Does Managing Your Schedules Keep You Awake At Night?

Throughout my career, there was often something on my mind keeping me awake as a lay my head down at night, usually a work-related issue. Some thoughts that crept into my mind were…
  • Did I handle that personnel issue the best way possible?
  • Oh no! I forgot to call that physician back!
  • How am I going to keep Mr. Always-Arrives-Early from becoming upset at the staff when they don’t put him on before his ontime.
  • How am I going to meet the budget??
  • The surveyors have been doing their rounds, is one of my clinics next?
  • Patient satisfaction surveys go out next week, what are my patients going to say about the care they are receiving?
That last one was particularly bothersome as I knew that one of the biggest complaints that patients state on these surveys is not getting on at their on-time. These are the thoughts that create nightmares!  (just in time for Halloween!) I’m sure that a part of the reason they kept popping up in my mind is that I did not fully feel in control of them! Do any of these thoughts sound familiar to you? If so, you are not alone! So many people that I talk to have very similar thoughts keeping them up at night. I often tease that the RN after my name meant that I was Really Nice. That was true, and I will add in for me that I was not a huge fan of conflict in my early managing years. I wanted to make everyone happy, my patients, their families, the staff and physicians. As a clinic manager, I knew that it was my responsibility to ensure the safety and satisfaction of my patients and staff. I learned that one of the best ways I could do that was to maintain control over both patients and staff schedules.

Why is managing the patient and staff schedule so important?

(1) Patient Safety / Quality of Care

When you walk out onto the treatment floor during a turnover, do you hear multiple alarms? Are they alarming for longer than during a non-turnover time? Are all your staff busy, everybody with their heads down? Many will call this chaotic. I will add that I also consider a “chaotic” turnover like this unsafe. Like many of you I, too, am a believer in patient-centric care. I also believe that there needs to be a person, preferably multiple people, in an organization and each individual clinic that are ensuring that the ability to provide safe and quality care are paramount, and that care is being provided even when that means not being able to meet the patient’s exact desire. For example:  Let’s say you have a 12-station clinic and work with a 4:1 PCT to patient ratio. You have three PCT’s coming in one hour before the first patient’s start time of 0600, and a Charge RN arrives 30 minutes prior. You have an open spot at 0620, but your new patient wants 0700. If none of your other patients currently at 0700 want to move to the 0620, do you find yourself saying, “Well, I will give my new patient the time they want, and the nurse can put them on.” Great! You accommodated the patient’s desire, but at what cost? You now have four patients going on at 0700 and only three direct patient caregivers (PCT’s). COULD your Charge RN initiate the treatment? Yes, I’m guessing they are capable. The better question you may want to ask yourself is SHOULD your Charge RN initiate or discontinue a treatment? My thought is no. And the main reasons are that it becomes an unsafe setting for your patients and I want to see the RN’s have improved job satisfaction and be able to have the time they need to provide the type of quality care that they want and need to be able to provide. Many RN’s have shared their frustrations with having a nursing license and spending more of their time assisting with patient put-ons and take-offs. Then once turnover is over, they still have their RN duties that they had to stop doing to get this done. Many add in that much of their overtime hours at the end of the day are for documentation that they could not get done during their shift. When your Charge RN’s are putting patients on or taking them off alongside the PCT’s, they are not available for emergencies, unable to provide oversight or to help troubleshoot because their heads are down. This is not to say that an RN should never be assigned a pod or a patient, rather, my example stresses the importance of having your RN’s that are not assigned a pod be unencumbered so that they are available for their RN duties.

(2) Efficient Care / Meeting Budgets

Safety is always the number one goal. Caregivers do not choose to work in dialysis with a desire to provide poor quality and unsafe care. We are just not wired that way. As a healthcare organization, your leadership understands the importance of you being able to give and for your patients to receive high quality and safe care. Poor care and the resulting outcomes are NOT good for a business’ bottom line or for patients or unhappy staff (high turnover). While it may feel there is an occasional disconnect between organizational leaders and the clinic staff, this is what it means to provide efficient care. Organization leaders are often looking at actual numbers worked and treatment (revenue) numbers after the fact. They may be giving the clinic manager feedback that their costs are too high, but to the clinic manager and staff, they seem VERY busy and feel understaffed.

How can you solve this?

It truly goes right back to providing safe/quality care! If your patient schedule has a smooth workflow in each pod (only one patient going on the machine or coming off the machine at one time in a pod, and the direct patient caregiver assigned to the pod has the time built into the schedule that allows them to meet the needs of each patient (especially higher acuity patients), you will be set up to provide efficient care. Costs go up when staff are added for busy turnovers instead of smoothing out the schedule, or the nurse must stay extra hours to complete their work because they were needed to help with a busy turnover. Thanks for reading!  Now it’s your turn.   We’d love to hear from you!
  • What techniques have worked for your organization when it comes to not accommodating the exact time requested?
  • How have you created a culture of safety in your clinic in which letting a patient know that the exact time they want is not possible?
  • Have you felt the need to add staff to accommodate a busy turnover? Could the issue have been solved by smoothing out the work, allowing for the assigned caregiver to provide the care independently?

