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-^kD-AOSR 358 



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ACADEMY OF HEALTH SCIENCES (ARMY) FORT SAM HOUSTON TE — ETC F/G 6/5 
FAMILY PRACTICE MODELS FOR AN ARMY COMMUNITY - A DEMONSTRATION ~ETC(U) 
JUL 76 D F 6ERSTENBER6ER * T B ESCHEN 

HCSD-76-008 NL 



| OF 2 

A&34558 


























ADA034358 




FAMILY PRACTICE MODELS FOR AN ARMY COMMUNITY - A DQIONSTRATION PROJECT 




A detailed study and analysis of the development and operation of a 
neighborhood-based family practice clinic at Fort Ord, California 



LTC Duane F. Gerstenberger , MD, MPH, US Army 
MAJ Thomas B. Eschen, MD, MPH, US Army 
1LT Terry M. Lctz, MSC, US Army 
A. David Mangelcdorff , Ph.D. 

Health Care Studies Division 

Academy of Health Sciences, United States Army 
Fort Sam Houston, Texas 78234 



July 1976 
Final Report 




Approved for public release; 
distribution unlimited. 



Prepared for: 

UNITED STATES ARMY HEALTH SERVICES COMMAND (HSPA-A) 
Fort Sam Houston, Texas 78234 \ 





NOTICE 

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not to be construed as an official 
Department of the Array position 
unless so designated by other 
authorized documents. 





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IM1 

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Family Practice Models for an Army Community 
A Demonstration Project^ 



B XA. p jsmc'k.cpyERgo 

Final ^e£*»t r r 




AUTHGRfp) 



Duane F. Gerstenberger -LS6% MC 
Thomas B. /Esc hen, MC 



8. CONTRACT OR GRAN T NUMBERf*) 



Terry M./Lotz*.-iLf, NSC 



9. PERFORMING ORGANIZATION NAME AND ADDRESS 



Health Care Studies Division 

Academy of Health Sciences, United States 'Army 
Fort Sam Houston, Texas 78234 



II. CONTROLLING OFFICE NAME AND ADDRESS 

Commander 

United States Army Health Services Command 
ATTN: HSPA-A 



10. PROGRAM ELEMENT. PROJECT, TASK 
AREA 8 WORK UNIT NUMBERS 



771 



JulFl976 



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MONITORING AGENCY 'NAMC A AODRESSf// dIHoront from Controlling Olllco) I IS. SECTTRlTV Ct.A A9.~tw thlo rmport) 



Unclassified 



15*. DECLASSIFICATION/ DOWNGRADING 
SCHEDULE 



16. DISTRIBUTION STATEMENT (of thio Roport) 



Approved for public release; distribution unlimited. 



17. DISTRIBUTION STATEMENT (o( tho obatroct ontorod In Block 30, it dllforont from Roport ) 




IS. KEY WOROS fContinu* on rorota » aldo If nocootary on d Idontiiy by block number) 



^Family practice; family physician; ambulatory care; outpatient care; neighbor- 
hood clinic; patient satisfaction; staff satisfaction; co-located x-ray, lab, 
and pharmacy; patient panel. 



ABSTRACT (Continue on rereree aim If wcw H i y an d Identity by block number) 



►The objectives o>: this study were to study in detail, analyze, and describe 
the development and operation of a neighborhood-based family practice clinic 
in an Army setting. Voluminous demographic data was collected on 1469 
families who were members of the clinic; data were compiled on over 45,000 
encounters between patients and family practitioners. Patient and staff 
satisfaction was studied; patient utilization of other sources of care, both 
within and without the military, were evaluated with assistance of inputs 



POPP 

I JAM 79 



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SECURITY CLASSIFICATION OF THIS PAGE 








•■CO*l TV CLASSIFICATION OF THIS PAOS<Wh«t Data Inland) 



from the OMB Military Health Care Study and from the Office for the Civilian 
Health and Medical Program of the Uniformed Services (OCHAMPUS). Major con- 
clusions were that the neighborhood clinic Is not as efficient and effective 
as one located in or near a hospital; that assigning a set panel of families 
to a family physician is not an effective method of managing a family practice 
workload; and thac families assigned to a family practice panel still receive 
a majority of their care from other sources. 



StCUNITV CLASSIFICATION OF THIS PAGEfWh»n Data Inland) 




SUMMARY 



At the Army’s first Seminar on Ambulatory Health Services held 
in 1971 at Fort Sam Houston, Texas, it was > recommended that neighbor- 
hood family practice clinics be established to provide primary and 
comprehensive care, both outpatient and inpatient, to military health 
care eligible beneficiaries. Prior to establishment of the second 
Army family practice training program at Fort Ord, California, it was 
determined that the development and operation of this new health care 
delivery method should be studied in detail, analyzed, and described, 
in order to document or refute these empirical recommendations and 
their equally untested underlying assumptions. 

An on-site study team, attached to and under the guidance of 
the Health Care Studies Division, Academy of Health Sciences, Fort 
Sam Houston, Texas, collected data from the opening of the Fort Ord 
Family Practice clinics in 1973 until mid-1975. Voluminous demo- 
graphic data was collected on 1469 families who were members of the 
North Fort Old Family Practice Clinic. Over 45,000 encounters be- 
tween patients and family physicians were documented in detail, in- 
cluding patient information, provider identity, length of visit, 
problem, prescriptions, lab studies, x-rays, referrals, and immuni- 
zations. Patient and staff satisfaction surveys were developed, 
validated, administered in the family practice and several control 
clinics on multiple occasions, and the results analyzed. Ancillary 
data was obtained from the Office of Management and Budget (0MB), 
Military Health Care Study (MHCS), and from the Office for the 
Civilian Health and Medical Program of the Uniformed Services 
(OCHAMPUS). Advantages and disadvantages of a neighborhood-based 
clinic, when compared with a hospital-based clinic, were sought. 

The North Fort Ord Family Practice Clinic ranked highest among 
the clinics tested in patients' satisfaction with the medical care 
provided. Though staff satisfaction was high, there was no differ- 
ence in satisfaction between the family practice staff and those of 
other clinics. The neighborhood clinic was found to be inefficient 
in its utilization of resources, and to offer few advantages while 
demonstrating many disadvantages, when compared to a clinic based in 
or near a hospital. 

It was also determined that assigning patients as a panel to 
a specific physician was an inefficient and ineffective way of man- 
aging a family practice workload. The number of patients seen per 
day was controlled by the number of appointments scheduled, the 
number of walk-ins accepted, and the number of no-shows, and appeared 
to bear little relationship to the existence of or size of a patient 
panel. 



ii 



Though it had previously been thought that family physicians 
took care of 80 to 90-plus percent of their patients problems, data 
obtained in this study and from the 0MB MI{CS indicated that families 
received ful?.y 60 percent of their care from other sources. The 
study provides doubts that the continuity of care under family 
practice is significantly improved over other methods of primary 
care delivery, and suggests many areas worthy of further evaluation. 

Action-oriented recommendations suggest that neighborhood-based 
clinics not be established where hospital facilities are adequate, 
that panels of patients not be assigned specific physicians but rather 
that a different system be devised, and that further evaluation of 
family practice inpatient load and family practice outpatient pro- 
ductivity be done. 



ACKNOWLEDGEMENTS 



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* * 



* * * * * 



The project officers wish to express their appreciation to the 
several physicians on the staff of the North Fort Ord Family Practice 
Clinic for their assistance in data collection and for their gracious 
acceptance of the constant scrutiny of the on-site study team. 



MAJ Rizwan Nomani is due special thanks for his assistance with the 
section on clinic cost comparisons, as is 1LT Robert W. Tardy, who 
was on-site Project Officer during the last year of data collection. 
Mrs. Kathryn Katler provided valuable assistance throughout the 
study as management analyst, as did SP4 Mike Wunder in automation of 
the voluminous data base and in computer programming. 



COL Joseph Powers, Health Services Command Consultant in Ambulatory 
Care, was always ready with sage advice, an open mind, and a helping 
hand, in return for which the authors can only give their thanks. 



The authors greatly appreciate the efforts of COL William G. Peard, 

C, Health Care Studies Division (HCSD) , LTC Anna Koneck, Nurse Methods 
Analyst, HCSD, and MAJ Rizwan Nomani, OR/SA, HCSD, for review of the 
manuscript and for their many Invaluable comments and suggestions. 

It is obvious that in a study of this magnitude, thanks are due to 
a multitude of others, without whom little could have been accomplish- 
ed — to those many unnamed, behind-the-scenes contributors, is sent 
a heartfelt thanx you. 




} 

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iv 








FAMILY PRACTICE MODELS FOR AN ARMY COMMUNITY 
A DEMONSTRATION PROJECT 




TABLE OF CONTENTS 

SECTION 

SUMMARY 

ACKNOWLEDGEMENTS 



PAGE 

ii 

iv 



TABLE OF CONTENTS . . . 
LIST OF FIGURES & TABLES 

1. INTRODUCTION . . . 

a. Purpose . . . 

b. Background . . 

2. OBJECTIVES .... 

3. METHODOLOGY .... 

a. Overview . . . 

b. Facilities . . 




c. Data Collection Instruments 4 

d. Revised Study Proposal 5 

e. Study Team Interaction With Clinics 5 

f. Study Process/Outcome ^ . 5 

4. PROCEDURES, FINDINGS, AND RELATED DISCUSSION 6 






SECTION 



(1) Procedures 

(2) Findings 

(a) Demographic Data on Families With Active Duty 

Sponsors 

(b) Demographic Data on Families With Retired/ 

Deceased Sponsors 

(3) Discussion of Questionnaire Data 

b. The Encounter Form . 



7 

7 

13 









(1) Procedures 

(2) Findings 

(a) Number of Visits by Month and Provider • . . 

(b) Number of Visits by Relationship of Patient to 

Sponsor 

(c) Appointment Status ... 

(d) Type of Clinic 

(a) Provider 

(f) Primary Problem 

(g) Second Problem Treated at Same Visit .... 

(h) Length of Visit 

(i) Prescriptions Ordered 

(j) EKGs Ordered 

(It) X-ray Pro> hires Ordered 

(£) Laboratory Procedures Ordered 

(m) Immunizations and Skin Tests Requested . . . 

(r.) Referrals 

(o) Utilization Rates 

(3) Discussion of Encounter Data .... 

c. The Patient Satisfaction Survey 

(1) Methodology 

(2) Findings 

(3) Discussion of Patient Satisfaction Data 




SECTION 



PAGE 



d. The Staff Satisfaction Survey 53 

(1) Background and Methodology 53 

(2) Findings 53 

(3) Discussion of Staff Satisfaction Data 56 

e. The OMB Study 58 

(1) Methodology 58 

(2) Findings 58 

(3) Discussion of OMB Data 65 

f. The CH/.MPUS Study 67 

(1) Methodology 1 67 

(2) Findings 68 

(3) Discussion of CHAMPUS Data 71 

g. Cost per Clinic Vist — Comparisons 72 

h. The Transportation Study 77 

(1) Methodology 77 

(2) Findings ..... 77 

(3) Discussion of Transportation Data 78 

i. Evaluation of Co-located X-ray, Lab, and Pharmacy .... 78 

j. Neighborhood-based Clinic: Advantages/Disadvantages . . 80 

k. Patient Panel System 82 

(1) Aavantages/Disadvantages 82 

(2) Patient Panel Size 86 

(3) Alternatives to the Panel System 87 

vii 




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SECTION " PAGE 

l. Physician Productivity 88 

m. Utilization of Health Services 90 

5. CONCLUSIONS 90 

6. RECOMMENDATIONS 92 

7. REFERENCES 93 

8. APPENDIX 

A. Original Study Questions 94 

B. Revised Study Proposal Study Questions 98 

C. Application For Enrollment 102 

D. Medical History Questionnaire 105 

E. Methods of Enrollment 115 

F. Sample Encounter Form 117 

G. Patient Satisfaction Questionnaire 119 

H. Staff Satisfaction Questionnaire 123 

I. Staff Satisfaction - Tables of Results 133 

J. Sample 0MB MHCS Encounter Form 140 

K. Number of Visits Per Consult, Various Specialties . 142 

L. Cost Analysis Format 162 

9. LIST OF ABREVIATIONS, ACRONYMS, AND SYMBOLS 166 

10. DISTRIBUTION 168 





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LIST OF FIGURES & TABLES 



FIGURE PAGE 

4a-l Families With Active Duty Sponsor 9 

4a-2 Families With Retired /Deceased Sponsor 9 

4a-3 Active Duty Sponsors & Eligible Dependents 10 

/ 

4a-4 Ret. ired /Deceased Sponsors & Eligible Dependents .... 10 

4a-5 Pay Grade 11 

4a-6 Race, Religion, Education 12 




TABLE 




4b-l Number of Patient Visits by Month & Provider ..... 15 

4b-2 Patient Visits by Relationship to Sponsor 16 

4b-3 Appointment Status 17 

4b-4 Primary Problem 19 

4b-5 Second Problem 20 

4b-6 Length of Visit 21 

4b-7 Length of Visit by Patient Prefix 22 

4b-8 Length of Visit by Provider 23 

4b-9 Length of Visit by Primary Problem 24 

4b-10 Prescriptions by Number of Visits 25 

4b-ll Prescriptions by Patient Prefix 26 

4b-12 Prescription by Provider 27 

4b-13 EKG by Patient Prefix 28 

4b-1.4 EKG by Provider 29 

4b-15 Types of X-rays Ordered ( 30 

4b-16 X-rays by Patient Prefix .....' 31 

4b-17 X-rays by Provider 32 

4b-18 Types of Laboratory Procedures 33 

4b-19 Lab Procedures by Patient Prefix 34 

4b -20 Lab Procedures by Provider 35 

4b-21 Skin Tests and Immunizations 36 

4b-22 Referrals by Department . 37 

4b-23 Referrals by Patient Prefix 38 

4b-24 Referrals by Provider 39 

4b-25 Clinic Utilization Rates 40 




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TABLE 



PAGE 




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4c-l Resoondents by Clinic and Date Surveyed 44 

4c-2 Grand Mean and Dispersion 45 

4c-3 Clinics' Mean for Item Clusters . 46 

4c-4 Demographic Variables 49 

4d-l Return Rates by Clinic 54 

4d-2 General Satisfaction Levels 57 

4e-l OMB Nor.relevant Visits 60 

4e-2 Primary Care Clinics 61 

4e-3 Part Primary/Part Specialty Care Clinics 62 

4e-4 Specialty Care Clinics 63 

4e-5 Clinic Summary Data 64 

I 

4f-l Utilization of CHAMPUS by Active Duty Families .... 69 

4f-2 Utilization of CHAMPUS by Retired/Deceased Sponsor 

Families 70 

4g-l Rank Order of Clinics (1st & 2d Qtr, FY 75) 74 

4g-2 Rank Order of Clinics (3d & 4th Qtr, FY 75) ...... 75 

4g-3 Rank Order of Clinics (l3t & 2d Qtr, FY 76) 76 

4h-l Transportation Data 78 



4k-l Administrative Functions Performed for t^he Family 

Fractice Clinics by the HCSD Team at Ft. Ord .... 85 



f~ 1 




x 



FAMILY PRACTICE MODELS FOR AN ARMY COMMUNITY - 



- A DEMONSTRATION PROJECT 



1. INTRODUCTION. 

a. Purpose . The purposes of the project are to study in detail, 

analyze, and describe the development and operation cf an Army family 
practice clinic, and to provide such information to The Surgeon General 
for use in planning future health care delivery to military-care 
eligible beneficiaries. . 

b. Background . The priorities within health care delivery have 
been subjected to significant revision over the past several years, 
with the gradual awakening of the medical profession to the importance 
of ambulatory care. It is moot whether this change has been due to a 
desire to upgrade quality or rather to reduce costs. In any case, 
outpatient services no longer play second fiddle to the inpatient 
clinical areas. Within the medical, political, and consumer arenas 
emphasis has shifted to ambulatory care, and with the shift in 
emphasis have come shifts in manpower, resources, and research efforts. 

A natural outgrowth of the shift in emphasis to ambulatory 
care has been a revival of interest in the Family Practitioner as a 
key element in the delivery of such care. Interest has indeed waxed 
and waned since 1902, when the family physician was fondly spoken-of 
by Sir William Osier. (Osier, 1902). At times the God-like patriarch 
to his patients, and at others the second-rate purveyor of "scientific 
medicine" to his specialist colleagues, he seemed to be a dying breed 
in the '50s and early '60s. Combined with a great feeling of loss for 
the old-time GP, who knew his patients’ names, parents, children, 
problems and all, really cared for them, made himself available to 
them at any hour of the day or night, and so forth, was a feeling that 
he just was net able to handle the myriad modern diseases and treat- 
ments in a truly scientific manner. 

The doctors themselves did little to allay this feeling. 

Fewer and fewer medical students chose the practice of general 
medicine, and many of the medical school faculty frowned on those 
who did. The graduate was either going to be a specialist, or "just 
a GP". The practitioner himself realized that the very volume of his 
practice prevented him from keeping abreast of the rapidly changing 
medical scene, and his attempts to limit his practice furthered the 
expectation of his eventual demise. 



r 




I 

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The shift in emphasis to ambulatory care, and the revival 
of interest in the Family Practitioner led, not to re-use of the old 
GP mold, but rather to the birth of a new specialty, that of Family 
Practice. Supporters envisioned a new breed, incorporating all the 
good that could be found in the old GP, while eliminating or changing 
that which was not so good. Ideally, what was felt to be needed was a 
primary care physician who could respond to all the needs of the 
family (medical, social, and emotional) and who had the necessary 
training to provide competent outpatient and inpatient care for a 
broad range of problems on a continuing basis. Such care was to be, 
by definition, accessible, acceptable, complete, continuous, com- 
prehensive, efficient, effective, etc., in short, ideal, quality 
medical care. In this atmosphere the "Specialty of Family Practice" 
developed; residencies began to mushroom throughout the country; and 
in February 1969, the Advisory Board of the American Medical Associ- 
ation Council on Medical Education approved the new specialty of 
Family Practice. 

This study is an early attempt to look at Family Practice 
as it developed in the Army, with the hope that the findings will 
be of value to future decision makers. Priorities are in a state 
of flux. Each additional bit of information will hopefully aid in 
channeling our medical energies in the direction of efficient, high- 
quality health care delivery. 

In November 1971, The Surgeon General sponsored a Seminar 
on Ambulatory Health Services in San Antonio, Texas. One of the 
recommendations of the Emergency Room and Family Practice Sub- 
committee was that "Family Practice Clinics be established to pro- 
vide primary and comprehensive care (general medical, pediatric, 
obstetric, and minor surgical) on both an outpatient and inpatient 
basis." The Army's first family practice resident-training program 
was established in mid-1972 at Martin Army Hospital, Ft. Benning, 
Georgia. 



Prior to the establishment of a second family practice 
residency program and clinic, and unaware of its eventual location, 
the Health Care Research Division (now Health Care Studies Division 
(HCSD)) submitted an "Application to Conduct Research" for a study 
to be titled "Family Practice Models for an Army Community: A 

Demonstration Project." The research effort was directed at 
establishing and putting into operation at this second site, a 
neighborhood-based family practice clinic, which could be studied 
systematically, along with the hospital-based clinic, in order to 
"capture" early experience, and in order to establish a data-base 
upon which sound planning of future family practice clinics could 
proceed. 




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2 . 



OBJECTIVES . 



a. To investigate the feasibility of providing comprehensive 
health and social services to panels of Army family units, within the 
context of family practice clinics. 

b. To systematically explore and describe in detail the ex- 
perience of a broad program of family-oriented health and social ser- 
vices, and to document problems encountered and attempts at problem 
resolution. 

c. To explore and describe experience with family practice 
models — one neighborhood-based and the other hospital-based — and 
to comparatively analyze advantages and disadvantages associated with 
each approach. 

d. To establish a setting which could serve as an ongoing lab- 
oratory for the conduct of research into problems relevant to family- 
oriented health end social services. 

e. To assure the ready availability of one functioning family 
practice clinic which could assimilate some of the output of the 
family practice residency programs. 

3. METHODOLOGY . 

a. Overview . In September 1972, approval for the study was 
received from The Office of The Surgeon General (OTSG) , with Fort Ord, 
California, selected as the study site. The approval was subject to 
the availability of a suitable building at Fort Ord for the neighbor- 
hood-based clxnic. 

The study plan called for the establishment of a clinic 
proximate to bcth enlisted and officer on-post housing. It was sug- 
gested that an existing building, such as a large duplex family 
quarters, be modified to house the clinic, and that it be staffed 
with three trained family physicians, one social workers, and an 
appropriate mix of other health care personnel. Another hospital- 
based family practice clinic was to be established approximately six 
months later, when more family physicians became available. 

However, by the time the study plan was approved by HSC, 
the Fort Ord Medical Department Activity (MEDDAC) was already com- 
mitted to the establishment of a Family Practice Clinic (FPC) in the 
hospital. Moreover, five fully-trained family practitioners, in- 
cluding the Program Director, had been assigned. The residency train- 
ing program was to begin in July 1973, the application for approval 
of which was based on a plan to utilize clinic space in the hospital, 



3 



I 




and it was felt that to change this plan would delay the start of the 
program, and could invite the disapproval of the Residency Review 
Committee during subsequent reviews. The MEDDAC suggested that this 
did not preclude establishment of a second (neighborhood-based) FPC 
to be opened in July 1973, or later, as additional Family Practice 
staff became available. 

Such was the situation in October 1972, when the first on- 
site study team member arrived at Fort Ord. By December, the on-site 
team was complete and consisted of a management analyst (MOS 2610) , a 
statistician (MOS 6400), a psychology-social work technician (MOS 
91G20), and a clerk typist (MOS 71B20) . The Project Officer was a 
physician (MOS 3153) assigned to HCSD, Academy of Health Sciences 
(AHS), Fort Sam Houston, Texas. With the exception of the statis- 
tician, each of these positions was filled by several different per- 
sons during the period of the study, and there were times when one 
or more of the positions were unfilled. 

b. Facilities . On 8 January 1973, a hospital-based Family 
Practice Clinic, henceforth known as the Hospital Clinic, was opened. 
The search for adequate quarters for the neighborhood-based clinic 
resulted in saving a wing of the old cantonment-type hospital from 
the wreckers for such use. It was located slightly over two miles 
from the new Silas B, Hayes Army Hospital, was near two housing areas, 
and could be modified as required. The neighborhood -based clinic was 
opened on 30 July 1973. Although this sequence of clinic openings 
was the reverse of. that planned in the original study proposal, data 
was collected at both clinics from the time of their openings. The 
major study effort was concentrated, however, on the neighborhood- 
based clinic, which subsequently became known as the North Fort Ord 
Family Practice Clinic (North Clinic). 

c. Data Collection Instruments . The description of data 
collection and analysis efforts, as proposed in the original study 
proposal were very broad and ambiguous, stating that "A range of 
data collection methods will have to be used, to include direct ob- 
servation, interviews, questionnaires, utilization of tally counts, 
maintenance of a historical log, etc., as required by the particular 
question under investigation." (Original study questions, which 
have been modified several times, can be found in Appendix A). 

It was left to the on-site Study Team to determine just 
what information was needed, and how to go about collecting it. 

Initial work in the Fall of 1972 involved identification of essen- 
tial baseline data to be acquired on the patients served by the 
clinics, and development of the instrument for data collection. A 
questionnaire was prepared, and was ready for distribution by the 
middle of October 1972. The necessity for an encounter form was 
also recognized, and one was developed by the Study Team in con- 
junction with the Hospital Clinic staff. 










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Some data, such as encounter-form data, were collected on a 
continuing basis. Other smaller studies werq begun and ended over 
shorter periods. Many other collection instruments were used to 
collect such data as patient and staff satisfaction information, and 
information from inpatient and outpatient records. These will be dis- 
cussed more fully in subsequent sections. * 

d. Revised Study Proposal . In May 1974 a Revised Study Proposal 
was submitted to L T S Army Health Services Command (HSC) , and was 
approved on 12 July 1974. It called for extension of the study for an 
additional year, to December 1975, and an additional clerk typist and 
a computer programmer (MOS 74F20) for the on-site Study Team. A new 
set of study questions was outlined (See Appendix B) . 1 

The second clerk typist was never assigned. The computer 
programmer wr.s not assigned until January 1975, and it was decided 
that for the short remaining time of the study, he could be better 
utilized at HCSD, Ft. Sam Houston, Texas (FSHTX) , than at Ft. Ord 
with the on-site team. In late 1973 a physician at the North Clinic 
with an MPH degree had begun acting as consultant for the on-site team 
part-time (two half-days per week), assisting in study design and 
analysis . 



e. Study Team Interac tion With Clinics. A symbiotic relation- 
ship was established between the on-site Study Team and the clinic 
personnel. The additional administrative functions required of a 
family practice clinic, such as distributing, collecting, and filing 
applications for clinic membership, maintenance of a waiting list, 
notifying families of acceptance, and assigning patients to doctors' 
panels as spaces became available, were handled by the Study Team. 

In return, the clinic receptionist, doctors, and other providers 
filled out a short encounter form on each patient seen, and helped 
in other data collection efforts. As will be seen later, however, 
such tasks for the doctors were kept at a bare minimum, and did not 
significantly affect their available time for patient care. 

f. Study Process /Outcome . The outcome of the study is related 
directly to the process which actually occurred , not to any that was 
anticipated orior to commencement. The initial study proposal was 
very general in its description of what was proposed, and the method- 
ology to be employed for its accomplishment. The major weakness of 
the study proposal was the assumption that the on-site study team 
would have the power to manipulate variables in order that different 
configurations of clinic structure could be studied and compared. 

This is particularly evident from many of the original study questions 
(Appendix A), in statements such as: "What are the optimum numbers 

. . "What are the most satisfactory arrangements . . .," and 
"How many families should be assigned . . .". 







