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Chair Utilization in Dialysis — An Ineffective Metric

When I first started in dialysis back in 2003, my first job was at DaVita as an industrial engineer focused on process improvement. As I reflect on my time there, I really had a dream job! I was to visit clinics nationwide in search of process excellence in the hopes of trying to standardize some into corporate-wide processes.

One day, I was asked to go visit a clinic in Scottsdale, AZ, where the facility administrator (or FA) was doing things a little differently. My bosses wanted to know what made their place run so well. All I was told is that they were doing things a little differently.

To this point, I had worked a little bit with an internal group of FAs and regional directors (RDs) focused on improving how we schedule patients. The used nothing more than an Excel spreadsheet, but with none of the functionality that Excel could really help with. This was my early experience with Excel, so the model that I built, while better than what they had, wasn’t much to brag about. I built a spreadsheet that helped administrators to highlight scheduling conflicts associated with turnover. And this was eventually incorporated with a staffing component and a productivity component that became known as the SWC Productivity Model… I was proud of this work.

Prior to visiting this Scottsdale clinic, though, the COO of the company shared with me some ideas about chair utilization. He was a former industrial engineer from Georgia Tech as well… one of the reasons DaVita recruited from that school I suppose. His thoughts were that we could get more patient throughput if we could figure out how to speed up turnovers.

Turning over a chair is the process of taking off one patient, then cleaning the station and resetting the machine, and then starting the next patient. At that time, the process took approximately 45 minutes. My boss was hoping to cut this down to 30 minutes. The 15-minute savings across the board at an organization the size of DaVita would be a huge savings! And he wanted me to think even deeper, about maybe the possibility swapping out chairs and even machines in order to reduce turnovers to a 15-minute process. The increase of the fixed cost of equipment would pale in comparison to the labor cost savings.

In essence, if a chair was sitting idle, the clinic was not making money. So reducing that idle time would mean that (1) staff would not have to stay as long to complete the same amount of work, and (2) it could allow the potential for more patients on a 3rd or 4th shift without incurring longer staff hours. These were my drivers. And this made a lot of sense from a process standpoint to my industrial engineering brain. And it is with that mindset that I went Scottsdale to meet Gary Hamilton (my eventual co-founder at ScheduleWise) to see how he managed his clinic.

Gary was so welcoming to me. He was keen to share with me how he did things, and happy that corporate had noticed his management style was different. While I was eager to learn what I could at Gary’s center, to tell the truth, I was a bit dismayed that he was very much opposed to using the patient scheduling model I had built. In short, he didn’t find it worth his time. In his opinion, it was a tool that RDs used to micro-manage their FAs. And since his unit ran in the top 2% of all DaVita clinics, he didn’t feel like he needed extra busy work.

But this is why it is important to be open-minded. Because you never know where your next enlightened idea will come from. Gary allowed me to sit on the clinic floor to observe for as long as I cared to. He introduced me to his staff, and I inquired with them how they viewed the overall administration of the clinic. And they were all very happy with how things ran. It was the first clinic I stepped into where turnover was not chaotic. It was all so orderly, as one would expect. Alarms were quiet. No one was running. It was a calm environment at all times.

Later, Gary shared with me how he looked at the job of scheduling patients… In most clinics, the FA is a nurse. Thus, when there are problems on the floor, or call-offs, the FA often steps in to work the floor, and ultimately, is the cause for a typical form of burnout among FAs. Gary was not an RN, so he had to make the absolute best use of his nurses to avoid these situations.

Thus, he managed his patient schedule with more awareness of the impact of the schedule… with an emphasis on ensuring that each staff person would have no more than one activity during the 15-minute put-on and take-off activities. In this way, he could ensure that his PCTs could handle the work of putons, takeoffs and monitoring, while the nurses would be able to focus on assessments, passing meds, and care plan management. All that just from paying attention to the work load at each point of the day! It seems so simple. So how did he do that???

Early, rudimentary workflow management.

He showed me his system, a grid of 1’s and 0’s every 15 minutes throughout the day. It was the early way of managing the work. From that grid, I set about building a new model to incorporate what we now call workflow into a visual aid that would help FAs see the workload they were expecting their staff to manage each and every day. This eventually was fine-tuned and deployed as the Catch The Wave model and scheduling methodology. With this model, staff could see their workflow for the first time. And they had a tool to help them manage it better.

