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?