5 



In actuality, the study team did liot have such manipulative 
powers. Its function was merely that of observer; except for the 
administrative assistance the team provided to the clinic, it re- 
mained merely, as it were, "outside the one-way glass," observing 
structure and function of a family practice clinic as it developed 
under its own, hospital-supervised administration. 

Thus, the study in its various phases answers some of the 
questions specifically; some of them generally; and some of them not 
at all. Accordingly, the subsequent discussions, conclusions, and 
recommendations make no attempt to relate specific answers to specific 
study questions. Rather, the goal is the presentation of an accurate, 
integrated compendium, with individual items discussed only as they 
relate to major topic areas. 

4. PROCEDURES, FINDINGS, AND RELATED DISCUSSION. 

Each of the data collection procedures will be described in more 
detail in the following paragraphs, followed in each case by findings 
and discussion related to the specific findings. Discussion of other 
topics follows in separate sections. 

a. The Application-Questionnaire . 

(1) Procedures. The one page Application (Appendix C) and 
nine page Questionnaire (Appendix D) served the dual purposes of ob- 
taining a roster of those families wishing to join the family practice 
system and gaining demographic information on each of the families who 
utilized the clinics. As there were several methods of obtaining pa- 
tients for the clinics (see Appendix E) , a Questionnaire was not ob- 
tained from each family during the early days of the clinic; however, 
in January 1974, the long questionnaire became the application form. 

In other words, in order for a family to be considered for inclusion 
in the program and to be placed on the waiting list, the questionnaire 
had to be voluntarily completed. It was felt that willingness to do 
so indicated interest in the program. After that time, questionnaire 
information was available on all new clinic families. 

(2) Findings. Of the 1627 families who visited the North 
Clinic at least twice between July 1973 and June 1973, questionnaires 
were completed by 1469, or 90 percent. Of these, 1030 were active 
duty families and 439 were retired/deceased sponsor families. Of 
those families on whom complete data was available, 612 were initially 
assigned to the Hospital Clinic and were transferred to the North 
Clinic when it opened. (The ratio of active duty to retired/deceased 
sponsor families in the clinic cannot be interpreted to represent the 
true ratio in the population, as the clinic ratio was artificially 
maintained by the selection procedure). 



6 




; 1 




i 






i 




(a) Demographic Data on Families With Active Duty 
Sponsors. The average active duty family in this sample was com- 
posed of a male sponsor, age 33, his spouse, age 31, and two chil- 
dren, a boy and a girl, both age nine. Ninety- three percent of 
sponsors were Army, 69 percent white, and 56 percent protestant. 
Ninety-four percent had completed high school, and 50 percent had 
some college. Moreover, 55 percent of the sponsors had completed 
less than 12 years of service, 56 percent were in pay grades E-5 thru 
E-7, and 81 percent indicated plans to make a career in the military. 

For the spouse, 69 percent were white, 55 percent 
protestant, and 81 percent had completed high school. (See follow- 
ing pages for charts and graphs which more completely depict the above 
data) . 

(b) Demographic Data on Families With Retired/Deceased 
Sponsors. The average retired family (including those with a deceased 
sponsor — less than three percent in this sample) was composed of a 
male sponsor, age 54, his spouse, age 51, and one and one-half children, 
equally divided between boys and girls age 15. Eighty-eight percent of 
sponsors were Army retirees, 74 percent were white, and 61 percent were 
protestant. Ninety-two percent of sponsors had completed high school, 
and 59 percent had some college. Ninety-four percent of the sponsors 
had completed twenty or more years of service, and 56 percent had re- 
tired in Pay Grades E-6 thru E-8. Sixty-eight percent of the spouses 

of retired/deceased sponsors were white, 59 percent were protestant, 
and 80 percent had completed high school. (See the following pages 
for charts and graphs which more completely depict the above data). 

Figures 4a-l and 4a-2 are population pyramids 
depicting the sex/age distribution of the family members in the North 
Clinic panels , both those with active duty sponsors (Fig. 4a-l) and 
those with retired or deceased sponsors (Fig. 4a-2). 

Figures 4a-3 and 4a-4 are distributions of family 
size as a percent of families of that type (active duty or retired/ 
deceased) seen in the North Clinic. 

Figure 4a- 5 represents the distribution of Pay 
Grades of the sponsors of families in the North Clinic. 

Figure 4a-6 is a representation in chart form of 
three other demographic variables of the sponsors and their spouses, 
their race, religion, and education. 

NOTE: Pages five and six of the Questionnaire (Appendix D) deal with 

Army and civilian medical care utilization during the year prior to 
making application for family practice care. Unfortunately, the 



7 

( 






questions were posed in such a way that no average utilization figures 
can be obtained. Data from pages seven and eight of the Questionnaire 
will be provided in a subsequent report. 






Figure 4a-l Figure 4a-; 








4a-3 Figure 4a-4 




FAMILY SIZE 

(RETIRED I DECEASED SPONSORS t ELIGIBLE DEPENDENTS! 






Figure 4a-6 


























































I 



(3) Discussion. The demographic data presented are des- 
scriptive statistics and require little explanation. It is interest- 
ing to note that the average active duty family is composed of four 
members, evenly distributed between father, mother, son and daughter, 
and that the average retired/deceased sponsor family is composed of 
three and one-half members, again evenly distributed. 

b. The Encounter Form . 

(1) Procedures. Development of an encounter form was begun 
early in the study, in conjunction with the Hospitai Clinic staff. 

The form was modified several times over a period of months until a 
finalized form was initiated in December 1973 (Appendix F) . This en- 
counter form, with only slight modifications which did not affect data 
collection, was used throughout 1974. 

The encounter form not only collected data necessary for 
the study, but also was used as a routing and disposition sheet, where 
the physician or other provider could check the requirements for X-ray, 
lab, immunization, and consultation, and also indicate when the patient 
needed to be seen again. The provider was thus encouraged to fill out 
a form on each patient. 

At the time the patient checked-in, the receptionist 
completed the administrative data on the upper portion, including the 
date, name, sponsor's Social Security Number (SSN) with the family- 
member-identifying prefix, appointment status, type of clinic, and 
health care provider. The form was then attached to the front of the 
patient's chart. The nurse entered the complaint. The remainder of 
the form was completed by the health care provider, who gave it to 
the patient at the end of the visit. The patient then took the form 
to the lab, X-ray, nurse, or receptionist, as needed, and the last pro- 
vider collected the forms for appropriate disposition. 

Forms were collected from January 1973 thru December 1974 
at the Hospital Clinic and from August 1973 thru June 1975 at the North 
Clinic. The encounter forms were coded ojn the same form by the on-site 
study team and then sent to HCSD, FSHTX, where they were keypunched and 
stored on a CDC 6500 computer. 

The North Clinic encounters were also cumulated on a 
roster by family (SSN), so that relevant individual family utilization 
i data could be obtained. This roster also included visits at the 

Hospital Clinic between January and July 1973 for those families who 
had initially belonged to the Hospital Clinic and were then transferred 
to the North Clinic. This roster was cumulated and stored on the CDC 
6500 computer. 






13 





The data analysis was performed utilizing the canned 
statistical package "Statistical Programs for the Social Sciences" 
(SPSS). The programs most frequently utilized included 'codebook' 
and 'crosstab'. 

(2) Findings. During the period of the study, a total of 
45,898 encounter forms (Appendix F) were cpllected. Of these, 24,120 
came from the Forth Clinic, and 21,778 came from the Hospital Clinic. 
Blocks of data based on various time periods were extracted from these 
encounters; the main block reported on included all forms collected 
at the North Clinic between 1 January and 31 December 1974. This 
block of data included 13,175 encounters. 

Data from the encounters will be described in the order 
in which they appear on the encounter forms. The following blocks of 
data relate to the North Clinic during the period January thru Decem- 
ber 1974, unless otherwise specified. 




(a) Number of Patient Visits by Month and Provider, Jan 74 - Dec 74. 




Month not used in calculating average per active month. 

Physician provider; PR - Other provider (Nurse Practitioner, PA) 





(b) Patient Visits by Relationship to Sponsor. 

(Population ratio in this sample for sponsor: spouse: children was 1:1:2. 
Other dependents account for 0.39 percent of sample population.) 



TABLE 4b -2 



RELATIONSHIP 
OF PATIENT 
TO SPONSOR 


NUMBER OF 
VISITS 


PERCENT OF 
VISITS 


SPONSOR 


2757 


21.00* 


SPOUSE 


5724 


43. 61* 


• CHILDREN 


4571 


34.83* 


OTHER 






DEPENDENTS 


74 


0.56* 


TOTAL 


13,126 


100.00* 



(c) Appointment Status. During the period August 1973 
thru December 1973, a total of 5,093 visits were recorded. These visits 
were comprised of 'Appointments' and 'Walk-ins' until early in December. 
The latter part of December (835 of 1,056 visits) as well as all of 1974 
(13,175 visits) separated 'Emergency' visits fVom the appointments and 
walk-ins. The results of this distribution by° appointment status are 
tabulated on the following page (TABLE 4b-3) . 



16 




TABLE 4b-3 APPOINTMENT STATUS 



MONTH/ 
YEAR 1973 


VISITS 


VALK-INS/PERCENTACF. 


EMERGENCY 


’ i 

NOT 

RECOPDED 


AUGUST 


827 


71 


( 8.59*) 


-- 


3 


SEPTEMBER 


904 


74 


( 8.192) 


— 


15 


OCTOBER 


1,154 


131 


(11.352) 


— 


— 


NOVEMBER 


1,153 


154 


(13.362) 


— 


— 


DECEMBER 


1,056 


69 


( 6.532) 


3 


15 


(E»rl>) 


(221) 


(15) 


( 6.792) 


— 


(5) 


(La£c) 


(835) 


(54) 


( 6.472) 


(3) 


(10) 


• 1973 TOTAL 


5,094 


499 


( 9.802) 


3 


33 


MONTH/ 
YEAR 1974 


VISITS 


VALK-INS/PERCENTAGE 


EMERGENCY 


NOT 

RECORDED 


JANUARY 


1,157 


51 


( 4.412) 


8' 


— 


FEBRUARY 


1,046. 


84 


( 8.032) 


3 


— 


MARCH 


1,290 


74 


( 5.742) 


7 


-- 


APRIL 


1,149 


86 


( 7.482) 


5 


— 


MAY 


967 


95 


( 9.822) 


3 


~ 


JUNE 


832 


51 


( 6.132) 


4 


— 


JULY 


1,012 


33 


( 3.262) 


1 


— 


AUGUST 


1,280 


20 


( 1.562) 


2 


— 


SEPTEMBER 


1,082 


— 






— 


OCTOBFX 


1,197 


’ 24 


( 2.002) 


6 


~ 


NOVEMBER 


1,074 


24 


( 2.232) 


3 


— 


DECEMBER 


1,089 


68 


( 6.242) 


1 


— 


1974 TOTAL 


13,175 


610 


( 4.632) 


43 


— 


17 MONTH 
TOTAL 


18,269 


1,109 


( 6.072) 


46 

r 


33 









r 



j 



(d) Type of Clinic. Although the form was initially 
designed to show the nature of the visit, i.e., whether the visit 
was made during the 'regular' clinic hours or, during a fSpqcial 
Clinic' at night or on Saturdays, or 'Non-clinic', less than one 
percent of visits were recorded as other than the 'regular' clinic 
between January and July 1974 (47 of 7378 visits). Consequently it 
was concluded that further analysis of these data would be of little 
value to the overrll objectives of this study. 

(e) Provider. The data for each provider has already 
been furnished in Table 4b-l. 



j 

i 




18 







(f) Patient Encounter Data by Primary Problem. 

(Rank ordered by decreasing frequency of percent of recorded visits.) 

TABLE 4b-4 PRIMARY PROBLEM 



ORDER 


PROBLEM 


FREQUENCY 


PERCENT OF 
RECORDED VISITS 


1 


ACUTE (TEMPORARY PROBLEM) 


2,739 


22.142 


2 


CHRONIC PROBLEM, ROUTINE 


2,314 


18.707. 


3 


PARTIAL EXAM, WELL BABY, 
SCREENING EXAM, OR PREV. 
EDUCATION 


2,264 


18.292 


4 


CKRCNIC PROBLEM, FLARE-UP 


1,338 


10.812 


5 


ACUTE (TEMPORARY) PROBLEM 
FOLLOW-UP 


1,021 


8.25Z 


( 


PRENATAL AND POSTNATAL CARE 


926 


7.482 


7 


COMPLETE HX AND PE FINISHED 


522 


4.222 


8 


COUNSELING/ADVICE 


492 


3.982 


9 


ACUTE INJURY 


235 


1.902 


10 


ACUTE INJURY FOLLOW-UP 


176 


1.42Z 


11 


FAMILY PLANKING /CONTRACEPTION 


151 


1.222 


12 


ADMINISTRATIVE 


59 


0.482 


13 


IMMUNIZATION 


40 


0.322 




OTHER 


98 


0.792 




TOTAL VISITS WITH PRIMARY 
PROBLEM RECORDED 


12,375 


100.002 




NOT RECORDED 


800 


— 




TOTAL 


13,175 





19 





(g) Second Problem Treated during the Same Visit . (*) 



[' 

F 

TABLE 4b -5 SECOND PROBLEM 



ORDER 


PROBLEM 


FREQUENCY 


PERCENT OF 
RECORDED 
VISITS 


• 

PERCENT OF 
2ND PROBLEMS 


1 


C0UNSELI11C/ ADVICE 


469 


3.79Z 


22.272 


2 


CHRON7C PROBLEM, ROUTINE 


436 


3. 528 


20.702 


3 


PARTIAL EXAM, WELL BABY, 
SCREEN EXAM, OR PREV, 
EDUCATION 


433 


3.32Z 


20.662 


4 


ACUTE (TD1P0RARY) 
PROBLEM 


230 


1.862 


10.922 


S 


CHRONIC PROBLBI. FLARE-UP 


214 


1.732 


10.162 


6 


ACUTE (TEMPORARY) PROBLEM 
POLLCW-UP 


128 


1.032 


6.082 


7 


FAMILY PLANNING/ CONTRA- 
CEPTION 


71 


0.372 


3.372 


8 


IMMUNIZATION . 


33 


0.272 


1.572 


9 


ADMINISTRATIVE 


33 


0.272 


1.372 


10 


PRENATAL AND POSTNATAL CARE 


22 


0.182 


1.042 


11 


ACUTE INJURY 


11 


0.092 


0.322 


12 


ACUTE INJURY rOLLOW-UP 


9 


0.072 


0.432 


13 


COMPLETE IK AND PE FINISHED 


7 


0.062 


0.332 




OTHER 


8 


0.062 


0.382 




TOTAL RECORDED SECOND 
PROBLEMS 


2,106 


17.022 


100.002 


- 


PRIMARY PROBLEM ONLY 


10,269 








HO PRIMARY PROBLEM 
RECORDED 


800 








TOTAL 


13,173 







* Of the 12,375 visits In 1974 that had a Primary Problem recorded, only 
2,106, or 17.02 percent, had a second problem requiring evaluation and/or 
treatment during the same visit. The frequency of encounters and the 
percentage of second problems are provided In the table. 



20 





(r) Length of Visit. 

1 Length of Visit by Number of Visits. On the 
encounter form the provider recorded the 'Length of This Visit' by 
checking incremental time blocks of 0-5 minutes, 5-20 minutes, 20-40 
minutes, and Over-40 minutes. Observation by the HCSD study team 
revealed that the 0-5 minute block averaged approximately four minutes, 
the 5-20 minute block averaged approximately 15 minutes, the 20-40 
minute block averaged approximately 30 minutes, and the Over-40 minute 
block averaged approximately 52 minutes. The number of visits by these 
approximate average length of visit are provided in the table below: 



TABLE 4b -6 LENGTH OF VISIT 



LENGTH OF VTSIT/ 
AVERAGE 


NUMBER OF 
VISITS 


PERCENT OF 
RECORDED VISITS 


4 MINUTES 


291 


2.46X 


15 MIJjTTES 


8,629 


74.73X 


30 MINUTES 


2,333 


19.75Z 


52 MINUTES 


362 


3.06Z 


’ TOTAL RECORDED 


11,815 


100. 00Z 


NOT RECORDED 


1,360 




TOTAL 


13,175 






Average length of visit ■ 



S ((LENGTH OF VISIT) X (NUMBER OF VIS 
(TOTAL NUMBER OF RECORDED VISITS) 



Average length of visit ■ 18.82 minutes. 











i 



.2 Length of Visit by Patient 'Prefix. In the follow- 
ing table, the length of visit is tabulated by the relationship of the 
patient to the sponsor. 



TABLE 4b-7 LENGTH OF VISIT BY PATIENT PREFIX 



RELATIONSHIP OF 
PATIENT TO SPONSOR 


AVERAGE LENGTH 
OF VISIT 


NUMBER OF" 
VISITS 


SPONSOR 


20.19 Minute* 


2.454 


SPOUSE 


20.14 Minute* 


5,127 


CHILDREN 


16.93 Minute* 


4.066 


OTHER DEPENDENTS 


20.23 Minute* 


69 




SUB-TOTAL 


11,716 


RELATIONSHIP OR LENGTH "NOT RECORDED 


1.459 




TOTAL 


13,175 






3^ Length of Visit by Provider. Visit average 
length was calculated for each provider, using the formula given in 
Section 4b(2)(h)l^. The average was also calculated for ’ALL MDs* 
and for ''ALL OTHERS ' . Recall that the calculated overall average was 
18 . 82 minutes . 



TABLE 4b-8 LENGTH OF VISIT BY PROVIDER 



PROVIDER 


MINUTES 
PER VISIT 


NUMBER OF VISITS/ 
DATA CASED Oil 


NUMBER OF VISITS/ 
DATA NOT RECORDED 




mil 


16.36 


1,778 


36 




MD»2 


20.24 


2,654 


136 




MD#3 


15.35 


600 


545 




KDf 4 


17.24 


2,179 


148 




MDf5 


17.28 


1,264 


74 




KDt<, 


15.69 


1,043 


231 




HDl? 


18.07 


764 


56 




(ALL MDs) 


17.69 








PR#A 


28.54 


1,260 


79 




PR#B 


16.81 


154 


19 




PRfC 


17.60 


42 


14 




(ALL OTHERS) 


26.98 










SUB-TOTAL 


11,738 


1,338 




| PROVIDER NOT RECORDED 


99 






| 


TOTAL 


13,175 


V \ 





> 

' 



23 
















I 



U_ Length of Visit by Primary Problem. Length of 
visit was calculated for each category of primary problem recorded, and 
rank ordered in increasing average length of visit. 



TABLE 4b-9 LENGTH OF VISIT BY PRIMARY PROBLEM 



ORDER 


PROBLEM 


AVERAGE VISIT 
LENGTH/MINUTES 


1 


ADMINISTRATIVE 


14.66 MINUTES 


2 


ACJTE (TEMPORARY) PROBLEM FOLLOW-UP 


15.52 MINUTES 


3 


ACUTE INJURY 


15.55 MINUTES 


4 


ACUTE INJURY FOLLOW-UP 


15.59 MINUTES 


5 


IMMUNIZATION 


15.92 MINUTES 


’ 6 


ACUTE (TEMPORARY) PROBLEM 


16.19 MINUTES 


7 


PARTIAL EXAM, WELL BABY, 

SCREENING EXAM, OR PREV. EDUCATION 


18.15 MINUTES 


8 


CHRONIC PROBLEM, FLARE-UP 


18.73 MINUTES J 


9 


CHRONIC PROBLEM, ROUTINE 


19.70 MINUTES 


10 


PRENATAL AND POSTNATAL CARE 


20.29 MINUTES 


U 


CCUNSELINC/ADVICE 


22.53 MINUTES 


12 


FAMILY PLANNINC/CONTRACEPTION 


23.98 MINUTES 


13 


COMPLETE IK AND PE FINISHED 


34.48 MINUTES 




OTHER 


22.21 MINUTES 









5^ Length of Visit by Second Problem. Some 2,106 
> of the 13,175 visits in 1974 had a second problem listed. On 2,008 of 

these the time was recorded; 81.32 percent of these were 15 minute 
visits. The weighted average in minutes per visit for visits having 
a second problem recorded was 18.05 minutes (recall 18.82 minutes for 
all visits) . 



L 



A. 



24 










(i) Prescriptions Ordered. 

1 Number of Prescriptions by Number of Visits. 
During 13,175 visits to the North Clinic in 1974, 11,259 prescriptions 
were written, or 0.35 prescriptions per visit . The two extremes con- 
sisted of 6,870 visits, or 52.15 percent, with no prescriptions ordered, 
and three visits with nine prescriptions for each patient. This data 
is tabulated below: 

I 

TABLE 4b -10 PRESCRIPTIONS BY NUMBER OF VISITS 

( 



NUMBER OF RXs 
PER visit 0:) 


NUMBER OF 
VISITS 


TOTAL EX* 


PERCENT/VI SITS 
WITH (X) RXs 


0 


6,870 


— 


52.152 


I 


2,997 


2,997 


22.752 


2 


2,169 


A, 338 


16. A 62 


1 J 


795 


2,385 


6.0A2 


. * 


233 


932 


1.772 


5 


78 


. 390 


0.592 


6 


23 


138 


0.172 


7 


A 


28 


0.032 


8 


3 


2A 


0.022 


9 


3 


27 


0.022 


TOTAL 


13,175 


11,259 


100.002 




Prescription by Patient Prefix. 
pAMCAA.pU.onA wsu£tzn?) Data is tabiated below. 



( Foa whom wcah 



T^BLE 4b-ll PRESCRIPTION BY PATIENT PREFIX 



Relationship to 
sponsor 


NUMBER OF 
VISITS 


PERCENT /VISITS 
WITH NO RXs 


MEAN NUMBER/ 
RXs PER VISIT 


SPONSOR 


2.741 . 


52.102 


0.89 


SPOUSE 


5,697 


49.942 


0.91 


CHILDREN 


4,549 


54.832 


0.76 


OTHER DEPENDENTS 


74 


51.352 


1.32 


% NOT RECORDED 


114 






TOTAL 


13,175 







26 













1 







f 

/ 



_3 Prescription by Provider. [By whom we/ie 
pA.&6CAA.p£i(M4 MVLcttert ? ) 



TABLE 4b-12 PRESCRIPTION BY PROVIDER 



PROVIDER 


NUMBER/ 

VISITS 


PERCENT/VISITS 
WITH NO RXs 


MEAN NUMBER/ 
RXs PER VISIT 


MDfl 


1,814 


39.03Z 


1.01 


MD02 


2,790 


46.67Z 


0.92 


KD#3 


1,145 


48.03Z 


0.90 


MD04 


2,327 


59.60Z 


0.68 


• MD05 


1,338 


37 22Z 


1.35 


MD#o 


1,274 


81.79% 


0.31 


MD07 


820 


50.73Z 


0.95 


PR0A 


1,339 


59.67Z 


0.74 


PR#B 


173 


41.62Z 


0.97 i 


PR#C 


56 


67.86Z 


0.64 


SUB-TOTAL 


13,076 






PROVIDER NOT 


99 






RECORDED 








TOTAL 


13,175 





















27 









(■j; EKGs Ordered. 






■ 



1 EKG by Visits. During 13,175 visits in 1974 
to the North Clinic, EKGs were ordered 255 times, or at 1.94 percent 
of visits. 



2 EKG by Patient Prefix. [On wkom weAZ EKG 6 
0 /ideA.e.d?) Results are tabulated below. 



TABLE 


4b-13 EKG BY 


PATIENT PREFIX 




RELATIONSHIP OF 
PATIENT TO SPONSOR 


NUMBER OF 
EKGs ORDERED 


PERCENT OF 
EKGs ORDERED 


PERCENT OF VISITS 
(FROM 4 .b. (2) (b) ) 


SPONSOR 


95 


37.262 


71.002 


SPOUSE 


136 


53.332 


43.612 


CHILDREN & OTHER 
DEPENDENTS 


24 


9.411 


35.392 


TOTAL 


255 


100.002 









I 



28 







_3 EKG by Provider. (8i/ u)hom WUXe. EKGi oAdeA&d?) 
i 



TABLE 4b-14 EKG BY PROVIDER 



1 . — 

PROVIDER 


NUMBER OF 
VISITS 


NUMBER OF 
EKCs 


PERCENT OF 
VISITS WITH EKC 


MD01 


1,811 


12 


0.667. 


MD02 


2,790 


21 


0.752 


M DI3 


1,144 


8 


0.702 


mu 


2,327 


30 


1.292 


MD/5 


1,337 


63 


4.712 


m/6 


1,274 


66 


5.182 


m/7 


820 


18 


2.202 


OTHER 


1,672 


37 


2.212 


TOTAL 


13,175 


255 


1.942 







(k) X-ray Procedures Ordered. 

1^ Numbers and Types of X-rays Ordered. During 
13,175 visits, 953 x-rays were ordered. Approximately one-half of these 
x-rays were 'Chest, PA & LAT'. Nine other types account for an addition- 
al quarter. Forty-eight infrequently ordered types account for the final 
quarter. The ten most commonly ordered are tabulated below. 