But that was just the tool. Along with the tool came a radical change in schedule methodologies! You either loved it or you hated it (we’ll save that story for another time). But in the end, it was in the improved scheduling methodologies where the real opportunities were to be able to provide quality care both effectively (meaning the right people were doing the right jobs) and efficiently (meaning providing proper amount of time needed to provide care).

So what about Chair Utilization?

Simply put, it proved to be an unimportant metric. The old adage of what gets measured gets managed is very true. If you are looking to improve chair utilization, you most certainly can incrementally improve it… but for what purpose and at what cost? The goal of improving chair utilization was primarily to save money. To do so without regard to other scheduling principles would have most likely resulted in impossible turnovers, burned out staff, and reduced safety for patients. Sadly, this is still what a lot of clinics do because it is the easiest way they understand how to reduce labor costs.

With Catch The Wave, ultimately the precursor to ScheduleWise, we showed how to provide quality dialysis care and reduce labor costs through better workflow management and better alignment of staffing to the patient needs. Managing schedules from this workflow perspective proved to be far superior than managing chair utilization. And thus, this is why the metric itself, in my opinion, is ineffective to track in this manner.

For me personally, though, chair utilization does represent something good. Seeking a better understanding of that metric led to my visit to Scottsdale and that is etched into my memory as the launching point to a long and fruitful journey to bring new tools to drive this smarter way of patient scheduling. It is my hope to continue to share what we have learned with those willing to hear our stories, and especially with those able to utilize the principles of workflow management for the betterment of the health of their patients.

Until next time!

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Dialysis Culture Must Change — Everything Good Is Bad

how engineers think

Working at some clinics recently rekindled a thought I had a couple of years ago while reading a book called “Applied Minds – How Engineers Think” written by Guru Madhavan.

In it he described many world problems where good engineers came up with good solutions, but without considering other important factors, for example culture and tradition. He summed it up this way, “Nothing on earth has only benefits. Every positive thing can also have bad outcomes. That’s why mindlessly privileging efficiency and productivity while not considering other native factors is a flawed approach.”

In trying to solve certain problems in dialysis, very much encounter some of that sentiment. That is, the cultures and traditions of dialysis make it harder to deploy good solutions. In fact, you could even say that the notions of efficiency and productivity have actually helped to create some of the culture that is now heavily rooted in our industry. Think about the idea of calling in patients to fill open chairs when a patient is known to be hospitalized or is a no-show.

Think of the idea of sending staff home when the patient load reaches a certain point. These are both measures enacted to improve productivity and efficiency in the clinic. They have become an accepted part of the culture of working in a dialysis clinic. Yet, these are hardly the best ways to improve productivity or efficiency in a way that promotes patient safety and well-being first. But the culture is already established. And new solutions that attempt to address these problems are met with challenges due to our dialysis culture.

I think through these challenges because with ScheduleWise we share with staff and even patients how certain scheduling methodologies will help improve patient safety and well-being first, and productivity second. This should be viewed as a positive thing! Yet, the culture is so rooted that any notion of schedule change upsets the status quo. And this could be considered as a bad outcome. So Madhavan was right, “Every positive thing can also have bad outcomes.” Or as I like to shorten it, everything good is bad.

So let’s dig in just for a bit to explore this assertion in more detail by examining two things: What are the cultures and traditions in our industry? And how do we define ‘productive’?

Tackling the last question first, “productive” by the standards of the LDOs, the Large Dialysis Organizations (Davita and Fresenius), a dialysis clinic should be able to operate at roughly one-half of the average treatment time. How on earth do you figure that? (I’ll explain that in a future post!) Most clinics are hardly productive by this measure, even the LDOs! In fact, based on the 2019 National Cost & Quality Benchmarking Report published by the Renal Services Exchange, the breakdown of clinical productivity across the different organization types shows that clinics are managing 2.6 hours per treatment for direct patient care staff hours on a per treatment basis.

Figure 1. Productivity data from the 2019 RSE National Cost and Quality Benchmarking Report

Based on our assertion above that clinics should be able to operate at one-half of the average treatment time, operating at 2.6 hrs/treatment would suggest a 5.2 hour average run time! As a national average, we are still less than 4.0 hours. So we should be able to operate at the maximum, on average, at 2.0 hours per treatment.

So this begs the question, how is it that clinic staff feel productive, given that they arguably have more than enough hours to get the job done?? And that, I would argue gets to the cultures and traditions question. In short, their system, that is, the system of scheduling and treating patients, has morphed into its own culture over time. A culture that allows patients to have too much ownership in the chair they sit in or ownership of the time they begin dialysis. This forces operations to accommodate the patient, thereby stacking up work on their staff if need be, such that the nurse must step in to help with the workload, or that a new technician be hired to reduce the ratios or help with turnovers. We have allowed patients to control the culture, and as a result, allowed operational efficiency to decrease. And when attempts are made to address this issue (good or bad), they are met with cultural backlash. And culture wins much of the time.

