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!

Considering the Capacity of Your Dialysis Clinic


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. 


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.


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. 


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.

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.