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!

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!

Why Is the Patient Schedule So Important and Who Should Be Responsible for It?


In all my years working in dialysis, I have not come across any other management issue that impacts so much in our clinics than the patient schedule.  Why is it so important to you?

 Each and every dialysis clinic’s existence depends on the satisfaction of its patients for its success. It’s no secret that patients can be demanding, and it’s not just the results of their medical treatment that matter to them. Their experiences and interactions with your clinic and your staff have an impact as well. As you want to keep the patients that dialyze in your clinic satisfied and healthy and the staff feeling that they can provide quality care, there are a few things you need to keep in mind.

  • Ensuring that your patient schedule allows the necessary time for the patient to receives their full treatment and for the nurses to have time to review labs and monitor vascular access impacts clinical outcomes.
  • If you want your staff to treat your patients right, you need to provide them with an ideal work environment. This means giving them the time needed to provide the care you are expecting of them. This time is not the same for every patient.  Some patients take 15-minutes to put on the machine and others take 20-minutes.  Because of these different acuity needs, your patient schedule should not be set up treating every patient the same way.
  • Giving the patients’ the times that they prefer and getting them on at their scheduled time impacts the patient satisfaction surveys. When the time that they prefer is not available, how you handle communicating that to the patients, discussing and documenting it in your QAPI Meetings as not getting the time they desire would be considered a patient grievance and resolving it to a level that is either acceptable to the patient or documented as to why you are unable to accommodate the patients specific request is key. Keep in mind, it is not a requirement to give the patients the exact time or chair that they desire.  It is however a requirement through Medicare’s Conditions for Coverage to document and address patient grievances.
  • The staff feeling that they have the time needed to provide quality care, getting out at their scheduled time, and getting the hours they were hired to work impacts staff satisfaction. When the patient schedule is chaotic with pods to busy for the caregiver assigned to work independently and the nurses have to set aside their nursing duties to assist with turnover on a regular basis, their job satisfaction declines and overtime is often required to get their duties completed.
  • Understanding how treatments, missed treatments and staff hours worked impacts the bottom line.

So with all that said, I’m going to share why I feel it is the manager’s ultimate responsibility.  Think of this.  If you were the owner of a prominent, well-respected spa/fitness center, who would you want to be ensuring that safety and quality standards were met or exceeded?  Who would be your go-to person if you were receiving feedback that those standards were sub-par? Would it be the person checking clients in, the massage therapist, the trainer or would it be the manager?

As we have worked with clinics all over the U.S., we have seen the responsible party being everything from the Clinic Manager, Nurse Manger, the Social Worker, Patient Care Technician, or the Administrative Assistant.  We have also seen in a few instances that schedules were managed by an offsite scheduler whose only job is the patient schedule for multiple locations.  I often get asked which the best is, and my answer is always the same.  The ultimate responsibility of the patients and staff schedules belongs to the manager.  They are the CEO of their business, the dialysis clinic.

Scheduling often takes a village to get it right.  To go from a good schedule to a great schedule, getting input from the different roles in the clinic is extremely valuable!  The nurse manager (if a different person then the clinic manager) reviews the outcomes and gets orders for any necessary duration changes. The Social Worker is aware of transportation or other issues that may make a certain time or days difficult for patients.  The Patient Care Technician knows which patients are not best to sit next to each other and which patients may take more time than others or have higher acuity needs which impact the amount of time that the caregiver will need to be with them. The Administrative Assistant may also be aware of transportation issues and is often the “ear” of what patients may be unhappy about and discussing in the lobby.  Each of these roles has valuable information, but none have ALL the information needed to create the best patient schedule.

It is for those reasons that I feel that it is the responsibility of the clinic manager to pull all that information together and create and maintain the patient and staff schedules.  Could another person in the clinic be assigned the task?  Yes, and they could do a good job with it, but even in those cases, heavy oversight must be there by the person ultimately responsible — the clinic manager.

We’d love to hear from you!

  • In your clinic/organization, who (what role) is responsible for creating and maintaining the patient and staff schedules?
  • If your clinic is not meeting any of their goals, whether that be clinical, satisfaction or financial, have you investigated how they are scheduling and how that may be impacting the clinic in not being able to meet those goals? What did you see?

Even a Bad Plan Is Better Than No Plan

ScheduleWise - Hannibal A-Team

“I love it when a plan comes together!”
— Hannibal Smith

Here’s an often heard bit of conventional wisdom “…even a bad plan is better than no plan at all.” While I love to be the contrarian, I have difficulty arguing against this sound bit of logic.

