Setting the record straight – ScheduleWise & Fresenius

Often we are asked or even told that Fresenius owns ScheduleWise. Au contraire, mon frere! So let me set the record straight. Fresenius uses ScheduleWise. They do not own ScheduleWise. ScheduleWise LLC is and has always been owned and operated by its three principal founders, Gary and Mary Kay Hamilton and Mark Sessoms.

Fresenius did obtain a permanent license of ScheduleWise in 2015. And we (Gary and Mark) joined FMC (now FKC) to help them roll out the software to their (at the time) 2200+ clinics. And I (Mark) also continued to lead a separate development team to improve the software for FKC’s specific needs.

In the interim, Mary Kay and Brandon continued to manage ScheduleWise and introduce it to new clients, but our software development was at a standstill.

By 2018, Mark returned full-time to ScheduleWise to rebuild our product from the ground up with the help of our talented and growing development team (Alan, Suzanne, Waleed, Mike, and Doug).

By March 2019, with a completely overhauled application, we proudly released ScheduleWise 2.0!

And since then we’ve been hyper-focused on building and releasing improved features nearly every month! And that is our commitment to you, to continue to provide the dialysis industry’s most ubiquitous and, dare I say, best scheduling platform!

But we know that software is just one piece of the puzzle. Without our 20+ years of scheduling knowledge, innovation, and coaching, ScheduleWise is just a software. But the two in combination produce a winning solution for your organization to thrive in the new decade!

We hope to continue serving our clients well into the future! And if you’re not yet aware of how we can help your organization, give us a call!

Are There Too Many Variables in the Patient Schedule for a Computer to Handle?

Remember, my purpose in writing for this blog is to share what we’ve learned over the past 30 years in dialysis. Lots of grand ideas come and go. Buzzwords that promise a lot of improvement, but are not sustainable. Instead, the goal here is to share with you the ideas and methods that stick. And hopefully, after reading some of our words, you may begin to think differently about your approach to your business. Whether you act on that new understanding is totally your choice!

So today, let’s tackle one of the sentiments that I hear come up frequently as a knock against scheduling software… that there are too many variables in the patient schedule for the computer to handle.

As an engineer, this is just striking to me. Our human brains are magnificent and capable of amazing feats. But we are also humans succumbing to emotions, persuasion and forgetfulness. Here are some examples:

  • A staff request to be off next week
  • One of your physicians wants all of her patients on the same shift, but the transportation company can’t manage moving one of those patients from their schedule.
  • Two patients like to sit next to each other because they are buddies
  • Another patient, a very cantankerous man, doesn’t want to sit underneath the air-conditioning vent.

While you may be able to remember these small-ish issues, in two weeks with twenty other changes, and the stresses of a day-to-day dialysis clinic, will you be able to remember all the details? And if you pass it off your scheduling duties to your Charge Nurse, or Social Worker, or Admin Assistant… will they be aware of all of these details? And if so, are they trained to keep all of those issues in mind when managing changes to the patient schedule? And how will they effectively communicate that back to you?

This is why computers are so much more adept at handling the mounting variables of managing a patient schedule. The computer won’t forget the details, so long as you enter them in. Futhermore, the computer can be programmed to assist you with decision making along a set of rules that you give it. And it can be programmed to take into account constraints around patient treatment times, or physician rounding, and anything else that may impact the schedule.

What’s nice about this is that after you set up these guidelines, and the computer can warn you when your schedule is out of bounds, meaning it does not comply with all of the parameters or constraints that you set up.

All this will just make life easier. Yes, you still have to manage your schedule. Yes, you still have to enter patients and schedule into a system. You are doing those things now anyway. But something new might be to start entering in constraints and rules-based logic into your schedule. This is something where computers shine and really aid us in our everyday work. This is, of course, assuming the scheduling app you use is designed for that purpose. Most do not. That is another discussion.

But getting back to the central argument, that a computer can’t handle all of the variables of patient schedule just, to turn a phrase, does not compute!

