Issues and Solutions in Accurately Measuring ClinicalFull-Time Equivalents

Elaine Gallagher, MBA and Dean Rapoza, MBA

As with private practices, measuring, assessing, and re-warding clinical productivity are critical to successfulmanagement of academic practices. Academic prac-

tices have the added challenge of simultaneous researchand educational activities.

Determining the proportion of effort devoted to clinical, re-search, and teaching activity for every faculty member allowspediatric department chairs to clarify roles and expectationsfor faculty. This clarity also benefits faculty, increasing the like-lihood of improved productivity and professional satisfaction.

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

In support of the AMSPDC, the Association of Adminis-trators in Academic Pediatrics (AAAP) annually producesa comprehensive survey of pediatric faculty compensationand productivity. Chairs and their administrators use thissurvey to guide decisions regarding faculty compensationand expectations for faculty clinical productivity. To providemaximally reliable survey data, the AAAP has recently fo-cused on reducing inconsistencies in measuring CFTEsamong participating institutions.

This article summarizes our journey in minimizing vari-ability in reporting of faculty CFTEs, in order to yield an ac-curate and optimally useful measure of clinical productivity.

Assessing the Problem

To validate the perception that survey respondents havebeen using different criteria to set CFTEs, we charted surveydata of wRVUs against CFTE. Review of data for neonatol-ogists demonstrated a lack of correlation between wRVUsand CFTEs (Figure; available at www.jpeds.com).

Work group discussions among interested volunteermembers of the AAAP revealed that some institutions havedefined CFTE on the basis of proportion of maximum clini-cal effort, and others have defined CFTE on the basis of pro-portion of 40 hours. Table I (available at www.jpeds.com)

AAAP Association of Administrators in Academic Pediatrics

AMSPDC American Medical School Pediatric Department Chairs

CFTE Clinical full-time equivalent

WRVU Work relative value unit

highlights the variability in productivity as measured bywRVU per CFTE between these two methods.

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

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

Current Proposed Enhancements

The work group has identified a handful of questions de-signed to explore other potential factors that might be asso-ciated with variability in clinical productivity and, in anyevent, would allow for closer comparison with like institu-tions. The group will propose to the AAAP membershipthat each survey respondent address the following generalquestions: type of organization (eg, free-standing children’shospital, hospital within a hospital, pediatric services withingeneral hospital, etc.); number of inpatient beds; number offaculty in the department; and number of CFTEs in the de-partment. These measures will be stratified into thirds, withthe levels for each third determined by the data received foreach particular criterion.

We will also seek consent from the AAAP membership torequest responses to 3 more queries that may be valuable infurther clarifying productivity expectations: Is nonphysicianprovider activity included in the reported wRVUs billed un-der a given physician’s name? The most clinical effort a phy-sician in this role would be expected to perform is ___outpatient sessions per week (sessions defined as equivalentto 4 hours). The maximum effort that providers in 24-hourservices (eg, emergency medicine, neonatology, pediatriccritical care, cardiac critical care, hospitalist care) would beexpected to attend is ___weeks of clinical service per year.

From the Department of Pediatrics, The Children’s Hospital of Philadelphia (E.G.) andthe Department of Pediatrics, University of Pennsylvania School of Medicine (E.G.),Philadelphia, PA; and the Connecticut Children’s Medical Center, Department ofPediatrics, University of Connecticut, Hartford, CT (D.R.)

The authors declare no conflict of interest.

0022-3476/$ - see front matter. Copyright ª 2010 Mosby Inc.

All rights reserved. 10.1016/j.jpeds.2010.07.030

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Perfect is the Enemy of Good

Increasing the length of the survey and the number of factorson which the data are stratified create challenges. The workgroup is also sensitive to requiring too much detail frommembers, thereby dissuading participation. A lower responserate would fundamentally reduce the reliability of the dataand defeat the purpose of requests for more detailed informa-tion. We cannot control for all variables, including somevalid factors such as service mix (eg, inpatient, outpatient,procedures) and patient acuity.

The AAAP will continue to balance ease of completion forsurvey respondents with the desire for more exact data andcategories. Administrators and chairs must be comfortablethat the data represent an effective tool to suggest further in-quiry, as much as to lead to conclusions and provide guid-ance. The data cannot provide definitive answers to whatare reasonable productivity expectations for a given institu-tion, division, or faculty member.

A New Definition of CFTE

The critical issue in calculating CFTEs remains creatinga standard approach to the numerator and the denominatorin the calculation. We settled on the following proposed def-inition as guidance for current survey respondents to mea-sure CFTEs for each of their faculty:

In general, the calculation of faculty clinical effort is universal: totalbillable clinical effort divided by total effort. It is understood that insti-tutions have different expectations for total effort. It is also understoodthat particular specialties within a given institution have different ex-pectations for total effort. For this survey, members should use their in-stitution’s accepted standard for each full-time position. For example,a physician who spends thirty hours per week, on average, on billableclinical activities and typically works sixty hours per week would beconsidered a 0.5 CFTE.

The definition further clarifies: ‘‘Clinical effort should berestricted to that portion of effort for which a billable profes-sional charge may be generated for the service provided.’’Thus, clinical administrative effort is not included in the nu-merator.