Indulging in other traditions and culture of dialysis as an industry, everywhere I have visited
clinicians state that dialysis should not be like a manufacturing line. It shouldn’t be “hook ’em up and get ’em off”

Yet, in most clinics that I have visited before implementing ScheduleWise, the system in use is more like the lunch rush at a restaurant where at the beginning of each shift patients flood the lobby, and expects to begin treatment as soon as possible. Staff rushes to get everyone on as soon as they can. And then calm… everyone is running… but as the first shift ends and the next shift begins, the cycle repeats, this time with more people and more variables. Staff does their best to manage. But they are no longer following a schedule. They are just reacting to events.

On the other hand, a manufacturing line by design must be orderly, timely, and above all safe for the worker. Could we employ some of those principles to dialysis in order to conduct a safer and smoother initiation and termination of treatment, and overall a more effective treatment for the patient? I should think so! But it starts with challenging the norms of the culture, and applying a good solution, then refining that solution with feedback.

The current system has also created a by-product of promoting only the fastest staff, or the most strong-willed. Note that I did not say the strongest techs. These techs can get the job done fast. But what do they miss? Are they following policy and procedures? Are they always doing the other jobs required during the day because they seem to have the time?

And what does this mean for the slower techs? Do they learn to stay slow because they know that the nurse will step in and put on or take off their patient? What is the incentive for them to continue to manage their four patients if the RN always comes in and handles one? Does this cause resentment with the nurse or the other techs?

And patient-to-staff ratios? Staff are very clear about ratios. Not from a perspective of safety for patients. But from a keeping-score mentality that I only do my four patients. Or if I put on five patients and you only put on four, that it is not fair!

All of these concepts and more are heavily rooted in dialysis. They have formed the culture that we have accepted. Management has known no way to address it, as they are often rooted in the culture themselves having been promoted up from nurse to be administrators and directors. Only the higher-ups are distanced from this thinking. They see from their formulas and data that they should be able to “hit their numbers”, speaking of productivity and costs, but they cannot teach or train their staff how to reach these goals without running into the culture roadblocks.

This is the divide that must be bridged by your new solution, often a mix of technology, methodology, communication, and management. Good solutions are within your grasp! But you have to challenge, and ultimately change, the culture. It won’t happen overnight either. Even if the band-aid is ripped off, change is always met with hemming and hawing in anticipation of change. And then once the changes are in place, more hemming and hawing… the last shouts for a “return to the greatness” of their previous systems, except everyone knows that it wasn’t so great.

With ScheduleWise, and managing schedule changes, over time you will create a new normal. One of constant, incremental changes to your patient and staff schedules. The benefits will be a return to professionalism in the clinic where patients do not rule the roost, a proper realignment of staff to their roles with nurses being nurses and techs able to handle their assignments, better satisfaction from patients in getting their care safely, adequately and on time, and controlled costs on the part of the organization.

All of these are the positive outcomes that the solution intends. And there will be some bad outcomes along the way, all having to do with change on the part of patients, on the part of staff, and ultimately our culture.

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Creating Products That Last… or Not

So during this COVID-19 pandemic, I’ve been thinking about meaningful work. Our front-line healthcare providers are performing very meaningful work. They always do, but it seems more obvious now then ever.

In our industry, meaningful work is also obvious. Without dialysis, those with kidney failure would not live (a fact I fear that the average American does not realize). Those who work directly with patients each day realize the life-saving nature of their jobs. And that provides meaning to what they do every day.

But what about all those other things that go into keeping the business of dialysis alive. These jobs must have meaning, too. Without them, dialysis clinics might not be viable business entities, and therefore, unable to provide care to patients. So this, too, should be considered meaningful work. But it is one step removed from the front lines.

And what about those who work to provide the equipment and supplies that make our business of dialysis run. There are many — dialysis machines, special chairs, bicarb, saline, needles, lines, too many to mention. If you work in a clinic, you know all this stuff. What about the software? EMR’s, timeclocks, accounting & payroll. Again, too many to mention. All of these are necessary aspects of the business of dialysis. But now we are two and sometimes three steps removed from direct patient care. There is often a disconnect between the folks who do these jobs and the providers of care, but clearly everything is connected. The products and services are indispensable to the direct care givers in being able to do their jobs.