So how can we exemplify that with what we love to talk about most in this blog… how about the patient schedule?  🙂

Basically, your patient schedule is your plan. So rewording our conventional wisdom, it would go like this… “Even a bad patient schedule is better than no patient schedule at all.”

And to this, I would heartily agree! Do you?

Believe it or not, some clinics do not even have a true schedule! What they have is a first-come first-serve setup by shift. For example, first shift starts at 6:00 AM. So all first shift patients should arrive by 6. There are only so many patient care staff, though, so not all patients would actually go on at 6:00 AM. Instead, they are put on in a first-come, first-serve basis. (note: some of you may counter that this is a schedule… but I have to draw the line somewhere, my friends!)

As you can imagine, competition is fierce! So a significant number of patients arrive as early as possible. They might even be waiting outside the facility doors before it even opens so they can get the coveted 6:00 AM put-on times.

And assuming a 2-shift clinic (you could hardly manage a 3-shift clinic in this way), the same thing happens all over again for the second shift. Assume staff takes lunch together. And assume an average treatment duration of 4.0 hours. Thus, the second shift would start sometime around 12:00 or 1:00 PM.

Does this sound good to you?  It depends on what you do at the clinic, I suppose. But it is not a recipe for long-term success given the dwindling reimbursement rates and higher costs in just about every category from supplies to staff.

Here are some of the real problems with this type of plan:

  • There is no consistency day-to-day. Different patients show up each day and potentially get put-on in a different order. Every day (every shift even!) is a new adventure for the staff. This may be appealing to some… but this level of variability is not ideal for a clinic or a business. There is no feedback loop for you to make changes day-to-day to improve the workflow. It’s ever-changing!
  • It does not consider the manageability of each pod by its technician. All patients going on one by one is fine… but when do they come off? Several patients could come off at the same time. That takeoff time could get highly chaotic for the technicians and patients.
  • It does not consider the effectiveness of the nurse to do pre- and post- assessments in a timely manner. Again, while the pre-assessments may be somewhat orderly… the post-assessments could get really hectic.
  • It is tough to gauge patient satisfaction trends with no schedule. Obviously a survey might give you insight. My main assumption is that patients would prefer consistency in their schedules. It is tough to make any predictions on patient satisfaction.
  • It is just as tough to predict staff satisfaction. The day-to-day variability will attract certain types of staff who can handle it. They may like the long breaks. The best indicator here would be retention of your staff to understand how effective this method of scheduling is.
  • It is not a productive/efficient way to treat patients. Whereas the previous two bullets were uncertain, this one is clear. This type of plan is hardly a recipe for success along the cost front. It is just too much unproductive time… that is, time when staff is on the clock, but no patients are receiving treatment.
  • Ideally, we group tasks such that we minimize the time for turnovers, and we find time for lunches while patients are being treated. These costs directly hit the bottom line of the clinic, and a plan like this especially hurts the viability of the smaller independent dialysis clinics.

So the moral of the story is:    No Schedule = No Plan

And if you believe the conventional wisdom, then you believe that even a bad patient schedule, is better than no schedule at all.

Remember, even with a bad plan, you have a mechanism for feedback and revision. We learn from our mistakes. Without a plan, we tend to repeat our mistakes too often. Instead, having a plan, even a bad plan, forces us to think and reason about the problem more, instead of venturing into the unknown each day.

Here are some simple questions you can ask yourself to get feedback from your plan/schedule (not an exhaustive list):

  • Did the patients arrive on-time?
  • Did your schedule allow the technician to put the patient on at their scheduled on-time?
  • Were your nurses able to get their specific work tasks complete?
  • Did you meet your productivity goals?

Revise the plan/schedule:

Based upon the data from your feedback, you can tweak your bad schedule to make minor improvements each day.

Rinse and Repeat:

This is not a one-trick pony. A feedback loop is just that… a loop! This is what we talked about before in “The schedule is a living, breathing document!” You must manage it frequently.

After all, even a well-oiled, fine-tuned machine needs an oil change and a tune-up after continued use.

A few iterations with this simple process and it will become second nature. And you’ll love it when your plan finally comes together, too!

The Patient Schedule is a Living Document

ScheduleWise - Living Document

Having been in hundreds of clinics, sometimes what we’ve seen getting passed off as “tools” are nothing more than bullet points and platitudes and are just as often forgotten as soon as they are mentioned or read.

Here’s one: The patient schedule is a living document that must be managed daily.

It’s one of those easy to say phrases that just rolls off the tongue, but unfortunately is not practiced, at least not with respect to “managing” the schedule, and certainly not daily, and by the way, what the heck is a living document?

So let’s break this down so we understand.

