A Short History of Patient Scheduling Tools in Dialysis – Part 2

We left off having completed the B.C. mini-epoch, Before Computers. In this installment, we are going to revisit the timeline of patient scheduling tools and talk through the A.C. mini-epoch.

A.C. — After Computers

Once computers were on the scene, innovations came quickly. In 2003 when I began in dialysis, most clinics used either Microsoft Word or Microsoft Excel to manage their schedules. So I have to assume that some folks were inputting their patient schedules into a computer roughly by the mid-1980’s.  Let’s take a look at some of the technologies that people tried to use to help them with their patient schedules.

Word Processors: (evolution of word processors)
Word processor… now there’s an ancient term in computing! Nowadays, Microsoft Word is the dominant application, but Corel Word Perfect was what I used long ago. And I’m sure some savvy managers in dialysis transcribed their handwritten schedules into a word processor. And it allowed them to save their schedules, easily edit them, track files historically, and more easily share schedules with others. These were huge gains in productivity! But it was the simplest of use-cases for what the computer could really do. These were the baby steps we took… from handwriting schedules on paper to managing schedules on the computer. And we never looked back! Computers were here to stay! By the way, word processors are still in use. I ran across a schedule in MS Word just the other day!

DOS: (history of MS DOS)
A humble little DOS application for patient scheduling made its way on the scene. The only reason I know about this is because it was created by my first boss and mentor at DaVita, Doug Vlchek (Yoda). I never got to see it in action, just manuals of it. But I loved it! To my knowledge, it was the first “program” built for managing patient schedules at dialysis facilities. 

[INSERT YOUR COMPUTER APPLICATIONS HERE! As I have mentioned before, this timeline is based on my experiences within the dialysis industry. This history can only be complete with your input! If you know of any early applications that effectively predate the dominance of spreadsheets, please let me know and I will put in a blurb about it here! Anything that is 2005 or later would be considered internet-age, and so I plan to include those in a later installment.]

SPREADSHEETS: (history) (history) (history) (history)
Since this topic is near and dear to my heart, I have included several history links for those of you who care to indulge. =]

Not everyone knows this, but the now ubiquitous spreadsheet also has its roots in paper, specifically a long paper ledger that could be unfolded (spread) providing many columns for information management. There have been many incarnations of spreadsheet applications over the years: Visicalc was the first, Lotus 1-2-3 and Quattro Pro (both of which I used in my time) came later. But Excel is probably the most familiar spreadsheet application to everyone.

Dan Bricklin @ 11’17” Harvard commemorates the location of the invention of the first spreadsheet.

When I came to DaVita in 2003, most clinics were already using Excel. So I’d say that it is safe to assume that spreadsheets became the most ubiquitous patient scheduling tool around the mid-to-late-1990’s. But unfortunately these tools were using Excel as little more than graph paper to display the schedule within pretty boxes. And there were TONS of styles and colors. Remember when everyone used Comic Sans for everything!

But the power of using a spreadsheet is in using formulas to do the calculations work for you, like calculating the take-off time based on the put-on time plus the duration. Surprisingly, most people didn’t use Excel to do even this much. And for things like conditional formatting which could help you identify problem spots in the schedule… fuggedaboutit!

Most of the spreadsheets that I have encountered in my dialysis career do not utilize the spreadsheet in any way to help the administrators manage their schedule. They didn’t then and they still don’t now. It’s really puzzling to me, other than to say that it is not a clinician’s first inclination to learn how to use spreadsheets effectively.

Luckily, people with Excel skills came along and began to develop models to help with patient scheduling, and some of these models could get quite advanced, turning the patient schedule spreadsheet into a sophisticated little application.

Spreadsheets quickly became the de facto standard for scheduling at dialysis clinics. As an industry, we did some innovative things with this tool/application. It helped us to be more productive in managing the scheduling process. And it helped some organizations with standardization of scheduling processes because everyone was using the same tool and following the same rules.

But while we made significant progress, there were some obvious areas that the spreadsheet couldn’t address, such as allowing other users to access your schedule easily, or managing your data over time, and reporting trends in your data. These were the next stages of innovation that would need to be addressed in other ways, with better technology. But there is little doubt, spreadsheets provided us with a better way to manage our patient schedules… and staff schedules, too!

