Question from the field: “Should I set up a one size fits all schedule?”

Question from the field: “Should I set up my patient schedule with all four-hour slots so that I can easily move my patients from one spot to another? Kind of a one size fits all schedule?”

I dare to say that one size fits all philosophy is not true for clothes and definitely not true for meeting individual patient needs when setting up your patient schedule!

Every dialysis patient has the same needs, correct? They are there because their kidneys are not functioning at a level that can sustain life, so the same set-up and treatment should work for all. If we believe that to be the case, then providing care for them should be the same, right??

I think that we can agree that the belief that every patient is the same and should receive the same treatment is just a foolish thought. All patients with high blood pressure are not treated with the same medication or the same dose, and dialysis prescriptions are no different. Patients are scheduled for treatment durations based upon the current function of their kidneys, body size and other medical parameters. The prescribed treatment time changes based upon lab results, type of vascular access and physician assessment of what the patient needs.

If we stop there, plugging in only the  prescribed treatment time into our patient schedule, we are short-changing both the patients and the caregivers.  What more is there to consider, you may be thinking?  You’ve taken the time to work in ontimes between treatment starts (maybe 15 minutes) and time between an off in one chair and an on in the same chair (maybe 45 minutes). This may appear to  create a smooth schedule, but it will still cause the staff and patients a lot of frustration as one of the most important pieces of quality scheduling is missing — adding in time for patients’ individual needs, or their acuity needs!

Over the years, we have performed many time studies to better understand the workflow of the patient schedule.  We repeated those studies after Medicare’s 2017 ruling of vacating the station before disinfection and setting up for the next patient. Our studies showed that when staff follow their policies, it takes an average of 15 minutes to put a patient on and 15 minutes to take them off. The 15 minutes to initiate the treatment includes 10 minutes before blood hitting the dialyzer and 5 minutes post-treatment initiation. The 15 minutes for taking patients off was all after the alarm signaled that the treatment duration was met.  Let’s take a look at an example that shows a pod of patients that are all allotted 15 minutes to put on and 15 minutes to take off.

Example 1: All patients seen with equal needs
  • Blocks of time (orange line) in which the caregiver (green line) is putting on or taking off patients.
  • If all patients truly take 15 minutes or less for care, this schedule works

The word bolded above, “average”, is key. Patients have different needs, you know this, but you may not have considered it relative to how the patient schedule is set up and that more time may be needed between some patients while no extra time is needed between others. You may be able to meet those needs in that 15-minute span to put a patient on, but that same easy put on is a long bleeder at the end of treatment and needs 25 minutes after treatment before they are ready to vacate the station.  (See Example 2)

Example 2: Impact of acuity
  • As Mickey Mouse requires 25 minutes to be taken off, the caregiver is still busy providing his care when Donald Duck is scheduled off.
  • In these cases, something gives. The caregiver either asks for help (often the RN) or add/cuts time to patients’ prescription durations, which means that treatment may be against a physician’s order.

Thinking about your own patients, you know those who need additional time because they are in a wheelchair, a stretcher, possibly requiring a Hoyer for transfer.  But there could be others who are not so obvious and that’s where your PCT’s and RN’s come in. Ask them!  Engage them in the schedule set up and revising.  Create an environment in your clinic in which the caregivers share which pods are challenging, review each patient’s acuity needs in that pod and make adjustments to your schedule.

By taking the time to understand which patients need additional time, and accounting for that time, your smooth appearing schedule becomes a truly smooth, functioning schedule where the staff now have the time to care for each patient based on their individual needs.

Join the conversation! We’d love to hear from you!

  • Have a question you would like us to answer in a future post? Just ask!
  • In your clinics/organization, how do you account for patients that need additional time on your patient schedule?
  • How often do you review your schedule to ensure it is up to date with treatment durations and acuity needs

Acuity — One Size Fits All???

Question from the field: “Should I set up my patient schedule with all four-hour slots so that I can easily move my patients from one spot to another?  Kind of a one size fits all schedule?

