                12                 9                11

 5. Ten or more times                  6               21                13

 6. No basis to judge or
      no response                    30                16                24

 As shown above, a greater percentage of residents than staff physicians
 experienced a shortage of medical equipment.
      Opinions were divided on the availability of outpatient medical supplies.
 Overall, 19 percent of the physicians reported experiencing a shortage of
 supplies not more than once, if ever, but 20 percent claimed they had
 experienced such a-shortage 10 or more times. Twenty percent reported a
 shortage two or three times, 2 percent said they had experienced a shortage
                                             -4-
ENCLOSURE                                                    ENCLOSURE

four or five times, 9 percent reported a shortage six to nine times,
and 29 percent did not respond or said they had no basis. to judge.
     When asked how often they had experienced a. shortage. of outpatient
medical equipment, the responses;were similar to those in regard to;.
inpatient equipment in that many physicians'seldom experienced a shortage.
However, the residents did not indicate a higher incidence of shortage of
outpatient equipment as they did regarding inpatient equipment.. The
responses are shown in table 5.
                                    Table 5
                                   Staff
                                 physicians       Residents              Overall
                                 …-    -----   -(Percent)-..........
In the last year,
how often have you
experienced a shortage of
outpatient medical equipment:
1. Not more than once, if ever      28                 19                 24
2. Two or three times               10                 19                 14
3. Four or five times                2                  5                  3
4. Six to nine times                 8                 16                 12
5. Ten or more times                20                 16                 18
6. No basis to judge or
     no response                    32                26                  29
Ancillary Clinical Services
(Hadiology and Laboratory)
     Many physicians in the three larqest services were not satisfied with
the radiology service (see table 6). In total. 55 Percent of the staff
physicians and residents were generally or very unsatisfied with the
timeliness of delivery of the radiology services for inpatients. However,
the residents were proportionately more dissatisfied than the staff
physicians (72 percent compared to 40 percent). Furthermore, 44 percent
of the staff physicians and residents were generally or very dissatisfied
with the quality of the radiology service, and 42 percent were generally
or very dissatisfied with the availability. Similar dissatisfaction was
expressed for outpatient radiology services, but the residents and staff
physicians gave more similar responses.




                                         -5-
 ENCLOSURE                                                       ENCLOSURE

                                  Table 5
                       Physicians' Satisfaction with
                Inpatient and Outpatient Radiology Services
                                      Staff
                                   physicians           Residents            Overall
                                            …_ ______--(Percent)-…------
INPATIENT RADIOLOGY
Availability
  1. Very or generally satisfied       36                  16                  27
  2,,argina1;1, satisfied              18                  28                  23
  3. Very- or 'generally
        unsatisfied'                   32                  53                  42
  4. No: basis to. judge or no
        response                       14                   2                   9
Timeliness of delivery
  1. Very or generally satisfied       18                   7                  13
  2. Marginally satisfied              28                  19                  24
  3. Very or generally
       unsatistied                     40                  72                  5b
  4. No basis to judge or no
       response                        14                   2                   9
Quality,
  l. Very or generally satisfied       32                  26                  29
  2. Marginally satis''ied             18                  16                  17
  3. Very or generally
       unsatisfied                     34                   56                 44
  4. No basis to judge or no
       response                        16                    2                 10
OUTPATIENT RADIOLOGY
Availabil it
  1. Very or generally satisfied       24                   19                 22
  2. Margina-lly satisfied             20                   23                 22
  3. Very or generally
       unsatisfied                     34                   37                 35
  4. No basis to judge or no
       response                        22                   21                 22
Timeliness of service
  1. Very or generally satisfied       24                   12                 18
  2. Marginally-satisfied              14                   21                 17
  3. Very or generally
       unsatisfied                     38                   47                 42
ENCLOSURE                                                            ENCLOSURE
                                         Staff
                                      physicians              Residents           Overall
OUTPATIENT RADIOLOGY (cont.)        .   . .....---   …---   (Percent)-  -        --
  4. No basis to judge or no
       response                           24                    21                    23
Quality
  1. Very or generally satisfied          34                    21                    28
  2. Marginally satisfied                  8                    21                    14
  3. Very or generally
       unsatisfied                        34                    37                    35
  4. No basis to judge or no
       response                           24                    21                    23
     Overall the physicians were more satisfied with the laboratory service
than with the radiology service. For example, 49 percent of the respondents
were very or generally satisfied with the availability of inpatient
laboratory services, and 42 percent were very or generally satisfied with
the quality of those services. Opinions were divided on the timliness
of delivery in the laboratory service--31 percent were very or generally
satisfied, while 31 percent were very or generally unsatisfied. Mlost
physicians were satisfied with both Inpatient and outpatient laboratory
services. (See table 74
                                    Table 7
                         Physicians' Satisfaction with
                  Inpatient and Outpatient Laboatoratry Services
                                        Staff
                                     physicians              Residents        Overall
                                            -----
                                     .---------             (Percent)-.--    …---------
INPATIENT LABORATORY
Availability
  1. Very or generally satisfied          48                    51                    49
  2. Marginally satisfied                 20                    23                    22
  3. Very or generally
       unsatisfied                        20                    23                    22
  4. No basis to judge or no
       response                           12                     2                     8
Timpli np c nf dplivry

