SCCM Resource Library-What Is a Faculty cFTE and How Many Can I Get?

Video Transcription

Hello, my name is Mike Uche and I'm the Interim Chief of Critical Care Medicine at the Children's  Hospital of Montefiore in the Bronx, New York, and I'm honored to be invited to speak to you today on the topic of what is a faculty clinical full-time equivalent and how many  can I get. I do not profess to be an expert on the topic of FTE, and prior to becoming the Interim Division Chief four years ago, I didn't actually have to think that much about it.  But in the subsequent four years, thinking about FTE distribution among faculty members in our division has become an almost daily occurrence.  I have no disclosures or conflicts of interest. It appears to me that the definition of the clinical full-time equivalent depends on where you stand and what's your perspective.  And if we look at this seesaw or teeter-totter here, you can see on the one hand, up here, you can see the staff intensivist who is thinking, how can I get more protected time?  How can I advance my academic career? And on the opposite side of the teeter-totter is the chair who is thinking, how can I keep the CEO happy?  Am I getting the right economic return for my investment in ICU staff numbers? And being the chair, he tends to weigh a little bit more.  And in the middle of this, trying to keep the balance, is the division chief who's thinking, how can I get more clinical FTEs to cover clinical responsibilities, increase  academic productivity, and keep my chair happy? If you ask a bunch of intensivists, what is the definition of the clinical full-time equivalent  or FTE, you'll get a wide variety of answers. But the actual definition is quite economic in origin.  And that is, is that the clinical FTE is the total billable clinical effort divided by total effort.  And this is discussed very clearly in this letter that appeared in Journal of Pediatrics in 2010 from the Association of Medical School Pediatric Department Chairs, entitled, Issues  and Solutions in Accurately Measuring Clinical Full-Time Equivalents. If you look at one division of pediatric critical care medicine, you have seen exactly one division  of pediatric critical care medicine. Every PCCM division is different, both in preparation for this talk, as well as just trying to learn the job.  I've spoken to other division chiefs, particularly in the New York City region. And as you know, there are a lot of ICUs in the New York City area.  And I've learned that each of the divisions is different with respect to the amount of effort expected of a faculty member, how work is distributed among different faculty members,  how administrative duties are distributed, how productivity is assessed, how bonuses are given. And each place is essentially unique based on the relationship of the division chief  and their chair or in their department. So what I'm going to talk about today is a lot about how what I have learned and how  I have learned, some of which may be unique to my center, some of which may be shared by other centers.  But I also suspect that as these topics of FTE and effort and productivity are being assessed more and discussed more and more at administrative levels and by division chiefs  and hospital CEOs, things are becoming a little bit more similar. In our center, we use what's called the CARTS system.  And work and effort is divided among clinical, administrative, research, teaching, and strategic arms.  Here is a CARTS table for one mythical or example division of pediatric critical care medicine.  On the left side here, you see different physician members who have their work distributed among clinical effort or FTE.  Clinical FTE can be divided between inpatient, outpatient, not too relevant to us as intensivists, OR procedure time, other clinical effort for a total.  We also look at administrative effort, research effort, teaching, and hospital system strategic roles. And everyone's effort is apportioned among them.  For the purpose of our talk today, we're mostly focused on the clinical full-time equivalent, which is over on the left side in the blue.  Here's that same table for this mythical division of critical care with a couple of things indicated.  One, if you look at the far left column, which is the inpatient clinical FTE time, you may strike you as these numbers being slightly low for a typical division, but that's because  of a bookkeeping process in place. This particular division spends a lot of time doing procedural and imaging sedation and  chart bills for those services using anesthesia codes for which RVOUs are not associated. And as a result, about 15% of effort for most faculty members is put under a strategic  clinical column because RVOUs are not generated and these faculty should not be held responsible for RVOUs due to their effort because they're not delivered.  There's also a fellowship program director who has time removed from the clinical FTE. There's a residency program director within this division who has even more time apportioned  for administrative responsibilities. There's a division chief and medical director who has time taken away from their clinical  FTE in order to accomplish administrative responsibilities. There's a sedation director and a medical school course director who also get some time.  In this example division, there are 14 physicians, which add up to a total of about 7.65 clinical FTEs. Everyone gets about 10% for administrative duties.  No one has protected research time in this particular division. No one has grant funding for research.  That is a deficit and something we'd love to have resolved, but no one gets protected time. The fellowship program director gets 0.25 FTE.  That's mandated by the ACGME and it's untouchable. The residency program director gets about 0.5 FTE, which is mandated and untouchable.  Hospitalists are zero clinical FTE because they do not bill. The sedation director gets 0.1 FTE for administrative time.  The division chief gets 0.2 FTE and the medical director gets 0.2 FTE apportioned. There are required FTE allocations.  For instance, the pediatric residency program director has time specifically allocated based on recommendations from the ACGME and these are untouchable.  Depending on the size of the residency program is the amount of time allocated. This time can be allocated between program director and associate program director, but  for a residency program, say between 31 to 61 residents, that time's a total of about 1.0 FTE. A critical care fellowship program director also has mandated time allocated according  to ACGME policies. In this particular division, in which there are six fellows, the fellowship program director is given 25% time for administrative responsibilities.  A very interesting question is how much FTE is appropriate for a division chief? In 2013, Gerald Lachlan, Susan Bostwick, Howard Eigen, and George Dover wrote an article that  appeared in Journal of Pediatrics from the auspices of the Association of Medical School Pediatric Department Chairs on a proposed job description for the modern division director.  It's a very good article and one that I've looked at throughout the years as providing guidance for what I should be doing as a division chief.  It's also an article that my chair has distributed to all division chiefs in order to let them know what they should be doing.  This article includes 50 leadership, academic, financial, administrative, clinical, educational, research, and departmental responsibilities.  