I dare to say that one size fits all philosophy is not true for clothes and definitely not true for meeting individual patient needs when setting up your patient schedule!

Every dialysis patient has the same needs, correct? They are there because their kidneys are not functioning at a level that can sustain life, so the same set-up and treatment should work for all. If we believe that to be the case, then providing care for them should be the same, right??

I think that we can agree that the belief that every patient is the same and should receive the same treatment is just a foolish thought. All patients with high blood pressure are not treated with the same medication or the same dose, and dialysis prescriptions are no different. Patients are scheduled for treatment durations based upon the current function of their kidneys, body size and other medical parameters. The prescribed treatment time changes based upon lab results, type of vascular access and physician assessment of what the patient needs.

If we stop there, plugging in only the  prescribed treatment time into our patient schedule, we are short-changing both the patients and the caregivers.  What more is there to consider, you may be thinking?  You’ve taken the time to work in ontimes between treatment starts (maybe 15 minutes) and time between an off in one chair and an on in the same chair (maybe 45 minutes). This may appear to  create a smooth schedule, but it will still cause the staff and patients a lot of frustration as one of the most important pieces of quality scheduling is missing — adding in time for patients’ individual needs, or their acuity needs!

Over the years, we have performed many time studies to better understand the workflow of the patient schedule.  We repeated those studies after Medicare’s 2017 ruling of vacating the station before disinfection and setting up for the next patient. Our studies showed that when staff follow their policies, it takes an average of 15 minutes to put a patient on and 15 minutes to take them off. The 15 minutes to initiate the treatment includes 10 minutes before blood hitting the dialyzer and 5 minutes post-treatment initiation. The 15 minutes for taking patients off was all after the alarm signaled that the treatment duration was met.  Let’s take a look at an example that shows a pod of patients that are all allotted 15-minutes to put on and 15-minutes to take off.

The word “average”, is key. Patients have different needs, you know this, but you may not have considered it relative to how the patient schedule is set up and that more time may be needed between some patients while no extra time is needed between others. You may be able to meet those needs in that 15-minute span to put a patient on, but that same easy put on is a long bleeder at the end of treatment and needs 25 minutes after treatment before they are ready to vacate the station.  (see Example 2)

Thinking about your own patients, you know those who need additional time because they are in a wheelchair, a stretcher, possibly requiring a Hoyer for transfer.  But there could be others who are not so obvious and that’s where your PCT’s and RN’s come in. Ask them!  Engage them in the schedule set up and revising.  Create an environment in your clinic in which the caregivers share which pods are challenging, review each patient’s acuity needs in that pod and make adjustments to your schedule. By taking the time to understand which patients need additional time, and accounting for that time, your smooth appearing schedule becomes a truly smooth, functioning schedule where the staff now have the time to care for each patient based on their individual needs.

Join the conversation! We’d love to hear from you!

  • Have a question you would like us to answer in a future post?  Just ask!
  • In your clinics/organization, how do you account for patients that need additional time on your patient schedule?
  • How often do you review your schedule to ensure it is up to date with treatment durations and acuity needs?

Productivity! Fun with Numbers! (Part 2)

In my previous post on Productivity, I reviewed what Productivity is and a simple calculation of productivity equaling half of the average treatment duration in your clinic. This provides a ‘good’ productivity goal for organizations to use in determining an appropriate clinic-specific goal.

In this post, I will be going into more detail on how a productivity number relates to dollars and the impact that can be made by improving your productivity by as little as 0.1 hours/treatment.

I often get asked…

Question:      What’s the big deal about a productivity number of 1.7 versus 2.0?
Answer:         A lot! 

Let’s take a look at just how much that could be in dollars. What I’ll be describing is an
oversimplified way of looking at it, but I believe it will help make sense of something that can be quite complicated. 

For this example, I will use a $25.00 blended rate (RN=$35 and PCT $15 is roughly a $25 blended rate). Your hourly rates may give you a slightly different number, but $25 is good enough for our example.

