Schedule 4 Patient Flow AND Efficiency

Schedulers think in LEGO blocks.  They guess how much work an average staff member can do, and then schedule enough staff to meet the average amount of work each day.

To build a schedule, they plug staff into a grid, like identical LEGO blocks, to meet the demands of an average day.

4 problems with LEGO block scheduling:


1. Nobody is average.

2. No day is average.

3. Under-staffing makes patients wait.

4. Over-staffing makes costs go up.

Average doesn’t exist in clinical medicine.

Treatment protocols can be standardized, but the core of clinical medicine – history taking and physical examination – remains messy, relational and often intuitive.  Ask any emergency nurse: every doctor works at a different speed – same goes for the nurses.

Discussing speed makes most providers squirm. Slow providers say fast ones are slipshod and careless; fast providers say slow ones are lazy or talk too much.

Schedulers run from this time bomb.  It’s safer to assume average work speed, and hope that patients won’t wait, and costs won’t soar.

But patients wait… and costs soar.

How can this be resolved?

Let’s look at physician schedules.  First, we must re-frame provider ‘speed’ – defuse the time bomb. Dr. Marko Duic put it something like this:

“Every physician has a number stamped on his forehead that states the number of patients he can safely see per hour. Everyone can see the number, but no one can see his own number. Ask any nurse how many patients a physician sees in an hour, and they will tell you as accurately as reading a number off the doctor’s forehead.”

We can’t change the speed people work, and we must welcome every worker onto the schedule regardless of how fast or slow they work.

How can we build a schedule that minimizes patient waits AND maximizes staff efficiency?  Furthermore, how can you get staff to want such a schedule?

If you want to schedule for waits AND efficiency:

1. You must match demand with productivity.  You should know how many patients attend your ED per hour.  You know how fast your docs work.  Schedule enough MDs, based on their individual work speeds, to meet the average patient volumes by hour.  Some days you may need twice as many doctors, if they all happen to be slower on one day.

2. You need hour to hour flexibility.  Physicians must stay late, arrive early, go home early or call in more MDs for help when patient volumes warrant.  Let the physicians on duty control these decisions, and keep them accountable for the outcomes.

3.  You should let physicians chose whatever shifts they want.  Choice makes doctors happy.  Collect their shift preferences and have them indicate 50% more shifts than they want for whatever time frame you are scheduling (e.g., 1 month).  Juggle the MD lineup each day based on #1 above.

We will interview the provincial guru on MD scheduling, Dr. Marko Duic, in one of the next posts to bring out the details.

 

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Patient Waits Drop if Waiting Room Closed

See what happened to our wait times from the first day we closed our waiting room, without spending a penny:

On June 6th, 2011, patient waits plummeted from over 4 hours at the 90th percentile to just over 2 hours when we closed our waiting room.  90th percentile = how long 9 of 10 patients have to wait; it presents the worst case scenario.  Today, patients wait less than 60 minutes on average to see a physician – one of the shortest in Ontario.  

Physician Initial Assessment includes a complete history and physical examination; not just shaking hands in the corridor or having an alternate care provider see patients.

From day one, the left-without-being-seen rate crashed from 3-4% down to 0.4%.

Hoarding patients in the waiting room – like boarding admitted patients in the ED – prevents patients from receiving the care and treatment they need.  If you remove the waiting room reservoir and bring patients straight into the ED, they get seen, diagnosed and treated.

6 keys to success:

1. You need an outstanding team of nurses, physicians, allied health and administrative staff willing to try something new.  This can’t be overstated!

2. You need nurses willing to accept working differently.  Sometimes there will be crowds of patients; other times there will be none.  RNs will need to work together to move patients through when volumes surge instead of moving patients through when the nursing schedule allows.  Schedules must match patient volumes by time of day; not the time of day when stretchers open up.

3. Physicians must be willing and able to increase staffing to meet surges in patient volume.  MDs must arrive early, stay late or call in their peers for help if patient waiting threatens to exceed targets.

4. Wherever possible, replace stretchers with exam tables.  Ambulatory patients can be seen on exam tables and wait in chairs.  Stretchers attract admitted patients; stretchers kill patient flow.

5. You need an unlimited capacity mindset.  Every patient needs to come inside.

6. Physicians have to get comfortable moving/directing patients into exam rooms and back out into chairs.

We’ll dig into all these points in later posts.

For now, what’s holding you back?  Why wouldn’t you want to decrease patient waiting by closing your waiting room?

 

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Reservoirs Kill Patient Flow

Reservoirs often show up as extra capacity, and who wouldn’t welcome that?  Shiny new clinical space gets first place on hospital tours, center stage in photo shoots and prominent mention in ad covers.

We find reservoirs all over healthcare: special inpatient wards, waiting rooms, bigger clinics, bigger emergency departments…extra capacity.

But, mindlessly expanding capacity decreases patient flow – increases patient waiting – if we don’t guard against forming reservoirs.

 

5 features of reservoirs in healthcare:

 

 1. Reservoirs slow patient flow.  Like giant, hydro-electric dams, they convert high flow, hard-to-manage situations into low flow, contained events.

 

2. Reservoirs allow us to meter out patients – for example,
we trickle them in from the waiting room into the ED, or trickle them up to the inpatient wards – when we are ready to see them.

 

3. We find reservoirs familiar; a common solution to high flow demands. They’re socially acceptable.  In fact, most institutions pride themselves on the size of their reservoirs.

 

4. Reservoirs decrease chaos and make us feel safe, but patients feel just as scared and unsafe while parked in a reservoir.

 

5. Reservoirs fill easily.  They attract contents.  Reservoirs might empty now and then, but they tend to promote filling and storage (waiting).

 

Waiting rooms, gigantic emergency departments or even special inpatient wards are reservoirs, and patients do not benefit from them if they exist only to slow patient flow.

These fat areas in the stream of patient flow end up grinding flow to a halt without extreme vigilance to keep patients moving.

We have to match patient volumes with flow; not capacity.  Sure, we always need more beds, but we need increased flow more.   Flow doesn’t just mean flow out of the hospital; it means flow in, too.  We often blame long term care or families for not taking patients home, as though there’d be no waiting if there were no alternate level of care patients (ALC; patients who need long term care) in the hospital. Or, we blame the inpatient wards for not taking patients out of our EDs sooner.

Truth is: we didn’t have an ALC problem years ago, but we still had admitted patients in the ED.  ALC represents one (major) factor impeding flow, but it’s not the only issue.

In the same way, patients crowded ED waiting rooms long before holding admitted patients in the ED became such a problem.

 

Until we develop a culture of taking every patient in – in to the ED and up to the wards – when they present, and not just when we are ready for them, we will never get rid of reservoirs and crush patient waiting.

 

How can we balance maximal patient flow and institutional capacity?  Is bigger better?  How can we avoid building reservoirs?

 

 

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