Are There Too Many Variables in the Patient Schedule for a Computer to Handle?

Remember, my purpose in writing for this blog is to share what we’ve learned over the past 30 years in dialysis. Lots of grand ideas come and go. Buzzwords that promise a lot of improvement, but are not sustainable. Instead, the goal here is to share with you the ideas and methods that stick. And hopefully, after reading some of our words, you may begin to think differently about your approach to your business. Whether you act on that new understanding is totally your choice!

So today, let’s tackle one of the sentiments that I hear come up frequently as a knock against scheduling software… that there are too many variables in the patient schedule for the computer to handle.

As an engineer, this is just striking to me. Our human brains are magnificent and capable of amazing feats. But we are also humans succumbing to emotions, persuasion and forgetfulness. Here are some examples:

  • A staff request to be off next week
  • One of your physicians wants all of her patients on the same shift, but the transportation company can’t manage moving one of those patients from their schedule.
  • Two patients like to sit next to each other because they are buddies
  • Another patient, a very cantankerous man, doesn’t want to sit underneath the air-conditioning vent.

While you may be able to remember these small-ish issues, in two weeks with twenty other changes, and the stresses of a day-to-day dialysis clinic, will you be able to remember all the details? And if you pass it off your scheduling duties to your Charge Nurse, or Social Worker, or Admin Assistant… will they be aware of all of these details? And if so, are they trained to keep all of those issues in mind when managing changes to the patient schedule? And how will they effectively communicate that back to you?

This is why computers are so much more adept at handling the mounting variables of managing a patient schedule. The computer won’t forget the details, so long as you enter them in. Futhermore, the computer can be programmed to assist you with decision making along a set of rules that you give it. And it can be programmed to take into account constraints around patient treatment times, or physician rounding, and anything else that may impact the schedule.

What’s nice about this is that after you set up these guidelines, and the computer can warn you when your schedule is out of bounds, meaning it does not comply with all of the parameters or constraints that you set up.

All this will just make life easier. Yes, you still have to manage your schedule. Yes, you still have to enter patients and schedule into a system. You are doing those things now anyway. But something new might be to start entering in constraints and rules-based logic into your schedule. This is something where computers shine and really aid us in our everyday work. This is, of course, assuming the scheduling app you use is designed for that purpose. Most do not. That is another discussion.

But getting back to the central argument, that a computer can’t handle all of the variables of patient schedule just, to turn a phrase, does not compute!

Am I being controversial here? I don’t think so. Just reasonable. After all, I’m not saying that there aren’t people who can manage a patient schedule brilliantly. I’m only saying that a computer has a much greater capacity to keep track of all the necessary variables of patient scheduling, day after day, week after week, and given the right program, the capability to aid in your managerial decisions related to your patient (and even staff) schedules.

If I’ve made my case above, surely on that we can all agree. Still not convinced? Let us know. Get those thoughts out in the open by writing a comment below!

The Art AND Science of Patient Scheduling

Previously I took us down the philosophical rabbit hole of whether managing the patient schedule is an art OR a science. I wanted to consider a different path line of reasoning this time, shall we? This time that patient scheduling is necessarily both an art AND a science.

In my last post, we discussed the “control” aspect.  But for this post, let’s consider that you are in total control.  No computer is going to do the work for you.  So you have to put your thinking cap on and manage all the changes to the patient schedule this week.

You’ve been doing this patient scheduling thing a long time, so you know the ropes. You’ve learned over time all of the patients’ likes and dislikes, their acuities, and you have jotted down some notes so you do not forget certain things like a transportation issue with one patient, and when a certain doctor may round. All of these things are in your head, and you’ve developed a certain knack over the years that when you have to make changes to put-on times, you know what ontimes work best in what chairs.  When you put your pen to paper, you aren’t even thinking any more. The schedule seemingly just writes itself.