  • Every 0.1 hr/tx improvement saves $2.50/tx.

Here’s the math (don’t be scared!)

Back to our original question, if your current productivity is 2.0 hrs/tx and you get it down to a 1.7 hrs/tx,  it represents a 0.3 hours/tx savings.  Or $7.50 per treatment! 

Now take that dollar savings and multiply it by your average weekly treatment count, and you can see how quickly it adds up!  Assuming you do 300 tx/wk.  That comes out to saving $2,250… each and every week! 

And here are the monthly and annual potential savings:

  • $2,250 per week x 4 weeks = $9,000/month
  • $9,000 per month x 12 months = $108,000/year

The below table summarizes these findings:

WOW!  Right?!?!

When I first show our clients these numbers, their first thought often is, does this mean I have to cut staff?  If your organization is happy with its bottom line, then the answer is no. 

For most clinics/organizations, labor is their greatest expense, so if you’re looking to find cost savings, right-sizing your staff is the greatest opportunity to meet that goal.   As you have seen in this post, even a 0.1 improvement can improve the financial health of your clinic/organization! 

In my next and last post on this lovely topic, I will share a few ideas that you can implement to improve your clinic’s productivity.

We’d love to hear from you!

  • Did this help you get a handle on productivity calculations? 
  • Were your surprised what a difference in your clinic’s bottom line could be made by simply improving your productivity by 0.1?
  • Has this information been helpful?
    • If so, please feel free to share!
    • If not, please let me know how your organization looks at it differently.
    • We’re always interested in learning how we can best support the renal community!

Productivity! Does the word itself stress you out? (Part 1)

Productivity, this simple word is anything but simple and often causes hearts to race, stomachs to turn or we simply want to ignore it and hope that it goes away.  However, it’s a vital piece of information to help us understand ‘how much staff do I need’?  ‘Am I really short or am I over staffed?’

Part of the distaste for productivity could be related to not fully understanding it. 

It’s just some number given by finance, and what do they know about running a clinic?  Does it feel like you have no control in meeting the goal, if you even understand the goal to begin with?  Many people I have had the opportunity to work with are surprised at how easy it really is to understand, when it’s explained in terms of what it means to the daily operation of the dialysis facility and then equally find it easy to implement changes that can get them to their goal, or at least heading the right direction. 

Alright, time for some full disclosure. Like many of you reading this, I went to school for nursing. I cared about people, loved science and wanted to better understand how I could take care of others and bring them back to optimal health. After working as a staff and charge RN for a few years in dialysis, I became the manager of a clinic.  When I first started in the role the responsibilities were so different. At first, it was good! The main duties included monitoring outcomes, survey readiness, hiring (and occasionally terminating) staff and my favorite part, team building.  

As you may have noticed, there was no mention of running a multi-million-dollar business, which our clinics are. There were no business classes in my nursing school to help me understand P&L Statements, EBITDA, doing annual budgets, the bundle, payers, QIP and achieving a productivity goal. HECK! At first, I didn’t even know what made up the productivity goal. It was just a number I was supposed to achieve, and I was told every month (after the fact) if I made it or not. AND, there were no useful tools out there to help me figure it out proactively. It was very frustrating, to say the least!

OK, enough about me!  My goal here is to give you a better understanding of productivity, both from the perspective of what it is and how you can manage to it!   I recommend sharing this post with your entire team.  The more everyone understands it, the more successful you will be in meeting it… it really is a team effort!