  1. Very or generally satisfied          28                    35                    31
  z. Marginally satisfied                 34                    26                    30
  3. Very or generally
       unsatisfied                        26                    37                    31
  4. No basis to judge or no
       response                           12                     2                     8


                                      -7-.
    ENCLOSURE
                                Table 7 (cont.)                   ENCLOSURE
                                        Staff
  INPATIENT LABRATORY (cont.)        physicians        Residents              Overall
  Qualitr
   1. Very or generally satisfied           38            47                    42
   2. arrginally satisfied                  22            30                    26
   3. Very or generally
        unsatisfied                         26            21                    24
   4. No basis to judge or no
        response                            14                2                   9
 OUTPATENT LABORATORY
 Availability
   1. Very or generally satisfied           36            35                    35
   2. Marginally satisfied                  28            30
   3.Very or generally                                                          29
        unsatisfied                         16            14                    15
   4. No basis to Judge or no
        response                           20            21                     20
 Timeliness of laboratory services
   1. Very or generally satisfied          24            26                     25
   2.Marginally satisfied                  28            28                     28
   3. Very or generally
        unsatisfied                        26            26                    26
   4. No basis to Judge or no
        response                           22            21                    22
Quality
  l. Very or generally satisfied           34            40.                   37
  2. Marginally satisfied                  28            30                    29
  3.Very or generally
       unsatisfied                         16             9                    13
  4. No basis to Judge or no
       response                            22           21                     22
     Many physicians provided narrative comments about the ancillary services.
A frequently cited complaint was that many of the al;cillary service staff
 members had "bad attitudes" and were Inefficient, noting that civil service
regulations aike it extremely difficult to fire these people.   Some physicians
said they couldn't get prompt service and thtat it was 'aloest Impossible"
get x-rays or lab work during "off-hours."                                 to
                                             Both a staff physician and a
resident in the surgical service said that pre-operative lab tests and
take 2 to 3 days, thus adding to length of stay. The staff physician x-rays
suggested that a prtority pre-op lab and x-ray service be set up for
outpatients.

                                     -8-
   ENCLOSURE                                                  - ENCLOSURE


Staffing/Nurses and Clerical
     In general the physicians were satisfied with the training, experience,
and competency of the nursing staff; however, they were gore satisfied with
the registered nurses than with the licensed practical nurses or the nursing
assistants. The staff physicians and residents tended to agree on their
responses regarding registered nurses, but the residents were more
unsatisfied with the licensed practical nurses and nursing assistants than
were the staff physicians. (See table 8.)
                                    Table 8
                  Physicians' Satisfaction with Nursing Staff
                                          Staff
                                     physicians      Residents              Overall
                                     ----       -(Percent)------
REGISTERED NURSES
Trainina