One thing that is not addressed in this article is how much time should be given to a division chief in order to accomplish these responsibilities.  In preparation for this talk, I spoke with Dr. Lachlan and asked him, Jerry, how much time, when you made up this, when you came up with this description, how much time did  you think a division chief should need? And he said, I have no idea. We didn't discuss it at all. And in fact, he said, that'd be a great paper to write.  As for how much time a critical care medicine division chief should have allocated to fulfill  their leadership and administrative responsibilities, there are no guidelines, no recommendations, but there is some data.  And this data came through the Pediatric Critical Care Chiefs Network, curated by Michael Agus from Children's Hospital Boston.  And the question was asked, how much time were you given for your administrative responsibilities as division chief?  There was a robust response, probably the greatest response of any question asked on the network.  20 people responded. A range of 0 to 0.5 per time was given, averaged out about 19%, plus or minus about 15%.  The median was about 0.15, 15%, with an interquartile range of between 0.1 to 0.2. So although some people say that 20% of time should be given to a division chief for their  administrative and leadership responsibilities, the reality is a little bit less than that is actually a portion of time. What and who defines a clinical FTE?  It's a challenging question. And again, as I've said before, every center is different. There's one definition of a clinical FTE. It's our staffing model.  And this gives me an opportunity to talk about George Oforio-Monfo, someone who many of you know and someone who unfortunately passed away early this year at too young of an age.  George's departure leaves a great hole in many of our hearts. George was our division chief between 2015 and 2018. I got to know him as a mentor.  Everyone knows he's a great guy, and he truly is. But I also got to know him as a strategic thinker, an inspirational leader, and someone  who had really, really high-level knowledge of the organization and economics of health care.  And George defined, as in his role as division chief, this staffing model for a clinical FTE in our hospital.  One FTE would do 12 seven-day weeks of service in the ICU with two attendings per service time, 30 in-house calls, 12 five-day weeks of either sedation or MRI sedation, and any  work in excess of this was to be paid. And then Saturday and holiday calls were supplemented.  And this was actually quite beneficial, because at the time, we had lost a number of faculty members. People were doing a lot of work.  And this permitted a little bit of ease of the burden. Lest anyone think that we have a very easy life at Montefiore, shortly after George departed,  so did the chair who signed off on this. And as a result, very shortly afterward, any excess money or moonlighting went away. So what is the correct amount of work to do?  Well, the Association of Medical School Pediatric Department Chairs and their administrative  wing, the Association of Academic Administrators in Pediatrics, are studying this question. And they discuss it actively at their meetings.  Consulting groups such as McKinsey, Visinet, Clinical Practice Solution Center, Medical Group Management Association, COCR, are creating definitions and distributing to those who  use their services. In our department, 325 clinic sessions per year defines one clinical FTE. How does that correspond to what we do as critical care physicians?  I'm not really sure. Back of the envelope calculation, 325 four-hour clinic sessions comes out to about 1,300 hours per year. If you start adding up, what we do is intensivists.  For instance, 12 weeks times 10 hours times 7 days, 30 calls times 16 hours per call, three sedation days per month or eight hours a day times 12 months, easily comes out to  about 1,608 hours. And that's without actually thinking about whether hours on call or hours on weekends or weekend calls or holiday calls are any different than clinic sessions.  What is the best measure of quantity of effort? It's really unknown. Is it days, weeks, months of service? Is it shifts like our emergency medicine colleagues are using now?  Is it hours of work as some have proposed? Is it points or is it credits? Our neonatal colleagues have started to develop a point-based system for determining workload  for neonatology full-time equivalent. In our own division, we've begun work on devising a points or credit-based system for looking at effort.  In this system we're working on, a service day from Monday to Friday would be worth one credit, a service day on weekends and holidays would be two, a sedation day would be one,  a call from Monday to Thursday, maybe one and a half, and a call on Friday, Saturday, Sundays, and holidays, maybe two and a half.  Using a system like this, one FTE would be 225 points. But I have to say that it's not easy to get an administrative buy-in on something like this.  I, as division chief, look at a weekend or holiday call as a burden in excess of a weekend call or a weekday call. Chairs don't look at it that way.  They look at it as saying, well, why should you get more credit for a call on a holiday where you are unlikely to admit as many patients and generate as many RVUs as you would on  a regular Monday to Friday service day? If you want to look at a careful analysis of this, I recommend you read a description  that was done by Michael Quasny of the University of Michigan, who distributed this among pediatric clinical care chiefs in the network.  And I think you're chief, or you could probably access it, and it's a very careful comparison of these different methods of looking at effort.  Productivity, relative value units, and the imputed FTE. When thinking about clinical full-time equivalent, you easily morph into the area of productivity.  Measures of productivity include clinical revenue, shifts, hours, credits, work. And I do want to say that now that we're often using purchase scheduling systems, such as  QGENDA or MION, it's important to know that the benefit that these systems provide to us in organizing our complex scheduling also permit our administrators to know exactly  how many shifts are worked. And the hook that these companies are using to let our hospitals purchase these systems  is the potential increase in productivity and ability to closely analyze how much people are working. And then there's relative value units.  Productivity measures are utilized to improve revenue generation and also determine incentives. Relative value units, we all hear these terms.  RVUs are scaled units of care developed and managed by the Center of Medicare and Medicaid Services. They have three components.  They have the physician work component, or W, or work RVU, that's most relevant to us, and involves the expertise, skill, and time required to perform a service.  There's a practice expense component that includes the expense of actually operating the center and liability insurance, as well as a geographic cost index adjustment.  They're based on the recommendations of the AMA, Specialty Society Relative Value Scale Update Committee, or RUC.  And importantly, they're not designed as a measure of physician performance. For information on the use of RVUs in clinical practice, I recommend strongly this article  on Basic Primer for Finances in Academic Adult and Pediatric Pulmonary Divisions, published in CHEST in 2020.  