TABLE 4b -15 TYPES OF X-RAYS ORDERED 



ORDER 


T-TE X-RAY 


NUMBER 


PERCENT 
OF VISITS 


PERCENT 
OF X-RAYS 


1 


CHEST, PA & 1 AT 


490 


3.72Z 


49.35X 


2 


CHEST, PA 


55 


0.42Z 


5.54Z 


3 


UPPER Cl 


42 


0.32Z 


4.23Z 


4 


PATELLA 


42 


0.32Z 


4.23Z 


5 


SPIKE, LS 


28 


0.21Z 


2.82Z 


6 


• IVP 


27 


0.20Z 


2.72Z 


7 


BL 


23 


0.17Z 


2.32Z 


6 


SKULL SERIES 


22 


0.17Z 


2.22Z 


9 


FOOT 


21 


0.16Z 


2.11Z 


10 


SPINE, CERVICAL 


19 


0.14Z 


1.91Z 




OTHER (48 TYPES) 


224 


1.70Z 


22.55Z 




TOTAL 


993 


7.54Z 


100. OOZ 





2 X-ray Procedures by Patient Prefix. (On whom 
e x-fuuji o*.deAe.d?T 



TABLE 4b-16 X-RAYS BY PATIENT PREFIX 



RELATIONSHIP 


NUMBER OF 
VISITS 


NUMBER OF 
X-RAYS 


PERCENT VISITS WITH 
X-RAYS ORDERED 


SPONSOR 


2,741 


310 


11.31X 


SPOUSE 


5,697 


448 


7.86Z 


CHILDREN 


4,549 


215 


4.73Z 


OTHER DEPENDENTS 


74 


13 


17.57X 


SUB-TOT AI. 


13,061 


986 


7.55X 


INCOMPLETELY CODED 


114 


7 




TOTAL 


13,175 


993 


7.54S 






X-TUUfA QKdZKtdl) 



3^ X-Ray Procedures by Provider. [By whom wztut 



TABLE 4b-17 X-RAYS BY PROVIDER 



PROVIDER 


NUMBER OF 
VISITS 


NUMBER OF 
X-RAYS 


PERCENT VISITS WITH 
X-RAYS ORDERED 


MD01 


1,81 4 


94 


5.182 


MD02 


2,790 


217 


7.782 


MDff3 


1,145 


38 


3.322 


MD#4 


2,327 


135 


5.802 


MD05 


1,338 


164 


12.262 


mt(> 


1,274 


164 


12.872 


mm 


820 


58 


7.072 


TOTAL HD 


11,508 


870 


7.562 


PRIA 


1,339 


98 


7.322 


PRJB 


173 


17 


9.832 


PRIC 


56 


6 


10.712 


TOTAL OTHER 
PROVIDER 


1,568 


121 


7.722 


SUB-TOTAL 


13,076 


991 


7.582 


INCOMPLETELY 

CODED 


99 ’ 


2 




TOTAL 


13,175 


993 


7.542 







(£) Laboratory Procedures Ordered. 

1. Numbers and Types of Laboratory Procedures 
Ordered. During 13,175 visits, 10,258 lab procedures were ordered 
or 0.78 lab procedures per visit. 



TABLE 4b-18 TYPES OF LABORATORY PROCEDURES 



ORDER 


TYPE LAD 


NUMBER 


PERCENT OF 
LAD ORDERED 


1 


CBC & D1FF. 


1,389 


13.54Z 


2 


SMA-12, FAST INC 


924 


9.00Z 


3 


URINALYSIS 


911 


8.38Z 


4 


THROAT CULTURE 


751 


7.32Z 


* 5 


CLEAN CATCH 
URINALYSIS 


680 


6.63Z 


6 


RPR 


603 


5.88Z 


7 


CHOLESTEROL & 
TRIGLYCERIDES 


479 


4.67Z 


8 


URINE CULTURE 


471 


4. j9Z 


9 


PAP SMEAR 


438 


4.27Z 


10 


ELECTROLYTES 


370 


3.61Z 


11 


SMA-12, NON- FASTING 


327 


3.19Z 


12 


CERVICAL CULTURE 


303 


2.95Z 




OTHER 


2,612 


25.45Z 




TOTAL 


10,258 


100. OOZ 











RELATIONSHIP OF 
PATIENT TO SPONSOR 


NUMBER OF LAB 
TESTS ORDERED 


PERCENT OF 
RECORDED TESTS 


PERCENT OF VISITS 
(FROM 4 .b. (2) (b) ) 


SPONSOR 


2,275 


23.49X 


21.002 


SPOUSE 


4,670 


48.21Z 


43.6IZ 


CHILDREN 


2,668 


27.S5Z 


34.83Z 


OTHER DEPENDENTS 


73 


0.75Z 


0.56Z 


• SUB-TOTAL 


9,686 


100. 00Z 




INCOMPLETELY 

CODED 


81 






TOTAL 


9,767 








Laboratory Procedures by Provider. (8 y u)hom tab teAti OKd<LKidH\ 




CODED 





(m) Immunizations and Skin Tests Requested. During 
13,175 visits to the North Clinic in 1974, 1,637 immunizations and 
skin tests were ordered. Patients could receive immunizations at the 
hospital without referral, however. The following rank ordering indi 
cates the relative frequency with which certain tests were ordered. 



TABLE 4b-21 SKIN TESTS AND IMMUNIZATIONS 



ORDER 


TYPE SKIN TEST OR 
IMMUNIZATION 


NUMBER 


PERCENT OF SKIN TESTS 
AND IMMUNIZATIONS 


X 


TINE TEST 


763 


46.61Z 


2 


OPV 


299 


18.27Z 


3 


LPT 


281 


17.17Z 


• 4 


1>T 


134 


8.18Z 


5 


MHR 


65 


3.97Z 




OTHER (T. TOX, MEASLES 
AND RUBELLA. MUMPS, FLU, 
AND SMALL POX— (10-20 
EACTO 


73 


4.46Z 




OTHER RARE (LESS THAN 5 
EACH) 


22 


1.34Z 




TOTAL 


1,637 


100. OOZ 





(n) Referrals. 

Number of Referrals and Departments Referred to. 
During 13,175 visits, 629 referrals were made to other departments. 
These constitute 4.77 percent of total clinic visits. 

TABLE 4b-22 REFERRALS BY DEPARTMENT 



ORDER 


CLINIC 


NUMBER 


PERCENT 
OF REFERRALS 


l 


ORTHOPEDICS 


101 


16.0iZ 


2 


OBSTETRICS/GYNECOLOGY 


71 


11.281 


3 


DERMATOLOGY 


65 


10.33Z 


4 


ENT 


62 


9.86Z 


• 5 


OPHTHALMOLOGY 


44 


7.00% 


6 


SURGERY 


. 44 


7.00Z 


? 


INTERNAL MEDICINE 


40 


6.3fZ 


8 


UROLOCY 


39 


6.20Z : 


9 


OPTOMETRY 


34 


5.41Z 


10 


OCCUPATIONAL THERAPY/ 
PHYSICAL THERAPY 


24 


3.82Z 




OTHERS 


105 


16.69Z 


SUB-TOTAL 




629 


100. OOZ 


| VISITS WITHOUT REFERRALS 

1 RECORDED 


12,546 




1 TOTAL 




13,175 





37 




w<u le Kt^zM.n.d‘1) 



.2 Referrals by Patient Prefix. ['JJkich pa&Le.n£t> 



TABLE 4b-23 REFERRALS BY PATIENT PREFIX 



PREFIX 


NUMBER OF 
VISITS 


NUMBER OF 
REFERRALS 


PERCENT REFERRAL 
VISITS 


SPONSOR 


2,741 


180 


6.571 


SPOUSE 


5,697 


244 


4.282 


CHILDREN 


6,549 


193 


4.24Z 


• OTHER DEPENDENTS 


74 


3 


4.05Z 


SUB-TOTAL 


13,061 


620 




INCOMPLETELY CODED 


114 


9 




TOTAL 


13,175 


629 








Ji Referrals by Provider. (Bi/ whom WZAz ne.{ i <ZAAaJLt> 



TABLE 4b-24 REFERRALS BY PROVIDER 



PROVIDER 


NUMBER OF 
VISITS 


NUMBER OF 
REFERRALS 


PERCENT OF VISITS 
WITH REFERRALS 


KDfl 


1,814 


87 


4.802 


MD/’ 


2,790 


172 


6.162 


MD/3 


1,145 


31 


2.712 


MD/4 


2,327 


105 


4.512 


MU/5 


1,338 


56 


4.192 


HD/6 


1,274 


68 


5.342 


m/7 


820 


55 


6.712 


TOTAL yd 


11,508 


574 


4.992 


PR/A 


1,339 


44 


3.292 


PR/ 3 


173 


3 


1.732 


PR/C 


56 


3 


5.362 


TOTAL OTHER 
PROVIDER 


1,568 


50 


3.192 


SUB-TOTAL 


13,076 


624 




INCOMPLETELY 

CODED 


99 


5 




TOTAL 


13,175 

• 


629 


4.772 








(o) Utilization Rates. In order to determine the 
utilization rates at the North Clinic, a roster of North Clinic families 
was created. Each encounter was cumulated, by family, using the Social 
Security Number of the sponsor. Attempts 'rare made to correct for coding 
and other errors, so that all visits were applied to the proper family 
• and time period. However, due to the military environment, many families 

departed and new families arrived during the test period. Consequently 
the short term utilization was difficult to categorize. 

*• 

: 




1ABLE 4b-25 CLINIC UTILIZATION RATES 





ACTIVE 

DUTY 


RETIRED/ 

DECEASED 


FAMILIES 


326 


210 


PERSONS 


1,358 


740 


FAMILY SIZE: MEAN 


4.166 


3.524 


MEDIAN 


4.091 


3.233 


MODE 


4 


2 


VISITS IN 1974 


4,103 


2,735 


VISITS PER FAMILY 


12.586 


13.024 


VISITS PER PERSON 


3.021 


3.696 



I, 




It was determined, therefore, to select for analysis 
only those families who were definitely members of the clinic for the 
entire 1974 calendar year. This was done by selecting only those fam- 
ilies who had at least one visit to the North Clinic prior to January 
1974 AND one visit after December 1974. An additional requirement for 
selection was the availability of Baseline Data. In all, 326 active 
duty families and 210 families with retired/deceased sponsors met these 
criteria. It was recognized that this selection procedure could bias 
the sample slightly toward heavier health care utilizers. The results 
are given in Table 4b-25, above. 

1 ' i 



40 









■ 

i ' 




(3) Discussion. 

Most of the data in the preceding tables in this section 
are self-explanatory. However, there are some items of particular in- 
terest that require further discussion and elaboration. 

(a) Providers. An average of 242 visits per month per 
MD (using the averages per active month) equates to 60 visits per week 
or twelve per day. If these figures are multiplied by the average 
length of visit (as provided by the doctors themselves), the total 
average time spent in seeing clinic patients was 71.35 hours (242 X 
17.69 min.) per month, 17.84 hours per week, or 3.57 hours per day 
(assuming linear relationship). 

If, instead of using the average number of visits 
per month, the highest figure is used (341 visits for MD #1 in April 
1974), the figures become 85 visits per week or 17 visits per day. 

Using the average length of visit for MD//1 (16.36 min.), total average 
time spent in seeing clinic patients was 93.0 hou - > per month, 23.24 
hours per week, or 4.65 hours per day. 

It is also interesting to note that the number of 
EKGs, X-ray, and lab tests ordered per visit appears to depend more on 
who is providing the care than on who is receiving it. The most strik- 
ing example of this is in two groups of patients, each followed by two 
different physicians for six month periods. MD#1 and MD#3 served the 
clinic the first six months of 1974, and their panels of patients were 
taken over for the last six months by MD#6 and MD#5 respectively. In 
each case there was a large increase in tests ordered, even though the 
population of patients remained effectively the same. The percent of 
visits with EKCs ordered increased from 0.66 and 0.70 to 5.18 and 4.71, 
respectively. The percent of visits with X-rays increased from 5.18 
and 3.32 to 12.87 and 12.26, and the number of lab tests per visit in- 
creased from 0.34 and 0.45 to 1.29 and 1.04, respectively. Because of 
the small sample of physicians, no attempt was made to aralyze these 
data further, or to draw any conclusions. One can only speculate that 
the differences are due to differences in training and/or experience. 

(b) Patients. The spouse, though accounting for only 
about 25 percent of the population served, accounts for almost 44 per- 
cent of visits to the clinic. Data from the National Health Survey 
indicates similarly about twice as many visits for women at age 30 as 
for men (Vital and Health Statistics, 1971). 

Although the retired/decreased sponsor family is 
somewhat smaller than the active duty family (mean family size of 3.5 
compared to 4.2), the average number of visits per year is slightly 
higher (13.0 compared with 12.6). This is accounted for by the fact 
that utilization rates per person are higher for the retired/deceased 



41 



4 














sponsor family (3.7 compared with 3.0). As far as family practice 
utilization is concerned, then, the families can be considered 
equivalent . 

(c) Miscellaneous. 

o The number of prescriptions per visit (0.85) 
compares closely with that reported in The Milbank Memorial Fund 
Quarterly on "The Family Doctor" (0.59 to 0.86 prescriptions per 
visit). (Milbank, 1972). 

o The distribution of acute and chronic problems 
seen (about 50-50) is similar to data from the National Health Survey 
(Vital and Health Statistics, 1971). 

o Although 17 percent of visits had a second 
problem recorded, the length of visit with two problems was no greater 
than the length of visit in which only one problem was noted. 

c. Patient Satisfaction Survey . 

(1) Methodology. 

A variety of problems are involved in assessing con- 
sumers' attitudes. Respondents tend to reply in a socially acceptable 
manner, expressing few negative feelings; it is difficult to objective- 
ly quantify a series of subjective reports to assess satisfaction; and 
the reliability and validity of the measuring instrument must be 
addressed . 

The Patient Satisfaction Survey was administered with 19 
items assessing attitudes toward physicians, nurses, medical auxiliaries, 
professional interest, courtesy, quality of care, adequacy of informa- 
tion, and convenience of the clinic. 

The response format employed a five-point Likert scale 
from "completely dissatisfied" (1) to "neutral/undecided" (3) to 
"completely satisfied" (5). A "no contact and/or not applicable" 
response option was provided for each of the 19 statements. In 
addition, demographic information was collected regarding sex, age, 
military status, grade, education, family size, race, career inten- 
tions, and whetner the patient had an appointment. 

A cover letter from the Chief, Ambulatory Health Ser- 
vices, Ft. Ord, California, introduced the questionnaire (see Appendix 
G). The data collection instrument consisted of two parts: demo- 

graphic information and satisfaction attitudes. Patients were 

| 

l 



42 



administered the demographic portion before receiving treatment. The 
consumer satisfaction was assessed after a patient had received medical 
care. Patients using the clinic under study were sampled usually on 
Tuesday or Thursday depending upon what day the patient presented him- 
self for treatment. The survey was collected as the patient left the 
clinic . 



(2) Findings. 

(a) Overall Results. Patients from six clinics were 
surveyed on eight different dates from November 1973 to September 1975. 
The total number of patients responding was 1610. The sample consisted 
of 564 males, 1023 females, and 23 unidentified subjects. The number 
of patients surveyed by clinic and date is given in Table 4c-l. 

The overall response to all 19 patient satisfaction 
items was very satisfactory (mean responses to all items being greater 
than 4.00 "Mcstly Satisf led”) . The mean-item rating (the average of 
all items resporded to by a patient) was 4.54. Table 4c-2 summarizes 
the responses to each item, giving the grand mean and the dispersion 
around the grand mean for each clinic. 

The item clusters were the mean responses to the 
items answered dealing with a particular topic (such as Interest or 
Adequacy of Inf ormation) . The item clusters represent global measures 
of satisfaction. The grand mean responses for each item cluster were 
all greater than 4.50. Table 4c-3 summarizes the responses. 

(b) Reliability of Survey Instrument. 

A split-half reliability coefficient was computed 
comparing the average response to all odd-numbered items vs the average 
response to all even-numbered items. The simple correlation between 
the mean-odd and mean-even scores was .937. Correcting for the whole 
instrument, the reliability becomes .967. 

In addition, a Principal Components Factor Analysis 
of all 19 items was perfrrmed. A sample of 178 subjects responded to 
all 19 items. This factor analysis revealed one factor with an eigen- 
value greater than 1.000 (the actual value was 13.682), accounting for 
72 percent of the common variance with all 19 items correlating .600 
or greater (and 15 items correlating .800 and greater) with the first 
factor. A complete factor analysis of the 1610 subjects' responses to 
the 19 items revealed three factors with eigenvalues greater than 
1.000 (accounting for a cumulative 67.6 percent of the common variance). 
The first factor alone accounted for 55.7 percent of the common vari- 
ance. The first factor was labeled general satisfaction. The second 




I 



TABLE 4c-2 GRAND MEAN AND DISPERSION 



Orend naan and dispersion of 
allaici ' maan (corrected for covarying 
•at data) for individual itaau. 

8ATI6f\CTI0N ITEMS 



| B 

S 2 



8 y 

S 5 



I s 
06 £ 

* 3 
5 B 



1, Doctor's interest in my problem 


4.42 


• 

o 

-J 


-.08 


.32 


.22 


.24 


.18 


2. dura#' a interest in my problem 


4.51 


-.05 


-.07 


.21 


.17 


.07 


.19 


). Other medical personnel interest 

in ay problem (physician assistants, 
asioeiata, nurse clinicians) 


4.49 


-.Ot 


.05 


.21 


.04 


-.01 


.04 


4. Courteous trattaant by doctors 


4.74 


VI 

0 

1 


-.04 


.23 


.11 


.14 


.10 


). Courteous treatment by nurses 


4.67 


-.05 


-.03 


.19 


.10 


.21 


.06 


(. Courteous treatment by other Mdicsl 
person (physician assistants, 
amoslats, nurse clinicians) 


4.44 


-.04 


.0] 


.14 


.08 


.09 


-.02 


7. Courteous trertMnt by receptionist 


4.44 


-.04 


-.04 


.19 


.18 


.24 


.01 


1. Quality of health care 


4.52 


-.11 


.02 


.20 


.11 


.29 


.21 


9. Melting time in this clinic 


4.12 


-.15 


.05 


.22 


.29 


.22 


.07 


10. Convenience of location of this clinic 


4.42 


-.05 


.03 


-.12 


.13 


.15 


.12 


11. Convenience of operating hours of 
this clinic 


4.42 


-.05 


.02 


.05 


.07 


.17 


.02 


12. Adequacy of this clinic's physical 
facilities (seating, comfort, decor) 
in general 


4.58 


-.05 


.04 


.0? 


-.03 


.12 


.14 


11. Adequacy of information given to you 
about your medical problem by doctor 


4.54 


-.04 


-.04 


.23 


.13 


.27 


.09 


14. Adequacy of information given to you 
about your medical problem by nurse 


4.47 


-.04 


-.10 


.28 


.18 


.17 


.31 


15. Adequacy of information given to you 
about your med'eal psoblam by other 
personnel (phyuician assistants, 
amosista, nurse clinician) 


4.44 


-.04 


-.02 


.19 


.09 


.02 


.02 


1C. Continuity of health care provided 
(continued thorough care) 


4.55 


-.04 


-.10 


.24 


.17 


.14, 


.21 


17. Laboratory services provided by this 
facility 


4.49 


-.04 


-.13 


.26 


.14 


.17 


.16 


It. Pharmacy services provided by this 
facility 


4.48 


.00 


-.11 


.46 


-.04 


-.12 


.11 


It. E-ray services provided by this 
facility 


4.38 


-.01 


-.03 


.29 


-.18 


.25 


.27 



45 



-a* aiari 




identifiable factor was ancillary services (laboratory, pharmacy, and 
x-ray). The third factor was unidentified. A factor analysis of the 
1610 subjects' responses to 16 items (omitting the three items deal- 
ing with ancillary services) revealed two factors with eigenvalues 
greater than 1.000 (accounting for 65 percent of the common variance). 
A varimax rotation was performed on the factor structure; the two 
factors were labeled 1) non-physician interactions (nurses, reception- 
ists, other medical personnel) and 2) physician interactions/quality 
and continuity of health care. Since the reliability of a test is 
often considered the limit of the variance of the instrument which 
can be accounted for by the factors, the reliability of the survey 
instrument as determined by Factor Analyses falls between 65.0 and 
72.0 percent of the common variance being accounted for by the 
factors (simple correlation coefficients of between .81 to .85). 

(c) Validity. The validity of the survey instrument 
was assessed using correlations with specific criterion items. The 
simple correlations between the mean-item rating (average of all 
items to which the subject responded) and the individual 19 items 
ranged from .609 to .814 (median correlation was .760). The simple 
correlation between the mean-item rating and the item dealing with 
"Quality of Health Care" was .740. 

The correlation of the mean-odd score with the 
mean-item rating was .931, while the correlation of the mean-even 
score with the mean-item rating was .882. 

(d) Demographic analyses covarying out date. For 
each of the demographic variables of sex, race, highest level of 
education, military grade, status, whether patient had an appointment, 
and whether sponsor intended to make the military a career, separate 
analyses were performed. The effects of different times of adminis- 
tering the Patient Satisfaction Survey were accounted for by analyses 
of covariance. Separate analyses were performed for each item. 

For Sex , there was a significant F ratio on item 4 
(p = .038), males being significantly more satisfied than females. 
There were no other significant sex differences on any of the other 
items. 



For whether patient had an appointment ( Appoint - 
ment ) . there were significant differences between groups (yes vs no) 
on 15 of the 19 items and on the mean-item rating. Those individuals 
who did have an appointment scheduled reported significantly greater 
satisfaction with the 15 items. Table 4c-4 shows which items there 
were with significant differences. Significant differences exist for 
p values less than or equal to 050. 



47 






The career intentions of the sponsor ( Career ) showed 
significant differences between groups (yes, undecided, no) on 12 of 
the 19 items and on the mean-item rating. In all cases, responses of 
career-oriented sponsors were more satisfied than the other groups. 

The Status of the respondent indicated significant 
differences between groups (active duty dependent, active duty sponsor, 
retired dependent, retired sponsor) for 10 of the 19 items and the 
mean-item rating. Of the respondents, retired sponsors were most 
satisfied on all items. 

Of the responses broken down by military grade 
( Grade ) groups (company grade officers, field grade officers, warrant 
officers, E-l to E-5s, and E-6 to E-9s) , there were significant differ- 
ences between groups on 16 of the 19 items and on the mean-item rating. 
The warrant officer group was generally most satisfied. 

For Race , there were significant differences be- 
tween groups on three items (1, 4, and 11). The Chinese-Amer icans 
and Japanese-Americans reported the greatest dissatisfaction with 
these three items. 

For highest level of education reached ( Education ) , 
there were no significant differences between groups for any of the 
items. 



48 



I 



TABLE 4c-4 



INDIVIDUAL inns BROKEN DOWN BY DEMOGRAPHIC VARIABLES SHOWINC SIGNIFICANCE 
LEVEL FROM ANALYSIS OF VARIANCE (p VALUE) 





SATISFACTION 'TEMS 


B 

in 


l 


u 


STATUS 


GRADE 


SCHOOL 


RACE 


1. 


Doctor's Interest In my problem 


097 


001 


026 


242 


001 


103 


027 


2. 


Nurse's interest in my problem 


176 


002 


01 0 


001 


001 


270 


417 


1. 


Other medics! personnel Interest 
In my problem (pnyslcian assistants 
AMOSISTs, nurre clinicians) 


999 


106 


001 


001 


002 


999 


999 


4. 


Courteous treatment by doctors 


038 


001 


162 


073 


001 


999 


010 


3. 


Courteous trsstmsnt by nurses 


999 


006 


023 


018 


016 


345 


101 


«. 


Courteous treetaenc by other medicel 
personnel (physician assistants 
AMOSISTs, nurse clinicians) 


999 


084 


010 


016 


001 


999 


999 


7 . 


Courteous crestnent by raceptionist 


999 


002 


001 


278 


001 


173 


999 


8 . 


Quality of health cars 


163 


001 


174 


262 


014 


999 


999 


9 . 


Waiting time in this clinic 


999 


001 


076 


156 


085 


999 


191 


10. 


Convenience of location of this 
clinic 


117 


00? 


002 


041 


043 


999 


999 


11. 


Convenience of operating hours of 
this clinic 


266 


003 


Oil 


178 


081 


999 


033 


12. 


Adequacy of this clinic's 
physics) facilities in general 


033 


188 


999 


045 


147 


999 


999 


13. 


Adequsc) of information given to 
you about your medical problem by 
doctor 


999 


• 001 


003 


131 


001 


999 


167 


14. 


Adequacy of Information given to 
you about your medical problem by 
nuree 


999 


001 


013 


006 


001 


999 


999 


13. 


Adequacy of Information given to you 
about your medical problem by other 
personnel (physician assistants , 
AMOSISTs. nurse clinicians) 


999 


023 


001 


001 


001 


999 


999 


18. 


Continuity of health care provided 
(continued thorough cere) 


272 


001 


012 


005 


001 


999 


078 


17. 


Laboratory services provided by this 
facility 


999 


017 


999 


126 


007 


999 


999 


11 . 


Pharmacy services provided by this 
facility 


999 


023 


167 


012 


021 


999 


134 


19. 


Z-ray services piovlded by this 
facility 


999 


180 


999 


138 


031 


999 


999 


14*— -ltf rating ((antral aatla(actlon) 


133 


001 


001 


003 


001 


999 


17* 



49 



, ~. r .^ 



(e) Analyses across clinics covarying out date. 

Analyzing the separate items across clinics 
revealed significant differences between clinics on 12 of the 19 
items. For items in which there was a significant difference be- 
tween clinics, the Family Practice North Clinic was ranked highest 
in terms of patients’ satisfaction on items 1, 2, 4, and 18; Family 
Practice North Clinic co-ranked highest on items 5 aid 13 (with 
Pediatrics clinic) and co-ranked highest on items 14 and 16 with 
Internal Medicine Clinic. Family Practice Hospital Clinic was ranked 
highest for item 9. Pediatrics was ranked highest on items 7, 8, and 
11. Family Practice North Clinic was ranked lowest in satisfaction 
for item 10. 

2 _ Analyses of the mean responses to item-clusters 
revealed the following significant differences between clinics. For 
the mean-item response, the Interest-cluster, the Adequacy of Informa- 
tion-cluster, and the Ancillary personnel cluster, the Family Practice 
North Clinic was ranked highest. For the Courtesy-cluster and the 
Physician-cluster, the Family Practice North Clinic was tied with 
Pediatrics Clinic for highest ranking. 