It’s important to first state that meeting productivity does not ever mean that you compromise your quality of care in any way!  Quality and safety remain the first priority always!  If you are interested in a full presentation on this topic, you can go to the National Renal Administrator Association (NRAA) Education Station website https://www.pathlms.com/nraa and watch/listen to my presentation, “Understanding and Achieving Productivity”, which I presented at the Fall 2016 NRAA meeting and in February 2016 as part of the NRAA Webinar Wednesday series. https://www.pathlms.com/nraa/courses/2091/video_presentations/23511

To start this discussion, I would like to take a couple of minutes to explain the difference between the cost per treatment ($/tx) and productivity, which is typically measured in hours per treatment (hrs/tx).  When looking at dollars per treatment, you are looking at actual costs and this number is more often looked at in arrears, in other words, many weeks after the fact!  Salary and wages are more or less set by upper management and not very controllable by a clinic manager.  For example, if you have an experienced staff, use a lot of overtime and/or use RN’s to cover what would otherwise be PCT shifts, your dollars per treatment will be higher versus the clinic that has a blend of experienced staff, uses little overtime, doesn’t need to cover PCT shifts with RN’s and/or does not use travelers.  

While some overtime is controllable prior to it happening, for the most part as a manager, the dollars per treatment are impacted by less controllable factors.  Whereas focusing on and adjusting hours scheduled for an expected number of treatments is something that a manager has control over proactively.  By understanding how to calculate the needed staffing hours of PCT’s and RN’s, you can create a schedule that will meet your productivity goals.

Most dialysis organizations look at productivity as the number of hours worked by the PCT, LPN/LVN and RN on a per treatment basis.  These are the employees providing direct patient care (DPC) that are usually paid by the hour.  Your clinic may have additional support staff, not providing direct patient care (sometimes referred to as Indirect Patient Care or IPC or Fixed), such as nurse managers, dietitians, social workers, etc.  Depending on your organization, those hours may or may not count towards the total productivity goal.  If IPC and DPC are both used in the total productivity goal established by your organization, then using the calculation discussed in the next paragraph is not the correct final productivity number for you. In a future post, we will discuss how to determine total productivity including those support roles, what amount is the right amount for each of those roles and which portion of the total is the DPC portion. 

I am often asked what a “good” productivity number would be.

If by “good” you mean the right amount of staff to provide quality care to our patients in a safe environment, then I suggest taking the average treatment duration for all your patients and dividing that number in half.  For example, if your average treatment duration is 4.0 hours, if you divide that by two you get a productivity number of 2.0. If your average treatment duration is 3.5, then a “good” productivity goal would be 1.75.  Instead of having one goal for the entire organization, my suggestion would be to look at each clinic individually and apply different goals based on that clinic’s average treatment duration.  Two clinics with very different average treatment durations should not be expected to achieve the same productivity goal.

Using this rule of thumb will serve to establish a good starting point for a productivity goal giving you the minimum amount of staffing hours per treatment to provide safe and effective care to your patients.  If your budget allows, you can add additional staff to meet your additional needs.  Keep in mind that this goal is what you need to provide Direct Patient Care(RN, LPN, PCT).  It does not include the Indirect staff. 

Where do ratios come into the equation? 

For the vast majority of States, we see staffing ratios of 4:1 for our PCT’s and 12:1 for our RN staff.  You can usually meet those ratios by using the above approach. If, however, your state requires certain ratios (e.g. Georgia requires a 10:1 RN to patient ratio) or your organization’s policies require a smaller patient to staff ratio, then your productivity goal will most likely need to be higher.

And that is about all the productivity talk anyone can muster in one sitting!  Thanks for reading!  I hope this post helped you better understand what productivity is and how you may choose to set a realistic productivity goal for your clinic or organization.  There will be a Part 2 of this post in which I will provide more detail of how productivity relates to dollars and the financial health of the clinic and organization. 

We’d love to hear from you!

  • Does your organization have a set productivity goal for your clinic to meet?
  • How are you doing in meeting that goal?
  • If you are over your organization’s stated productivity goal, yet your staff tell you they feel that they need additional help, how are you handling the two different viewpoints?
  • Has this information been helpful? If so, please feel free to share! If not, please let me know how your organization looks at it differently. I’m always interested in learning how I can best support the renal community!

Does Managing Your Schedules Keep You Awake At Night?

ScheduleWise
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?

ScheduleWise

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?