  1. Very or generally satisfied         76               72                  74
  2. Marginally satisfied                16               16                  16
  3. Very or generally
       unsatisfied                        0                5                   2
  4. No basis to judge or no
       response                           £                7                   8
Level of experience
  1. Very or generally satisfied         73   -          70                   74
  2. Marginally satisfied                16              21                   18
  3. Very or generally
       uns .isffed                       0                2                    1
  4. No basis to judge or no
       response             _            6                7                    6
Competency
 1. Very or generally satisfied         70               58                   65
 2. Marginally satisfied                20               28                   24
 3. Very or generally
      unsatisfied                        2               12                    6
 4. No basis to judge or no
      response                           8                2                    5
LICENSED PRACTICAL NURSES
Training
 1. Very or generally satisfied       52                 37                  45
 2. Marginally satisfied              26                 30                  28
 3. Very or generally
      unsatisfied                       2                19                   10
 4. No basis to judge or no response 20                  14                   17
                                    -9-
  ECLOSURE-                                                            ENCLOSURE


                               Table 8 (cont.)
                                        Staff
                                     physicians            Residents          Overall
LICENSED PRACTICAL NURSES. (cont.)        -----     (Pe   rcent)-----

Level of experience
  1. Very or generally satisfied     .      56                37                   47
  2. Marginally satisfied                   22                28                   25
  3. Very or generally
     ; unsatisfied                              2             23                   12
  4. No basis to Judge or no
     ' response                             20                12                   16
Competency
  1. Very or generally satisfied            52               28                    41
  2. Marginally satisfied                   24               37                    30
  3. Very or generally
       unsatisfied                              6            28                    16
  4. No basis to judge or no
       response                             18                7                    13
NURSING ASSISTANTS
Traini ng
  1. Very or generally satisfied            38               28                    33
  2. Marginally satisfied                   28               28                    28
  3. Very or generally
       unsatisfied.                             4            26                    14
  4. No basis to judge or no
       response                             30               19                    25
Level of experience
  1. Very or generally satisfied            40               28                    34
  2. Marginally satisfied                   26               28                    27
  3. Very or generally
       unsatisfied                              6            28                    16
  4. No basis to judge or no
       response                             28               16                    23
Capetency
  1. Very or generally satisfied            36               19                    28
  2. Marginally satisfied                   24               33                    28
  3. Very or generally
       unsatisfied                          14               37                    25
  4. No basis to judge or no
       response                             26               12                    19

                                         -10-
  ENCLOSURE                                                  'CLOSURE


     Overall, the physicians were not satisfied with the number-of nurses
at the hospital. Forty-five percent felt the number of nurses was generally
or very inadequate, 29 percent thought the staffing level was marginally
adequate, 19 percent believed it was very or generally adequate, and 6
percent did not respond or said they had no basis to judge.
     In addition, many physicians did not believe that the clerical or
secretarial support was adequate. Forty-six percent believed the support
was gE -rally or very inadequate, while 32 percent believed itwas marginally
adequate, 20 percent believed it was more than or generally adequate, and 1
percent said they had no basis to judge.
     Many Written conmments received about the nursing and secretarial staff
were very similar to those about the ancillary service staff. Many believed
that the licensed practical nurses, nursing assistants, and secretaries
had bad attitudes, were inefficient, and took little initiative or pride
in their work. Many complained that civil service regulations made it
impossible to fire these inefficient people. Several respondents also
commented on the shortage of clerical support staff and inadequate nurse
to patient ratios.
Medical Records, Medical Library, and Research
     Overall the physicians were satisfied with the quality of the medical
records. Fifty-five percent said they were very or generally satisfied
with the completeness and accuracy of the records, while 24 percent were
narginally satisfied and 22 percent were very or generally unsatisfied.
However, 44 percent of the physicians were very or generally unsatisfied
with the availability of these records. In this area the staff physicians
were more unsatisfied than the residents. (See table 9 for a breakdown
on the responses.)
                                    Table 9
                       Physicians' Satisfaction Uith The
                        Availability of Medical Records
                                         Staff
                                     physicians         Residents          Overall
                                     -- ------------ (Percent)    .-------..------
Very or generally satisfied              28                 47               37
Marginally satisfied                     18                 21               19
Very or generally unsatisfied            54                 33               44