(3) Discussion. 

(a) Reliability and validity characteristics. The 
use of a five-point Likert format is a convenient method to allow 
respondents greater discrimination of the intensity of their beliefs 
regarding an issue, without sacrificing reliability (consistency) of 
the scale. 



The reliability of the Patient Satisfaction Survey 
was assessed using a split-half reliability coefficient (r = .967) 
and the amount of variance accounted for in Principal Components 
Factor Analyses of all 19 items (r = .822) and of the 16 items exclud- 
ing ancillary services (r = .806). The actual reliability of the Pa- 
tient Satisfaction Survey falls between .81 and .97, indicating very 
high inter-item consistency. These values exceed the reliabilities 
reported by Huika jst al in their scale for measuring attitudes toward 
physicians and primary medical care. 

The reliability of a scale generally exceeds the 
validity of the instrument, and this was found for the Patient Satis- 
faction Survey. Scale validity was assessed using correlations with 
criterion items. The simple correlation between the mean-item rating 
and item 8 "Quality of health care" was .740. Individual item correla- 
tions with the mean-item rating have a median correlation of .760. 

Both serve as estimates of the internal validity of the scale. 



50 





The reliability and validity determined for the 
Patient Satisfaction Scale are highly acceptable. 

Hulka, Zyzanski, Cassel, and Thompson (1970) used 
the Thurstone Method of Equal Appearing Intervals to develop a scale 
for the measurement of attitudes toward physicians and primary medical 
care. Judges evaluated statements for favorable (or unfavorable) 
attitudes. Three dimensions were determined: personal qualities of 

physicians, professional competence of physicians, and cost/convenience 
of care. Scale items were presented in a dichotomous format (agree - 
disagree) . 

In a follow-up article, Zyzanski, Hulka, and Cassel 
(1974) offered modifications in content, format, and scoring of their 
earlier scale. A Likert method providing a range of five response 
options from strongly agree to strongly disagree was utilized. The 
Likert scale format allowed for greater discrimination of the in- 
tensity of a respondent's belief regarding an issue. The Likert scale 
format produced scores that were consistently more reliable than scores 
computed using the Thurstone method. The split half correlations for 
the three component scales were: .75, .86, and .68. 

Lebow (1974) discussed consumer assessments of the 
quality of medical care. A variety of methodological issues must be 
considered: 1; reliability, the consistency of an instrument over 

repeated administrations; 2) concurrent validity, consensus between 
different measures of satisfaction; 3) reactivity, the extent patients' 
responses reflect their attitudes rather than the demand character- 
istics of the situation (being surveyed); 4) external validity, do 
patients' perceptions accurately reflect care given; 5) criterion ref- 
erence, what absolute measure of quality of care can be used for 
comparison; 6) variability in data, or lack thereof. There is a 
definite need for multi-trait, multi-method comparisons (Campbell and 
Fiske, 1959) to assess satisfaction. 

(b) Overall satisfaction. 

The overall response to all items was in the very 
satisfied direction (judging from the mean-item rating and the item 
clusters). The high level of satisfaction left little room for change 
because of a ceiling (the end-point of the continuum was 5.00). 

The item clusters were intended to help separate 
attitudes toward specific topics (such as toward Physicians in gen- 
eral, or Courtesy of the staff). The item clusters revealed very high 
satisfaction in all areas. 




51 



The only reservation regarding the overall high 
satisfaction echoes the concern expressed by Lebow (1974) regarding 
variability in the data, or lack thereof. In this population, the 
majority of the respondents were satisfied with what was asked about. 
Whether this reflects the consumers' total feelings toward the medi- 
cal care provided can only be guessed. 

(c) Demographic Characteristics. 

Overall, there were no significant differences 
between groups on the items for Education, on all but on item for Sex, 
and all but three items for Race. Women were significantly more dis- 
satisfied by the "Courteous Treatment by Doctors". Chinese-Americans 
and Japanese-Americans were least satisfied by the Doctor's Interest, 
Courteous Treatment, and the Convenience of the operating hours of 
the clinic. Perhaps there may have been some discrimination by the 
physicians toward minority groups (like women). However, the phy- 
sicians' behaviors did not significantly affect the overall level of 
perceived medical care. 

Whether the respondent had an Appointment, the 
Career intentions of the sponsor, the military Grade of the sponsor, 
and the Status of the respondent were all significant determiners of 
patients' attitudes. The significantly more satisfied consumers 
tended to have the following characteristics: Status — retired 

sponsor; military Grade — warrant officer or senior grade (frequent- 
ly officer); careerist; and had an Appointment. However, the amount 
of variance (R^) accounted for by the demographic variables is small 
(less than six percent at best). Differences between groups can be 
more attributable to the large sample size than to the demographic 
characteristics themselves (a large sample can make small differences 
statistically significant, but provide little further information). 

(d) Clinics. 

The Family Practice North Clinic was ranked high- 
est in terms of patients' satisfaction with the medical care provided. 
The physicians' Interest and Courtesy (and the Physician-cluster) and 
the continuity cf health care were reported as most satisfying. The 
only major patient dissatisfaction factor was the location of the 
Horth Ft. Ord Family Practice Clinic. This was surprising in light 
of the fact that the clinic was specifically designed as a 'neighbor- 
hood-based' clinic for the convenience of patients. A partial explana- 
tion for this apparent discrepancy can be found in Section 4h (only 
a portion of the patients came from the nearby housing area, and 
patients at times had to go back and forth to the hospital for special 
x-rays, procedures, consults, and other services not available at the 
North Clinic). 



52 






1 1 
I < 
I * 

! 

I ! 
I 



ii 






K 



t 

■ 



d . The Staff Satisfaction Survey . 

(1) Background and Methodology. One of the questions of 
great interest when the family practice program was conceived was 
whether family practice physicians and staff would be more satisfied 
in the work they were doing than physicians and staff members in other 
medical specialties and clinics. As a means of measuring satisfaction, 
a questionnaire was adapted from the Job Descriptive Index (Smith er al , 
1969). The questionnaire (Appendix H) was administered three times (in 
June and December of 1974., and in May 1975) to six primary care clinics 
at Silas B. Hayes Army Hospital, Fort Ord. The clinics included the 
Acute Minor Illness Clinic (AMIC) , the Emergency Treatment Room (ETR) , 
both Family Practice Clinics (North Clinic and Hospital Clinic), the 
Internal Medicine Clinic (IMC) , the Obstetrics and Gynecology Clinic 
(OB/GYN), and the Pediatric Clinic (PEDS). 

Lists containing the names of every individual in each 
of the clinics to which the questionnaire was administered were given 
to the NCOIC of each clinic. Two envelopes and a questionnaire for 
each individual on the list were also provided; one envelope was blank, 
while the other hai the individual's name on it and contained the Job 
Descriptive Index. Individuals were instructed that when the question- 
naire was completed, they were to seal it in the blank envelope and 
return it to the NCOIC. The NCOIC checked the individual's name off 
the list when questionnaires were returned. The envelopes were collect- 
ed and sent to HCSD, FSHTX, where they were opened and the results tabu- 
lated . 



(2) Findings. Analyses were made of the six satisfaction 
scores across clinics by times admir istered . Separate tests were 
made for physicians , in addition to the overall staf f results. The 
hypothesis being tested was that there were equal treatment effects 
(no difference between cell means). Significant F ratios indicate 
that the treatments differ in their effects upon the criterion vari- 
able, but do not indicate which treatments differ from one another nor 
to what degree they differ. The Scheff e^method of multiple contrasts 
was employed to separate the treatment effects of significant F ratios. 
Table 4d-l summarizes return rates found. 

For the first administration in June 1974, there was a 
significant F ratio for the staff sample for the satisfaction vari- 
able SUPERVISOR (F = 2.49(6/100), p = .027). There were no signifi- 
cant differences between clinic means. For the physician sample, 
there was a significant F ratio for the satisfaction variable FACES 
(F ■ 2.67(6/31), p = .032). There were no significant differences 
between clinic means of physician responses (Tables of results in 
Append ix I ) . 



53 



TABLE 4d-l RETURN RATES BY CLINIC 




Ft Ord Jun 3-7, 1974 Administration 



f_ 


CLINIC 


TOTAL 


RETURNED 


NO RESPONSE 


1 


Obstetric -Gynecology 


20 


18 


2 


2 


Family Practice - North 


15 


15 


0 


3 


Internal Medicine 


15 


13 


2 


4 


r'ed iatrics 


14 


12 


2 


5 


Acute Minor Illness Clinic 


30 


21 


9 


6 


Emergency Room 


26 


12 


14 


7 


Family Practice - Hospital 


19 


16 


3 




Grand Total 


139 


107 


32 




Ft Ord Dec 2-6, 1974 Administration 



#_ 


CLINIC 


TOTAL 


RETURNED 


NO RESPONSE 


1 


Obstetric-Gynecology 


16 


16 


0 


2 


Family Practice - North 


15 


12 


3 


3 


Internal Medicine 


21 


19 


2 


4 


Pediatrics 


12 


10 


2 


5 


Acute Minor Illness Clinic 


27 


25 


2 


6 


Emergency Room 


29 


27 


2 


7 


Family Practice - hospital 


20 


_12_ 


8 




Grand Total 


140 


121 


19 




Ft Ord May 19-23, 


1975 Administration 




t_ 


CLINIC 


TOTAL 


RETURNED 


NO RESPONSE 


1 


Obstetric-Gynecology 


20 


17 


3 


2 


Family Practice - North 


15 


13 


2 


3 


Internal Medicine 


26 


20 


6 


4 


Pediatrics 


15 


10 


5 


5 


Acute Minor Illness Clinic 


24 


19 


5 


6 


Emergency Room 


29 


29 


0 


7 


Family Practice - Hospital 


24 


15 


9 














Grand Total 


153 


123 


30 



i 



54 



Iu the second administration (in December 1974) there 
were significant F ratios for the staff sample for the satisfaction 
variables PAY (F = 2.78(6/110), p = .014) and FACES (F = 3.10(6/113), 
p “ 007). For PAY, the staff responses for Pediatrics were signifi- 
cantly more satisfied (p <.05) than the staff responses from the 
North Clinic. In addition, on FACES the Pediatric staff was more 
satisfied with their job than the staff from Internal Medicine (p <.05). 
There were no significant differences between physician responses in 
the various clinics in the December 1974 sample (Appendix I). 

In the May 1975 sample there were no significant differ- 
ences between s taff responses in the clinics, nor were there between 
physician responses (Appendix I) . 

The responses from all three administrations were 
pooled and tested for interactions between clinic and date-tested. 

For the pooled staff there were significant main effects for PAY 
broken down by clinic (F = 3.706(6/306), p = .002), CO- WORKERS broken 
down by date-tested (F = 4.105(2/306), p = .017), FACES broken down 
by clinic (F » 3.397(6/306), p = .003), and FACES broken down by date- 
tested (F = 4.670(2/306), p = .010). There were n£ significant inter- 
action effects in the pooled staff responses. Simple effects tests 
were performed through one-way ANOVAs. There were significant F ratios 
for: SUPERVISOR by clinics (F = 3.277(6/311) p = .003), though no 

significant differences between clinics; PAY by clinics (F = 3.181 
(6/333), p = .004) in which the PEDS staff was significantly more 
satisfied than the staff of the North Clinic and the ETR (p <.05); CO- 
WORKERS by date-tested (F = 4.649(2/334), p = .010), December 1974 
responses being significantly more satisfied than May 1975 (p <.05); 
FACES by clinics (F = 3.681(6/340), p = .001), PEDS being more satis- 
fied than Internal Medicine (p < . 05) ; and FACES by date tested 
(F = 3.780(2/344), p = .023), December 1974 responses being more 
satisfied than May 1975 responses (p <.05). 

The pooled responses of all physicians were tested for 
interactions between clinic and date-tested. For the pooled phy- 
sicians there were significant main effects for: SUPERVISOR broken 
down by clinics (F - 2.371(6/75), p = .037); PAY broken down by 
clinics (F = 2.571(6/87), p = .024); and PROMOTION broken down by 
clinics (F - 2.390(6/87), p *= .034). There were no significant inter- 
actions found. Simple effects tests were performed through one-way 
ANOVAs. There were significant F ratios for: PAY by clinics (F = 

2.176(6/106), p = .050), though no significant differences between 
clinics; PAY by date-tested (F ■ 3.652(2/110), p = .029) with 
December 1974 being significantly more satisfied than May 1975; 
PROMOTIONS by clinic (F = 2.766(6/102), p = .015), with no signi- 
ficant differences between clinics; and FACES by clinics (F = 2.235 
(6/105), p = .G45), with no significant differences between clinics. 



55 





(3) Discussion of Staff Satisfaction Data. From the 
separate administrations of the Job Descriptive Index, there y;ere 
no consecutively significant differences found between ‘staff or phy- 
sician responses between clinics. In testing the pooled responses 
for possible significant interactions between date-tested (of the three 
administrations) and clinic differences, there were no signif icant 
interactions detected for either staff or for physic ian responses. In 
examining the staff responses, the Pediatric staff was significantly 
more satisfied (p <.05) on the dependent variables PAY and FACES. 

In examining physician responses there appeared 
to be comparable results found between the March 1974 general satis- 
faction levels of varying medical specialties (see Table 4d-2) and 
the JDI results for the three administrations. There were no con- 
secutive significant differences between clinics (or specialties). 

The results suggest that generally the Ft. Ord physicians tested are 
satisfied with their job , but fail to show any greater or lesser 
satisfaction on the part of Family Practice physicians. 



56 



i 



TABLE 4d-2 

GENERAL SATISFACTION LEVELS BY SPECIALTIES OF PHYSICIANS 
AT FT. Oto, CALIFORNIA SURVEYED IN MARCH, 1974 



SPECIALTY MEAN STDDFV N 



1 . 


Radiologists 


2.638 


0.982 


2 


2. 


Preventive Medicine 


2.344 


0.143 


5 


3. 


General Medicine Officers 


2.282 


0.383 


19 


4. 


Internal Medicine 


2.265 


0.383 


lb 


5. 


OB-GYN 


1.907 


0,350 


6 


6. 


Surgeons 


2.775 


0.533 


22 


7. 


Anesthesiologists 


2.367 


0.151 


3 


8. 


Psychiatrists 


2.680 


0.383 


4 


9. 


Pathologists 


2.125 


0.294 


2 


Total Population 


2.402 


0.490 


79 



A 5-polnt Likert scale continuum where (1) equals very satisfied to 
(5) very dissatisfied was used. 




e. The OME Study . 



(1) Methodology. 

Though not originally intended to be a part of the 
study of Family Practice in the Army, the Department of Defense (DOD), 
Department of Health, Education, and Welfare (DHEW) , Office of Manage- 
ment and Budget (OMB) Military Health Care Study (MHCS) proved to be 
a valuable adjunct. (Report of the Military Health Care Study, 

December 1975). yn encounter study similar to that conducted in the 
Family Practice clinics had been planned by the on-site Family Practice 
study group for many of the other primary and specialty clinics at 
Ft. Ord, to begin about mid-1974. The purpose would have been to deter- 
mine the utilization of other medical facilities by Family Practice 
clinic patients. 

The OMB MHCS, however, conducted an Encounter Survey 
between 1 April 1974 and 31 July 1974, in the Northern California 
area, including all of the medical clinics at Ft. Ora. It was felt 
that to then ask. the clinic staffs to collect encounter data for 
the Family Practice study for several additional months would have 
been not only a severe imposition, but might well have resulted in 
inaccurate data. It was therefore decided to request specific data 
that could satisfy the Family Practice study needs, directly from 
the MHCS Office. 

Although the MHCS Encounter Survey (Appendix J) had 
initially included the Social Security Number (SSN) of the military 
or retired sponsor, these SSNs were subsequently purged from the files. 

A new identifying number was given each family, however, so that mul- 
tiple visits by the same family could still be associated. The MHCS 
Office was therefore requested to . . take the block of identi- 
fication numbers of those patients who had visited the North Ft. Ord 
Family Practice Clinic during the period of (your) study, and search 
this list against all other clinics in the immediate area for match 
. . ." They were then asked to ‘either send the individual encounter 
data cr summary statistics. 

(2) Findings. 

Subsequent to the request for encounter data on all 
visits in the Ft. Ord area made by members of the North Ft. Ord 
Family Practice Clinic, a computer tape listing 12,975 encounters 
was received frem the OMB MHCS (more correctly, from the Office for 
the Civilian Health and Medical Program of the Uniformed Services 
(OCHAMPUS), which was handling the automatic data processing (ADP) 
for the OMB MHCS). 



58 



Some 3,984 of the 12,975 visits were made to the North 
Clinic. This compares to 3,956 visits as recorded by this study, 
(see para 4b(2)(a)), a difference of only 0.71 percent. 

From the remaining 8,991, 1,857 can be subtracted as 
having no consequence for the study (Dental, Optometry, Podiatry, 

OT, and PT), as listed in Table 4e-l. 



The. remaining 7,134 (8,991 less 1,857) are listed in 
the succeeding three tables, divided into Primary Care (Table 4e-2), 
Part/Primary/Part Specialty Care (Table 4e-3), and Specialty Care 
(Table 4e-4). Clinics are ranked in order of decreasing frequency 
of visits within each table. 




TABLE 4e-l OMB NONRELEVANT VISITS 



DENTAL (HOSPITAL ONLY) 


307 


OPTOMETRY 


1,218 


PODIATRY 


46 

■ 


OCCUPATIONAL THERAPY 


11 


PHYSICAL THERAPY 


275 


TOTAL 


1,857 



i 



60 




i 



TABLE 4e-2 PRIMARY CARE CLINICS 
(Number of visits by month, 1974) 



CLINIC 


APRIL 


MAY 


JUNE 


JULY 


TOTAL 


EMERGENCY 

ROOM 


219 


203 


156 


178 


756 


TROOP CLINICS 


207 ' 


118 


115 


308 


748 


HOSPITAL FAMILY . 
PRACTICE CLINIC 


224 


146 


118 


51 


539 


ACUTE MINOR 
ILLNESS CLINIC 


ISO 


107 


97 


115 


469 


SUB-TOTAL 


800 


574 


486 


652 


2512 








TABLE Ae-3 PART PRIMARY/PART SPECIALTY CARE CLINICS 
(Number of visits by month, 1974) 




CLINIC 


APRIL 


MAY 


JUNE 


JULY 


PEDIATRICS 


10S 


95 


86 


' 48 


CYNECOLOCY 


75 


55 


41 


20 


OBSTETRICS 


• 

53 


36 


37 


30 


INTERNAL 

MEDICINE 


43 


42 


20 


22 


SUB-TOTAL 


276 


228 


184 


120 







TABIfE 4e-4 SPECIALTY CARE CLINICS 
(Number of visits by month, 1974) 



CLINIC 


APRIL 


MAY 


JUNE 


JULY 




ALLERGY 


302 


279 


209 


217 


1,007 


ORTHOPEDICS 


98 


112 


93 


85 


390 


IMMUNIZATION 


85 


102 


96 


81 


364 . 


PHYSICAL EXAM 
ROOM 


102 


103 


* 61 


75 


341 


DERMAT0L0CY 


78 


88 


33 


27 


226 


UROLOCY 


34 


i ” 


70 


44 


225 


OTOLARYNGOLOGY 


99 


46 


38 


32 


213 


PSYCHIATRY 


110 


31 


6 


27 


194 


GENERAL SURGERY 


59 


40 


31 


33 


163 


OPHTHALMOLOGY 


75 


24 


.23 


34 


158 


OCCUPATIONAL . 
HEALTH 


19 


35 


31 


20 


105 


OTHER CLINICS* 


172 


84 


93 


77 


426 


SUB-TOTAL 


1,253 


1,021 


788 


732 


3,814 


TOTAL FOR ALL 
CLINICS EXCEPT 
PAM. PRAC. 


2,329 


1,823 


1,438 


1,524 


7,134 



* - There were 22 other specialty clinics , which had less than 
100 visits each during the four month period. 








In Aummany, ^nom 1 kpnil thnu 31 July 1974, the iarne 
1 family practice patient panel membeu Mho made 3,9S4 vlilti to the Month 

Clinic alt>o made 7,134 vl&tt i to othen medical cllnloi. This data is 
summarized below ir\ Table 4e-5. 

. 

TABLE 4e-5 CLINIC SUMMARY DATA 



CLINIC 


APRIL 


MAY 


JUNE 


JULY 


TOTALS 


NORTH FORI ORD FAMILY PRACTICE 


1,233 


996 


783 


972 


3,984 


OTHER PRIMARY CARE (ETR, TROOP 
CLINICS, HOSPITAL FAMILY PRACTICE, 
AMIC) 


800 


574 


486 


652 


2,312 


PART PRIMARY/PART SPECIALTY CLINICS 
(BIT MED, OB, C», FEDS) 


276 


228 


184 


120 


808 


ALL OTHER SPECIALTY CLINICS 


1,233 


1,021 


788 


732 


3,814 


TOTAL VISITS BY THIS CROUP OF PATIENTS 
TO ALL CLINICS, APRIL - JULY 1974* 


3,362 


2,819 


2,241 


2 r 496 


11,118 



* - Not counting Dental, Optometry, Podiatry, OT or PT. 






(3) Discussion of the OMB MHCS Data. 





When the data received from the OMB MHCS was compared 
with the encounter data obtained from this study, the number of visits 
to the North Clinic during the four months of the MHCS, April thru 
July 1974, matched very closely (3,984 visits according to MHCS, 

3,956 from Family Practice Models encounter data). For this reason, 
as well as the overall quality of this high level study, it is reason- 
able to accept the veracity of the OMB data. The data is quite sur- 
prising, however, as it does not confirm earlier thinking or reports 
of utilization of other primary and specialty clinics by family 
practice patients. 

There has been a general feeling that the family 
practitioner takes care of 80 to 90 plus percent of his patients' 
problems. In a thesis based on data from the North Clinic outpatient 
chart review, it was concluded that "... the Family Practice Clinic 
is providing 94 percent of the care required by members who come into 
the clinic, and 72.5 percent of the care required by the total member- 
ship." (Perry, 1975). 

These conclusions are not substantiated by the OMB MHCS 
data, which show that, during the four month period of the study, only 
about 36 percent of this group of patients' visits were actually made 
to the North Clinic. Even if visits to the Hospital Clinic are in- 
cluded (some were evening or weekend visits), and visits to the 
Immunization Clinic are excluded, the total is raised to only about 
42 percent. ( Monthly Vital Statistics for July 14, 1975 reported 
that 40.4 percent of all office visits were made to general and family 
practitioners (Monthly Vital Statistics, July 14, 1975)). 

Fir3t of all, why does the OMB data suggest conclusions 
so significantly different from Perry's conclusions? Assuming that 
both the OMB MHCS data and Perry's data are accurate, the only explana- 
tion is that significant numbers of clinic visits did not get recorded 
in the patient's chart. This explanation is reasonable in light of 
the fact that North Clinic patient's charts are kept at the North Clinic , 
some two and a half miles from the hospital (and therefore from the 
other clinics), and that the records room at the North Clinic had no 
attendant outside of normal duty hours, making it inconvenient and 
difficult for a patient to obtain records to carry to other clinics. 





! 




i 



gain access to at the time. It is quite likely that, at times, they 
preferred not to be recognized as family practice panel members, but 
rather to gain the best of both worlds. It is likely therefore, 
that although the data from the two sources appears contradictory, 
it is not incompatible. 

There are many other interesting items in the data. 

Visits to the Troop Clinics by the sponsor numbered 748 during the 
four months, which would extrapolate to roughly 2244 for the year. 

Sponsor visits to the North Clinic in 1974 numbered 2757. (This 
latter included visits by retired sponsors; the Troop Clinic data 
are for active duty sponsors only). The active duty sponsor, then, 
visited the Troop Clinics more often than he did the North Clinic. 

Visits to the Troop Clinics were appropriate, as the 
sponsor had free access to both clinics (though he needed an appoint- 
ment at the North Clinic). Also a part of the visits to the Hospital 
Clinic were appropriate for North Clinic patients, as they were prob- 
ably evening or weekend visits in many cases. However, family prac- 
tice panel members were instructed that their care outside of duty 
hours would also be by the family practice doctors, all of whom 
rotated on call. Some of the visits to the Emergency Treatment 
Room (ETR) may have been seen by the family practice physician on 
call; however, all other visits to the ETR and to the Acute Minor 
Illness Clinic (AMIC) would have to be considered 'inappropriate' 

visits. | 

It is difficult to explain the large number of 'in- 
appropriate' visits during the four month period, except that the 
family practice physician was required to come in only for walk-ins 
with life threatening problems. If a patient called-in and talked 
to the family practice physician on call, as the system was sup- 
pose to work, and was told tb.-.t the problem was not serious and 
could await the morrow, he might well walk-in to the ETP or AMIC 
for more immediate care. After becoming aware of the family 
practice physicians' policy of coming in only for walk-ins with 
life threatening problems, the family practice walk-ins to the ETR 
or AMIC were treated and the family practice on-call physician was 
not notified unless ETR or AMIC personnel felt that the illness was 
serious enough to warrant family practice notification. This point 
should be remembered when discussing continuity of care. 

Many of the visits to the Part Primary/Part Specialty 
Clinics also appear to have been inappropriate, that is, not direct 
referrals from the North Clinic, but more likely patients seeking 
primary care that could have been provided by North Clinic physicians. 






66 




For instance, encounter data from the North Clinic listed only 21 
referrals to Pediatrics in 1974; the OMB MHCS data, however, showed 
334 visits by family practice patients to Pediatrics in four months. 
If a consult to Peds, on the average, results in about six visits, 
as determined earlier (Appendix K) , 21 consults would result in 

only about 126 visits during the year, whereas the OMB MHCS four 
month data would extrapolate to about 1,002. Only about 13 percent 
then (126/1,002) of Peds visits by North Clinic patients resulted 
from referrals from family practice. 