Am I being controversial here? I don’t think so. Just reasonable. After all, I’m not saying that there aren’t people who can manage a patient schedule brilliantly. I’m only saying that a computer has a much greater capacity to keep track of all the necessary variables of patient scheduling, day after day, week after week, and given the right program, the capability to aid in your managerial decisions related to your patient (and even staff) schedules.

If I’ve made my case above, surely on that we can all agree. Still not convinced? Let us know. Get those thoughts out in the open by writing a comment below!

Acuity — One Size Fits All???

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.

The word “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)

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?

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

ScheduleWise

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. 

Staffing

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.

Standards

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. 

Mentality

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.

Productivity! Fun with Numbers! (Part 2)

In my previous post on Productivity, I reviewed what Productivity is and a simple calculation of productivity equaling half of the average treatment duration in your clinic. This provides a ‘good’ productivity goal for organizations to use in determining an appropriate clinic-specific goal.

In this post, I will be going into more detail on how a productivity number relates to dollars and the impact that can be made by improving your productivity by as little as 0.1 hours/treatment.

I often get asked…

Question:      What’s the big deal about a productivity number of 1.7 versus 2.0?
Answer:         A lot! 

Let’s take a look at just how much that could be in dollars. What I’ll be describing is an
oversimplified way of looking at it, but I believe it will help make sense of something that can be quite complicated. 

For this example, I will use a $25.00 blended rate (RN=$35 and PCT $15 is roughly a $25 blended rate). Your hourly rates may give you a slightly different number, but $25 is good enough for our example.

  • Every 0.1 hr/tx improvement saves $2.50/tx.

Here’s the math (don’t be scared!)

Back to our original question, if your current productivity is 2.0 hrs/tx and you get it down to a 1.7 hrs/tx,  it represents a 0.3 hours/tx savings.  Or $7.50 per treatment! 

Now take that dollar savings and multiply it by your average weekly treatment count, and you can see how quickly it adds up!  Assuming you do 300 tx/wk.  That comes out to saving $2,250… each and every week! 

And here are the monthly and annual potential savings:

  • $2,250 per week x 4 weeks = $9,000/month
  • $9,000 per month x 12 months = $108,000/year

The below table summarizes these findings:

WOW!  Right?!?!

When I first show our clients these numbers, their first thought often is, does this mean I have to cut staff?  If your organization is happy with its bottom line, then the answer is no. 

For most clinics/organizations, labor is their greatest expense, so if you’re looking to find cost savings, right-sizing your staff is the greatest opportunity to meet that goal.   As you have seen in this post, even a 0.1 improvement can improve the financial health of your clinic/organization! 

In my next and last post on this lovely topic, I will share a few ideas that you can implement to improve your clinic’s productivity.

We’d love to hear from you!

  • Did this help you get a handle on productivity calculations? 
  • Were your surprised what a difference in your clinic’s bottom line could be made by simply improving your productivity by 0.1?
  • Has this information been helpful?
    • If so, please feel free to share!
    • If not, please let me know how your organization looks at it differently.
    • We’re always interested in learning how we can best support the renal community!

Productivity! Does the word itself stress you out? (Part 1)

Productivity, this simple word is anything but simple and often causes hearts to race, stomachs to turn or we simply want to ignore it and hope that it goes away.  However, it’s a vital piece of information to help us understand ‘how much staff do I need’?  ‘Am I really short or am I over staffed?’

Part of the distaste for productivity could be related to not fully understanding it. 

It’s just some number given by finance, and what do they know about running a clinic?  Does it feel like you have no control in meeting the goal, if you even understand the goal to begin with?  Many people I have had the opportunity to work with are surprised at how easy it really is to understand, when it’s explained in terms of what it means to the daily operation of the dialysis facility and then equally find it easy to implement changes that can get them to their goal, or at least heading the right direction. 