Some call this “the art of scheduling”. And they’d be right. Not many people have the ability, and not many people WANT this ability either! 😉  And when a schedule is done right, everybody is usually happy. They don’t look at the piece of paper with the schedule on it and want to immediately go and frame it, but they do consider the maker — the artist if you will — to have special talents.

But of course, this is the best case scenario. Every clinic has one or more persons in charge of managing the schedule, but not every clinic has an artist-in-residence. Learning these skills can often take years. And it’s a job that is often unwanted to boot!

But what happens when you add science to the equation? That is, if we learn all the techniques and considerations that the artist was able to apply to his or her craft of patient scheduling, and we could program our supercomputer to manage all this work for us, then all we would have to do is enter any new patients or changes to treatments, and with the click of the easy button, voila! Out pops a schedule worthy of admiration.

What’s nice about this last scenario is that ANYONE could manage the schedule. We no longer must depend on the artist. It’s not unlike the great advances we’ve seen with photography. We used to have just a few artists. They were experts with the technology of their day. And yes, they were indeed artists in their framing of their subjects and lighting and all the elements to consider when shooting. But along came the point-and-shoot cameras and the world of photography changed. And once the industry went digital, the costs for development were virtually zero, and thus the barrier to becoming more artistic for the average Joe decreased. And with smarthphones, now everyone has a camera in their pocket. And we have a world flush with photos. Everyone is now a photographer!

But is everyone an artist? Not necessarily. But one could say that there are many more artists than there were previously when the technology was more difficult, and the costs were higher, of course.  So we actually could attribute the rise in artistry and photography was due to the decrease in difficulty of the science of photography. To manage that, they had to hide all the science from the user (inside the camera), and make the interface dead simple. Art AND Science collaborating to make a better world of photography for all!

And so it is with scheduling software (you knew I’d come back to that, didn’t you?). The costs have decreased tremendously. The science has been hidden away in the algorithms underneath the hood so to speak. And the interface is simple so that anyone can manage the schedule.

Well, this will be the eventual congruence for patient scheduling, but as of today, we don’t trust the easy button yet. That gets back to the “control” issues I wrote about previously. Eventually, though, clinicians won’t want to waste any more time doing this task that the computer is better suited for. Instead, we’ll be content to know that we do have control of the inputs, and we’ll accept our eventual the transition to the Easy Button!

Between now and then, we still have some evolving to do. Slowly but surely the technology will get better and easier, and before long, we’ll all be artists!

Is Effective Patient Scheduling More An Art Or Science?

Vincent van Gogh's The Starry Night

Vincent van Gogh’s — The Starry Night — 1889 — at Google Cultural Institute

Let’s begin with a recent milestone in the art world. We now live in a world where art and science have collided. Computers have begun to mimic human creativity. It’s really amazing (and scary!) to see what has already been done. I found this particular article fascinating.

Computers Can Now Paint Like Van Gogh and Picasso

This was from September 2015!

If you followed the link to that article, you’d find that computers were able to mimic the style of some of the world’s greatist painters (think Van Gogh, Munch, Picasso) to create a relatively simple scene of row houses along a river.  It is incredible to think these were done by a computer!  And yet, not, given how far we’ve come with computing!

The next level of fascination for me is the human psyche when it comes to man vs. computer. I picture that if we had a young art prodigy in our midst who was able to paint any scene in the style of several of the great masters, we might say that they are nothing short of incredible imbued with talents from God above. But once we find out that a computer was able to do this (a sophisticated artificial neural network to be more accurate) we may tend to pass it off as not so incredible. Amazing yes, but almost an expectation these days… and we may even begin to find its faults, it’s non-human characteristics. Or maybe we won’t even like it precisely because it was done by a computer, because its imperfections are programmed… on purpose. This is fair since understandably we fear the eventual congruence of machine and humans (unless it makes for a great character! link to Data or Blade Runner). I know I do to a certain extent.