Similar low percents were found for other clinics in 
this group. It is apparent that family practice patients are using 
the primary care potential of these clinics, without being referred 
by their family practice physician. Whether this utilization is due 
to the long wait for appointments at the North Clinic, or to a desire 
to see a "specialist" is not clear. It is again apparent, however, 
that the patients use ("shop around for") the best of both systems. 

The discrepancy between referrals, corrected by the 
estimated number of visits per referral, ard the number of visits 
actually recorded by the OMB MHCS to the Specialty Clinics, though 
not as great as that demonstrated by the Primary and Part Primary/ 
Part Specialty Clinics, again showed that family practice patients 
were either being referred from other sources, or were somehow gain- 
ing direct access to the Specialty Clinics. Using the same means of 
calculation as above, 43 percent of Orthopedic visits by North Clinic 
patients were on referral from their physician ((101 X 5)/l,170), and 
38 percent of Dermatology visits by North Clinic patients were on 
referral from their family physician ((65 X 4)/678). 




The CHAMPUS Stud} 



(1) Methodology. 



In order to determine total health care utilization of 
family practice panel families, 0CHAMPUS (Office for the Civilian 
Health and Medical Program of the Uniformed Services) was asked to 
provide information on visits, hospital days, and costs, on a block 
of family practice patients. It was felt that the amount of CHAMPUS 
utilization might also reflect the patient's dissatisfaction with 
the military healch care delivery system. Consequently data for 1972 
and 1974 were requested. During 1972, the patients did not have 
access to a family practice clinic, whereas during 1974 they were 
all members of such a clinic. A gap was left between the two periods 
because of the long delays in compiling statistical CHAMPUS reports, 
and because of the staggered start of families in the family practice 
clinic in 1973. 







67 



Specifically, the Roster (see para 4b (o)) was searched 
for families shown to be members throughout 1974 by having at least 
one visit prior to January 1974 AND at least one visit after De- 
cember 1974. A further qualification was that the sponsor was on 
active duty or recired in 1972 (i.e., did not come on active duty in 
the interim). 



As a result of this search, 232 active duty families 
and 169 retired/deceased sponsor families were found to fulfill these 
criteria. The SSNs of the sponsors were sent to OCHAMPUS for search 
against their files. 

(2) Findings. 

Of the 232 active duty families, 87 had one or more 
CHAMPUS encounters during the two years; however, 30 of these en- 
counters wera for dental services. Dental CHAMPUS is not germane to 
this study, and is not reported here. In all, tin, 24.5 percent 
(57/232) of families were shown to have some CHAMPUS medical contact 
during the two years studied. 

Breakdown by year showed 36 families with one or more 
encounters in 1972 (15.5 percent (36/232); 27 had encounters in 1972 
only and 9 had encounters both years). Some 30 families had encounters 
in 1974 (12.9 percent (30/232); 21 in 1974 only and 9 both years). 

Similarly, of the 169 retired/deceased sponsor families, 
48 had one or more CHAMPUS encounters. Three of these were dental 
only. Thereiore ; 26.6 percent (45/169) of retired/deceased sponsor 
families had some CHAMPUS medical contact during the. two years. 

Breakdown by year showed 32 families with one or more 
encounters in 1972 (18.9 percent (32/169); 17 had encounters in 1972 
only and 15 had encounters both years. Some 28 families had encounters 
in 1974 (16.6 percent (28/169); 13 in 1974 only and 15 both years). 

This data includes three families which were on active duty in the 
Ft. Ord area in 1972 and retired in the area in 1974. 

Table 4f-l gives more detail on the active duty 
families' utilization of CHAMPUS, including the number of outpatient 
visits, the number of hospital days, and costs to the government. 

Though all the families obviously lived in the Ft. Ord area in 1974, 
as they were all members of the North Clinic, some 24 of them had 
CHAMPUS visits reports in other areas of the country in 1972, so 
their 1972 location is listed as unknown. Similar information is 
given in Table 4f-2 for the retired/deceased sponsor families; they 
were all in the Ft. Ord area both years. 



68 




TABLE 4f-l 


UTILIZATION 


OF CHAMPUS 


BY ACTIVE 


DUTY FAMILIES. 






1972 








NUMBER OF 

families 


OUTPATIENT 

VISITS 


HOSPITAL 

DAYS 


COST TO 
GOVERNMENT 


FORT ORD 
AREA 


12 


154 


379 


$16,252.02 


LOCATION 

UNKNOWN 


24 


59 


99 


$17,145.18 


TOTAL 


36 


213 


478 


$33,397.20 






1974 






TOTAL 


30 


182 


648 


$35,087.96 








I 

i 



TABLE 4f-2 UTILIZATION OF CHAMFUS BY RETIRED/DECEASED SPONSOR FAMILIES 







1972 




NUMBER OF 
FAMILIES 


OUTPATIENT 

VISITS 


HOSPITAL 

DAYS 


COST TO 
GOVERNMENT 


32 


295 


210 


$16,326.96 






1974 




28 


185 


109 


$18,310.14 




(3) Discussion of CHAMPUS Data. 

The size of the CHAMPUS sample is too small to allow 
conclusions to be drawn from changes in utilization over the two 
years. This is particularly true since one family in the active 
duty sample accounted for 77 percent of hospital days in 1972, 47 per- 
cent in 1974, and over 30 percent of all costs in both years. It can 
be seen, then, that one family with very high medical utilization can 
significantly influence the totals in a sample of this size. 

In the active duty sample, visits dropped slightly 
from 213 to 182 between 1972 and 1974, whereas hospital days and costs 
increased. (Costs are not adjusted for inflation). The average num- 
ber of CHAMPUS outpatient visits per year per family over a two year 
period was 0.85 (198/232), or about 0.28 per person (four person family 
less active duty member). 

In the retired /deceased sponsor sample, CHAMPUS out- 
patient visits dropped by 37 percent, hospital days dropped by 48 per- 
cent, and costs to the government increased 12 percent. This may well 
show decreased utilization of CHAMPUS by the retired family practice 
family, although again the sample is too small to give the figures 
much weight. The average number of visits per year per family in 
this sample was 1.42 over the two year period (240/169), or about 
0.41 per person (three and a half person family). 

in sum, about 15 percent of family practice families 
use some CHAMPUS for their medical care, including both those services 
not provided by the Army and just as a matter of preference. Utiliza- 
tion per person, however, is very low for this population, during the 
year prior to availability of family practice care as well as during 
the year that they were members of a family practice clinic, and 
accounts for only about 0.25 to 0.5 visits per person per year. 



71 






t 





g. Costs pei Clinic Visit . 

In order to relate cost data with patient workload, the mathe- 
matical relationships for the following costs were developed and calcu- 
lated from the data obtained during FY 74. 

o Average cost per Family Practice visit. 

o Average cost per general and specialty clinic visit. 

o X-ray, pharmacy, and lab costs per Family Practice visit. 

Ideally, these costs would be computed on the basis of actual 
expenses incurred during the year under study; however, accurate esti- 
mates of such information for FY 74 were not available. A number of 
alternate approaches were considered and the chosen alternate approach 
consisted of obtaining cost figures for FY 75 and then applying them 
against workload data for FY 74, FY 75, and the first half of FY 76. 
This procedure was based on the premise that such an approach would 
yield more realistic cost comparisons between average cost per patient 
visit for FY /4, 75, and 76 by eliminating any unusual or one time set- 
up costs normally associated with the establishment of a new clinic. 
Thus, under this procedure, the cost data for FY 75 could be used as 
the base year data in developing cost comparisons between FY 74, 75, 
and 76. Employing this concept, data pertaining to personnel costs 
(MPA), supply costs (OMA) , and patient workload data were obtained 
for each clinic at Ft. Ord. This data is given in Appendix L, en- 
titled "Cost Summary Format". MPA costs, adjusted MPA costs, OMA 
costs, patient workloads, and average cost per clinic visit are given 
for First Half of FY 75, Second Half of FY 75, and First Half of FY 76. 

The basis for developing the outpatient cost comparison 
hinged on identifying those costs that are directly attributable to 
the outpatient clinics themselves, both primary and specialty. As 
a result, MPA costs were adjusted to reflect only that portio” of 
expenses that were charged to the outpatient areas. The average cost 
per visit for each clinic was then calculated using the following 
equation: 

OMA costs + Adjusted MPA costs 
Average cost per visit = Clinic Workload 

The average cost per clinic visit for each clinic is given in the 
last columns of the tables in Appendix L, and has been furnished in 
rank order in Tables 4g-l thru 4g-3. The clinics have been arranged 
in descending order by dollar cost per clinic visit. 

The MF.DDAC, Ft. Ord, also provided figures on dollar costs 
for lab and x-ray support attributable to the North Clinic and the 
Hospital Clinic. They stated that these supportive costs were not 



■a 



- 3 



72 



excessive and compared favorably with all other clinics at Ft. Ord. 
Since no comparison figures were obtained, the data is not presented 
here. 

It is apparent that the costs per clinic visit at the North 
Clinic were high when compared with Internal Medicine, Pediatrics, 
and OB-GYN. The Hospital Family Practice Clinic costs per clinic 
visit were also consistently less than those at the North Clinic. 



73 



r 



TABLE 4g-l 



RANK 


RANK ORDER OF CLINICS 
BY AVERAGE COST PER VISIT 
(1st & 2d Qtr, FY 75) 

CLINIC 


AVERAGE COST 


1 


Nuclear Medicine 


$39.35 


2 


General Surgery 


22.77 


3 


Social Work. 


15.22 


4 


Emergercy Medical Services 


14.85 


5 


Cardiology 


13.44 


6 


Urology 


12.42 


7 


Neurology 


11.91 


g **** 


North Ft Ord Family Practice Clinic 


11.26 


9 


Hospital Family Practice 


9.67 


XO 


Allergy 


8.56 


11 


MedicaJ Exam 


7.88 


12 


ENT 0 OPTH 


7.60 


13 


Orthopedic 


6.69 


14 


Podiatry 


6.68 


15 


Internal Medicine 


6.40 


16 


Occupationel Therapy 


6.05 


17 


Acute Minor Illness 


5.96 


18 


Physical Therapy 


5.38 


19 


OB-CYN 


5.18 


20 


Pediatric 


4.81 


21 


Dermatology 


3.53 


22 


Optometry ■ 


3.44 




TABLE 4g-2 



RANK 


RANK ORDER OF CLINICS 
BY AVERAGE COST PER VISIT 
(3d & 4th Qtr, FY 75) 

CLINIC 


AVERAGE COST 


1 


Social Work 


$47.94 


2 


Nuclear Medicine 


32.55 


3 


Emergency Medical Service 


20.64 


4 **** 


North Ft Ord Family Practice Clinic 


.14.99 


5 


Neurology 


14.01 


6 


Cardiology ’ 


12.83 


7 


Urology 


11.54 


8 


General Surgery 


11.01 


9 


Allergy 


10.81 


10 


Hospital Family Practice 


9.73 


11 


ENT 


9.65 


12 


Acute Minor Illness 


7.22 


13 


Orthopedic 


6.73 


14 


Pediatric 


6.49 


15 


OB-GYN 


6.15 


16 


Internal Medicine 


6.12 


17 


Occupational Therapy 


5.20 


18 


Medical Exam 


5 .20 


19 


Physical Therapy 


4.86 


20 


Podiatry 


4.76 


21 


Dermatology 


3.93 



AVERAGE COST PER CLINIC VISIT AT FT ORD - $10.26 



75 



r 



TABLE 4g-3 



RANK 


RANK ORDER OF CLINICS 
BY AVERAGE COST PER VISIT 
(1st & 2d Qtr, FY 76) 

CLINIC 


AVERAGE COST 


1 


Nucleat Medicine 


$42.78 


2 


Social Work 


28.19 


3 


Neurology 


13.05 


4 


Urology 


12.49 


5 


Allergy 


12.31 


6 


Medical Exam 


12.21 


7 **** 


North Ft Ord Family Practice Clinic 


11,97 


8 


ENT 


11.56 


9 


Emergency Medical Service 


10.14 


10 


General Surgery 


9.25 


11 


Acute Minor Illness 


7.94 


12 


Orthopedic 


7.08 


13 


Internal Medicine 


6.75 


14 


Dermatology 


6.68 


15 


Pediatric 


5.79 


16 


Cardiology 


5.67 


17 


Occupational Therapy 


5.29 


18 


Hospital Family Practice 


5.44 


19 


Physical Therapy 


4.96 


20 


Podiatry 


4.92 


21 


OR-GYN 


4.89 




76 



h. The Transportation Study . 



(1) Methodology. 

One of the objectives of the study was to look at the 
advantages and disadvantages of a neighborhood-based clinic as com- 
pared to a hospital-based clinic. The North Clinic was established 
on the premise that a clinic located near family housing areas would 
offer convenience advantages to those families living in the con- 
tiguous area. By convenience was meant primarily ease of physical 
access to the clinic. 

To test one element of this convenience, a study was 
done on how patients arrived at the clinic, i.e., whether they walked, 
drove, took a taxi, and so forth. A simple form was designed which 
required only the date and answers to two questions, (1) Do you 
live in Patton Park?, and (2) How did you get to the clinic today? 
(Patton Park is the base housing area nearest the clinic) . 

A short trial of having the patient fill out the form 
did not prove successful. Therefore, the receptionist dated the 
form and clipped it to the patient's chart; then the nurse or dis- 
pensary attendant, who screened the patient asked the two questions, 
marked the responses, and collected the sheets. The study was con- 
ducted for four weeks in May 1975. 

(2) Findings. During May 1975, 870 patients were surveyed 
on whether they lived in Patton Park and how they got to the clinic. 
The responses are tabulated below in TABLE 4h-l. 



77 



TABLE 4h-l 



TRANSPORTATION DATA 





MEANS OF GETTINC TO THE CLINIC 


1 






HOW DID YOU 


GET TO THE CLINIC? j 


DO YOU 
PATTON 


LIVE IN 
PARK? 


DROVE 


RODE WITH 
A FRIEND 


BUS, TAXI, 
OR WALKED 


YES - 


168 


149 


7 


12 


NO - 


702 


671 


21 


10 


TOTAL 

RESPONSES 


870 


820(942) 


28(3.222) 


22(2.532) 



(3) Discussion of Transportation Data. 

As could be expected, only a very small proportion of 
patients came to the clinic by means other than private automobile. 

In fact, less than three percent of patients arrived by other means. 

The only gain, then, to those living near-by the North Clinic was not 
having to drive the additional two and a half miles to the hospital. 

The majority of patients, moreover, did not live in the 
adjoining housing area. Many of the on-post quarters are closer to 
the hospital than they are to the North Clinic. Also, the retirees 
who came from off -post often came in a gate closer to the hospital 
than to the Ncrth Clinic. The hospital was also closer to the PX, 
Commissary, and Service Station. The mere location of the clinic, 
then, offered almost no advantage over a location within the hospital. 

Although the hospital parking lot appears quite adequate, 
parking at the North Clinic was superb and very close to the entrance, 
so to this extent there was a slight convenience advantage over the 
hospital clinics. 

i. Evaluation of Co-located X-ray, Lab, and Pnarmacy . 

The North Clinic, isolated some two and a half miles from the 
hospital, installed on-5iite X-ray, laboratory, and pharmacy services. 




There is little question of the value of having such services avail- 
able locally. For purposes of this study, evaluation revolved pri- 
marily around productivity. 

(1) X-ray. 



Encounter data on X-rays ordered. Table 4b-14, shows 
that 993 X-rays were ordered during 1974 by the North Clinic doctors 
(average of four doctors). An evaluation of the types of X-rays 
ordered reveals that up to 90 percent could be taken and processed 
locally. Even if all were taken and processed locally, there would 
be only about 83 per month or four per clinic day. The Staffing Guide 
for US Army medical department activities, DA Pamphlet 570-557, in- 
dicates that one X-ray specialist can process up to 4,000 examinations 
per month. It appears, then, that the technician could be used more 
efficiently in a larger operation. 

In addition to the technician, equipment is a major 
expense in X-ray. A room had to be lead-lined, and additional 
supports had to be installed to strengthen the ceiling, for support 
of the overhead unit. The radiographic unit, transformer, collimator, 
table, and automatic film processing machine, and the small ancillary 
equipment, cost in excess of $60,000. The equipment, though capable 
of 24 hour operation, was used only during the day shift, five days 
a week, as the clinic was not open at other times. The equipment, 
then, was utilized less than 25 percent of its available time. 

(2) Laboratory. 

Observation of and by the laboratory technician re- 
vealed that he performed between 500 and 900 procedures a month, 
including those that he collected but did not process. This is com- 
patible with figures obtained in the Encounter Study, as listed in 
Table 4b-17. The 10,258 lab tests ordered in 1974 would average 855 
per month. A large proportion of them required specialized equipment 
for processing and could not be done locally, so that at times the 
technician merely collected the sample and then had to transport it 
to the hospital laboratory. 

According to standard workload data from DA Pamphlet 
570-557, 3,200 lab procedures a month are required to justify one 
lab technician. Again it is apparent that the technician could be 
more efficiently utilized in a larger operation. 

(3) Pharmacy. 



79 





Whereas in X-ray and the lab, the technician was not 
able to perform all the various tests ordered, the situation was 
somewhat the reverse in the pharmacy. The pharmacist filled more 
prescriptions than those written by the North Clinic doctors. He 
filled refills; other clinics in the area sent patients to the North 
Clinic pharmacy; and some patients from the hopsital clinics used its 
services in order to receive faster service than could generally be 
obtained at the hospital pharmacy. 



Table 4b-10 reveals that about 1,000 prescriptions were 
ordered per month by the North Clinic Physicians. The pharmacist 
kept a tally sheet for several weeks which revealed that he filled 
approximately twice that number, including refills and prescriptions 
from other clinics. He also counselled patients regarding drug mat- 
ters. Except for the fact that he had to make frequent trips to the 
hospital pharmacy to pick up supplies, the North Clinic pharmacist 
appears to have been well utilized. 



Neighborhood-Based Clinic : Advantages/Disadvantages. 



At the 1971 Seminar on Ambulatory Health Services held at 
Ft. Sam Houston, Texas (Proceedings of the Seminar, 1971), one ques- 
tion posed to the committees was "Should troop clinics be centralized 
or decentralized?" The Command Control Subcommittee answered that 
centralization is preferable, because ". . . of the obvious resultant 
concentration of personnel and equipment, thereby maximizing utiliza- 
tion of the services performed while reducing the costs that result 
from fragmentation". They went on to state, however, that decentral- 
ization is often made necessary ". . . when support must be provided 
to a widely dispersed population . . .", especially in a training base 
environment where clinics need to be within easy walking distance of 
the population served. 



Though not so specifically asked, the Emergency Room and 
Family Practice Subcommittee volunteered that "... decentralized 
neighborhood clinics staffed by family physicians is the ideal in 
those installations where it is applicable and where financing of 
additional separate facilities is available". One of the purposes 
of the present study was to evaluate the advantages and disadvantages 
of the neighborhood-based clinic concept. 



Throughout the period of the study, the advantages of the 
neighborhood-based clinic have been diligently sought-after — with 
little success. Most desirable characteristics appear to be avail- 
able in more abundance in a clinic within or adjacent-to a hospital, 
and most undesirable characteristics appear less a problem in the 
centralized setting. 










i 



80 



r 




. 



r 




> 



(1) Advantages. 

(a) Patients could park closer to the clinic entrance 
than was often the case at the hospital. 

(b) For those patients whose X-ray, lab work, or pre- 
scriptions were available at the North Clinic, the wait was usually 
less than at the corresponding service at the hospital. 

(c) The staff was able to function more autonomously 
and independently. 

(2) Disadvantages. 

(a) Those patients whose X-ray, lab, or prescriptions 
were not available at the North Clinic had to make an additional trip 
to the hospital. 

(b) Patient records, kept at the North Clinic, were 
relatively unavailable at night (the physician had to get the key and 
go get them or send for them) , 

(c) When an OB patient went into labor, the record 
had to be obtained from the North Clinic Record Room during the day. 
Each evening, the OB records had to be taken to Labor and Delivery, 
and each morning they had to be returned to the North Clinic. 

(d) Costs per clinic visit at the North Clinic were 
higher for each six month period of the 18 months studied, than at 
the Hospital Clinic. 

(e) Co-located X-ray was not cost effective. 

(f) Co-located lab was not cost effective. 

(g) The pharmacist, unable to maintain a complete 
drug inventory, had to make frequent trips to the hospital pharmacy 
for supplies. 



(h) For the physicians, there was no availability of 
"hallway consultation" with other specialists. 

(i) No immediate radiological consultation was avail- 
able. 

(j ) Isolation made it difficult for physicians to 
check inpatients during the clinic day. 



81 



(k) Isolation resulted in decreased personal contact 
of family practice physicians with other physicians at the hospital. 



(l) More time was lost from clinic hours for hospital 
staff meetings because of the time required to get back and forth. 
Lunch hours had to be 1 1/2 hours, to accommodate noon meetings. 

(m) Physical surroundings at the clinic were less 
attractive than at the hospital. 

(n) The clinic was less convenient than the hospital 
for retirees and for many in on-post housing. (The hospital was 
nearer the PX, Commissary, and Service Station) . 

There is little question that the disadvantages heavily 
outweigh the advantages. In those cases where a hospital is avail- 
able nearby with adequate clinic space, there appears to be little 
justification for the establishment of a neighborhood-based clinic. 

k. Patient Panel System . 

(1) Advantages/Disadvantages. 

Family practice, in its present configuration, is a 
relatively new specialty. Many of the present practice methods are 
based on assumptions, rather than on hard evidence of effectiveness. 
Such may be the case with the assignment of patients as a panel to 
individual family practitioners. It has been assumed that this is 
necessary t:o insure that the practitioner does not get overburdened 
with patient workload to the point that he loses proper time and re- 
lationship with patients. It was further assumed that the panel was 
essential for the continuity of care and for familiarity with the pa- 
tient and family. However, it is time to take a much closer lock at 
these supposed advantages. 

Selection of a patient panel is not accomplished with- 
out some difficulty. Unless there are enough family practitioners 
to care for all eligible patients (a condition not likely to occur 
in the near future), only some patients will be able to receive 
family practice care. When the clinic panels are full, waiting lists 
must be established for those wishing to join. Since the active duty 
population is mobile, excessive time on the waiting list decreases 
the time under the (continuous) care of one family practitioner. If 
only one list is kept for both active duty and retired families, the 
clinic population will eventually become entirely retired families, 
since the retired families can wait almost indefinitely and the active 
duty families will be moved. If separate lists are maintained, as 



82 



was done at Ft. Ord, with the proportion of active duty to retired 
families in the clinic arbitrarily maintained at a constant level, 
then the retired list will hardly move at all, once the panels are 
full, as the retirees are much more permanent in the area. A new 
retiree moving to the area and signing up for the clinic might have 
to wait literally years before acceptance. Even maintaining the two 
lists causes problems, as when an active duty family, known to have 
arrived and signed-up later than a retired neighbor, is accepted 
earlier. 



Control of the patient panel, once established, is 
also difficult. A manual system, using file cards, is cumbersome 
though necessary where automation is not available. Automation, 
on the other hand, required a significant amount of keypunch and 
computer time. The most frustrating problems are independent of 
whether a manual or automated system is used. These include cases 
where, even though patients are requested to report to the clinic 
before leaving the area in order to pick up their medical records, 
they often do not. Others just quit the clinic without notification. 
It is relatively impossible to determine with any certainty the exact 
number of families in a panel at any particular time. Some of the 
departed families were determined at Ft. Ord by checking through the 
entire post ETS/PCS roster, each month, for family practice panel 
families. Since the number leaving is very high compared to the 
numbers in family practice, this procedure is time consuming even 
with the aid of the computer. 

Family panel slots cannot be refilled if there is no 
indication that the family has ceased coming to the clinic. To re- 
place families that are known to have left the panel, as they leave, 
requires more administrative time than to do so by blocks; however, 
block refills ’-esults in more erratic panel sizes over time. 

Thece is also the problem that some families wish to 
change doctors after they are enrolled in a panel. This was dis- 
couraged at the North Clinic. However, as rapport between patient 
and physician plays an important role in a family practice clinic, 
some switching may well be desirable. It again, however, increases 
the administrative burden. 

The panel system was devised, among other reasons, as 
a means of keeping the number of clinic visits down to a manageable 
figure, i.e., to avoid the 80 patients/day situation of the old GP. 

It becomes readily apparent, however, that neither the existence of 
a fixed panel nor Its size is a controlling factor on the number of 
patient visits per day to a particular physician. Such would only 
be the case if the demand for services were no greater than the 



83 



AD-A034 958 
UNCLASSIFIED 



ACADEMY OF HEALTH SCIENCES (ARMY) FORT SAM HOUSTON TE--ETC F/G 6/5 
FAMILY PRACTICE MODELS FOR AN ARMY COMMUNITY - A DEMONSTRATION —ETC(U) 
JUL 76 D F 6ERSTENBERGER » T B ESCHEN 

HCSD-76-008 NL 



2 



! 



f 



1 




day-to-day supply. As it is, the only controlling factors are: (1) 

the number of appointments made; (2) the number of walk-ins accepted; 
and (3) the number of no-shows. This is, of course, given that the 
physician is available during the appointment hours. The existence 
of a panel and its size would only control the number of daily visits 
if all patients who needed and/or wanted to be seen were seen on the 
desired day. 



One of the other, perhaps more important, reasons for 
using the panel system is so that a physician can get to know his panel 
of patients, their families, and their problems. It is highly con- 
jectural, however, that a physician can r get to know' the members of, 
relationships between, and problems of some 300 to 600 or 800 families, 
during his period of overlap with them at a duty station they each 
inhabit for a limited time. 

