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!