Why Is the Patient Schedule So Important and Who Should Be Responsible for It?


In all my years working in dialysis, I have not come across any other management issue that impacts so much in our clinics than the patient schedule.  Why is it so important to you?

 Each and every dialysis clinic’s existence depends on the satisfaction of its patients for its success. It’s no secret that patients can be demanding, and it’s not just the results of their medical treatment that matter to them. Their experiences and interactions with your clinic and your staff have an impact as well. As you want to keep the patients that dialyze in your clinic satisfied and healthy and the staff feeling that they can provide quality care, there are a few things you need to keep in mind.

  • Ensuring that your patient schedule allows the necessary time for the patient to receives their full treatment and for the nurses to have time to review labs and monitor vascular access impacts clinical outcomes.
  • If you want your staff to treat your patients right, you need to provide them with an ideal work environment. This means giving them the time needed to provide the care you are expecting of them. This time is not the same for every patient.  Some patients take 15-minutes to put on the machine and others take 20-minutes.  Because of these different acuity needs, your patient schedule should not be set up treating every patient the same way.
  • Giving the patients’ the times that they prefer and getting them on at their scheduled time impacts the patient satisfaction surveys. When the time that they prefer is not available, how you handle communicating that to the patients, discussing and documenting it in your QAPI Meetings as not getting the time they desire would be considered a patient grievance and resolving it to a level that is either acceptable to the patient or documented as to why you are unable to accommodate the patients specific request is key. Keep in mind, it is not a requirement to give the patients the exact time or chair that they desire.  It is however a requirement through Medicare’s Conditions for Coverage to document and address patient grievances.
  • The staff feeling that they have the time needed to provide quality care, getting out at their scheduled time, and getting the hours they were hired to work impacts staff satisfaction. When the patient schedule is chaotic with pods to busy for the caregiver assigned to work independently and the nurses have to set aside their nursing duties to assist with turnover on a regular basis, their job satisfaction declines and overtime is often required to get their duties completed.
  • Understanding how treatments, missed treatments and staff hours worked impacts the bottom line.

So with all that said, I’m going to share why I feel it is the manager’s ultimate responsibility.  Think of this.  If you were the owner of a prominent, well-respected spa/fitness center, who would you want to be ensuring that safety and quality standards were met or exceeded?  Who would be your go-to person if you were receiving feedback that those standards were sub-par? Would it be the person checking clients in, the massage therapist, the trainer or would it be the manager?

As we have worked with clinics all over the U.S., we have seen the responsible party being everything from the Clinic Manager, Nurse Manger, the Social Worker, Patient Care Technician, or the Administrative Assistant.  We have also seen in a few instances that schedules were managed by an offsite scheduler whose only job is the patient schedule for multiple locations.  I often get asked which the best is, and my answer is always the same.  The ultimate responsibility of the patients and staff schedules belongs to the manager.  They are the CEO of their business, the dialysis clinic.

Scheduling often takes a village to get it right.  To go from a good schedule to a great schedule, getting input from the different roles in the clinic is extremely valuable!  The nurse manager (if a different person then the clinic manager) reviews the outcomes and gets orders for any necessary duration changes. The Social Worker is aware of transportation or other issues that may make a certain time or days difficult for patients.  The Patient Care Technician knows which patients are not best to sit next to each other and which patients may take more time than others or have higher acuity needs which impact the amount of time that the caregiver will need to be with them. The Administrative Assistant may also be aware of transportation issues and is often the “ear” of what patients may be unhappy about and discussing in the lobby.  Each of these roles has valuable information, but none have ALL the information needed to create the best patient schedule.

It is for those reasons that I feel that it is the responsibility of the clinic manager to pull all that information together and create and maintain the patient and staff schedules.  Could another person in the clinic be assigned the task?  Yes, and they could do a good job with it, but even in those cases, heavy oversight must be there by the person ultimately responsible — the clinic manager.

We’d love to hear from you!

  • In your clinic/organization, who (what role) is responsible for creating and maintaining the patient and staff schedules?
  • If your clinic is not meeting any of their goals, whether that be clinical, satisfaction or financial, have you investigated how they are scheduling and how that may be impacting the clinic in not being able to meet those goals? What did you see?

Even a Bad Plan Is Better Than No Plan

ScheduleWise - Hannibal A-Team

“I love it when a plan comes together!”
— Hannibal Smith

Here’s an often heard bit of conventional wisdom “…even a bad plan is better than no plan at all.” While I love to be the contrarian, I have difficulty arguing against this sound bit of logic.