For patients to 'know they have a doctor' :’.s another of 
the theoretical advantages of the panel system. However, it seems to 
lose much of Its value when (1) the waiting time for appointments is 
very long; (2) the doctor shares night call with many others (up to 
14 at Ft. Ord); and (3) after hours, only patients with "life threaten- 
ing emergencies" are seen. 

Unless family practice services can be offered to all 
military health care eligible beneficiaries in the area, discrimination 
would result. It can be seen from the 0MB MHCS cited previously that 
patients who are members of the family practice clinic do not limit 
their visits to this clinic, but in fact only make about 42 percent of 
their visits there. Family practice becomes an additional point of 
access to health care that is open to some and not to others. 




The amount of administrative time required by the panel 
system was mentioned earlier. At Ft. Ord it was determined to require 
in excess of 72 hours per month just to maintain the panels. A list 
of administrative functions necessary to maintain the panels, and 
the time required, is given in Table 4k-l. 









■! 







TABLE 4k-l 

ADMINISTRATIVE FUNCTIONS PERFORMED FOR THE FAMILY PRACTICE CLINICS 
BY THE HCSD TEAM AT FT ORD 



CONTINUOUS SERVICES 



HOURS PER MONTH 



A. Collect and file applications 

B. Keep distribution areas supplied with 
application forms 

C. Keep current file of applicants by date 
of application (type cards and assign 
sequence numbers) 

D. Answer phene calls from applicants 
concerning status 

E. Supply clinic with encounter forms, and 
collect, separate, and file them 

F. Update card file from ETS/PCS roster 



PERIODIC SERVICES 

A. Type, reproduce, and collate application forms 

B. Maintain random MD list for assignment of 
patients 

C. Re-allocation of patients on transfer of MD 



occurrence 



D. Patient acceptance procedures 



7.5 hrs 
per block 
of patients 



E. Update Information on patients assigned 
each MD 



occurrence 



Control of the panels, then, requires over one-half of 
all the time of an administrative assistant, and even then, the con- 
trol is far from perfect. It appears that, in spite of the fact that 
the panel system has been considered necessary for family practice, 
it is fraught with problems that tend to negate its values, and as 
well is a costly system to maintain. 



Patient Panel Size. 



In spite of all the above disadvantages of the panel 
system, it may be elected to continue with this system. If this is 
done, what is the appropriate panel size? At Ft. Ord, approximately 
325 families were assigned to each family physician. Ft. Sill, 

Oklahoma was aiming at approximately 600 families. The Navy announced 
that at the Navy hospital at Millington, Tennessee, ,: Each practitioner 
will provide continuous care for about 400 Navy families, but eventually 
will care for up to 800 families. (US Med, Mar 1, 1975). 

Where do these numbers come from? Are they as arbitrary 
as they appear? Probably not quite: they are based on estimates of 

utilization, length of average visit, working hours, and assumptions 
that panel members will get most of their primary care at the family 
practice clinic, and so forth. 

From the previous section it can be readily seen that 
the panel size itself controls nothing, but only influences the length 
of the waiting list for appointments. The waiting time in turn in- 
fluences the utilization of both the family practice clinic and other 
clinics where access may be easier or faster. 

It has already been stated that the study team was not 
permitted to manipulate the size of individual physician panels in 
order to study other characteristics. Also, almost all family practice 
clinics have 'cut-offs' on appointments, that is, they only book 
appointments up to a certain future date, often not more than two weeks. 
Other patients who call in are told to call back on a certain date to 
make an appointment. Therefore, it is usually impossible to determine 
what the true demand for service is, that is, what the length of the 
waiting list would be if no such arbitrary cut-off were used. 

In spite of all the above, if a panel system is to be 
used, the following determinations from this study should help set 
the appropriate size. (Remember that these determinations were made 
from data collected from a specific neighborhood-based clinic). 

o The average family makes about 12.5 to 13 visits 
per year to family practice. 



86 






o The average length of visit to family practice 
is 17 to 18 minutes 

Approximately 3.6 hours per year, then, are required 
to care for the average family in the family practice clinic. If the 
average annual number of clinic hours per physician is divided by 
this number, the initial panel size can be determined. However, as 
noted in the previous section, maintaining the size with any accuracy 
is nearly impossible. 

(3) Alternatives to the Panel System. 

If it is accepted that the panel system and panel 
size has very little influence on the number of patients seen per 
day or on physician productivity, that it is extremely difficult to 
effectively control the panel, that it is very costly in administrative 
time to maintain it, and that it is not absolutely necessary to the 
'continuity of care' concept, acceptable alternatives must be sought. 

One alternative would be to just do away with the panel 
system and appoint any patient who calls. This would result almost in 
a reversion to the old general outpatient clinic and its problems, and 
as such, would not be acceptable to providers or consumers. 

Another alternative would be to eliminate only the 
administrative control of the panel and allow it to develop itself, 
similar to the way a private physician's panel develops. This method 
would eliminate the assignment and control problems and the administra- 
tive costs, but maintain the benefits of the system. 

More specifically, it is suggested that there be no 
control of the patient panel, that is, no assignment, waiting list, 
keeping track of, limiting, or other Influencing of the panel size 
except as follows: 

(a) Appointments for formerly seen family practice 
patients and members of their families could be made at any time, 
with their physician . 

(b) Appointments for new patients could only be made 
for vacancies available in the immediate two-week period. 

As a new panel developed, more and more appointment 
slots would become filled with formerly seen patients, until finally 
there were no appointment slots for new patients within the two-week 
period, and the panel would be "full". 




f 



87 



Over a period of time, as patients left the system, 
open slots would again begin to show up during the two-week period, 
and would be automatically filled with new patients. When a doctor 
was transferred, Ms former patients would be referred to his replace- 
ment In the same way. 

This system, or one like it, would: 



o Eliminate the necessity for panel control and 
the associated administrative costs. 

o Allow daily appointment slots to be kept full. 

o Allow families to change doctor by reapplying 
as a new patient. 

o Partly remove the inequity of some patients 
having family practice availability and others 
not having it. 

o Eliminate the need to set the number of families 
in a doctor's panel — the doctor would be assign- 
ed a specific number of appointments per day, as 
he is now, and it would not be necessary to even 
know how many families this comprised. 

Such a system, though obviously not perfect, would tend 
to eliminate many of the problems with the present panel system. It 
would, however, maintain all the good features of the present system. 

As mentioned bafore, it would not be unlike what happens in the 
civilian community, in the establishment and maintenance of a private 
physician's panel of patients. 

Still other alternatives should be sought. Perhaps a 
more efficient system, with little loss of continuity, would result 
if a panel of patients had a ' panel of physicians ' , rather than being 
attached to only one specific physician. Such questions are beyond 
the scope of the present study, but provide fertile ground for further 
research. 

Z. Physician Productivity. 



The mere mention of physician productivity is often enough 
to open a veritable Pandora's Box of charges and countercharges. 
Innuendos and defensive postures. When evaluating a new method of 
health care delivery, however, the subject cannot be totally ignored. 
In private, fee-for-service practice, income bears a direct relation- 
ship to productivity, Mithin the. &pe.cZaZty and gzogAaphic a/iea ofi 
practice.. In a salaried system, such as federal service, however, no 
such Incentive/measuring device is available. 



I 
r 



* 



1 



It is easy to find fault with the use of the number of visits 
per unit time as a measure of productivity. The length of the visit 
may in fact be related to quality of care; spending more time with a 
patient may well alleviate the need for a subsequent visit, or sub- 
stitute for the visit of another family member. Telephone consulta- 
tions may take the place of a visit; knowledge of the family may aid 
in preventive care, and so forth. However, at the present time, the 
number of visits is the only measure of productivity that is available 
for the comparisons in outpatient areas. 



In reality, it may be a better measure of productivity than 
some would admit. The annual output in visits per physician is a 



reflection of the number of hours spent in clinical outpatient care. 



as well as the number of minutes spent per patient. 



Measured in this way, using only the gross numbers for the 
North Clinic for 1974, 13,175 visits, divided by an average of 3.8 
physicians (one physician consulted one-fifth time with the HCSD 
on-site study team), the outpatient care productivities in thousands 
of visits per physician manyear for the North Clinic family practice 
physicians is 3.467 . (The patients seen by the nurse practitioners 
are included as part of the productivity of the physicians). 



The outpatient care productivities in thousands of visits 
per physician manyear, as reported in the Report of the Military 
Health Care Study , Supplement: Detailed Findings, December 1975, 



page 281, for selected specialties, are as follows: 



Medicine 

OB-GYN 

Pediatrics 

General 



7.819 

7.771 

8.568 

12.724 



Reinhardt (1975) lists average weekly patient loads, in 
visits, and average practice hours per week, for various specialists 
in solo and group practice. For group practice, single specialty, 
he gives the following figures, based on 1965-1967 data: 



Internists 

OB-GYN 

Pediatrics 

General Practitioners 



140 visits per week 
138 visits per week 
169 visits per week 
213 visits per week 



These figures should be compared with a figure of approxi- 
mately 70 visits per week for the North Clinic physicians in 1974 
(based on overall figures, 13,175 visits in 47 weeks by four phy- 
sicians) . 



89 



This gross comparison indicates that the number of visits 
per physician manyear at the North Clinic was low compared with 
General Practitioners and compared with other primary care special- 
ists (Medicine, GB-GYN, and Pediatrics). The reasons for this lower 
productivity have not been investigated by this study. 

m. Utilization of Health Services . 

Visits to the North Clinic, per person, were calculated for 
a sample of families known to be members of the clinic, throughout 
1974. For the active duty family, there were 3.021 visits per per- 
son per year; for the retired/deceased sponsor family, the figure 
was 3.696 vi3lts per person per year (Table 4b-25). 

The data obtained from the OMB MHCS through OCHAMPUS re- 
vealed that only about 36 percent of visits by the group of families 
assigned to the North Clinic were actually made to the North Clinic. 
The families made 3,984 visits to the North Clinic between 1 April 
and 31 July 1974, while they made 7,116 visits to other clinics dur- 
ing the same period (exclusive of Dental, Optometry, Podiatry, 0T 
and PT visits). The visit rate per person, adjusted by this figure, 
would be 8.39 visits per person per year for active duty family mem- 
bers, and 10.26 visits per person per year for retired/deceased 
sponsor family members. 

To these figures must be added utilization of CHAMPUS by 
eligible members, in order to estimate total utilization. The 
figures given in Section 4f(3) are, for the active duty dependent, 
0.28 visits per person per year, and for the retired family member, 
0.41 visits per person per year. 

Overall, utilization rates for family practice panel mem- 
bers are high when compared with the rate of about 4.5 visits per 
person per year for nonactive duty military beneficiaries in north- 
ern California, as reported in the OMB MHCS. (Military Health Care 
Study, 1975). 

5. CONCLUSIONS. 

a. The North Ft. Ord Family Practice Clinic was ranked highest, 
among six Ft. Ord primary care clinics, in patients' satisfaction 
with the medical care provided. The physicians' interest, courtesy, 
and the continuity of health care were reported as most satisfying. 
The only major patient dissatisfaction factor was the location of 
the North Ft. Ord Clinic. (Section 4c (3)). 








' wi.".. mi ■ .■ '■ - - 11 ' 1 ■ ■ ■ 



31 







( 



b. A clinic staffed by four physicians does not provide a 
co-located X-ray unit with a sufficient workload for efficient opera- 
tion. (Section 4i(l)). 

c. A clinic staffed by four physicians does not provide a co- 
located laboratory with a sufficient workload for efficient operation. 
(Section 4i(2)). 

d. The free-standing neighborhood-based clinic should not be 
established in areas where a nearby hospital has adequate clinic space. 
(Section 4k) , 

e. Job satisfaction among North Ft. Ord Family Practice phy- 
sicians did not differ from that of other clinics’ physicians at Fort 
Ord. (Section 4d). 

f. Physicians productivity, in visits per physician manyear, at 
the North Clinic was low compared with Internal Medicine, Obstetrics/ 
Gynecology, and Pediatrics. (Section 4m). 

g. The arbitrary assignment of panels of families to specific 
physicians i3 an inefficient and ineffective method for management 
of family practice workloads. (Section 4 Z) . 

h. In this study overall utilization of health care services by 
family practice panel members was demonstrated to be high when compared 
with other nonective duty military beneficiaries. (Section 4m). 

i. Only about 40 percent of North Clinic family practice panel 
members' visits were actually made to the North Clinic family practice 
physicians. (Section 4e(3)). 

j . Cost per clinic visit at the North Clinic was higher than at 
the Hospital Family Practice Clinic, and higher than Internal Medicine, 
Obstetrics/Gynecology, and Pediatrics. (Section 4g). 

k. CHAMPUS utilization was low both during and prior to family 
practice, for a sample of 401 families, and there was no significant 
difference between the number of families in the sample who used 
CHAMPUS while enrolled as family practice members, compared with the 
number of families in the sample who used CHAMPUS prior to establish- 
ment of family practice. (Section 4f(3)). 

t. The many specific findings in Section 4, PROCEDURES, FIND- 
INGS, AND RELATED DISCUSSION, can provide useful information to those 
operating or planning to operate a military family practice clinic. 

Some especially useful items are considered to be: 




■ 



91 





(1) The distribution of patient visits. (The spouse, for 
instance, though comprising approximately 25 percent of the population 
of family practice panel members, made 43.6 percent of North Clinic 
visits) . 



(2) The length of patient visit. (For physicians at the 
North Clinic, average was 17.69 minutes). 

(3) The ratio of consultants to family practitioners. 

(See Appendix K) . 

m. There is a tendency for physicians in a neighborhood clinic 
setting to minimise their inpatient workload because of the physical 
distance to the hospital. (Conclusion based on subjective impressions 
and not on validated data) . 

6. RECOMMENDATIONS . 

a. Neighborhood-based clinics should not be established when a 
hospital with adequate clinic space is located within a reasonable 
distance and transportation is available. 

b. Patients should not be assigned to family practitioners as 
a set panel. The individual physician practice population should be 
allowed to develop itself as suggested in Section 4 t, or some other 
alternative found. 

c. Methods of improving the productivity of family practitioners 
in a neighborhood clinic should be considered, in such areas as: 

(1) Increased number of clinic appointments per day; 

(2) Increased hours devoted to clinical patient care; 

(3) Increased use of physician extenders. 

d. Productivity of family practice physicians in hospital- 
based clinics should be studied, and compared with that of other 
primary care practitioners. 

e. The inpatient load usually cared-for by family practitioners 
in hospital-based practice needs to be documented. 

f. The many specific findings in Section 4, PROCEDURES, FIND- 
INGS, AND RELATED DISCUSSION, should be made available to those 
operating or planning to operate a military family practice clinic. 



92 



REFERENCES CITED 



1. Campbell, D. T., and Fiske, D. W. , Psychological Bulletin , 1959, 

56: 81 - 105. 

2. Hulka, B. S. , Zyzanski, S. J. , Cassell, J. C. , and Thompson, 

S. J., Medical Care , 1970, ji: 429 - 436. 

3. Lebow, J. L., Medical Care , 1974, 12: 328 - 337. 

4. Military Health Care Study , Report and Supplement: Detailed 

Findings, Department of Defense, Department of Health, Education, 
and Welfare, Office of Management and Budget, Washington, D.C., 
December 1975. 

5. Osier, William, Chauvinism in Medicine, In Aequanimi tas With Other 

Addresses . (3rd ed) New York: Blakiston & Co., 1932, pp 264-289. 

6. Perry, F. M. , A Preliminary Analysis of the Visit Rates of 
Patients in a Military Family Practice Health Care Program . 
Master's Thesis, Naval Postgraduate School, Monterey, California, 
September 1975. 

7. Proceedings of the Seminar on Ambulatory Health Services , 

Sponsored by The Surgeon General, Department of the Army, 

Brooke Army Medical Center, San Antonio, Texas, November 1971. 

8. Reinhardt, Uwo E. , Physician Productivity and the Demand for 

Health Manpower . Cambridge, Mass: Ballinger Publishing Com- 

pany, 1975. 

9. Smith, P. C., Vendall, L. M. , and Holin, C. L. , The Measurement 
of Satisfaction in Work and Retirement . Chicago, Illinois: 

Rand McNally & Company, 1969. 

10. Vital and Health Statistics , Report, U.S. Department of Health, 
Education and Welfare, Series 10, Number 97^, Washington, D.C., 
December 1975. 

11. Vital and Health Statistics , Report U.S. Department of Health, 
Education and Welfare, Vol 24, No 4^, Supplement 2, Washington, 
D.C., July 14, 1975. 

12. Wolfe, S., and Badgley, R. F., The Family Doctor , Milbank 
Memorial Fund Quarterly, Vol 1, No 2, Part 2 , April 1972. 

13. Zyzanski, S. J., Hulka, B. S., and Cassell, J. S. , Medical Care , 

1974, 12: 611 - 620. 



93 



APPENDIX A 



ORIGINAL STUDY QUESTIONS 

1. Questions related to size and composition of the family practice 
group and size of panel served: 

a. What is the smallest number of family practice physicians that 
should be in a family practice group, such that each family unit can 
preserve identification with its physician, and physicians can provide 
coverage one for another during non-clinic hours? 

b. What are the optimum numbers and types of supportive health 
care personnel (such as nurses, nurse-clinicians, 91Cs, 91Bs, and X-Ray 
and laboratory technicians) for the family practice group? Is it 
feasible to cross-train individuals to serve in multiple roles (e.g., a 
combined X-Ray and laboratory technician)? 

c. What are the most satisfactory arrangements for incorporating 
into the family clinic a program of comprehensive social services to work 
with such problems as abuse of alcohol and other drugs, marital and 
other family conflicts, deliquency and juvenile court matters, child 
abuse, out-of-wedlcck pregnancies, need for adoptive and foster home 
services, requirements for nursing home placements, need for homemaker 
services by ill mothers, coordination and referral services for the 
physically and mentally handicapped, situation-related tensions which 
find expression in somatic complaints, preparation fot psychiatric 
referrals, etc.? 

d. How many families should be assigned to each physician in the 
family practice group to assure services which are at once comprehensive, 
personalized, and economical? 

2. Questions related to facilities, equipment, and supply needs: 

a. What are the facility, supply, and service needs of the family 
practice group in the hospital-based setting? In the neighborhood- 
based setting? What arrangements are most satisfactory to meet those 
needs? 



b. What are the pharmacy support needs of the f amily practice 
group in both settings? How can those needs be best met in each setting? 

3. Questions related to administrative support needs: 

a. What arc tne requirements for clerical support in the family 
practice group? What level Oi clerical skill is required? 

b. Is there need for a full-time administrative NCO in the family 
practice clinic? What, if any, other administrative personnel are 
needed? 




I 

I 



( 




I 




4. Questions related to appointment system and clinic operation hours: 



a. What is the most satisfactory schedule for normal clinic 
operating hours? 

b. What appointment system is most advantageous for the family 
practice clinic? 

c. What is the most advantageous arrangement for taking calls 
during non-clini.c hours? What problems and/or benefits are associated 
with using non-phyoicians (e.g., 91C or nurse-clinician) as first call 
person during non-clinic hours? 

d. What proportion and what types of problems arising during non- 
clinic hours can be managed satisfactorily by telephone? 

e. Is it economical for the physician to see patients during non- 
clinic hours at his own clinic? Or does that system require uneconomical 
presence of supportive staff in the clinic during these hours? 

5. Questions related to medical records: 

a. What, if any, modifications of the problem-oriented medical 
record prove tc be advisable for use in family practice clinics? 

b. What system for record maintenance works out well in family 
practice? What are the consequences of permitting family units to keep 
their own records in their own possession? 

6. Questions related to health services utilization, and other health- 
related behavior and consumer satisfaction: 

a. What are the patterns of utilization of health services provided 
in the hospital-baned clinic? In the neighborhood-based clinic? What 
kinds of problems do they bring to the clinic and with what frequency? 

b. To what extent do panel members use other health-related 
resources in the military and civilian community? Why do they do so? 

For what kinde of problems? 

c. How doee consumer satisfaction with family clinic services 
compare with their reactions to services received in the past? How does 
it compare with the satisfaction of non-panel members who are cared for 
in the general medical clinic? 

d. What approaches to consumer grievance-management seem to work 
best in the family practice clinic setting? 

e. What are patterns of family health behavior in such areas as 
self-treatment, drug-taking, family-planning, etc.? 




96 



7. Questions related to the relationship of the family practice clinic 
to other MEDDAC services: 




a. How well is the family practice clinic received by other parts 
of the MEDDAC patient-care community (e.g., pediatrics, OB-GYN, internal 
medicine, general surgery services)? By the MEDDAC administrative 
community? What advantages and disadvantages do they associate with 
this kind of clinic? 

b. What, if any, problems arise in connection with family practi- 
tioners providing inpatient care for their patients? 

c. What patterns of specialty referral and consultation emerge in 
family practice clinics? How do these patterns differ from those in the 
general medical clinic? 

d. What kinds of laboratory and X-Ray support does the family 
practice clinic require? 

e. What are the patterns of utilization of hospital beds by panel 
families? 

8. Questions related to staff satisfaction: 

a. How does staff satisfaction in the family practice clinic compare 
with staff satisfaction in other parts of the MEDDAC? 

b. What changes or improvements are needed to increase family 
practice clinic staff satisfaction? 



I 









jg . . ifr W* * * - 



APPENDIX B 



REVISED STUDY PROPOSAL STUDY QUESTIONS 

1. What is the panel size assigned each physician in the North Fort Ord 
Clinic and how many families and patients utilize his services? 

2. What type of population is seen by the Family Practice Clinic in 
terms of numbers of family members, ages of sponsor and dependents, race, 
officer, or enlistee, sex, retired or active duty, residence on or off 
post, and previous utilization of health services? 

3. Of those families enrolling in the North Fort Ord Family Practice 
Clinic, how many actually utilize the Clinic and what are their utiliza- 
tion patterns in terms of visits? 

4. How often do Family Practice patients utilize other hospital clinics, 
and what proportion of the patients are referrals from the Family Practice 
Clinic as opposed to self-referrals or referrals from other clinics 
outside the Family Practice Clinic? 

5. What is the military hospitalization pattern for Family Practice 
patients including length of stay, referral or Family Practice care, and 
level of care (Intensive Care, General Ward, Operating Room, or Delivery 
Room) ? 

6. In what volume and for what types of care do Family Practice Clinic 
families utilize the CHAMPUS programs? 

7. To what extent do panel members use non-CHAMPUS health resources in 
the civilian community? 

8. How many patients who never joined the Family Practice program utilize 
Family Practice Services? 

9. What are the supporting services utilized by a three and 4/5th 
doctor Family Practice Group? 

10. From what sources do patients officially enrolled in the North Fort 
Ord Family Practice Clinic actually obtain primary care? 

\ 

11. What are the facility, supply, and service needs of the North Fort 
Ord Family Practice Clinic, and what arrangements were arrived at to 
meet those needs? 

12. What system for taking call during nonclinic hours was arrived at 
and how? 

13. Do any problems arise in connection with family physicians' providing 
inpatient care for their patients? 



-»• fr '-' .i 



99 



r 






14. What is the best way to select a control group from the potential 
non-Famlly Practice patients of Silas B. Hays Army Hospital that Is 
comparable to the Family Practice Clinic in terms of number of family 
members, number of outpatient visits, whether they are active duty or 
retired, pay grade of the sponsor, race of the sponsor, and race of the 
spouse? 

15. Of the control group, how many actually utilize the primary care 
clinics (AMIC, Pediatrics, GYN, ETR, and Internal Medicine) and what are 
their utilization patterns? 

16. How often and for what reasons do patients in the control group 
utilize other hospital clinics? 

17. What is the military hospitalization pattern for patients in the 
control group in relation to length of stay, specialty of the physician 
primarily responsible for the patient’s care and level of care (Intensive 
Care, General Ward, Operating Room, or Delivery Room). 

18. What volume and for what types of care do control group patients 
utilize the CHAMPUS program? 

19. To what extent does the control group use non-CHAMPUS health-related 
resources in the civilian community? 

20. What is the number of patients in the control group utilizing the 
North Fort Ord Family Practice Clinic and hospital Family Practice 
Clinic as their source of primary care? 

21. What are the supporting services (Laboratory, X-ray, and Pharmacy) 
utilized by health care providers in the primary care clinics (AMIC, 
Pediatric Clinic, Gyn Clinic, Internal Medicine and the Emergency Room) 
in their delivery of medical care to patients in the control group? 

22. What are the differences in utilization of health resources by 
patients in the Family Practice Clinic panel compared to patients in 
the control group? 

23. How do the total costs in dollars compare between delivering care 
including hospitalization to a panel of patients in the North Fort Ord 
Family Practice Clinic and to a matched control group whose care is 
provided in the general clinic approach? 

24. How does consumer satisfaction with Family Practice Clinic services 
compare with the satisfaction with services received in the past? How 
does it compare with consumer satisfaction of patients treated in other 
primary care clinics? 

25. What are some of the differences in the care delivered to Family 
Practice patients as opposed to control group patients which indicate 
but do not measure the differences in quality of care delivered in the 
two methods? 












' 




J 



10C 



< 



26. How do resource utilization costs in dollars compare between 

delivering care in the following approaches: The North Family Practice 

Clinic, the hospitaL-based Family Practice training program clinic, 
and the other primary care clinics delivering care to control group 
patients? 

27. How does patient panel size influence the availability of Family 
Practice physicians to their patients? 

28. Is there a critical number of hours per week that the family phy- 
sician must be available for his patients to see him if cortinuity is to 
be maintained? 

29. How does staff satisfaction in Family Practice Clinic compare with 
staff satisfaction in other parts of the MEDDAC patient care community? 