So where am I going with this?

“Most of us wish we could create work that lasts…
because that implies it matters, and it makes a difference,
and it will be appreciated by the people who use it.”

–Esther Schindler from SmartBear

With ScheduleWise, I feel that we have contributed to the dialysis industry in creating something that helps to make a difference, at least in the lives of our clients, in helping them to organize their day so their staff can provide the best and safest care possible given all the constraints of scheduling patient care. It’s no easy task. But this is where the meaning comes in in our line of work.

But the second part of the quote above is about creating work that lasts. I realize the truth about software in general.

“Don’t take yourself too seriously.
Your code will not be around in 100 years.”

–Christopher Byerly from Quora

In reflecting on our own history, ScheduleWise code hasn’t lasted 10 years, much less 100! We are constantly reinventing ourselves and rewriting our code! We’ve completely rebuilt the application top-to-bottom three times so far in our short 12 years. Clearly we are gluttons for punishment!

But you see, despite our best efforts to deliver a quality product, sometimes a complete redesign is warranted. Sometimes new technology compels us to rebuild. And sometimes in order to provide the functionality that best solves our clients’ problems, it just makes sense to rebuild from scratch.

Now compare that with something like antique furniture, quality is essential. We expect it to last, maybe with some minor touch-ups. Or with a house, the 100 year-old house. We love that idea! But the truth is, most 100 year-old houses are merely shells of their original selves, literally. The inside gets gutted and modernized with each new owner. Yet, to preserve the 100 year-old moniker, you can’t just tear it down and rebuild, even though that makes the most sense.

In any case, software is a different animal. And though we finally feel we have the right platform on which to build further, I won’t be the least bit surprised if we rebuild ScheduleWise yet again in the next five years.

So remember this, we all strive to have meaningful work in this world. And we are trying to do our very best in delivering the world’s best dialysis scheduling software. But I try not to take it too seriously. Because our code will not be around in 100 years.

Come to think of it, if we’re lucky and artificial kidneys become commonplace, maybe even dialysis won’t be around in 100 years! Of course then we’ll all need new jobs, but our patients will be happier and healthier, and isn’t that the real objective?

Be safe everyone!

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Setting the record straight – ScheduleWise & Fresenius

Often we are asked or even told that Fresenius owns ScheduleWise. Au contraire, mon frere! So let me set the record straight. Fresenius uses ScheduleWise. They do not own ScheduleWise. ScheduleWise LLC is and has always been owned and operated by its three principal founders, Gary and Mary Kay Hamilton and Mark Sessoms.

Fresenius did obtain a permanent license of ScheduleWise in 2015. And we (Gary and Mark) joined FMC (now FKC) to help them roll out the software to their (at the time) 2200+ clinics. And I (Mark) also continued to lead a separate development team to improve the software for FKC’s specific needs.

In the interim, Mary Kay and Brandon continued to manage ScheduleWise and introduce it to new clients, but our software development was at a standstill.

By 2018, Mark returned full-time to ScheduleWise to rebuild our product from the ground up with the help of our talented and growing development team (Alan, Suzanne, Waleed, Mike, and Doug).

By March 2019, with a completely overhauled application, we proudly released ScheduleWise 2.0!

And since then we’ve been hyper-focused on building and releasing improved features nearly every month! And that is our commitment to you, to continue to provide the dialysis industry’s most ubiquitous and, dare I say, best scheduling platform!

But we know that software is just one piece of the puzzle. Without our 20+ years of scheduling knowledge, innovation, and coaching, ScheduleWise is just a software. But the two in combination produce a winning solution for your organization to thrive in the new decade!

We hope to continue serving our clients well into the future! And if you’re not yet aware of how we can help your organization, give us a call!

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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!

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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?

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Regain Control of Your Dialysis Clinic

regain control

In my previous blog post, I discussed where the loss of control comes from in many clinics that I have either worked at as a Patient Care Tech, or that I have had the opportunity to work with as clients of ScheduleWise.  And most likely, you will find those reasons pertain to your clinics as well.  So, the big question… How do we regain control and then manage our patient workflow?

You might be thinking, ‘What the heck is workflow?’ Workflow is loosely defined as a sequence of tasks or processes through which work passes from initiation to completion.  In our world of providing dialysis care, one thing that workflow translates very directly to is the work required to initiate and terminate treatments, better known to us as put-ons and take-offs.  We can think of these put-ons and take-offs as workflow events.