We’re not done with spreadsheets yet, though! In Part 3 of the series, I’ll dive deeper into Excel and some modeling ideas that I either saw or created with Excel. There are a number of these models that I will share, and I encourage you to take a look at them… if only for a walk down memory lane.

See you there!

[CALL TO ACTION! I would really appreciate you sending your own spreadsheet schedule templates to me if you'd be willing. I'll post them as part of this little history we are creating (without real patient info, of course)! It will be a grand tribute to the ideas that helped shape scheduling in this industry over the past five decades.]

A Short History of Patient Scheduling Tools in Dialysis

The dialysis industry is coming up on the 50th anniversary since Medicare extended coverage to individuals with ESRD. In that time, a lot of things have changed. If you’ve been working in dialysis for 20 years or more, then chances are you’ve seen a number of scheduling methods and tools come and go!

While I know this is just a small, non-clinical part of the rich history of dialysis… this is such a fascinating topic in the history of this industry — at least for my experience in it. I figured that it needs to be recorded somewhere, so I thought to take a stab at it. And in this five-part series, I’ll look specifically at the history of dialysis scheduling tools and applications.

What I will attempt to outline in these posts is a simple timeline of dialysis scheduling tools that I have been witness to during my career in dialysis. But this timeline cannot be considered complete without your input. I know there are other tools out there, so I hope some of you reading this might share what you know (and even the tools you’ve used! or at least a screenshot) and I will share them here and fit them into the timeline.

In a simplistic attempt to categorize these innovations, I have broken up the history into mini-epochs. Let us call them B.C., A.C., A.E., A.I. Pretty soon, you’ll know what they all mean. Let’s begin!

B.C. — Before Computers

That’s right! You thought I was getting religious on you. =] B.C., in this timeline, means before computers! Before computers were adopted as being useful in the clinic for managing the schedule, we had a few different ways to help us track and manage schedules.

Can you believe it? It’s almost unthinkable now that someone would have to write out the schedule every day by hand. But still, even as recently as 5 years ago, I have seen handwritten schedules in use. I guess those clinical managers never saw the need to adopt a new tool, tried and true in their own systems they were! They say that old habits die hard, but geez louise!

PHOTOCOPIER: (a tribute to the photocopier)
How did we make copies of our schedules to distribute before the photocopier came of age? Carbon Copy paper was certainly around, but I’m not so certain that it was all that
practical for making copies of patient schedules. But what is certainly unforgettable is the serious contribution of the photocopier! These machines were in use way before desktop computers, and they allowed us to make copy after copy of schedules for staff and nurses stations. Enter in a few changes manually, and you just saved a LOT of time with your schedule!

Interestingly, this is a technology that has not gone out of style either, as they are still very much depended on even today!

While I never witnessed the use of a white board in person, I have been told that schedules were also managed this way in some clinics. It’s not hard to imagine how it was used. One downside with this method, though, you really couldn’t keep a copy of your schedule. So I’m not sure this qualifies as an innovation, so much as for a point in history.

Alright! Now here is a cool concept! Let’s represent our patients with magnets on a board, and when we put them on dialysis, we’ll move their magnet into place so we know who is running and where they sit. And if they had a magnetic whiteboard, they could write all over it, too. When I started dialysis in 2003, this was the scheduling tool in use at one of the first centers I visited.

And I’m not being sarcastic with my “cool concept” accolade. Believe it or not, these sorts of boards are in use at manufacturing facilities the world over. So yes, I do think this is a cool concept to apply to dialysis patient schedules. It actually gave a visual representation of the floor, and a real-time understanding of who was running. It served as a schedule and a real-time operations tool, though I’m guessing it was used in conjunction with a handwritten schedule, or otherwise you’d lose your schedule as soon as you move magnets around the board.

So let’s not discount the humble magnet board as an innovative step toward scheduling patients!

[NOTE: Pictures tell a thousand words. If you readers have any pictures of these relics of patient scheduling, do please share!]

So that was a healthy dose of nostalgia. =] There is a lot to cover in a 50-year timeline, so I’m keeping each part purposefully short.