So how can we exemplify that with what we love to talk about most in this blog… how about the patient schedule?  🙂

Basically, your patient schedule is your plan. So rewording our conventional wisdom, it would go like this… “Even a bad patient schedule is better than no patient schedule at all.”

And to this, I would heartily agree! Do you?

Believe it or not, some clinics do not even have a true schedule! What they have is a first-come first-serve setup by shift. For example, first shift starts at 6:00 AM. So all first shift patients should arrive by 6. There are only so many patient care staff, though, so not all patients would actually go on at 6:00 AM. Instead, they are put on in a first-come, first-serve basis. (note: some of you may counter that this is a schedule… but I have to draw the line somewhere, my friends!)

As you can imagine, competition is fierce! So a significant number of patients arrive as early as possible. They might even be waiting outside the facility doors before it even opens so they can get the coveted 6:00 AM put-on times.

And assuming a 2-shift clinic (you could hardly manage a 3-shift clinic in this way), the same thing happens all over again for the second shift. Assume staff takes lunch together. And assume an average treatment duration of 4.0 hours. Thus, the second shift would start sometime around 12:00 or 1:00 PM.

Does this sound good to you?  It depends on what you do at the clinic, I suppose. But it is not a recipe for long-term success given the dwindling reimbursement rates and higher costs in just about every category from supplies to staff.

Here are some of the real problems with this type of plan:

  • There is no consistency day-to-day. Different patients show up each day and potentially get put-on in a different order. Every day (every shift even!) is a new adventure for the staff. This may be appealing to some… but this level of variability is not ideal for a clinic or a business. There is no feedback loop for you to make changes day-to-day to improve the workflow. It’s ever-changing!
  • It does not consider the manageability of each pod by its technician. All patients going on one by one is fine… but when do they come off? Several patients could come off at the same time. That takeoff time could get highly chaotic for the technicians and patients.
  • It does not consider the effectiveness of the nurse to do pre- and post- assessments in a timely manner. Again, while the pre-assessments may be somewhat orderly… the post-assessments could get really hectic.
  • It is tough to gauge patient satisfaction trends with no schedule. Obviously a survey might give you insight. My main assumption is that patients would prefer consistency in their schedules. It is tough to make any predictions on patient satisfaction.
  • It is just as tough to predict staff satisfaction. The day-to-day variability will attract certain types of staff who can handle it. They may like the long breaks. The best indicator here would be retention of your staff to understand how effective this method of scheduling is.
  • It is not a productive/efficient way to treat patients. Whereas the previous two bullets were uncertain, this one is clear. This type of plan is hardly a recipe for success along the cost front. It is just too much unproductive time… that is, time when staff is on the clock, but no patients are receiving treatment.
  • Ideally, we group tasks such that we minimize the time for turnovers, and we find time for lunches while patients are being treated. These costs directly hit the bottom line of the clinic, and a plan like this especially hurts the viability of the smaller independent dialysis clinics.

So the moral of the story is:    No Schedule = No Plan

And if you believe the conventional wisdom, then you believe that even a bad patient schedule, is better than no schedule at all.

Remember, even with a bad plan, you have a mechanism for feedback and revision. We learn from our mistakes. Without a plan, we tend to repeat our mistakes too often. Instead, having a plan, even a bad plan, forces us to think and reason about the problem more, instead of venturing into the unknown each day.

Here are some simple questions you can ask yourself to get feedback from your plan/schedule (not an exhaustive list):

  • Did the patients arrive on-time?
  • Did your schedule allow the technician to put the patient on at their scheduled on-time?
  • Were your nurses able to get their specific work tasks complete?
  • Did you meet your productivity goals?

Revise the plan/schedule:

Based upon the data from your feedback, you can tweak your bad schedule to make minor improvements each day.

Rinse and Repeat:

This is not a one-trick pony. A feedback loop is just that… a loop! This is what we talked about before in “The schedule is a living, breathing document!” You must manage it frequently.

After all, even a well-oiled, fine-tuned machine needs an oil change and a tune-up after continued use.

A few iterations with this simple process and it will become second nature. And you’ll love it when your plan finally comes together, too!

The Patient Schedule is a Living Document

ScheduleWise - Living Document

Having been in hundreds of clinics, sometimes what we’ve seen getting passed off as “tools” are nothing more than bullet points and platitudes and are just as often forgotten as soon as they are mentioned or read.

Here’s one: The patient schedule is a living document that must be managed daily.

It’s one of those easy to say phrases that just rolls off the tongue, but unfortunately is not practiced, at least not with respect to “managing” the schedule, and certainly not daily, and by the way, what the heck is a living document?

So let’s break this down so we understand.

