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!

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?

Does Managing Your Schedules Keep You Awake At Night?

Throughout my career, there was often something on my mind keeping me awake as a lay my head down at night, usually a work-related issue. Some thoughts that crept into my mind were…
  • Did I handle that personnel issue the best way possible?
  • Oh no! I forgot to call that physician back!
  • How am I going to keep Mr. Always-Arrives-Early from becoming upset at the staff when they don’t put him on before his ontime.
  • How am I going to meet the budget??
  • The surveyors have been doing their rounds, is one of my clinics next?
  • Patient satisfaction surveys go out next week, what are my patients going to say about the care they are receiving?
That last one was particularly bothersome as I knew that one of the biggest complaints that patients state on these surveys is not getting on at their on-time. These are the thoughts that create nightmares!  (just in time for Halloween!) I’m sure that a part of the reason they kept popping up in my mind is that I did not fully feel in control of them! Do any of these thoughts sound familiar to you? If so, you are not alone! So many people that I talk to have very similar thoughts keeping them up at night. I often tease that the RN after my name meant that I was Really Nice. That was true, and I will add in for me that I was not a huge fan of conflict in my early managing years. I wanted to make everyone happy, my patients, their families, the staff and physicians. As a clinic manager, I knew that it was my responsibility to ensure the safety and satisfaction of my patients and staff. I learned that one of the best ways I could do that was to maintain control over both patients and staff schedules.

Why is managing the patient and staff schedule so important?

(1) Patient Safety / Quality of Care

When you walk out onto the treatment floor during a turnover, do you hear multiple alarms? Are they alarming for longer than during a non-turnover time? Are all your staff busy, everybody with their heads down? Many will call this chaotic. I will add that I also consider a “chaotic” turnover like this unsafe. Like many of you I, too, am a believer in patient-centric care. I also believe that there needs to be a person, preferably multiple people, in an organization and each individual clinic that are ensuring that the ability to provide safe and quality care are paramount, and that care is being provided even when that means not being able to meet the patient’s exact desire. For example:  Let’s say you have a 12-station clinic and work with a 4:1 PCT to patient ratio. You have three PCT’s coming in one hour before the first patient’s start time of 0600, and a Charge RN arrives 30 minutes prior. You have an open spot at 0620, but your new patient wants 0700. If none of your other patients currently at 0700 want to move to the 0620, do you find yourself saying, “Well, I will give my new patient the time they want, and the nurse can put them on.” Great! You accommodated the patient’s desire, but at what cost? You now have four patients going on at 0700 and only three direct patient caregivers (PCT’s). COULD your Charge RN initiate the treatment? Yes, I’m guessing they are capable. The better question you may want to ask yourself is SHOULD your Charge RN initiate or discontinue a treatment? My thought is no. And the main reasons are that it becomes an unsafe setting for your patients and I want to see the RN’s have improved job satisfaction and be able to have the time they need to provide the type of quality care that they want and need to be able to provide. Many RN’s have shared their frustrations with having a nursing license and spending more of their time assisting with patient put-ons and take-offs. Then once turnover is over, they still have their RN duties that they had to stop doing to get this done. Many add in that much of their overtime hours at the end of the day are for documentation that they could not get done during their shift. When your Charge RN’s are putting patients on or taking them off alongside the PCT’s, they are not available for emergencies, unable to provide oversight or to help troubleshoot because their heads are down. This is not to say that an RN should never be assigned a pod or a patient, rather, my example stresses the importance of having your RN’s that are not assigned a pod be unencumbered so that they are available for their RN duties.

(2) Efficient Care / Meeting Budgets

Safety is always the number one goal. Caregivers do not choose to work in dialysis with a desire to provide poor quality and unsafe care. We are just not wired that way. As a healthcare organization, your leadership understands the importance of you being able to give and for your patients to receive high quality and safe care. Poor care and the resulting outcomes are NOT good for a business’ bottom line or for patients or unhappy staff (high turnover). While it may feel there is an occasional disconnect between organizational leaders and the clinic staff, this is what it means to provide efficient care. Organization leaders are often looking at actual numbers worked and treatment (revenue) numbers after the fact. They may be giving the clinic manager feedback that their costs are too high, but to the clinic manager and staff, they seem VERY busy and feel understaffed.

How can you solve this?

It truly goes right back to providing safe/quality care! If your patient schedule has a smooth workflow in each pod (only one patient going on the machine or coming off the machine at one time in a pod, and the direct patient caregiver assigned to the pod has the time built into the schedule that allows them to meet the needs of each patient (especially higher acuity patients), you will be set up to provide efficient care. Costs go up when staff are added for busy turnovers instead of smoothing out the schedule, or the nurse must stay extra hours to complete their work because they were needed to help with a busy turnover. Thanks for reading!  Now it’s your turn.   We’d love to hear from you!
  • What techniques have worked for your organization when it comes to not accommodating the exact time requested?
  • How have you created a culture of safety in your clinic in which letting a patient know that the exact time they want is not possible?
  • Have you felt the need to add staff to accommodate a busy turnover? Could the issue have been solved by smoothing out the work, allowing for the assigned caregiver to provide the care independently?