In Part 2 of this series, we’ll move on to the next mini-epoch, A.C. — After Computers. Once computers were on the scene, innovations came quickly. And we’ll revisit the first part of the A.C. mini-epoch from word processors up through the modern spreadsheet!

Parkinson’s Law and Arbitrary Deadlines

When I was in Corporate America, including my time at DaVita and Fresenius, there were endless deadlines. Everything was required ASAP or by some seemingly arbitrary date.

There is an old adage called Parkinson’s Law that states “work expands so as to fill the time available for its completion.” Sometimes it is indeed the work that expands… maybe in scope as you get deeper into a project. Sometimes the work to be done is not properly defined when ascribing a time period in which to complete it. And then for most of us, there is our friend procrastination. Knowing that we have a given amount of time, we leave the work until the last minute to complete it.

So if we were to compress the “time available” part of Parkinson’s Law, the work could only expand so much. So the arbitrary deadline helps us limit the unnecessary expansion of work. And work will most certainly be completed more quickly, right? I don’t buy it.

Stress of these artificial time constraints can ultimately burn you out. Plus, I wonder if we do our best work under such constraints.

I mean, what really happens when a deadline is missed. Nobody dies. The world still turns. Is it really going to cost the company all that much because the work wasn’t completed “on time”, but a week later?

A tale of two deadlines…

In my last corporate job, I had to cancel the software update on the night of the release. We simply weren’t ready despite our best efforts. Doing so would have had a major negative impact for our customers. I cancelled the release without a second thought. And I got chewed out royally for my decision.

The next time I was in the same situation, I allowed the version update to be released as planned. And our customers were none too happy. And our team paid the price for it for the many months afterward dealing with the fallout. Again, we simply weren’t ready despite our best efforts. We couldn’t meet the deadline.

And the point of that is… who really cares? Nobody. Nobody cares until it starts to impact them. A missed deadline may look bad to a higher-up or a manager. But in software development, the end user appreciates the gesture without ever knowing it. And who even remembers that a deadline was missed? I’d be really surprised if the higher-ups remember. But those folks who dealt with months of the aftermath. We surely remember hitting that deadline.

Moral of the story…

And this is why at ScheduleWise, we don’t worry about deadlines. Yes, we plan dates. But these dates are more like lines in the sand… drawn to give us a goal in which to complete our work. But truth be told, I have missed far too many of them by now. Sometimes by a week. Sometimes by a month. And nobody cares. The world still turns.

But I can tell you this… I’m certain that my team is happy that they don’t have to deal with the unneeded stress because I want to hit a date. And I’m certain that our users are happy, too, because they haven’t had to feel the aftermath of a rushed software update! If we are not ready, I simply delay the release.

The work does eventually get complete, though. And even with our slower, less stressful pace, we still continue to be the world’s best workflow and scheduling application for dialysis companies! Who needs a deadline for that?

Solving Problems Is Hard!

The fact is that solving problems is hard. If a given problem still exists, you can bet that a lot of people have already come along and failed to solve it. Easy problems evaporate; it is the hard ones that linger.

— Steven D. Levitt and Stephen J. Dubner, authors of Freakonomics

Optimizing a Patient Schedule

Now THAT is a hard problem to solve! It might be the hardest problem in dialysis. After nearly 50 years, this problem of scheduling patients and assigning staff in an optimal way has been with us for as long as most working dialysis professionals can remember. It is a really hard problem to solve!

If you’ve ever given it a try, you know exactly what I mean. Especially after you take that carefully crafted document that you worked so hard on and place it into the hands of a patient care tech or nurse and ask them to work that optimized schedule. That is where the rubber meets the road. And then you wait… You wait for your staff tell you in no uncertain terms how you just failed abysmally at making anyone’s day better! Their turnovers are even worse than before, and they can’t possibly get their breaks with this optimized patient schedule. And let’s not even get into what the patients are saying!

Ok, I painted a pretty bleak picture. It’s not all doom and gloom. But that, my friends, is where the fun of solving the patient schedule really begins! That is, assuming you are a glutton for punishment like me.

It is not an easy task to ensure all patients get the exact time and chair they want, and that all the staff get to come in to work and go home when they please. That is not the nature of this business. But at the center of all of this is the patient schedule. And if you can solve it, be proud! Because you have really accomplished something.