Here's a table listing work RVUs generated for specific billing codes, including the critical care codes that our adult colleagues use and we use in our patients over six years  old, such as 99, 291, and 292, about four and a half for the initial code, initial hour, and 2.2 and a quarter for a subsequent half hour.  The neonatal codes, which has existed for some time, which generate a lot of work RVUs. And the pediatric critical care codes, which came to us in the mid-90s, thanks to the work  of a number of dedicated intensivists under the leadership of David Haimovich, who got these codes brought into our practice and approved and have been able to, for us as  pediatric intensivists, generate a good number of work RVUs, and a reason for some jealousy from our adult colleagues in terms of the ability for us to generate large numbers.  Benchmarks for RVU generation have been established and are revised annually. These benchmarks come from a variety of sources, including the Clinical Practice Solution Center,  which was a successor for the Faculty Practice Solution Center, and as a result of a merger  of Vizient, a consulting firm, and the American Association of Medical Colleges, the AAMC. There's also ASPEDEC, the American Medical School Pediatric Department Chairs Association,  who works with the AAAP, or the Association of Administrators in Academic Pediatrics, to collect data on RVUs from faculty members and distribute those among members.  There are other organizations and consulting groups that do this as well, such as the Medical Group Management Association.  This data is usually proprietary and is available to members of their individual organizations. So here are some work RVU benchmarks for pediatric medical care medicine.  They come from different organizations, the AAAP, the Clinical Practice Solution Center, the Faculty Practice Solution Center, and you can see that they differ in their means  from year to year. They also break their data into percentiles. What I find interesting about this data, particularly the CPSC data from 21 to 22, is how few people  are actually involved in contributing this data. There's about 200 faculty members' data is brought in for the formation.  These companies are relatively explicit in their methodology and their analytics, so you can see what they have done.  But there are approximately 60 to 80 pediatric intensivists just in the New York region, and that constitutes almost a third to close to half of the numbers of people who might  contribute to these benchmarks for intensivists across the board.  RVU generation and a physician's designated FTE are combined to look at productivity. The use of the imputed CFTE is described well in Dr. Charlie Schlein's article, The  Pediatric Intensive Care Unit Business Model, which was published in Pete's Clinics of North America in 2013.  And this article by Charlie of Northwell Health in Long Island remains one of the few published articles on the business of pediatric critical care medicine.  The imputed clinical FTE is equal to the work RVUs generated by a staff member divided by a benchmark.  Then it goes further to look at the imputed CFTE divided by the actual reported CFT for that staff member.  This table looks at the imputed FTE analysis of our mythical division of critical care medicine. And if we look at Dr. One here, in 2021, this doctor generated 4,378 work RVUs.  The CPSC fifth percentile benchmark in 2021 is 6,116. The ratio of 4,378 to 6,116 is 0.72. This same faculty member has a reported or scheduled clinical FTE of 0.65, therefore  0.72 divided by 0.65 comes out to 111 or 111%. So this faculty member is generating more RVUs than they in theory were expected to based on their clinical FTE.  So we go down the table and carry on the analysis and you can see most of the numbers are over 100, which is good.  And then you come to a faculty member here whose number, whose imputed to reported ratio is much less than 100.  And this is a very unique faculty member because this person only works nights in the ICU. So their entire service FTE is based on night call in the ICU.  Now this patient doesn't generate a whole lot of RVUs because there just aren't as many admissions at night as there are during the day or as many notes to write at night as  there are during the day. This type of staff member really raises concern by administrators because of the amount of revenue that they're generating.  But this type of practice member does have a lot of advantages to a division by reducing the number of calls that all are doing.  So how can the imputed to reported ratio help us and hurt us? With an imputed to reported ratio of greater than 100, there is support that the staff are working productively.  Of course, it depends on which benchmark is chosen. And on more than one occasion, when I've met with leadership and explained how well my  faculty is doing based on their imputed to reported ratios, the response I get is, well, if you had just chosen a bigger benchmark or a better benchmark, they would not be doing  so well. When staff are working at less than 100% on an I to R ratio, it is difficult for administrators to support additional staff and their pushback is given.  Super high imputed to reported ratios will lead administrators and chairs to ask, why can't everyone do that if one person is doing that?  And of course, if we look at this whole idea of RVU benchmarks, the more benchmarks that we generate as a specialty, the higher the benchmarks will be and the bar will just be  raised even more. Here are my conclusions and thoughts on the matter of the clinical full-time equivalent in pediatric critical care medicine.  I believe that critical care leaders need to be well-versed in the calculus that I've described.  We should create guidelines for what constitutes an appropriate clinical FTE pediatric intensivist. By hours, weeks, calls, RVUs, points, whatever we decide is best.  Other specialties are doing this. For instance, this article published in the Journal of Trauma and Acute Care Surgery in  December of this year, last year, a study was reported on defining 1.0 FTE in trauma and acute care surgery. We have very little data in pediatric critical care.  And I will give a shout out to Dr. Nicholas Ettinger from Baylor College of Medicine who distributed a survey in this fall, this last fall, asking these exact questions.  And I excitedly look forward to hearing the results of Nick's study. Department chairs, administrators, CEOs are studying what we do and listening to consultants about this topic.  We should also. Data is necessary to make arguments for additional staff and any additional non-clinical, that is non-billable time. Economic pressures are only increasing.  Every minute of non-billable time is a precious commodity and there are pressures to reduce it all the time.  Protected research time without funding to support it will be extinct if it isn't already. PCCM, as a specialty, should collect data regularly so we know what our colleagues are  doing regionally and locally. And speaking to our hospital leadership with data and recommendations of our specialty societies will only benefit us.  I thank you very much for listening. I'm happy to answer any questions and you can send them in, we can talk in person, you can by email in any way or phone call.  I'm happy to discuss this. And again, as I said, I realize I'm not an expert in this matter, but this is just my experience and my journey. Thanks again.