And such are the mind games we play when we apply computers (more specifically optimization algortithms) to patient scheduling. The computer can now help us produce the perfect schedule… a thing of beauty. One that meets all of our patient’s needs and our staff’s desires, with just some inputs and the click of a button. Art, meet Science.

And that’s where it all goes wrong… because the moment we “lose” control to the machine is the moment we start finding fault with all that it provides. Sure, we have control of the inputs. Things like which patients run on which shifts. What are the patient’s durations?  How long are the treatment durations? Etc.

But do we have control of ALL of the inputs? Are we also plugging in the constraints of patient transportation? The preferred patient ontimes or preferred seating assignment? And do we have control of the methods used to derive the schedule? Does the computer take into consideration the workload on the patient care techs and provide buffer for adverse events? The questions go on…

And the simple answer is… we (in this case, the users) don’t know! Because it’s all hidden away in the black box we call the computer. Instructions were given to it, and it follows those instructions by creating the best possible schedule based on its constraints and its objective function. This gets into the scienc-y part of it all. So let’s skip that. Ultimately we accept the science because it is beyond our capabilities, but the art, **that we can judge!** and quite frankly, we often don’t care for it. Maybe it’s because we can’t really argue with a computer. And getting mad at it doesn’t really do anything either!

So, in the grand argument of patient scheduling being an art or science, I would posit the difference comes down to “taste”. Where the word taste can be substituted with control. If you are OK with giving up some control, than you can appreciate the science of scheduling. But if you have that rare person in your clinic who manages a satisfactory and workable schedule week after week, then you may be in the art camp.

What really may get your goat is that you (nurses and techs working the floor) have lost control either way. You have given up control to either an artist, or a computer. We just think we’re in control to some degree because we can argue with the artist when the schedule doesn’t work well!  🙂

Where do you fall on the art vs. science argument?

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

Hello World

ScheduleWise - Hello World

Hello world! Is it too late to start our blog???

Hello out there!

Hello out there???

Hello?

This is the typical pattern of excitement when starting a new blog, and then not knowing if there’s anybody even “listening”.

So what’s with the blog anyway?  Glad you asked.  I’ve been searching and searching the web for anything related to patient scheduling specific to dialysis for quite some time.  And as you probably know, it’s time-consuming and tedious to sift through the chaff of Google search results to find any nugget of substance.  But there are some bits of wisdom out there!  The problem is, even when you find them, can you really apply any of that to your own clinic’s schedule?  Often it’s not so easy.

So with Getting Schedule Wise (the name of this blog), we are aiming to change that.  While we intuitively understand that the schedule causes some of our day-to-day problems on the floor… we just don’t give enough credit to how many problems might actually be resolved if we take the time to create AND MAINTAIN a better patient schedule.  We hope to help you get wise. ScheduleWise. =]

In this blog, we aim to provide thoughtful commentary on how you might create a better patient schedule for your dialysis unit.  We’re putting it all out there.  All that we’ve learned over the past 30 years in this industry in various positions on the treatment floor (RN, PCT, Reuse) and in management (facility administrator, clinical services director, vice presidents operational excellence), and let’s not forget, the past 10 years of helping our clients improve the workflow of their patient schedules with ScheduleWise, our workflow management software.

It would be a lie to say that we’ve seen it all.  But we’ve seen a heck of a LOT!  And we’d like to share that knowledge with you.  So at the end of the day, I hope people will find us out here in our little corner of the internets…

But could you help, too?  As you read further into the blog over the coming months, if you find our information helpful, please do share with your colleagues, and with us, too!  You may be helping more folks out there to find our blog and learn something useful that impacts their clinics and patients.  So contribute to the conversation in the comments. Heck, even volunteer to write a post or two!

So get ready for the most exciting, inspirational, … ok, let me not over do it.  It is scheduling after all. =]  But get ready.  We hope to help give you a little spark to take back to your own unit and be able to rework your patient schedule for a calmer, safer environment for your patients and a more satisfying work environment for your staff!  =]

Ciao for now!
Mark