Of course, then the very next week, two patients expire, you have three new patients, and you just lost a couple of your staff. Where does it end?! It’s back to the old drawing board.

Is There Any Hope?

One day, I promise… there will be an easy button. I talked about this very thing in my post “Is Effective Patient Scheduling More An Art Or Science?” But you will have to let go and welcome your new computer/robot overlords.

Until then, there are easier ways to address the seemingly constant problem of the patient schedule. But don’t get me wrong. It’s still a HARD problem to solve. Even though we think ScheduleWise is the best tool for the job… even we know that we haven’t fully solved this problem. It still takes work! And so we continue to work at it, sharing with you the techniques and principles we have learned in working with over 3000 clinics, and coaching organizations on how to manage their workflow.

In the meantime, if you are stressing out dealing with your patient or staff schedules, let us know in the comments down below. After all, you have enough stress, and this is the stuff that should keep US up at night… not you!

ScheduleWise’s Top 20 Features of 2020

This may be late, but as they say, better late than never!

If you ever want to take an adventure through our Release Notes, you may find a treasure trove of features that escaped your attention in the past year. But we wanted to be sure you didn’t miss these!

Here’s a look at some of the big features that were released in ScheduleWise this year.

On the Patient Schedule:
Pod Graphs — update individually, zoom, blocks, breaks, open chairs
Staff breaks and lunches
Mega button – Export, Productivity, and Center Graph all on one button
Export Templates can display staffing data
Drag/Drop Shared Chairs and Unavailable Chairs

On the Patient Demographics Screen:
Easy Delete button
Callback Timesheet for bringing back patients from the lobby

On the Staff Schedule:
Copy Shifts Modal
Copy All Shifts in Panel
Assign Nurses to Pods/Charge
Display float hours
Assigned shifts modal
Discontinued Shifts

On the Dashboard:

On the Users Screen:
Last Login Date
Automated Password Resets
Mobile access for staff schedule

New Screens:
Screen Tours
EHR Activity (integration)
Merge Patient Screen

So if you weren’t aware about some of these updates and want to know more, then take a dive into the Release Notes and you’ll learn how to make the most of ScheduleWise while managing your patient and staff schedules!

Question from the field: “Should I set up a one size fits all schedule?”

Question from the field: “Should I set up my patient schedule with all four-hour slots so that I can easily move my patients from one spot to another? Kind of a one size fits all schedule?”

I dare to say that one size fits all philosophy is not true for clothes and definitely not true for meeting individual patient needs when setting up your patient schedule!

Every dialysis patient has the same needs, correct? They are there because their kidneys are not functioning at a level that can sustain life, so the same set-up and treatment should work for all. If we believe that to be the case, then providing care for them should be the same, right??

I think that we can agree that the belief that every patient is the same and should receive the same treatment is just a foolish thought. All patients with high blood pressure are not treated with the same medication or the same dose, and dialysis prescriptions are no different. Patients are scheduled for treatment durations based upon the current function of their kidneys, body size and other medical parameters. The prescribed treatment time changes based upon lab results, type of vascular access and physician assessment of what the patient needs.

If we stop there, plugging in only the  prescribed treatment time into our patient schedule, we are short-changing both the patients and the caregivers.  What more is there to consider, you may be thinking?  You’ve taken the time to work in ontimes between treatment starts (maybe 15 minutes) and time between an off in one chair and an on in the same chair (maybe 45 minutes). This may appear to  create a smooth schedule, but it will still cause the staff and patients a lot of frustration as one of the most important pieces of quality scheduling is missing — adding in time for patients’ individual needs, or their acuity needs!

Over the years, we have performed many time studies to better understand the workflow of the patient schedule.  We repeated those studies after Medicare’s 2017 ruling of vacating the station before disinfection and setting up for the next patient. Our studies showed that when staff follow their policies, it takes an average of 15 minutes to put a patient on and 15 minutes to take them off. The 15 minutes to initiate the treatment includes 10 minutes before blood hitting the dialyzer and 5 minutes post-treatment initiation. The 15 minutes for taking patients off was all after the alarm signaled that the treatment duration was met.  Let’s take a look at an example that shows a pod of patients that are all allotted 15 minutes to put on and 15 minutes to take off.