Video Summary

The Interim Chief of Critical Care Medicine at the Children's Hospital of Montefiore in the Bronx, New York, discusses the topic of clinical full-time equivalents (FTE) and how they are determined in pediatric critical care medicine. He explains that the definition of clinical FTE varies depending on the perspective, with intensivists often seeking more protected time for academic advancement, while chairs focus on economic return and the satisfaction of the CEO. The speaker goes on to explain that each division has its own unique distribution of work and administrative duties, making it difficult to determine a standard definition of FTE. He discusses the use of metrics such as work RVUs (relative value units) and benchmarks to measure productivity and determine FTE allocation. The speaker concludes by emphasizing the need for critical care leaders to be well-versed in FTE calculations and to collect data in order to make arguments for additional staff and non-clinical time.

Asset Subtitle

Administration, 2022

Asset Caption

Children's hospitals, and pediatric ICUs (PICUs) specifically, face a number of ongoing challenges that have only intensified in the era of COVID-19. Budget constraints, workforce shortages, new demands for staffing models, and decreased reimbursements by public and private payers have increased the administrative strain on PICU faculty and critical care management. This session aims to identify major administrative challenges facing pediatric critical care leaders. Each presentation will highlight strategic approaches to mitigating these challenges today and in anticipation of additional unforeseen health system pressure.

Meta Tag

Content Type Presentation

Knowledge Area Administration

Knowledge Level Intermediate

Knowledge Level Advanced

Membership Level Select

Tag Pediatric Intensive Care Unit PICU

Year 2022

Keywords

clinical full-time equivalents

pediatric critical care medicine

definition of clinical FTE

work RVUs

FTE allocation

collect data

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