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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!

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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!

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Losing Control of Your Dialysis Clinic

Losing Control of Your Dialysis Clinic

Maintaining control of a dialysis floor is no easy feat.  Clinics are constantly going through change.  New CMS regulations, new staff, patient duration changes, shifts, acuities…etc.  The list is long.  Patients as well, have gone through quite a bit of changes themselves.  Not too long ago, most of them were living a normal life not requiring dialysis.

I found while working as a technician in hospital acutes that there is unfortunately not a lot of mental preparation given to the patients about what life will be like as a dialysis patient.  Many patients that I worked with in acutes knew very little about dialysis, and how long they will need treatment.  And when they begin outpatient treatment they are told when to arrive at the clinic, how long they will run, how often they will run, what to eat, how much fluid they should drink, and what medications need to be taken.  It’s easy to see how patients could feel like they are not in control.

Having worked with many outpatient clinics, I hear many of the same complaints.   In some clinics, I hear that the patients at times seem to be in control of the floor.   “Patient A will not move from that chair.  Patient B will yell at us if we change her time!  And Patient C has threatened to call the network!!!”  Does this sound familiar at all?

As clinical staff, we joined the medical field to help people.  Being caring often means that we tend to avoid confrontation or situations that may make a patient upset.  So as change occurs in the clinic, our day-to-day workflow may seem not to work any longer, and we end up just trying to “survive the day.” To make it work, we may call patients in early, we may pause treatments, or call our nurse over to help.  All this, just to get through the day.  None of this is new to anyone, I’m sure.  But essentially, control of the floor has been lost.  So how do we regain it?

First, we have to talk about where the loss of control comes from.   And believe it or not, the main culprit usually lies with us and our ability to manage the patient schedule.  The patient schedule changes constantly, but are we maintaining the schedule for these changes?  Here are some of the biggest reasons for change to a patient schedule:

  • Changes in patient treatment durations
  • Shift changes 
  • Discharges and Admissions 
  • Changes in patient acuities

Most changes to the schedule are unavoidable and often out of a clinic’s control.  Yet we are tasked with providing safe patient care, that is also reliable with concern to on and off times.  And that’s where constraints come in.  Patients have lives outside of the clinic, after all!  And many of our patients rely on outside transportation to and from dialysis, so their schedule is central to their lives.  I’m sure we have all seen patients left in the lobby if they run late or are put on early.

Here are some other important patient hurdles that need to be overcome:

  • Patients who work
  • Childcare needs
  • School
  • Patient preferences on where and when they have treatment

These constraints are often equally as difficult to navigate.  And in working with our clients, I stress that the clinic must always look at the big picture and not solely on particular “wants” of every individual patient.  Yes, I know it is easier said than done.

So we’ve covered a lot of ground here…  going over some of the basic issues causing a feeling of lost control in the clinic.  Do you have some experiences you’d like to share on this topic?  Please write them in the comments below.

And then join our email list so you don’t miss my next post where I’ll discuss how to regain control of your clinic through workflow management in which I’ll share with you some of the techniques we have implemented with clinics across the country.

 

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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?

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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?
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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?
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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!

Posted on

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!

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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

Posted on

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