Patient schedules change.  And they change fairly regularly.  Each week, physicians changes orders, transportation needs change for the patient, new patients get added to the schedule, and some patients expire or transfer, so they get removed from the schedule, et cetera, et cetera.

So when ANY of the above things happen, the schedule must be updated.  And while this is a relatively simple activity, we often don’t consider all of its ramifications.  Even a simple duration increase of 15 minutes can have a tremendous impact on the schedule.

What is the effect of these changes to the schedule?  Actually, let’s start with WHO will make the change?  Wait, can we even assume the change was made to the schedule?

Orders sometimes get changed in the Electronic Health Record, but not on the schedule itself.  That can make for an interesting and hectic day when your staff are expecting one thing based on the schedule, and then surprised that Mr. Jones’s treatment will be run 15 minutes longer, and Mrs. Brown is going to be angry because she doesn’t start on time.

The possibilities can get ugly if the schedule isn’t updated at all.  So ok, let’s say the change was, indeed, made both in the EHR and on the patient schedule.

So then we get to the question of WHO updated the schedule?  I’d like to assume that the person updating the schedule has the bigger picture in mind, so that they ensure patient safety and pod management is considered when changing schedules… every clinic has a scheduling guru.  But sometimes we just need to ensure that the change is made so it doesn’t get lost amid the 10,000 other tasks each day.  So the non-guru makes the necessary changes to durations and on-times, and hopefully communicates it to the “schedule guru” to make any other necessary adjustments.

And so finally we get back to the original question, what is the effect of these schedule changes?  Effect on what exactly?  There are two considerations:

  1. the effect on the patient in terms of transportation and any change in the patient’s on-time or chair;
  2. the effect on the staff in terms of providing them a schedule to be able to manage their pod safely and effectively.

Most of the time, we consider the effect on the patient’s transportation, that is, we ensure that either the new on or off-time does not affect their transportation constraints, or we communicate with the transportation company to make the necessary changes.

Where we often fail with the schedule change is on the staff side of things.  We assume
the technician will be able to adjust accordingly to the new on or off-time.  And we do not give enough consideration to the altered workflow when turning over the pod with this new off-time.  If we don’t consider the impact to the technician’s workflow, then we are doing a disservice to our staff.

Here are some examples of the potential change in workflow for the tech.  First off, we want to ensure that increase in Mr. Jones’s duration doesn’t create a new off-time that would overlap the next patient in the chair, Mrs. Brown.  We need to ensure that at least 45 minutes is available for turnover the chair (a topic of debate and one we will give attention to in another post).  And of course, Mrs. Brown isn’t going to be happy that her time is changed. Again, a later topic. =]

Other possibilities are that the new off-time could now coincide with the off-time of another patient in the same pod.  So how would the tech handle this situation where two patients come off at the same time. It’s stressful.  And leads to cutting corners on policies and procedure, or cutting times.  Often, it leads to getting help from the nurse, who is now torn away from his or her duties to manage a takeoff.  And don’t think the patients don’t feel that stress.  They are now being cared for by someone who is needlessly stressed. I must humbly offer that this is not putting our best forward for optimal care.

OR the new off-time could coincide with another put-on.  All the same things that I enumerated above could come into play.  It’s really a no-win situation for all involved.

Once you understand the potential pitfalls, it is easy enough to avoid them. How? By shuffling things around.  That is, changing some patient times or their chairs, which is akin to opening Pandora’s Box.

This is where I get to stress that it is incumbent on the clinical manager to make these necessary changes for the safety and quality care of our patients, as well as to provide a manageable pod for our direct patient care staff.  In short, to MANAGE the patient schedule.  If we do not, we pay the price.  Patient satisfaction decreases as their on-times become meaningless, and they have no choice but to have stressed out staff caring for them.  And staff satisfaction goes down as turnovers remain hectic which leads to a decrease in staff retention.  The schedule is connected to everything.  So clinical managers must make the hard changes up front and be confident that this is for the greater good for optimal care.

For our sake, and the length of this post, today is a happy day, and we will assume that the change to Mr. Jones’s treatment duration caused no issues.  Sometimes things work out just fine like that.  Not often, but sometimes. =]

Just remember that the schedule must be MANAGED daily.  Each day the clinical manager must ensure that his or her direct patient care team can handle their patient load in a safe manner and have the time to deliver optimal care.

I’m glad you took the time to read about the patient schedule as a living document.  Never again will you be able to hear this phrase and be unaware of all that it entails.  A simple duration change can have a ripple effect through a pod.  Just imagine when there are three and four changes!

Please share your own stories or comments below.  And if you don’t agree with anything I’ve written above, please share that too.  It is only through open dialogue that we come to understand one another.  Let’s just be respectful while doing it.

–Mark Sessoms