Alright, time for some full disclosure. Like many of you reading this, I went to school for nursing. I cared about people, loved science and wanted to better understand how I could take care of others and bring them back to optimal health. After working as a staff and charge RN for a few years in dialysis, I became the manager of a clinic.  When I first started in the role the responsibilities were so different. At first, it was good! The main duties included monitoring outcomes, survey readiness, hiring (and occasionally terminating) staff and my favorite part, team building.  

As you may have noticed, there was no mention of running a multi-million-dollar business, which our clinics are. There were no business classes in my nursing school to help me understand P&L Statements, EBITDA, doing annual budgets, the bundle, payers, QIP and achieving a productivity goal. HECK! At first, I didn’t even know what made up the productivity goal. It was just a number I was supposed to achieve, and I was told every month (after the fact) if I made it or not. AND, there were no useful tools out there to help me figure it out proactively. It was very frustrating, to say the least!

OK, enough about me!  My goal here is to give you a better understanding of productivity, both from the perspective of what it is and how you can manage to it!   I recommend sharing this post with your entire team.  The more everyone understands it, the more successful you will be in meeting it… it really is a team effort!

It’s important to first state that meeting productivity does not ever mean that you compromise your quality of care in any way!  Quality and safety remain the first priority always!  If you are interested in a full presentation on this topic, you can go to the National Renal Administrator Association (NRAA) Education Station website https://www.pathlms.com/nraa and watch/listen to my presentation, “Understanding and Achieving Productivity”, which I presented at the Fall 2016 NRAA meeting and in February 2016 as part of the NRAA Webinar Wednesday series. https://www.pathlms.com/nraa/courses/2091/video_presentations/23511

To start this discussion, I would like to take a couple of minutes to explain the difference between the cost per treatment ($/tx) and productivity, which is typically measured in hours per treatment (hrs/tx).  When looking at dollars per treatment, you are looking at actual costs and this number is more often looked at in arrears, in other words, many weeks after the fact!  Salary and wages are more or less set by upper management and not very controllable by a clinic manager.  For example, if you have an experienced staff, use a lot of overtime and/or use RN’s to cover what would otherwise be PCT shifts, your dollars per treatment will be higher versus the clinic that has a blend of experienced staff, uses little overtime, doesn’t need to cover PCT shifts with RN’s and/or does not use travelers.  

While some overtime is controllable prior to it happening, for the most part as a manager, the dollars per treatment are impacted by less controllable factors.  Whereas focusing on and adjusting hours scheduled for an expected number of treatments is something that a manager has control over proactively.  By understanding how to calculate the needed staffing hours of PCT’s and RN’s, you can create a schedule that will meet your productivity goals.

Most dialysis organizations look at productivity as the number of hours worked by the PCT, LPN/LVN and RN on a per treatment basis.  These are the employees providing direct patient care (DPC) that are usually paid by the hour.  Your clinic may have additional support staff, not providing direct patient care (sometimes referred to as Indirect Patient Care or IPC or Fixed), such as nurse managers, dietitians, social workers, etc.  Depending on your organization, those hours may or may not count towards the total productivity goal.  If IPC and DPC are both used in the total productivity goal established by your organization, then using the calculation discussed in the next paragraph is not the correct final productivity number for you. In a future post, we will discuss how to determine total productivity including those support roles, what amount is the right amount for each of those roles and which portion of the total is the DPC portion. 

I am often asked what a “good” productivity number would be.

If by “good” you mean the right amount of staff to provide quality care to our patients in a safe environment, then I suggest taking the average treatment duration for all your patients and dividing that number in half.  For example, if your average treatment duration is 4.0 hours, if you divide that by two you get a productivity number of 2.0. If your average treatment duration is 3.5, then a “good” productivity goal would be 1.75.  Instead of having one goal for the entire organization, my suggestion would be to look at each clinic individually and apply different goals based on that clinic’s average treatment duration.  Two clinics with very different average treatment durations should not be expected to achieve the same productivity goal.