Example 1: All patients seen with equal needs
  • Blocks of time (orange line) in which the caregiver (green line) is putting on or taking off patients.
  • If all patients truly take 15 minutes or less for care, this schedule works

The word bolded above, “average”, is key. Patients have different needs, you know this, but you may not have considered it relative to how the patient schedule is set up and that more time may be needed between some patients while no extra time is needed between others. You may be able to meet those needs in that 15-minute span to put a patient on, but that same easy put on is a long bleeder at the end of treatment and needs 25 minutes after treatment before they are ready to vacate the station.  (See Example 2)

Example 2: Impact of acuity
  • As Mickey Mouse requires 25 minutes to be taken off, the caregiver is still busy providing his care when Donald Duck is scheduled off.
  • In these cases, something gives. The caregiver either asks for help (often the RN) or add/cuts time to patients’ prescription durations, which means that treatment may be against a physician’s order.

Thinking about your own patients, you know those who need additional time because they are in a wheelchair, a stretcher, possibly requiring a Hoyer for transfer.  But there could be others who are not so obvious and that’s where your PCT’s and RN’s come in. Ask them!  Engage them in the schedule set up and revising.  Create an environment in your clinic in which the caregivers share which pods are challenging, review each patient’s acuity needs in that pod and make adjustments to your schedule.

By taking the time to understand which patients need additional time, and accounting for that time, your smooth appearing schedule becomes a truly smooth, functioning schedule where the staff now have the time to care for each patient based on their individual needs.

Join the conversation! We’d love to hear from you!

  • Have a question you would like us to answer in a future post? Just ask!
  • In your clinics/organization, how do you account for patients that need additional time on your patient schedule?
  • How often do you review your schedule to ensure it is up to date with treatment durations and acuity needs

The Software We Use To Run Our Business

Tools of the trade are not the same anymore. Instead of hammers, screwdrivers and pliers, we have laptops, phones, and iPads. And that is just the hardware. The software is what really makes these new tools come to life.

But have you ever taken a moment to consider just how many tools, software applications, websites, and services that you need/use to run a small business? It is literally astounding just how many we use at ScheduleWise! To create, deploy, and support our Scheduling/Workflow Management Software, we have had to become competent and sometimes expert users in so much other software!

In a recent fit of wild transparency, I’ve highlighted below the most prominent applications/services that we use to run ScheduleWise. Not all of them do we use every single day, but for the most part, we touch each of these applications at least once per month.

When they say that software is eating the world, you can see why!

Here is a listing…

For administering the business:
Google Apps
— email
— calendar
MS Office – Excel Rocks!
Website – Content Management System – WordPress / Elementor
TeamWork for Proj Mgt and Dashboards.
iPhone and apps galore!
TeamWork Desk for Support
Adobe Acrobat / PDFsam
FreeCommander – File Manager
ScheduleWise – That’s right, we use our own app to do work for our clients.

For development of ScheduleWise:
SQL Server Management Studio
Sophos VPN
Viviotech Hosting
Chrome Dev Tools / Firebug
ColdFusion Dev Server
ColdFusion Security Analyzer
Adobe XD
NPM – Node

Software no longer in use… either replaced or no longer needed:

For administering the business:
Google Apps
— Analytics
— Adwords
Website – Content Management System – MURA

For development of ScheduleWise:
Lighthouse Issue Management
Cisco VPN Clients
Tortoise SVN
Hosting.com/Edge Hosting

Oh! And I would certainly be remiss if I didn’t mention good old paper and pencil! I have my handy, dandy notebooks which I have been journaling, ideating, and diagramming for the past 12 years.

So that about covers all of the applications, tools, and services that we use to run our little company. When we started ScheduleWise back in 2008, we didn’t know all the things that we didn’t know. We knew how to optimize patient schedules and workflow and created an application that did just that. For all the other stuff it takes to run a business, we learned over time. As needs arose, we found tools and services to help us along the way. It’s no wonder that most small business do not survive the first five years. There is just so much to learn and do!

Truth be told, it’s probably easier today than anytime in human history to find just the right application or specialist for a job. Not only are the tools themselves most likely out there (ScheduleWise is one of those such tools!), but also insanely important is the ability to find them with the help of your favorite search engine.