The concept of clinical effort as a proportion of total effortlessens the possibility of individual or inconsistent defini-tions of total expectations (eg, maximum clinical effort, 40hours, etc) serving as a source of confusion. This approachto clinical effort respects the individuality of institutionsand specifically acknowledges the factor of higher work stan-dards for a given physician as a legitimate variable in measur-ing clinical productivity. Inclusion of only those elements ofclinical effort that relate to billable activity is an equally im-portant aspect of the definition.

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

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Future Challenges to a More Perfect Survey

The exclusion of certain clinical activities provides more re-liable data by matching measurable work to the effort associ-ated with it. However, this approach will lead to exclusion ofa portion of clinical work for some faculty. For example, thesurvey will exclude any work that has no wRVU associatedwith it, such as contracted work whereby another party bills,capitation contracts, or global or bundled billing arrange-ments. To the extent that faculty participate in clinical activ-ities that are not billable, we will no longer measure thetotality of their clinical effort or productivity.

Exclusion of a portion of clinical work is problematic on twofronts. First, it leads to confusion for chairs if budgeted facultyfull-time equivalents differ from CFTEs, as submitted in thesurvey. To the extent that these numbers are reviewed by thirdparties such as deans, clarifying such data may be confusing atbest and troublesome at worst. Second, the prevalence of fac-ulty who provide clinical services that are not directly billedis significant and is growing. The proportion of nonbillable ac-tivities will increase further as we move into the era of healthcare reform. Finding a means to apply wRVUs to such nonbil-lable activities would allow their inclusion in future surveys.The AAAP will need to explore how best to guide respondentsin consistently applying wRVUs to activities that do not usewRVUs to generate revenue. The association will need toonly include what we can define accurately, to retain the integ-rity of matching productivity (wRVUs) with effort (CFTE).

The Brave New World

The introduction of Accountable Care Organizations and theattendant payment and care delivery reforms have the poten-tial to not only challenge the wRVU as the gold standard ofclinical productivity, but even to challenge the validity of thewRVU as a measure of successful clinical productivity.

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

The challenge of accurately measuring provider productiv-ity is clearly a journey, not a destination, for chairs, adminis-trators, faculty, and each of our organizations. The AAAP willcontinue to work diligently to diagnose and address prob-lems. We are confident that the AAAP will continue to pro-vide the most comprehensive and authoritative resource forbenchmarking pediatric subspecialty compensation and pro-ductivity in the future, regardless of the magnitude of chal-lenges that we face. We will continue to seek feedback aswe advance our work in this arena. n

Acknowledgments available at www.jpeds.com.

Reprint requests: Dean Rapoza, MBA, Connecticut Children’s Medical

Center, Department of Pediatrics, University of Connecticut, 282 Washington

St, Hartford, CT 06106. E-mail: drapoza@ccmckids.org.

Gallagher and Rapoza

Figure. Clinical productivity—neonatologists.

Table I. Effect of alternate measures of total effort

Institution A Institution B

Clinical denominator Full work week(40 hours)

Maximum clinicalhours (24 hours)

Expected clinical hours 24 h/wk 24 h/wkCFTE 0.60 1.00Total wRVUs 4000 4000wRVUs/CFTE 6667 4000

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

Table II. Effect of inclusion of nonbillable time

Institution A Institution B

Clinical denominator Work week (40 hours) Work week (40 hours)Direct patient

care; billable20 h/wk 20 h/wk

On-call from home 10 h/wk 10 h/wkClinical research session 4 h/wk 4 h/wkCFTE 0.50 FTE 0.85 FTETotal wRVUs 3000 3000wRVUs/CFTE 6000 3529

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

Table III. Differing relative value unit reference years

Volume(same)

InstitutionA wRVUs

InstitutionB wRVUs

RBRVS Ref Year 2009 201099201 NPV–Level 1 100 0.45 0.4899202 NPV–Level 2 300 0.88 0.9399203 NPV–Level 3 600 1.34 1.4299204 NPV–Level 4 300 2.30 2.4399205 NPV–Level 5 100 3.00 3.17wRVUs/CFTE 2103 2225

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

November 2010 NOTES FROM THE AMSPDC

Issues and Solutions in Accurately Measuring Clinical Full-Time Equivalents 698.e1

Acknowledgments

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

Mark Amox, University of Arkansas for Medical Sciences; DennyBardeau, Alberta Children’s Hospital; Gail Cohen, University of Col-orado Children’s Hospital; Mary Corcoran, Stanford University Schoolof Medicine; Marcene Dickes, The Children’s Mercy Hospital; DennisHarris, University of Miami Miller School of Medicine; Jon Hayes,University of Oklahoma Health Sciences Center; Anna CarolHerman-Giddens, University of North Carolina School of Medicine;Elizabeth Hickle, MetroHealth Medical Center; Jackie Jew, Universityof California, San Francisco; Lori Mackey , University of CincinnatiCollege of Medicine; Tom Malin, Medical College of Wisconsin; Con-stance Marr, University of Maryland School of Medicine; Jim Mor-gridge, Northwestern University, Feinberg School of Medicine; BillyNewton, Duke University School of Medicine; Gwen Pfeifer, Duke Uni-versity Medical Center; Chuck Rydzy, Johns Hopkins University Schoolof Medicine; Patrick Shumaker, Wayne State University School ofMedicine; Marsha Wendt, University of Wisconsin School of Medicineand Public Health; Lisa Wohlert, Yale University

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