Using this rule of thumb will serve to establish a good starting point for a productivity goal giving you the minimum amount of staffing hours per treatment to provide safe and effective care to your patients.  If your budget allows, you can add additional staff to meet your additional needs.  Keep in mind that this goal is what you need to provide Direct Patient Care(RN, LPN, PCT).  It does not include the Indirect staff. 

Where do ratios come into the equation? 

For the vast majority of States, we see staffing ratios of 4:1 for our PCT’s and 12:1 for our RN staff.  You can usually meet those ratios by using the above approach. If, however, your state requires certain ratios (e.g. Georgia requires a 10:1 RN to patient ratio) or your organization’s policies require a smaller patient to staff ratio, then your productivity goal will most likely need to be higher.

And that is about all the productivity talk anyone can muster in one sitting!  Thanks for reading!  I hope this post helped you better understand what productivity is and how you may choose to set a realistic productivity goal for your clinic or organization.  There will be a Part 2 of this post in which I will provide more detail of how productivity relates to dollars and the financial health of the clinic and organization. 

We’d love to hear from you!

  • Does your organization have a set productivity goal for your clinic to meet?
  • How are you doing in meeting that goal?
  • If you are over your organization’s stated productivity goal, yet your staff tell you they feel that they need additional help, how are you handling the two different viewpoints?
  • Has this information been helpful? If so, please feel free to share! If not, please let me know how your organization looks at it differently. I’m always interested in learning how I can best support the renal community!

The Art AND Science of Patient Scheduling

Previously I took us down the philosophical rabbit hole of whether managing the patient schedule is an art OR a science. I wanted to consider a different path line of reasoning this time, shall we? This time that patient scheduling is necessarily both an art AND a science.

In my last post, we discussed the “control” aspect.  But for this post, let’s consider that you are in total control.  No computer is going to do the work for you.  So you have to put your thinking cap on and manage all the changes to the patient schedule this week.

You’ve been doing this patient scheduling thing a long time, so you know the ropes. You’ve learned over time all of the patients’ likes and dislikes, their acuities, and you have jotted down some notes so you do not forget certain things like a transportation issue with one patient, and when a certain doctor may round. All of these things are in your head, and you’ve developed a certain knack over the years that when you have to make changes to put-on times, you know what ontimes work best in what chairs.  When you put your pen to paper, you aren’t even thinking any more. The schedule seemingly just writes itself.

Some call this “the art of scheduling”. And they’d be right. Not many people have the ability, and not many people WANT this ability either! 😉  And when a schedule is done right, everybody is usually happy. They don’t look at the piece of paper with the schedule on it and want to immediately go and frame it, but they do consider the maker — the artist if you will — to have special talents.

But of course, this is the best case scenario. Every clinic has one or more persons in charge of managing the schedule, but not every clinic has an artist-in-residence. Learning these skills can often take years. And it’s a job that is often unwanted to boot!

But what happens when you add science to the equation? That is, if we learn all the techniques and considerations that the artist was able to apply to his or her craft of patient scheduling, and we could program our supercomputer to manage all this work for us, then all we would have to do is enter any new patients or changes to treatments, and with the click of the easy button, voila! Out pops a schedule worthy of admiration.

What’s nice about this last scenario is that ANYONE could manage the schedule. We no longer must depend on the artist. It’s not unlike the great advances we’ve seen with photography. We used to have just a few artists. They were experts with the technology of their day. And yes, they were indeed artists in their framing of their subjects and lighting and all the elements to consider when shooting. But along came the point-and-shoot cameras and the world of photography changed. And once the industry went digital, the costs for development were virtually zero, and thus the barrier to becoming more artistic for the average Joe decreased. And with smarthphones, now everyone has a camera in their pocket. And we have a world flush with photos. Everyone is now a photographer!

But is everyone an artist? Not necessarily. But one could say that there are many more artists than there were previously when the technology was more difficult, and the costs were higher, of course.  So we actually could attribute the rise in artistry and photography was due to the decrease in difficulty of the science of photography. To manage that, they had to hide all the science from the user (inside the camera), and make the interface dead simple. Art AND Science collaborating to make a better world of photography for all!