But the next time you have a big, glorious idea, and you’re thinking about starting a company of your own, take heed! You’ll be learning a LOT more than you bargained for. But isn’t that half the fun?!

The Rule of 100: Be willing to do something one hundred times to get good at it.

fencing finals

I was getting frustrated with my step-daughter. She recently acquired a knack for whining that she isn’t good at something and therefore wants to blame everyone else and give up.

For example, in a recent quiz in chemistry, her teacher said she got all the hard math stuff correct, but missed the easy problems. So her takeaway was that she just isn’t good at chemistry. Forget that all last year she griped about just not being good at math… Ugh.. teenagers!

It is amazing that we take these lessons like this from childhood into our adult lives without ever really reflecting how these ideas came into being. So it’s something we want to correct now while she is still young.

In another area, she has become a pretty competitive high-school fencer. In just one year, she went from no knowledge of the sport and limited coordination to becoming one of only two girls to letter in their freshmen year in the history of the school!

I reminded her that just 12 short months ago, she could barely hold the épée or do her footwork drills. But eventually, she found her groove and began to excel. It took hundreds of those drills over several months for her to not just get good at her fencing skills, but to learn to enjoy the process as well. She still hasn’t become the champion fencer that she is striving to be, but she is continuing to build her skills and experience. Touché!

So I challenged her rationale and likened her fencing to her school work. Clearly one is fun and challenging while the other is, well, in her eyes, just challenging. But the central tenet remains the same. If you only go through your drills once or twice, you’ll never be proficient, much less expert at that skill.

The same is as true with fencing as it is with solving math or chemistry problems. You can’t just do one or two problems and claim that you’re good or not good at it. You have to do hundreds! Hopefully you learn to enjoy the process along the way, but you will most assuredly progress in attaining the new skill! She acquiesced, but didn’t seem thoroughly convinced. Teenagers. =]

This is what I think of as the the Rule of 100, that is, being willing to do something 100 times in order to get good at it. Put another way, don’t let your initial ineptitude or trepidation prevent you from something challenging that you want/need to accomplish.

Do the work. Learn the skill. Become expert at it!

Thinking about this in our line of work, although we train people how to use our software ScheduleWise… what we are really doing is helping people learn how to change. Changing their patient schedule entails a whole lot more than just changing a schedule!

It consists of determining a better schedule, communicating with patients, families, transportation, staff, and physicians. It encompasses teaching how to communicate, hand-holding to help managers take back control of their clinics, and constant course-correction with staff and patients as they get used to a new normal.

And when you see the teams we work with have those lightbulb moments when everything just clicks, and they see how well their clinic can function, it’s not just highly rewarding for us, everyone wins!!!

For the clinics we are helping, this is likely their first time with such an undertaking. A wholesale change to the patient schedule isn’t something that a clinic undergoes all that often. So it is easy for people to become dismayed because they haven’t yet mastered the skills to sustain the optimized workflow of their patient schedules.

But the point isn’t to view the schedule change as one-time event. Think of it as the first step toward constant change and improvements. Each day that a new patient need is identified, the schedule may change. Each new change is an opportunity to build on your newly acquired skills of learning how to modify your schedule in order to maintain an optimized workflow.

After implementation, the first few times of managing schedule changes on your own are often full of hesitancy. No one wants to change what they just worked so hard to achieve in optimizing their schedules! But this is the essential skill you must practice in order to gain the proficiency that leads to mastery.

Remember the Rule of 100! The first 10-15 times, it will take you awhile. You will feel uncomfortable making changes, asking patients to change their time or chair again. After 40-50 times, you’ll be over that uncomfortableness, but there might be a handful of harder scheduling issues that involve multiple changes, or reworking an entire pod.

After 100 changes to the schedule, you’ll find most of the schedule changes to be pretty routine, with a harder challenge happening once every so often. After 200 changes, nothing will surprise you any longer. You’ll have mastered your schedule and learned to maintain an optimized workflow! Kudos to you!

Don’t worry, though! New challenges will reveal themselves as you master one skill after another. The learning never stops. Just remember to embrace the Rule of 100!

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!

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.