30. What are the changes in patient utilization of medical services 
observed when a Family Practice program is instituted? 

31. What are the costs and productivity of the general clinic approach 
to primary care? 

32. What are the costs, benefits, end problems of maintaining a separate 
pharmacy. X-ray and laboratory unit within the North Fort Ord Family 
Practice Clinic as opposed to utilizing the central X-ray, pharmacy, and 
laboratory facilities at the hospital? 



101 



FAMILY PRACTICE SERVICE 

U.S. ARMY MEDICAL DEPARTMENT ACTIVITY (MEDDAC) FORT ORD 
FORT ORD, CALIFORNIA 93941 






t 




AMNOS-M ED-FP 

SUBJECT: Family Practice Medical Care 

TO: Active and Retired Military Families 



1 July 1973 



You and your family are Invited to make application to participate in the Family 
Practice Medical Care Program at Fort Ord. In January 1973, Silas B. Hays Army 
Hospital began a new program in providing health care to active and retired 
servicemen and their fami li es. Because of limited resources, only a few families 
could be invited to Join the program at its beginning. Families already partici- 
P*l^ n 8 In the program are encouraged to continue and do not need fill out the 
application. 



More Family Practice doctors have now been assigned, and more space has been 
acquired, ao that a new Family Practice Clinic will be opened in the old hospital 
area this summer. Two buildings have been extensively remodeled and equipped. 

The nev clinic will be able to provide Family Practice care for over 2000 families. 
The new clinic, called the "North Fort Ord Family Practice Clinic", will operate 
mainly by appointment during the day, with a doctor on call to care for acute 
emergencies at night or on weekends. The Family Practice Center at the hospital 
will continue tc operate as it has in the past. 

Doctors trained In the specialty of Family Practice provide total medical care to 
•***■•• famillea. The Family Practice doctor can personally care for about 85 
percent of eech family member's medical problems.’ He consults with and works 
closely with other specialists aa needed. All the members of the family have one 
doctor whom they see first, and who cares for them when 111 or injured or pregnant, 
or for routine problems such aa well baby exams, PAP tests, periodic check-ups, 
etc. 

All active and retired military families In the Fort Ord aree are eucouraged to 
application for Family Practice care. The number of families that can be included 
!• limited. Most of the families selected will receive their care at the North 
Fort Ord Family Practice Clinic In the old hospital area, on Third Avenue, between 
10th and 12th Streets. Selection considerations will Include closeness of the home 
address to the clinic, time remaining in the Port Ord area, and etatue (active or 
retired). A representative cross section of officer and enlisted and active and 
retired military famillea will be selected. 

If your family decides to make application for Family Practice care, please complete 
the attached form and mall It to the address at the top of the form. Families 
•elected will be notified by mall and will be provided more Information at that 
time. The first families selected will be notified by mid-summer. Additional 
families will be added to the program gradually, so that a family not selected 
Initially may be selected later. If you make application, please continue to 
obtain medical care in the usual way until you have been notified that your family 
has been selected. Families already receiving care at the Main Hospital Family 
Practice Center need not apply, and are encouraged to continue with their Family 
Practice Care, 



Family Practice Sarvics 



1 i 

103 



L 






FAMILY PRACTICE SERVICE 

U.S. ARMY MEDICAL DEPARTMENT ACTIVITY (MEDDAC) FORT ORD 
Fort Ord, California 939U1 



Sponsor's 3 SAN D ate 

Name and Ages of Sponsor and All Dependents Living In TMs Area: 

Sponsor 

Spouse ___________________________________ 

Children 



Active 



Retired 



Rank or Grade 



Branch/Service 



Military Unit 

(or business address} 

Local Heme Address 

Estimated date of departure from Fort Ord area 
Any Major Health Problems in Family? 



W S9L, 20 Jun 73 



APPENDIX D 



MEDICAL HISTORY QUESTIONNAIRE 



(Copies reduced in size) 



onsor's Name: 



SPONSOR INFORMATION 



Hirst 



Today 1 8 Data 



Present Marital Stati’ss Never Married Married Divorced 

Widowe d Separate d 

Pay Grade (circle one) s E-l E-2 £-3 E-l* E-5 E-6 E-7 E-8 E-9 

WO-1 CWO-2 CW1-3 CWO-1* 

0-1 0-2 0-3 0-1* 0-5 0-6 0-7 0-8 0-9 

Branch or Service (circle one) : USA USN USAF USMC USCO Other 



Sponsor 'a Date of Birth: 



Statue: Active 



Retired 



Nuaber of Eligible Spouse 

Dependents t Children^ 

Other ~ 



Duty or Buaineea Addre#s_ 
Horns Addrass 



If family is living in the Ft Ord area, including 
cities on the Peninsula, what is the estimated 
date of departure? 

Departure Date 



Spouse's Name: 

last 

Saoc i Date of Birth(DOB) i_ 



FAMILY INFORMATION 



Living in Ft Ord area (including 
olti.es on the Penirwula) ? 

Iss No 



Children's Names(oldest to youngest) I SPECIFY LAST NAME IF DIFFERENT FROM PARENTS 

' Living in Ft Ord area? Sex DOB 

Hrst MI (including cities on peninsula) Day/Month/I 

_ Living in Ft' Ord area? Sex DOB 

(including cities on peninsula; Day/konth/Y 

-- Living in Ft Ord area? Sex DOB 

(including cities on peninsula) Day/Month/I 

Living in Ft Ord area? Sex DOB 
(including cities on peninsula) Day/kontb/Y. 

4 

- Living in Ft Ord anea7 S ex DOB 

(including dUee on peninsula) Day/Mo nth/j 

(NS! REVERSE SIDE IF NECESSARY) 



106 



. OTHER ELIQIBLE DEPENDENTS 

Living in Ft Ord area? Sex D O B 

"Waive ' Relationship (including oities on peninsula} Day/Mo/Yr 

Living in Ft Ord area? Sex DOB 

N&me kelationship" (including cities on peninsula} Day/Ho/Ir 



THE KJUOV.'IiK INFORMATION WILL BE USED ONLY TO DESCRIBE THE POPULATION SERVED AND TO 
GET IOUR VIEWS TO ADD IN OUR PLAHNKQ TO BETTER SERVE YOUR HEALTH CARE NEEDS. 

NOTEj THE FOLLOW! Nu INFORMATION PERTAINS TO THE SPONSOR . 

1. Sponsor's raoe or ethnio group* 2. Sponsor's religious preference i 



"White (Caucasian) 
Black 

Moxican-Anerican 
Puerto Rioer. 
American Indian 



"Protestant 

jCatbolic 

Jewish 

Not Above; Please 
Speoify 

None 



_Chineee American 
_J aptness American 



Not Above; Please 

Specif y 

3. What ia the highest level of formal civilian education the sponsor has consisted? 
S ight years or less ' 

S oao high school but did not graduate 



H igh school graduate 

T wo years college or leas with no degree 
A e too late Degree 

M are than two years college but no degree 
B aohelore Degree (other than LIB) 

L LB. JD, ox equivalent 

M asters Degree 

# 

E arned Doetwate (PhD, MD, eto.) 



107 





5* Mow many years of total active federal military service has sponsor completed? 
L eas than 6 months } 

At least 6 months but less than 2 years 

A t least 2 years but less than 1* years 
A t least it years but less than 8 years 

At least 8 years but less than 12 years 

A t least 12 years but loss than 16 years 
A t least 16 years but less than 20 years 
A t least 20 years 

6. Does the sponsor intend to malce the military a career? 

D efinitely No 
P robably I'o 
U ndecided 
P rooably Tes 
D efinitely Tea 

Mot Applicable (Retired, Deceased, etc.) 



IT TDD DO NOT HATS A SPOUSE AT THE PRESENT TIKE 
SUP THE NEXT PAOE (Page U)’ 



1 - 

108 






\ 



NOT* I THIS PAGE PERTAINS ONLY TO THE SPOUSE. IP IOU ARE NOT MAPHIH) HO TO PAGE 5 
6. Highest level of formal civilian education spouse has oompletedi 

Eight years or less 

S ome high school but did not graduate 
H igh school graduate 

T wo year? of college or less with no degree 
Associate Degree 

M ore than two years of college but no degree 
B achelors Degree (other than LL8) 

L IB. JD or equivalent 
M asters Degree 

E arned Dootorate (PhD, MD, etc.) 

9. Spouse's race or ethnio group* 

W hite (Cauovsian) 



M exioan-Amsrloan _ 

P uerto Hi can 
A merioan Indian 

>» 

C hinese Amerioan 

Japanese Amerioan 

M ot Above; Please 
Specif y 

10. Spouse 'a religious preference i 
P rotestant 
C atholic 

J ewish 

M ot Above; Plesse 
Speolfy , 



109 



ARMY MEDICAL CLINIC UTILIZATION 



11. Spo nsor '3 utilization of Army Cl inic s for outpatient care during the past 12 
months. (Other than routine physical chains and immunizations): 



More than 19 times 



N ever during the past year h times M ore than 19 times 

Once 5-9 times 

T wice 1 0- Hi times 

3 times 1 5-19 times 

Spouse 1 s utilization of Army Clinics for outpatient care during the past 12 
months. (Incluae all visits for any purpose): 



_Never during the past year 



b times 



_5-9 times 
_10-li| times 

_15-19 times 

_More than 19 times 

_Not Applicable; I have no spouse 



Eligible children's combined total number of visits to Army Clinics for outpatient 
oare during the past 12 months. (Include all vlsite for any prupoae) s 

Never during the past year 



J» times 
J - 9 tin es 
_10-U* times 
_15-19 time# 

_More than 19 times 

Mot applicable; I have no eligible children. 



110 



r 



. . CIVILIAN K.'DTCAL CLTNJC UTILIZATION 

lit. Sponsor 'a utilization of civi lia n m e dical facilities for outpatient care during 
the past 12 months j “ ~ 



__Never during the past year i t times 

__Oncc . 5-9 times 

_Twice 1 0 - 1 L times 

J> time 6 15-19 times 



More than 19 times 



15. Spouse's utilizauion of civilian r.edical facilities for outpatient care during 
the past 12 months i • ' 



Jlever during the past year 
_0nce 
_Tiri.ce 
times 
It times 



_5-9 times 

_1D-14 tines 

_15-1 9 times 

_More than 19 tines 

_Not applicable} I have no spouse 



16. Eligible ch il dren 's combined total number of visits to civilian medical facilities 
for outpatient oaie during the past 12 months i "* ' ' ~ 

N ever during the past year 

O noe 

T wlca x 

3 tines 
I t times 

5-9 times 

1 0- lit tinea 

15-19 tines 

M ere than 1 $ tines 

N ot applicable) 1 have no eligible children. 



Ill 



17. The following item.-! are to help us determine 
the spon sor 1 e satisfaction with outpatient 
Army Health Care at Silas B. Hays Army 
Hospital, Ft Ord (Check the cne bax that 
best describes your feelings), 

WHAT HAS BEBH SPONSOR'S SATISFACTION 
IN TERMS OF? . , 

t‘ 1. Doctor's interest in your prdblem 

2. Nurse 1 e inteatist in your problem 

3. Courteous treatment by doctors 

U. Courteous vreatment by nurses 

5. Courteous treatment by receptionist 

6. Quality of health care 

7. Waiting tine is the Acute Minor 
Illness Clinic (Do not write times) 

8. Convenience of location of the 
Aoute Minor Illness Clinio 

9 . Convenience of operating hours of 
the Acute Minor Illness Clinio 

10. Adequacy of the Acute Minor 
Illneee Clinic 'e physical facil- 
ities (seating, oomfort, decor) 
in general 

11. Adequacy of information given to you 
about your medical problem by dootor 

12. Adequacy of information given to you 
about your nedioal problem by nurse 

13. Continuity of health care provided 

14. Laboratory serricea provided by the 
hoepltal facility 

1$. Pharmacy services provided by the 
hospital facility 

16. X-ray services provided by the 
hospital facility 



■■■■■ 

■■■■■ 





i 



The following items are to help us determine 
the spouse ' s satisfaction with outpatient 
Army Health Caro at Silas B. Hays Army 
Hospital, Ft Ord (Check the one box that ■ 
best describes your feelings). 

WHAT HAS BEEN SPOUSE'S SATISFACTION 
IN TERMS OFs * — 

1. Doctor's interest in your problem 

2. Nurse's interest in your problem 

3. Courteous treatment by doctors 
It. Courteous treatment by nurses 

$. Courteous treatment by receptionist 

6. Quality of health care 

7. Waiting time in the Acute Minor 
Illness Clinic (Do not write times) 

8. Convenience of location of the 
Acute Minor Illness Clinic 

9 . Convenience of operating hours of 
the Aoute Minor Illness C lini c 



i/ 






ff/mWM 



10. Adequacy of the Acute Minor 
Illness Clinio'e physical facil- 
ities (seating, onmfort, deoor) 
in general 

11. Adequacy of Information given to you 
about your medical problem by doctor 

12. Adequacy of Information given to you 
about your medical problem by nurse 

13. Continuity of health ears provided 

lit.. Laboratory sarvicea provided by the 
hospital facility 

15. Pharmacy eervicea provided by the 
hospital facility 

16. Z-ray services provided by tbs 
hospital facility 



113 






40fJt+ < ■»**«»* - 




APPENDIX E 

METHODS OF ENROLLMENT 



Two methods of selecting panel members were used at Ft. Ord, the 
brigade system and an application enrollment system. 

(1) The Brigade System. When the Hospital Family Practice 
Clinic first opened, each of the four doctors was assigned the perma- 
nent party personnel from one of the four training brigades on post. 

No direct method of entry was provided for retired personnel. Doctors 
were allowed to request individual families for their panels, so that 
residents could pick up families with interesting and varied diseases 
and also follow families of patients whom they took care of on their 
rotations on other services. 

This system set up automatic assignment of patient to 
physicians, and provided for automatic replacement of those leaving 
post. However, it excluded retired personnel. Also, a change in 
brigade assignment necessitated a change in doctor or a breakdown 
in the assignment system. Since families were not required to come 
to family practice for care, there was no system for regulating the 
number of families handled by each physician, should the number of 
interested families vary among the brigades. Pressures from retired 
personnel and personnel in units outside the training brigades devel- 
oped. Transfer of personnel between brigades and then the elimination 
of one brigade led to the eventual complete breakdown of the system. 

(2) The Application Enrollment System. With the opening 
of the North Fort Ord Family Practice Clinic, the program was made 
available to all military health care eligible families in the Fort 
Ord area. Publicity regarding family practice was placed in the 
weekly post newspaper and disseminated by other means to units on 
post. Applications were placed in the post exchange, the commissary, 
the Welcome Center, the outpatient desk at the hospital, and at both 
the family practice clinics. 

Filling out an application and returning it to the 
family practice clinic placed the family on one of four lists, (1) 
active enlisted, (2) active officer, (3) retired enlisted, or (4) 
retired officer. Selection for participation was then on a first- 
come basis from each of the four lists. (Living in the contiguous 
housing area gave families some priority for the North Clinic, and 
families expecting to leave within six months were generally not 
accepted). After the panels were filled, waiting lists were kept 
of those wishing to join when space became available. 



I 




116 






l 1 



HEALTH CARE STITT) I ES C/NTT 
NORTH FAMILY PRACTICE CLINIC 



I. Data: 



2. Patient e Name: 



3. Sponsor'* SSAN (with patient's prefix): 



4. AppolntJtent Statue: 
(20) Emergency 



] mn 



(21) Appointment 



(22)W*lk-ln 



t. Reelth Cere Provider (Nem* or #):_ 



7. Patient'* Complaint 



PROVIDER TIKE ON PROBLEM 



9. LENGTH OF THIS VISIT 



Moat Tim* 



Second Moat 



(160)Acute Injury ........ 


..(180) 


(210) 


0-5 nln. 


( *61) Acute Injury followup 


..(181) 


(211) 


5-20 min. 


(L62)Acute( temporary) problem... 


..(182) 


(212) 


20-40 min. 


(163)Acut*9tsmporary) problem flu. (183) 


(213) 


Over 40 min. 


(I64)Chvcnlc problem* routine..., 
(163)Chro*\ic problem, flare-up.. 


..(184) 

..(185) 


10. X- 


-RAY 


(16o)Prenatal 6 poatntal care... 
(lG7)Partlal exam, well baby. 


..(186) 


(240)Chast-P.A. 



screening lab, or prav. *d...(187) 

(168) Compiete HX and PE flnlahad. . (188) 

(169) Tamlly planning /Contraception (189) 

(170) Couns*llng/Advica (190) 

(1 71) Immunisation ,..(191) 

072) Administrative (192) 

(173)Oth.r (193) 



(241)Che*t-P.A. 1 Let. 



Other 



Other Nursing Car*_ 



(22^ PHARMACY: « of RX_ 

(2)1) KC 



11. LAB 



(330)SHA-12, Pasting 
(3bl)SHA-12, non-fasting 

(332) Chol 4 Trlgly 

(333) lilac trolytss 
<>C2)*4 
("21)Na+ 

(334) Clucnas, fasting 

(333)<!luc>>a*, hr pp only 

()M)Clucoaa, 2 hr p high 

sugar meal 

(357)tfg 

(338) Nononucl. Screen 

(339) Ru balls Screen 
()7*>Tj 13T* 



(360)CBC & Dlf f 
(36DCBC 4 Indicias 

(362) Hct. 

(363) Slckla Call 
(370)C4PD 



12. n*WHI2ATI0HS 



(610) OFV 

(611) DPT 

(612) DT 



(615) MHR 

(616) Meael*e t Rubel 

(617) Vump* 



(364) Urlnakyaie 

(365) Claan catch L'A 

(366) Urin* culture 
(36/)Throat culture 



(61 J)T. To* (618)Flu 
(61*)Tb teat (619)Smallpox 



Other 



(368) GC scraan 

(369) PAP 

(504) Pregnancy tost 



NEXT APPOINTMENT 






13 min 



Other Lab 



30 min. 



13. REFER TO 



(700) D*nt*l 

(701) Dermatology 

(702) INT 

(703) Int**nal Had. 

(704) Mant Hyg/Soc Wk 
(703)Naurology 
(71b)Nucl*ar Had. 

( /06)OB-GYN 
(707)OT/PT 



(709) 0phthalmology 

(710) 0ptometry 

(711) 0rthop*dic* 

(712) P*dlatrlcs 
(717)Pr*vsntlva Had. 

(713) P*yehlaery 

(714) Surg*ry 
(713)Urology 



43 mla._ 
60 min. 



(0 min with Nurse Clln_ 

P.E. with Nursa Clin 

Other 



HP *37 Rev 14 Dac 73 



Other 



COPT AVAILABLE TO DDC DOES NOT 
PEWIT FIIU.Y LEGIBLE PRODUCTION 



118 




.1 : 



APPENDIX G 

PATIENT SATISFACTION QUESTIONNAIRE 
(Reduced in size) 




1 



j * 

i 

\ 

> THE ATTACHED QUESTIONNAIRE HAS BEEN DESIGNED TO 
PROVIDE US WITH INFORMATION ABOUT THE PATIENTS WHO 
ARE USING THIS CLINIC. THIS INFORMATION WILL BE USED 
ALONG WITH ADDITIONAL DATA TO IMPROVE OUR SERVICE TO 
YOU. ' ' . 

PLEASE COMPLETE THIS FORM AND TURN IT IN TO THE 
HOSPITAL REPRESENTATIVE IN THE WAITING AREA WHEN YOU 
LEAVE THIS CLINIC. 

A SMALL GROUP OF RANDOMLY SELECTED PATIENTS WILL 
SE ASKED TO TAKE A -FEW MOMENTS AND .COMPLETE ANOTHER 
SHEET CONCERNING SATISFACTION WITH THEIR VISIT TODAY. 

, t 

. THANK YOU VERY MUCH FOR YOUR COOPERATION. 



4 




THIS QUESTIONNAIRE IS ANONYMOUS 
PLEASE DO NOT INDICATE YOUR NAME 



IN THE BOX BELOW, WRITE IN 
THE LAST DIGIT OP YOUR 
SPONSORS SOCIAL SECURITY 
ACCOUNT NUMBER 



□ 



Please circle the eppropriete 
response (or each item below: 



Your Sex: 

<•> Mele 

Your Age: 

(a) Less than 19 veers 

(b) 18 - 35 years 



(b) Female 



Clinic 



Surveyor 



FOR OFFICIAL USE ONLY 
t 2 3 4 5 6 78 9 



Time 



l : — . s — : I — ! 

12 13 14 15 



□ □ 

10 11 

Oate (dry/month/yesr) ; ji "* jl |, J 
IB 17 18 18 20 21 



(0 

(d| 



36 - 50 years 
61 years or older 



Your Status: 

la) Active Duty Dependent 
(b) Active Duty Sponsor 
(C) Retired Dependent 



(d) Retired Sponsor 

(e) Other 



Sponsor's Grade: 

E-1, E-2, H-3. E-4, E-5, E-6, E-7, E-8, E 9 

WO-1. CWO-2, CWO-3, CWO-4 

0-1, 0-2, 0-3, 0 4, 0 5, 0-6, 0-7, 0 8, 0-9 



What is your highest level of education now? (Include GED credits, if any) 

(a) No high school 
Some high school 

High school graduate or GED certificate or diploma 
One or two years of college or vocational school (Include Associate degree) 
More than two years of college 
College degree (BA, BS. or equivalent) 

Graduate Study up to and Including Masters Degree 
Dootorel Degree or equivalent 



(b) 

(0 

Id) 

(a) 

<0 

!8 



22 



□ 



23 



□ 

24 



□□ 

25 26 



□ 

27 



& Number of persons in your Immedlete family (including yourself): 
(a) 1 (a) 5 

. (b) 2 (0 6 

(c) 3 (g) 7 or more 

<d) 4 

' 7. Your Race or Ethnic Group: 

(a) White (e) Chine se-Amgrican 

(b) Black (f) Japanese-American 

(c) Mexlcan-Amei ican (g) Filipino 

(d) American Indian (h) None of than, olaase specify 



y 



v 

T 




□ 



t. Did you have an appointment today? 

(a) Yas (b) No 

l 

8. Does tha sponsor inttnd to maka the military a caraar? 

(a) Yas * (c) Undecided 

(b) No (d) Not Applicable 




L.J 

31 



COPY AVAILABLE TO DDC DOES NOT 
PERMIT FULLY LEGIBLE PRODUCTION 



121 




12. Adequacy of this clinic's physical facilities (seating, 
comfort, dxcor) in general 

13. Adequacy of information given to you about your 
medical problem by doctor 

14. Adequacy of information givnn to you about your 
medical problem by none 

15. Adequacy of information given to you about your 
medical problem by other medical personnel 

(Physic inn Assistants, Amoclsts, Nurse Clinicians) 

16. Continuity of health care provided 



If you hive not yet hid contact with any or ill of the services listed belo’v, 
the correct response is NO CONTACT TODAY. 



17. Laboratory eerviCM provided by this facility 

18. Pharmacy rervlecs provided hy this facility 
18. X-ray service* provided by thl* facility 

Wt would appreciate any further comments you have,_ 





• 
























IM8 




• 











INTRODUCTION 



This booklet contains a questionnaire from the Academy of Health Sciences. 

It is distributed locally by the Health Care Studies Unit, but will be 
tabulated & analyzed at Ft. Sam Houston. It is designed to reflect your 
perception of your present job. On the basis of your responses, a comparison 
of staff satisfaction among the various clinics at Silas B. Hays Army 
Hospital will be made. 

Your responses to chese questionnaire items will be used for research 
purposes only. DO NOT IDENTIFY YOURSELF BY NAME OR SOCIAL SECURITY ACCOUNT 
NUMBER. 

Upon completion please place this questionnaire in the blank envelope, 
seal it, Insert the sealed envelope in the envelope with yaur name on it, and 
return to the person who gave them to you. He will remove the outer envelope 
with your name on it so the questionnaire will be completely annonymous when 
it is returned to the Health Care Studies Unit. 




myyjj 



INSTRUCTION'S 



i 





In this booklet are a number of adjectives and 
phrases wnlch could be used to describe five im- 
portant dimensions of your present Job: your 

„ i work, your supervisors, your pay, your opportunity 
for promotion, ar.d your co-workers. 

Put a "Y" in the blank beside an item if the item 
describes the particular aspect of your Job 

•i. 

printed at the top of the part-uular page (i.e., 
work, pay). 

Put an "JI" in the blank beside an item if the 
Item does not describe the particular aspect of 
your Job printed at the top of the particular 
pegs (i.e., work, pay). 

Put a "?" in the blank beside on item if you 
cannot decide whether the item describes the 
particular aspect of your job printed at the 
top of the particular page (i.e., work, pay). 






COPY AVAILABLE TO COG KES NOT 
PERMIT FULLY LEGIBLE PRCOuCTi© 



125 




WORK 



Fascinating 


(01) 


Routine 


(02) 


Satisfying 


(03) 


boring 


(04) 


_____ Good 


(05) 


Creative 


(06) 


Respected 


(07) 


Hot 


(03) 


Pleasant 


(09) 


Useful 


(10) 


Tiresome 


(ii> 


Healthful 


• ’ (12) 


Challenging 


(13) 


_____ On ydur feet 


(14) 


_____ Frustrating 


(15) 


Simple 


(16) 


Endlesa 


(17) 


_____ Gives sense of accomplishment 


(18) 




126 



X 





i 



t 




I 



SUPERVISOR 

/ 



Asks my advice 


(19) 


_____ Hard to please 


(20) 


Impolite 


(21) 


_____ Praises good work 


(22) 


_____ Tactful 


(23) 


_____ Influential 


(24) 


_____ Up-to-date 


(25) 


_____ Does not supervise enougi 


(26) 


_____ Quick tempered 


(27) 


'Tells me where I stand 


(28) 


_____ Annoying 


(29) 


_____ Stubborn 


(30) 


Knows Job well 


(31) 


Bad 


(32) 


- Intelligent 


(33) 


Leaves me on my own 


'(34) 


Lazy 


05) 

\ 


Around when needed 


(36) 



\ 



127 




/ 



PAY 



Incone cdequate for normal 

expenses 


(37) 


Satisfactory profit sharing 


(38) 

, j 


Barely live on incone 


(39) 


Bad 


(AO) 


Incone provides luxuries 


(Al) 


Insecure 


(A2) 


Less than I deserve 


(A3) 


Highly paid 


(AA) 


Underpaid 


• (A5) 



128 



Z 



I 



PROMOTIONS 



Good opportunity for advancement 
Opportunity somewhat limited 
Promotion on ability 
Dead end job 

Good chance for promotion 
Unfair promotion policy 
Infrequent promotions 
Regular promotions 



Fairly good chance for promotion 



129 



CO-WORKERS 



1 ’ ' 



*«.. 