And so it is with scheduling software (you knew I’d come back to that, didn’t you?). The costs have decreased tremendously. The science has been hidden away in the algorithms underneath the hood so to speak. And the interface is simple so that anyone can manage the schedule.

Well, this will be the eventual congruence for patient scheduling, but as of today, we don’t trust the easy button yet. That gets back to the “control” issues I wrote about previously. Eventually, though, clinicians won’t want to waste any more time doing this task that the computer is better suited for. Instead, we’ll be content to know that we do have control of the inputs, and we’ll accept our eventual the transition to the Easy Button!

Between now and then, we still have some evolving to do. Slowly but surely the technology will get better and easier, and before long, we’ll all be artists!

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.

 

Is Effective Patient Scheduling More An Art Or Science?

Vincent van Gogh's The Starry Night

Vincent van Gogh’s — The Starry Night — 1889 — at Google Cultural Institute

Let’s begin with a recent milestone in the art world. We now live in a world where art and science have collided. Computers have begun to mimic human creativity. It’s really amazing (and scary!) to see what has already been done. I found this particular article fascinating.

Computers Can Now Paint Like Van Gogh and Picasso

This was from September 2015!

If you followed the link to that article, you’d find that computers were able to mimic the style of some of the world’s greatist painters (think Van Gogh, Munch, Picasso) to create a relatively simple scene of row houses along a river.  It is incredible to think these were done by a computer!  And yet, not, given how far we’ve come with computing!

The next level of fascination for me is the human psyche when it comes to man vs. computer. I picture that if we had a young art prodigy in our midst who was able to paint any scene in the style of several of the great masters, we might say that they are nothing short of incredible imbued with talents from God above. But once we find out that a computer was able to do this (a sophisticated artificial neural network to be more accurate) we may tend to pass it off as not so incredible. Amazing yes, but almost an expectation these days… and we may even begin to find its faults, it’s non-human characteristics. Or maybe we won’t even like it precisely because it was done by a computer, because its imperfections are programmed… on purpose. This is fair since understandably we fear the eventual congruence of machine and humans (unless it makes for a great character! link to Data or Blade Runner). I know I do to a certain extent.

And such are the mind games we play when we apply computers (more specifically optimization algortithms) to patient scheduling. The computer can now help us produce the perfect schedule… a thing of beauty. One that meets all of our patient’s needs and our staff’s desires, with just some inputs and the click of a button. Art, meet Science.

And that’s where it all goes wrong… because the moment we “lose” control to the machine is the moment we start finding fault with all that it provides. Sure, we have control of the inputs. Things like which patients run on which shifts. What are the patient’s durations?  How long are the treatment durations? Etc.

But do we have control of ALL of the inputs? Are we also plugging in the constraints of patient transportation? The preferred patient ontimes or preferred seating assignment? And do we have control of the methods used to derive the schedule? Does the computer take into consideration the workload on the patient care techs and provide buffer for adverse events? The questions go on…

And the simple answer is… we (in this case, the users) don’t know! Because it’s all hidden away in the black box we call the computer. Instructions were given to it, and it follows those instructions by creating the best possible schedule based on its constraints and its objective function. This gets into the scienc-y part of it all. So let’s skip that. Ultimately we accept the science because it is beyond our capabilities, but the art, **that we can judge!** and quite frankly, we often don’t care for it. Maybe it’s because we can’t really argue with a computer. And getting mad at it doesn’t really do anything either!

So, in the grand argument of patient scheduling being an art or science, I would posit the difference comes down to “taste”. Where the word taste can be substituted with control. If you are OK with giving up some control, than you can appreciate the science of scheduling. But if you have that rare person in your clinic who manages a satisfactory and workable schedule week after week, then you may be in the art camp.

What really may get your goat is that you (nurses and techs working the floor) have lost control either way. You have given up control to either an artist, or a computer. We just think we’re in control to some degree because we can argue with the artist when the schedule doesn’t work well!  🙂

Where do you fall on the art vs. science argument?