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.

Mark Sessoms

Mark Sessoms

I'm supposedly a helluva industrial engineer since my alma mater is Georgia Tech. But what I really seem to be good at and really enjoy is in continuous process improvement. I've been tackling scheduling practices in dialysis since 2003, and after meeting with Gary, we thought we could do something better. Five years later, the stars aligned and ScheduleWise was born... where these days, I mostly oversee software development.

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