* 



Stimulating 
Eoring 
Slow 

Ambitious 
Stupid 
Responsible 
Fast 

Intelligent 

Easy to make enemies 

Talk too much 

• • 

Smart 
Lazy . 

Unpleasant 
No privacy 
Active 

Narrow interests 

Loy«l 

Hard to neat 



( 55 ) 

( 56 ) 

( 57 ) 

( 58 ) 

( 59 ) 

( 60 ) 
( 61 ) 
( 62 ) 

( 63 ) 

( 64 ) 
( 63 ) 
( 66 ) 

(67) 

( 68 ) 

(69) 

(70) 

(71) 

(72) 



130 



* 




p- 

f: 1 



Pul a check under the (ace that cxpreiscs now you (eel about your 
i fiP cc noraj, lncludln C the work, the pay. the luperviston. the 

opportunities for promotion ond (ho people you work with. 



fsx c^) c^\ r^, 

fSSf SlA? VS? VS? V-? 



□□□□□□ 



( 73 ) 



131 



r*<l 



> - • 



BIOGRAPHICAL /DEMOGRAPHIC INFORMATION 




Age lest birthday (in years) 

Marital Status (circle one below): 

Single Married Widowed 



Divorced 



If currently on active duty, how many years of active duty 
have you completed, and what is your present rank? 



^ears rank: 



Length of time since graduation from 

Medical/Dental/Veterinary/Nursing School 
(Only applies to active duty MC,VC,DC, & ANC) 



_ye* rs 



Current position (circle one): 

MD RN LPN PA Pharmacist 


\ » 


Social Worker 


Clinical Spec 


Co'rpsman 


Lab Technician 


X-Ray Technician 


’ NCOIC 

» 


Records Clerk 


Receptionist 


Secretary 

4 


Clerk Typist 


Other (specify): _ 



Clinic you are currently working in: 

AMIC ER PAM. PRAC. HOSP^ ^ 

I NT. MED. OB-GYN PEDIATRICS ' 

PAM. PRAC, NORTH 



/ 

132 



( 74 - 75 ) 



( 76 ) 



( 77 - 80 ) 



(1-2) 



( 3 - 4 ) 



I 



( 5 ) 















APPENDIX I 

STAFF SATISFACTION - TABLES OF RESULTS 






June 1974 Staff Satisfaction 


























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December 1974 Staff Satisfaction 










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138 


* — - 








' 



1975 Staff Satisfaction 






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APPENDIX J 

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( 



APPENDIX K 

NUMBER OF VISITS PER CONSULT, 
VARIOUS SPECIALTIES 




APPENDIX K 



i 



t 

[ 

I 



I 



Early in the course of the study, consults to other clinics 
were evaluated and a determination made of specialist support re- 
quired by family practitioners. This data was published in Pro- 
gress Report II dated January 1974. The following pages have been 
extracted directly from that data. Though it is realized that the 
evaluations were made very early in the study, the data obtained 
from the various .specialties on clinic time available and antici- 
pated time necessary to handle consults, as well as the number of 
return visits expected to result from a consult, is still valid 
and is the part referenced in the current text. 

In order to estimate the amount of time available in each 
specialty area for outpatient care, and to determine the total 
time generated for the specialist from one consultation, dis- 
cussions were held with members of the teaching staff at Brooke 
Army Medical Center, with physicians at the Academy of Health 
Sciences, and with physicians at a post hospital. It was ex- 
plained to each that the theoretical consult was to be an average 
of all consults received by that specialty from fully trained 
family physicians, and, when estimating the, average number of 
follow-up visits the consult would require, the physicians were 
asked to keep in mind that the patient would be sent back to the 
referring family physician as soon as possible. Surgery time, 
time for rounds, etc., was averaged over five days. 

The following pages list determinations for the various 
specialties 













GENERAL SURGERY 



The mean time available for dally outpatient care was determined as 
follows: 



540 minutes (0730-1630) minus the sum of the following: 



60 minutes 
48 minutes 
57 minutes 



240 minutes 
0 minutes 



Lunch . 

P.T. day averaged over 5 days. 

Leave and TDY; assume 24 days leave and 5 
days TDY are taken during the year * ap- 
proximately 2.5 days/month, averaged over 
5 days. 

Estimated weekly time spent on rounds on 
non-operative days averaged over 5 days. 
Estimated weekly time spent on rounds on 
non-operative days averaged over 5 days. 



135 minutes * Estimated mean time available for dally 
outpatient care. 



The consultative workload generated by the four family physicians in 
the hospital-based family practice clinic for the six-month period 
from February 1973 through July 1973 was determined as follows: 



30 minutes ■ Estimated time for the initial consulta- 
tive visit. 

60 minutes » Time for the estimated number of follow-up 
visits, four 15 minute visits. 



f, j 



. ■ ’ 



90 minutes ■ Estimated total work generated for the 
specialist for one consultation. 



i 



3,6 ■ Total number of consults from the 4 family 
physicians from February 1973 through July 
1973. 



3,240 minutes ■ Estimated total work generated by consults 
made from February through July 1973. 




* 

Determination of the number of family physicians one general surgeon 
can support. 

17,010 minutes * Total time available to one general surgeon 
for outpatient care for 6 months (assume 21 
weekdays per month) . 

3,240 minutes ■ Total work generated from the 36 consultations. 

The total work generated from consultations represents 19% of the 
available outpatient time. Therefore, each family physician will require 
4.75% of a general surgeon's available time (19% f 4 ** 4.75%). 

It is therefore estimated that one general surgeon can support 21 
family physicians (100% ■? 4.75% «= 21) if all of his outpatient time were 
devoted to seeing patients referred from family physicians. 






145 



- 






r 






ORTHOPEDICS 

The mean time available for daily outpatient care was determined as 
follows: 

540 minutes (0730-1630) minus the sum of the following: 

60 minutes ** Lunch. 

48 minutes ■ P.T. day averaged over 5 days. 

57 minutes ■ Leave and TDY; assume 24 days leave and 5 
days TDY are taken during the year * ap- 
proximately 2.5 days/month, averaged over 
5 days. 

192 minutes • Estimated weekly surgical time averaged 
over 5 days (4 half days per week) . 

12 minutes - Estimated weekly time spent on rounds on 
non-operative days averaged over 5 days 
(60 minutes — 1 day) . 

171 minutes - Estimated mean time available for daily out- 
patient care. 



The consultative workload generated by the four family physicians in 
the hospital-based family practice clinic for the six-month period 
from February 1973 through July 1973 was determined as follows: 

30 minutes - Estimated time for the initial consulta- 
tive visit. 

60 minutes ■ Time for the estimated number of follow- 
up visits, four 15 minute visits, 

90 minutes ■ Estimated total work generated for the 
specialist from one consultation. 

78 » Total number of consults from the 4 family 
physicians from February 1973 through July 
1973. 

7,020 minutes ■ Estimated total work generated by consults 
made from February through July 1973. 



146 



Determination of the number of family physicians one orthopedist can 
support. 



21,546 minutes ■ Total time available to one orthopedist for 

outpatient care for 6 months (assume 21 week- 
days per month) . 

7,020 minutes * Total work generated from the 78 consultations. 

The total work generated from consultations represents 33% of the 
available outpatient time. Therefore, each family physician will require 
8.25% of an orthopedist’s available time (33% ? 4 ■ 8,25%). 

It is therefore estimated that one orthopedist can support 12 family 
physicians (100% i 3.25% - 12) if all of his outpatient time were devoted 
to seeing patients newly referred from family physicians. 




i 

i 



s 




UROLOGY 



The mean time available for daily outpatient care was determined as 
follows: 

540 minutes (0730-1630) minus the sum of the following: 

60 minutes = Lunch. 

48 minutes = P.T. day averaged over 5 days. 

57 minutes * Leave and TDY; assume 24 days leave and 

5 days TDY are taken during the year = ap- 
proximately 2.5 days/month, averaged over 
5 days. 

144 minutes » Estimated weekly surgical time averaged 
over 5 days (3 half days per week) . 

24 minutes ■ Estimated weekly time spent on rounds on 
non-operative days averaged over 5 days 
(60 minutes — 2 days). 

207 minutes - Estimated mean time available foe daily 
outpatient care. 

The consultative workload generated by the four family physicians in 
the hospital-based family practice clinic for the six-month period 
from February 1S73 through July 1973 was determined as follows: 

45 minutes ■ Estimated time for the initial consultative 
visit . 

75 minutes * Time for the estimated number of follow-up 
visits, five 15 minute visits. 

120 minutes ■ Estimated total work generated for the 
specialist from one consultation. 

36 ■ Total number of consults from the 4 family 
physicians from February 1973 through July 
1973. 

4,320 minutes ■ Estimated total work generated by consults 
made from February through July 1973. 



148 







I 




t 





Determination of the number of family physicians one urologist can 
support. t j 

26,082 minutes ■ Total time available to one urologist for 
outpatient care for 6 months (assume 21 
weekdays per month) . 

A, 320 minutes * Total work generated from the 36 consultations. 

The total work generated from concultations represents 17% of the 
available outpatient time. Therefore, each family physician will require 
4.25% of a urologist's available time (17% ~ 4 family physicians = 4.25%). 



It is therefore estimated that one urologist can support 24 family 
physicians (100% i 4.25% ■ 23.5) if all of his outpatient time were 
devoted to seeing patients referred from family physicians. 





149 



1 




540 minutes (0730-1630) minus the sum of the following: 



60 minutes = Lunch. 

48 minutes = P.T. day averaged over 5 days. 

57 minutes ■ Leave and TDY; assume 24 days leave and 5 

days TDY are taken during the year = approxi- 
mately 2.5 days/month, averaged over 5 days. 

0 minutes * Estimated weekly surgical time averaged over 
5 days. 

60 minutes = Estimated weekly time spent on rounds on 
non-operative days averaged over 5 days 
(60 minutes daily) . 



315 minutes = Estimated mean time available for daily out- 
patient care. 



The consultative workload generated by the four family physicians in 
the hospital-based family practice clinic for the six-month period 
from February 1973 through July 1973 was determined as follows: 

45 minutes - Estimated time for the initial consultative 
visit . 

80 minutes » Time for the estimated number of follow-up 
visits, four 20-minute visits. 

125 minutes - Estimated total work generated for the 
specialist from one consultation. 

14 ■ Total number of consults from the 4 family 
physicians from February 1973 through July 
1973. 

1,750 minutes ■ Estimated total work generated by consults 
made from February through July 1973. 



9 



150 



Determination of the number of family physicians one psychiatrist can 
support. 



39,690 minutes - Total time available to one psychiatrist 
for outpatient care for 6 months (assume 
1 21 weekdays per month) . 

1,750 minutes = Total work generated from the 14 consultations. 

The total work generated from consultations represents 4% of the 
available outpatient time. Therefore, each family physician will require 
1% of a psychiatrist's available time (4% i 4 family physicians = 1%). 

It is therefore estimated that one psychiatrist can support 100 family 
physicians (100% ■? 1% *» 100) if all his outpatient time were devoted to 
seeing patients referred from femily physicians. 



/•. t 



f 



151 



4 



f 







I 

f 

















PEDIATRICS 



The mean time available for daily outpatient care was determined as 
follows: 



540 minutes (0730-1630) minus the sum of the following: 



60 minutes 
48 minutes 
57 minutes 



0 minutes 
60 minutes 



Lunch . 

P.T. day averaged over 5 days. 

Leave and TDY; assume 24 days leave and 5 
days TDY are taken during the year = ap- 
proximately 2.5 days/month, averaged over 
5 days. 

Estimated weekly surgical time averaged 
over 5 days. 

Estimated weekly time spent on rounds on 
non-operative days averaged over 5 days 
(60 minutes daily). 



315 minutes 



Estimated mean time available for daily 
outpatient care. 



The consultative workload generated by the four family physicians in 
the hospital-based family practice clinic for the six-month period 
from February 1973 through July 1973 was determined as follows: 

45 minutes « Estimated time for the initial consulta- 
tive visit. 

75 minutes *= Time for the estimated number of follow- 
up visits, five 15 minute visits, 

120 minutes = Estimated total work generated fro the 
specialist from one consultation. 

7 = Total number of consults from the 4 family 
physicians from February 1973 through July 
1973. 

840 minutes * Estimated total work generated by consults 
made from February through July 1973. 



1 



152 




Determination of the number of family physicians one pediatrician can 
support. 



39,690 minutes - Total time available to one pediatrician 
for outpatient care for 6 months (assume 
. 21 weekdays per month) . 

840 minutes = Total work generated from the 7 consultations. 

The total work generated from consultations represents 2% of the 
available outpatient time. Therefore, each family physician will require 
0.52 of a pediatrician's available time (2% ~ 4 family physicians = 0.5%). 

It is therefore estimated that one pediatrician can support 200 family 
physicians (100% ~ 0.5% = 200) if all of his outpatient time were devoted 
to seeing patients referred from family physicians. 



153 



INTERNAL MEDICINE 



The mean time available for daily outpatient care was determined as 
follows: 

540 minutes (0730-1630) minus the sum of the following: 



60 minutes 
48 minutes 
57 minutes 



0 minutes 



Lunch . 

P.T. day averaged over 5 days. 

Leave and TDY ; assume 24 days leave and 5 
days TDY are taken during the year = approxi- 
mately 2.5 days/month, averaged over 5 days. 
Estimated weekly surgical time averaged over 
5 days. 



90 minutes ■ Estimated weekly time spent on rounds on 
non-operative days averaged over 5 days 
(90 minutes daily) . 

285 minutes ■ Estimated mean time available for daily out- 
patient care. 



The consultative workload generated by the four family physicians in 
the hospital-based family practice clinic for the six-month period 
from February 1973 through July 1973 was determined as follows: 

45 minutes * Estimated time for the initial consulta- 
tive visit. 

45 minutes * Time for the estimated number of follow-up 
visits, three 15 minute visits, 

90 minutes ■ Estimated total work generated for the 
specialist from one consultation. 

79 ■ Total number of consults from the 4 family 
physicians from February 1973 through July 
1973. 

7,110 minutes - Estimated total work generated by consults 
made from February through July 1973. 



i 



v 



154 



Determination of the number of family physicians one internist can 
support. 



r 



35,910 minutes ■ Total time available to one internist for 
outpatient care for 6 months (assume 21 
weekdays per month) ., 

7, 11C minutes * Total work generated from the 79 consultations. 

The total work generated from consultations/ represents 20% of the 
available outpatient time. Therefore, each family physician will require 
5% of an internist's available time (20% i 4 family physicians = 5%). 

It is therefore estimated that one internist can support 20 family 
physicians (100% •} 5% ■ 20) if all of his outpatient time were devoted 
to seeing patients referred from family physicians. 










r- 

i 






j 



DERMATOLOGY 

The mean time available for daily outpatient care was determined as 
follows: 

540 minutes (0730-1630) minus the sum of the following: 

60 minutes * Lunch. 

48 minutes * P.T. day averaged over 5 days. 

57 minutes ■=* Leave and TDY; assume 24 days leave and 5 days 
TDY are taken during the year = approximately 
2.5 days/month, averaged over 5 days. 

0 minutes ■ Estimated weekly surgical time averaged over 
5 days. 

0 minutes * Estimated weekly time spent on rounds on non- 
operative days averaged over 5 days. 

375 minutes ■ Estimated mean time available for daily out- 
patient care 



The consultative workload generated by the four family physicians in 
the hospital-based family practice clinic for the six month period 
from February 1973 through July 1973 was determined as follows: 

30 minutes ■ Estimated time for the initial consultative visit. 

45 minutes ■ Time for the estimated number of follow-up visits, 
three 15 minute visits. 

75 minutes ■ Estimated total work generated for the specialist 
from one consultation. 

25 ■ Total number of consults from the 4 family 

physicians from February 1973 through July 1973. 

1,875 minutes ■ Estimated total work generated by consults made 
from February through July 1973. 



Determination of the number of family physicians one dermatologist 
can support. 

47,250 minutes ■ Total time available to 1 dermatologist for out- 
patient care for six months (assume 21 weekdays 
per month) . 

I,d75 minutes ■ Total work generated from the 25 consultations 



156 



r 



The total work generated from consultations represents 4% of the avail- 
able outpatient time. Therefore, each family physician will require 1% 
of a dermatologist's outpatient time (4% 7 4 family physicians - 1 %). 

It is therefore estimated that one dermatologist can support 100 family 
physicians ( 100 % 7 1 % m 100 ) if all of his outpatient time were devoted 
to seeing patients referred from family physicians. 







OPHTHALMOLOGY AND OTOLARYNGOLOGY* 

The mean time available for daily outpatient care was determined as 
follows: 

540 minutes (0730-1630) minus the sum of the following: 

60 minutes * Lunch. 

48 minutes ■ P.T. day averaged over 5 days. 

57 minutes * Leave and TDY; assume 24 days leave and 5 days 
TDY are taken during the year = approximately 
2.5 days/month, averaged over five days. 

120 minutes ■ Estimated weekly surgical time averaged over 
5 days (2 1/2 half days). 

30 minutes ■ Estimated weekly time spent on rounds on non- 
operative days averaged over 5 days (60 minutes — 
2 1/2 days). 

225 minutes - Estimated mean time available for daily out- 
patient care. 



The consultative workload generated by the four family physicians in 
the hospital-based family practice clinic for the six-month period 
from February 1973 through July 1973 was determined as follows: 

30 minutes - Estimated time for the initial consultative 
visit. 

45 minutes ■ Time for the estimated number of follow-up 
visits, three 15 minute visit. 

75 minutes ■ Estimated total work generated for the specialist 
from one consultation. 

73 ■ Total number of consults from the 4 family 

physicians from February 1973 through July 1973. 

5,475 minutes ■ Estimated total work generated by consults made 
from February through July 1973. 

Determination of the number of family physicians one ophthalomologist 
and one otolaryngologist can support. 

29,862 minutes ■ Total time available to one "EENT" specialist for out- 
patient care for 6 months (assume 21 week- 
days per month) . 

■ 1 

I 
'1 

\ 



158 





5,475 minutes * Total work generated from the 73 consultations. 

The total work generated from consultations represents 18% of the avail- 
able outpatient time. Therefore, each family physician will require 
4.5% of an "EENT" specialist's time (18% i 4 family physician - 4.5%). 

It is therefore estimated that one "EENT" specialist can support 22 
family physicians, or that one ophthalmologist and one otolaryngologist 
can each support 44 family physicians (100% z 4.5% = 22.2; 22.2 x 2 = 44.4) 
if all of their outpatient time were devoted to seeing patients referred 
from family physicians. 



1 











i*' I 

i 

*It was necessary to consider these together instead of separately, 
because their clinics are combined and referrals to either are made 
to EENT. 




159 



OBSTETRICS AND GYNECOLOGY 



The mean time available for daily outpatient care was determined as 
follows: 



540 minutes (0730-1630) minus the sum of the following: 



60 minutes 
48 minutes 
57 minutes 



192 minutes - 



12 minutes 



171 minutes - 



Lunch . 

P.T. day averaged over 5 days. 

Leave and TDY; assume 24 days leave and 5 
days TDY are taken during the year = approxi- 
mately 2.5 days/month, averaged over 5 days. 
Estimated weekly surgical time averaged over 
5 days. 

Estimated weekly time spent on rounds on 
non-operative days averaged over 5 days 
(60 minutes - 1 day). 

Estimated mean time available for daily out- 
patient care. 



The consultative workload generated by the four family physicians in 
the hospital-based family practice clinic for the six-month period 
from February 1973 through July 1973 was determined as follows: 



30 minutes ■ Estimated time for the initial consulta- 
tive visit. 

60 minutes • Time for the estimated number of follow- 
up visits, four 15 minute visits. 

90 minutes ■ Estimated total work generated for the 
specialist from one consultation. 

50 » Total number of consults from the 4 family 
physicians from February 1973 through July 
1973. 

4,500 minutes ■ Estimated total work generated by consults 
made from February through July 1973. 



160 



Determination of the number of family physicians one obstetrician- 
gynecologist can support. 

21,546 minutes * Total time available to one obstetrician- 
gynecologist for outpatient care for 6 
months (assume 21 weekdays per month) . 

4,500 minutes * Total work generated from the 50 consultations. 

The total work generated from consultations represents 21% of the 
available outpatient time. Therefore, each family physician will require 
5.25% of an obstetrician-gynecologist’s available time (21% r 4 family 
physicians - 5.25%). 

It is therefore estimated that one obstetrician-gynecologist can support 
19 family physicians (100% ~ 5.25% - 19) if all of his outpatient time 
were devoted tc seeing patients referred from family physicians. 



( I 



I 



y / 



APPENDIX L 
COST ANALYSIS FORMAT 

(Data for determination of cost per clinic visit) 



; 

u 

I 



162 




Average Coat Per Visit - Adjusted MPA + OHA 

Patient Workload 




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Adjusted MPA Cost - (MPA Cost)*fc*), where denotes percentage of time devoted to outpatient care 

Average Cost Per Visit - Adjusted MPA + OMA 

Patient Workload 



i 



LIST 


OF ABBREVIATIONS, ACRONYMS, AND SYMBOLS 




AMIC 


Acute Minor Illness Clinic 




AVG 


Average 




BE 


Barium Enema 




CBC 


Complete blood count 




CHAMPUS 


Civilian Health and Medical Program for 
Uniformed Services 


the 


DHEW 


Department of Health, Education, and Welfare 


DIFF 


Differential (blood count) 




DOD 


Department of Defense 




DPT 


Diphtheria, Pertusis, and Tetanus 




DT 


Diphtheria and Tetanus 




EKG 


Electrocardiogram 




ENT 


Ear, Nose, and Throat 




ETR 


Emergency Treatment Room 




EXAM 


Examination 




FAM PR HOSP 


Hospital Family Practice Clinic 




FAM PR NORTH 


North Fort Ord Family Practice Clinic 




FLU 


Influenza 




FPC 


Family Practica Clinic 




FPH 


Family Practice Hospital (i.e., Hospital 
Practice Clinic) 


Fam 


FPN 


Family Practice North (i.e., North Fort 
Practice Clinic) 


Ord : 


FSHTX 


Fort Sam Houston, Texas 




GI 


Gastrointestinal 




GMC 


General Medical Clinic 




GP 


General Practitioner 




HCSD 


Health Care Studies Division 




Hospital Clinic 


Hospital Family Practice Clinic 




HSC 


Health Services Command 




HX 


History (medical) 




IMC 


Internal Medicine Clinic 




I NT MD 


Internal Medicine 




INT MEDCN 


Internal Medicine 




IVP 


Intravenous Pyelogram 




Lab 


Laboratory 




LAT 


Lateral 




LS 


Lumbosacral 




MEDDAC 


Medical Activity 




MHCS 


Military Health Care Study 




MMR 


Mumps, Measles, & Rubella 




MOS 


Military Occupation Specialty 




MPA 


Military Pay, Army 




MFH 


Master of Public Health 





166 






1 



1 i 



NCOIC 


Noncommissioned Officer in Charge 


North Clinic 


North Fort Ord Family Practice Clinic 


OB/GYN 


Obstetrics and Gynecology 


OCHAMPUS 


Office of Civilian Health and Medical Program 
for Uniformed Service 


OMA 


Operations and Maintenance, Army 


OMB 


Office of Management and Budget 


OPV 


Oral Polio Vaccine 


OTSG 


Office of The Surgeon General 


PA 


Physician Assistant 


PA 


Posteroanterior (in radiology) 


PE 


Physical Examination 


PEDS 


Pediatrics , 


PREV 


Preventive 


PR 


Provider (used for medical provider other than MD — 
such as nurse clinician, Physician Assistant) 


RPR 


Reiter Protein Reaction 


RX 


Prescription 


SMA-12 


Trade name for auto analyzer used in medical lab 


SPSS 


Statistical Program for the Social Sciences 


SSN 


Social Security Number 


Z 


Summation Sign 


T.TOX 


Tetanus Toxoid 




PRIMARY DISTRIBUTION LIST 



Distribution: 

i 

Active Army: 

TSG, USA (5) 

DASG-HHC-C (3) 

Consultant, Amb Care, USAREUR (5) 

I 

Commanders , US Army MEDDACs and MEDCENs 

>Ft. Belvoir (1) 

Ft. Benning (1) 

Ft. Bragg (1) 

Carlisle Barracks (1) 

Ft. Ord (3) 

Ft. Polk (1) 

Ft. Sill (1) 

Ft. Bragg (1) 

The Surgeon General, USAF (1) 

The Surgeon General, USN (1) 

Additional: 

DDC (12), HSC (5), Stimson Library AHSUSA (1), 

Joint Medical Library, Offices of the Surgeons General, US Army/ 
US Air Force, The Pentagon, RM IB-473, Washington, DC 20310 (1) 
Joint Medical Library (AAFJML) , Forrestal Bldg., Washington, DC 
20315 (1)