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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10 Replies to “Schedule 4 Patient Flow AND Efficiency”

  1. Excellent article

    I love this line “Slow providers say fast ones are slipshod and careless; fast providers say slow ones are lazy or talk too much.”

    I also love this one: “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.”

    1. Thanks again, Scotty!

      Do you think the concepts are clear enough for folks to give it a try?

      I suspect we need to build in the details in another post.

      Shawn

  2. I certainly agree with the need and the drive to reduce waiting times. It is a quality of care indicator, and patient satisfaction is linked to it. However, there is a true subtext to all this. Regardless of what administrators say, the unspoken is that they want “fast” ER doctors in the ER. Here is why:

    It makes colleagues’ jobs easier: they do not show up to a crowded ER. Nurses like it. When patients wait, they get angrier, and they take that anger out on the nurses. Nurses like the ER doctor who orders little, because it is less work, and the doctor who gets the patient in and out quickly. Administrators have numerical wait time goals they have to meet, which is tied to financial rewards for the department and also the rewards from their superiors. Even the Ministry was a “wait-time” strategy for ERs.

    Again, I reiterate, I understand the need to reduce wait times as a quality of care criterion. But, where are the other measures of “quality of care” in the ER. Is anyone measuring atient satisfaction of the patient who was seen quickly, but with less time with the MD, compared the patient who waited, but spent more time with the MD to explain things carefully. Is anyone measuring the “bounceback” rate of patients seen quickly compared to patients who waited, but had a more thorough assessment.

    In my view, while wait-times are measured, there should also be a global measurement of number of missed diagnosis, and number of bouncebacks to the ER as well. If doctors are compared by speed, they should also be compared by other aforementioned indicators

    Otherwise, we have a perverse incentive, and emergency loses credibility as a specialty which “churns the patients in and out” but is not a true quality of care and patient safety leader.

    1. Brilliant comment, Scotty! Love it.

      Jensen and Mayer say that in the ED we “Do fast things fast, and slow things slow.

      We must never cut corners on history taking, clinical examination, investigation, treatment and disposition. Patients need to be given as much time as they need to understand what’s going on so they can partner in the treatment/outcome.

      The beauty of this scheduling approach is that we can schedule 8 or 10 or as many ‘slower’ doctors as we want.

      You’ve experienced listening to someone explain a complex issue with brevity. You get it the first time. You’ve also seen how the same issue can be delivered in such a way that even after 30 minutes of discussion, you still don’t understand it!

      We must champion quality as you say. We must resist forcing everyone to ‘take as long as everyone else’. Some physicians can explain things concisely so that patients get it right away. Other docs can’t do it. THAT’S OK!

      Again, thanks for sharing your thoughts!

      Shawn

      1. Hi Ajay,

        A patient’s 6-hour stay in the ED may consist of 30 minutes of actual quality interventions (like talking to MD during assessment and reassessment, discharge instructions) 30 minutes of regulatory interventions (make chart, talk to clerk, and the other 5 hours is waiting in between these things. What we’re trying to do is to cut down the 5 hours of non-value added time; not get doctors to reduce the 30 minutes they spend with a complex patient.

        There’s no evidence that admin likes faster doctors. They just don’t want patients waiting, and we accomplish that by scheduling more slow doctors (9) on days when they predominate, than fast doctors (5-6 in a day) when it’s mostly fast guys. Most days, it’s a mix so we have 7-8 docs.

        There’s also no evidence that slow docs provide more diagnostic accuracy, or that fast docs miss stuff–we’ve looked for that in our complaints, in our bouncebacks, in every quality audit we’ve done. It’s just not there.

        We don’t advocate for speed. We accommodate for physician speed or slowness to save patients time. There’s no value to patients of waiting 4 hours for a doctor when they could have waited 40 minutes–don’t you agree?

        Marko

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