Breaking this down further, we know from experience that each workflow event lasts typically 15 minutes each for your average patient with normal acuity.  And that a workflow event requires undivided attention from a technician. 

Workflow events are not particularly difficult during first shift put-ons.  We put each patient on roughly 15 minutes apart, one after the other.  That’s the easy, no-brainer part.  But things become more difficult, and sometimes untenable, during turnover.  In a typical 4:1 pod there are 8 workflow events during a turnover from first to second shift (4 take-offs and then 4 put-ons).   This same idea goes into 3rd and 4th shifts as well.

So what does this all mean? 

When these workflow events overlap one another during turnovers, that is when two or more events are scheduled to happen at the same time (e.g. two take-offs occurring at 10:00AM).  When this happens in several different pods and over each turnover, the clinic begins to feel chaotic, and many issues arise:

  • Patient safety concerns
  • Technicians feel rushed
  • Nurses are called into the pod for help
  • Patient and staff satisfaction decreases
  • Treatment durations may be cut short which impacts adequacy and other outcomes

Knowing this is half the battle.  And that gives us the power to solve this issue and we can begin to regain control!

Understanding our workflow as clinical staff, we are the ones tasked with making sure our patients are receiving safe quality treatment above all other constraints.

Therefore, it is imperative that we construct the patient schedule so that we have no more than one patient event at a time scheduled per pod assignment.  Often deeper thought is required than simply spacing the time between patient events at 15 minutes.  Especially given that there are many more hurdles we face today than simply initiating and terminating treatments, including:

  • Patient acuities both pre- and post-treatment.
    • Hoyer lifts
    • Bleeders
    • Staff needing to hold access sites
    • Wheelchairs/walkers
    • Visually impaired
  • Patients who take extra time to vacate their chair
  • Consistent tardiness
  • Patient scheduling constraints
    • Work
    • Transportation
    • School
    • Childcare
    • General preferences on time and location in the clinic

These constraints are typical in every clinic, so staff must identify the workflow constraints that need to be overcome, and then work the schedule around them.  In the clinics I have worked with, we often employ new scheduling methodologies to tackle all of the numerous constraints.  But you must be very attentive to each of the workflow events to set your staff up for success in meeting the demands of the patient schedule.  This is where a scheduling application like ScheduleWise really shines (shameless plug!) in displaying your workflow events in an intuitive chart to help you avoid chaotic turnovers, and meet your clinic’s overall goals!

We then come to schedule execution.  I have always shared with our clients to always follow the schedule to the best of their ability.  Meaning, do not deviate by calling patients in early and rearranging the schedule anew each day.  That being said, there are always unforeseen issues that arise, and are unavoidable.

  • Machine failures
  • R.O. issues
  • Late patient arrivals
  • Unforeseen patient events

The issues above are often unavoidable on a day to day basis.  Where clinics often compound the problem is self-inflicted to some degree.  Schedules are not followed for avoidable reasons. 

  • Patients demand to be put on early and we oblige
  • Patients are called in early to back fill open chairs
  • Patients are moved around the floor without careful consideration given to their durations or acuities
  • Treatment appointment times are not adjusted when treatments durations are changed

Self-inflicted may seem like a harsh phrase.  But we have to admit our problems if we are to solve our problems.  If you ask yourself the question, “Why do our patients come in or ask to be put on early?”  Typically, the answer is because we put them on early and that became the expectation.  And there are many more reasons that point back to us as staff for the reason turnovers are chaotic.

When the patient schedule is updated, adjusted regularly, and followed as written with the overall workflow in mind, many issues begin to subside over time.

  • Patients trust that their appointment time is correct
  • Early arrivals decrease
  • Patients cutting treatment time decrease
  • Patient and staff satisfaction increase
  • Professional roles on the floor are realigned (i.e. nurses get to be nurses)

In a follow-up post I would like to talk about the complexity of the patient schedule and the fact that it is fluid.  Often, we think of the schedule as stagnant and never changing, but it is quite the opposite.  Schedules are always changing, and the needs of your patients is always changing.

See you next time!

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Considering the Capacity of Your Dialysis Clinic

ScheduleWise

There are four primary components that a clinical manager is responsible for when managing the operations of a dialysis clinic:  (i) clinical outcomes, (ii) compliance to regulatory agency / corporate policies, (iii) revenues, and (iv) expenses.  This post will be focused on the revenue component.