Patient schedules change.  And they change fairly regularly.  Each week, physicians changes orders, transportation needs change for the patient, new patients get added to the schedule, and some patients expire or transfer, so they get removed from the schedule, et cetera, et cetera.

So when ANY of the above things happen, the schedule must be updated.  And while this is a relatively simple activity, we often don’t consider all of its ramifications.  Even a simple duration increase of 15 minutes can have a tremendous impact on the schedule.

What is the effect of these changes to the schedule?  Actually, let’s start with WHO will make the change?  Wait, can we even assume the change was made to the schedule?

Orders sometimes get changed in the Electronic Health Record, but not on the schedule itself.  That can make for an interesting and hectic day when your staff are expecting one thing based on the schedule, and then surprised that Mr. Jones’s treatment will be run 15 minutes longer, and Mrs. Brown is going to be angry because she doesn’t start on time.

The possibilities can get ugly if the schedule isn’t updated at all.  So ok, let’s say the change was, indeed, made both in the EHR and on the patient schedule.

So then we get to the question of WHO updated the schedule?  I’d like to assume that the person updating the schedule has the bigger picture in mind, so that they ensure patient safety and pod management is considered when changing schedules… every clinic has a scheduling guru.  But sometimes we just need to ensure that the change is made so it doesn’t get lost amid the 10,000 other tasks each day.  So the non-guru makes the necessary changes to durations and on-times, and hopefully communicates it to the “schedule guru” to make any other necessary adjustments.

And so finally we get back to the original question, what is the effect of these schedule changes?  Effect on what exactly?  There are two considerations:

  1. the effect on the patient in terms of transportation and any change in the patient’s on-time or chair;
  2. the effect on the staff in terms of providing them a schedule to be able to manage their pod safely and effectively.

Most of the time, we consider the effect on the patient’s transportation, that is, we ensure that either the new on or off-time does not affect their transportation constraints, or we communicate with the transportation company to make the necessary changes.

Where we often fail with the schedule change is on the staff side of things.  We assume
the technician will be able to adjust accordingly to the new on or off-time.  And we do not give enough consideration to the altered workflow when turning over the pod with this new off-time.  If we don’t consider the impact to the technician’s workflow, then we are doing a disservice to our staff.

Here are some examples of the potential change in workflow for the tech.  First off, we want to ensure that increase in Mr. Jones’s duration doesn’t create a new off-time that would overlap the next patient in the chair, Mrs. Brown.  We need to ensure that at least 45 minutes is available for turnover the chair (a topic of debate and one we will give attention to in another post).  And of course, Mrs. Brown isn’t going to be happy that her time is changed. Again, a later topic. =]

Other possibilities are that the new off-time could now coincide with the off-time of another patient in the same pod.  So how would the tech handle this situation where two patients come off at the same time. It’s stressful.  And leads to cutting corners on policies and procedure, or cutting times.  Often, it leads to getting help from the nurse, who is now torn away from his or her duties to manage a takeoff.  And don’t think the patients don’t feel that stress.  They are now being cared for by someone who is needlessly stressed. I must humbly offer that this is not putting our best forward for optimal care.

OR the new off-time could coincide with another put-on.  All the same things that I enumerated above could come into play.  It’s really a no-win situation for all involved.

Once you understand the potential pitfalls, it is easy enough to avoid them. How? By shuffling things around.  That is, changing some patient times or their chairs, which is akin to opening Pandora’s Box.

This is where I get to stress that it is incumbent on the clinical manager to make these necessary changes for the safety and quality care of our patients, as well as to provide a manageable pod for our direct patient care staff.  In short, to MANAGE the patient schedule.  If we do not, we pay the price.  Patient satisfaction decreases as their on-times become meaningless, and they have no choice but to have stressed out staff caring for them.  And staff satisfaction goes down as turnovers remain hectic which leads to a decrease in staff retention.  The schedule is connected to everything.  So clinical managers must make the hard changes up front and be confident that this is for the greater good for optimal care.

For our sake, and the length of this post, today is a happy day, and we will assume that the change to Mr. Jones’s treatment duration caused no issues.  Sometimes things work out just fine like that.  Not often, but sometimes. =]

Just remember that the schedule must be MANAGED daily.  Each day the clinical manager must ensure that his or her direct patient care team can handle their patient load in a safe manner and have the time to deliver optimal care.

I’m glad you took the time to read about the patient schedule as a living document.  Never again will you be able to hear this phrase and be unaware of all that it entails.  A simple duration change can have a ripple effect through a pod.  Just imagine when there are three and four changes!

Please share your own stories or comments below.  And if you don’t agree with anything I’ve written above, please share that too.  It is only through open dialogue that we come to understand one another.  Let’s just be respectful while doing it.

–Mark Sessoms