                                      -11-
  ENCLOSURE                                                         ENCLOSURE


     The physicians were satisfied with the availability of medical
references.. Seventy-four percent reported that very often or frequently
they could find the necessary medical references, while 8 percent said
that as often as not they could find this material,. 16 percent said they
could find it only occasionally or rarely, if ever, and 2 percent did
not respond or said they had no basis to judge.
      Forty-five percent of-the- responding physicians-claimed that research
facilities were very-often or frequently available and 39 percent said
that research equipment was very often- or- frequently available. The
breakdown of the responses is shown in table 10.
                                      Table 10
                                                                  No basis to
                           Very often or As often Occasionally or judge or no
                             frequently   as not rarely, if ever    response
                           ------ ----------           .. (Percent)…------------------
Are the followini
readily available:
  Research facilities            45               13              15                27
  Research equipment             39               17              17                27
Admissions and Patient Load       -

     Based on the questionnaire responses, the-medical school affiliation
does not appear to influence admissions to the hospital. For example,
admissions are rarely, if ever, hindered by disinterest in the case or the
case not meeting teaching or research needs. However, 38 percent of the
physicians said that frequently or' very often a veteran is not admitted
because his illness is not severe enough. A breakdown of the responses
is shown in table 11.
                                      Table 11
                                                                                No basis to
                           Rarely, if ever, As often  Frequently                judge or no
                           or occasionally   as not or very often                 response
How often is a veteran
not admitted for the
following reasons:
1. Illness is not severe
   enough                       37                 12                  38            13
2. No one wants the case        81                  2                   4            13
3. Case is not important
   enough                       82                     2                1            15
4. Case does not meet
   teaching needs               86                     1               0             13
5. Case does not meet
   research needs               81                     0                0            19
                                           -12-
  ENCLOSURE-                                                     ENCLOSURE


                                Table 11 (cont.)
                                                                              No basis to
                           Rarely, if ever, As often  Frequently              judge or no
                           or occasionally   as not or very often               response
                                …(Perc----------(------Pecent)        ---    --    ---

6. There are no beds
   available                      71                 5           12               12
     In regard to patient load, 73 percent of the-physicians believed that
the amount of time they spent with each patient was more than or generally
adequate for the practice of good medicine, 17 percent felt the tire-was
marginally adequate, 6 percent believed it was generally or very inadequate,
and 3 percent did hot respond or said they had no basis to judge. When
asked how long outpatients have to wait, the responses were as follows:
          Under 1/2 hour                           2 percent
          From 1/2 to under 1 hour                13 percent
          From 1 to under 2 hours                 28 percent
          From 2 to under 3 hours                 20 percent
          3 or more hours              -           8 percent

          No basis to judge or no response        29 percent
     Because some physicians complain that many outpatients take advantage
of the free medical services available to them, we asked the physicians
what proportion of the outpatient requests for medical services were-
unnecessary. The responses were as follows:
          None or almost none                     12 percent
         About 1 in 20                            20 percent
          About 1 in 10                           16 percent
          About 1 in 7                             6 percent
          About 1 in 5                             8 percent
         About 1 in 4                              5 percent
         Hore than 1 in 4                          4 percent
          No basis to judge or no response 28 percent


                                           -13-
  ENCLOSURE                                          ENCLOSURE



     Several written comments were received regarding the type of patient
seen in the VA system. One staff physician-said the patients are very
demanding and ungrateful' and suffer from self-induced illnesses, such
as alcoholism. A resident indicated that VA patients believe that
the hospital: should-take.care of all their problems.and as a result,
they come'in.for' unimportant reasons-. ': Another:'resident stated: that
many patients have nowhere to go upon discharge, so in many cases
the hospital is being used' as a nursing home.




                                    -14-