In the current paradigm of fixed reimbursement for a bundle of services, a clinic’s primary source of revenue is derived from providing dialysis treatments.  It’s a simple equation — more treatments equal more revenue.  And clinic managers control this revenue stream, which comes directly from the ability to provide dialysis treatments.  And that ability results from available chairs, or in other terms, the capacity to provide additional treatments. 

Does your clinic have the capacity to provide additional dialysis treatments and increase revenue? 

Understanding and maximizing the capacity of a given clinic is crucial, and could significantly impact the viability of your clinic or organization, and even the ability for patients to have access to care.

Capacity Constraints

Capacity is dependent on a number of variables or constraints such as staffing, physical plant, scheduling standards, and the clinic’s mentality towards accepting new patients. 

Staffing

The most cited constraint on capacity is a sense of being understaffed.  This may or may not actually be the case as clinics often feel they are “at capacity” and cannot accept new patients, and that they are constantly working to simply survive the day.  This is most often a result of a treatment schedule that is appointment- based, and does not focus on the workflow to effectively utilize their resources. 

This is not to say that staffing isn’t a legitimate constraint.  But more often than not, there are increased capacity opportunities if you were able to utilize current staff more effectively.  Believing your clinic is understaffed without quantifying should never be an excuse to turn away new patients.

Physical plant

Physical plant refers to the infrastructure used in operation of a facility.  We tend to immediately think of the number of stations in the clinic, but this is just one component.  Capacity as it relates to the physical plant is more about how effectively are you utilizing those stations? 

Constraints of the physical plant must consider the window of time available to provide treatments, with the two most common variables being the regeneration need of the reverse osmosis (RO) system, and limitations to the hours of operation due to lease restrictions.  If a clinic has a lease restriction saying they can only operate from 5am to 9pm, they have 16 hours to operate within.  If a clinic’s RO system requires 4 hours to regenerate, they have a 20-hour window to operate within.  In each case, there is a constraint.  If a clinic only operates 2 shifts over approximately 11 hours, they have additional capacity.

Standards

Every clinic or organization should have a set of scheduling standards.  Standards refer to the amount of time that is required to perform various tasks such as put-ons, take-offs, and turning over a station between patients from one shift to the next.  It is the time that the staff member providing direct patient care is solely focused on caring for their assigned patient.  These standards should be incorporated into the patient treatment schedule.   Based on the many time studies we have been in involved with, the general industry-standard of 15 minutes for both put-ons and take-offs bears out.  And a turnover standard of at least 45 minutes is recommended, though with the CMS changes to guidelines last year, some clinics require a bit more for turnover time.  These standards are for minimally acute patients.  Patients with greater dependency on direct patient care staff such as hoyer-lift and stretcher patients, and patients that experience prolonged bleeding post treatment, will certainly need more time to be determined on a case-by-case basis.

To be sure, your clinic’s standards will impact capacity.  For example, a clinic that has mostly minimally acute patients with a 45-minute turnover standard will have more capacity than a clinic of the same size that primarily treats high acuity patients that require significantly more time to care for and require a 90-minute turnover standard.  It is imperative that the needs of each patient are considered and not simply over-scheduling time when not necessary. 

Mentality

Many clinics do not like or want to accept new patients for a number of reasons.  With the need to provide access to patients needing care, more effectively utilizing the available resources, and increase revenues, the mentality and culture needs to be one of wanting to do whatever is possible to accommodate growth. 

Another consideration for this section is the resistance to opening additional shifts.  Maybe the rounding physicians don’t want to see 4th-shift patients, for example.  This significantly restricts capacity.  Adding the 4th shift can increase capacity by 25-30% in most cases.  Consider that the physical plant and equipment is already available, so those additional treatments only require their variable costs of supplies and labor, and fixed costs, such as rent, and overhead are reduced on a cost per treatment basis due to greater economy of scale.

Maximizing Capacity

The benefits to a clinic or organization that maximizes capacity are many.  From the patient perspective, there is increased access to care, as well as wider selection of treatment times.  From a financial perspective, the fixed-cost portion of every additional treatment is reduced due to economy of scale.  Variable costs such as supplies will remain constant, while labor costs could go up if contract labor or overtime is required to support the additional capacity.  The additional labor cost is generally immaterial relative to the additional revenue, and we will explore this in a future post.

Maximizing capacity from existing clinics also helps mitigate or potentially eliminate the need to build additional clinics.  In CON markets, or markets where certification takes years, this could be a tremendous savings. 

Now that we have reviewed the basics for understanding capacity in the dialysis clinic, in my next post, I will share with you just how you can Create Capacity in your clinic.

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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!

Posted on

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!