How to minimize overbooking at infusion centers: establish a pathway

Smart infusion scheduling has always been a hard problem to crack. With operational constraints, varying nurse schedules, and very sick patients it is hard to construct a flawless schedule that fits the needs of everyone involved. Ensuring that each day runs smoothly has become a daunting and elusive task, while efficient appointment planning remains crucial to a positive patient and provider experience.

Schedulers attempt to keep appointments on track, yet three common issues persist:

• Patients wait a long time for their appointments to commence, especially in the middle of the day. The biggest backups occur between 10:00 a.m. and 2:00 p.m.
• At the same time, chair utilization is uneven throughout the day. It starts out low and ends low, but the midday peak puts appointments at or above chair capacity almost every day. This may cause bottlenecks in chair usage, labs, pharmacy, and other resources, with massive under-utilization at others, repeatedly throwing the balance off.
• Infusion nurses often miss their lunch and other breaks due to high demand throughout the day. They have high levels of overtime and emergency callbacks on their days off as well, which ultimately leads to an unhappy staff and/or high turnover.

Tools have been created to try to level load schedules, but overbooking is simply a reality at most infusion centers. The key is to figure out how to manage it in ways that mitigate negative impact.

Dangers of overbooking

Overbooking occurs even in the most efficient infusion environments for a number of valid reasons. An infusion center might need to coordinate an appointment around a clinic visit, or long treatments need to be scheduled with enough time to complete before the center closes. It is also common to fill up schedules far in advance, but schedulers are asked to accommodate last-minute priority treatments. Sometimes, overbooking occurs based on patient availability issues or happens when the center receives wrong or incomplete treatment information. In the centers that try to safeguard nurse and staff breaks, the decision to schedule around these times often creates bottlenecks. As a result, staff just gets overloaded at a different time.

COVID-19 has brought another dimension to the overbooking problem. Infusion centers have had to remove chairs to create social distancing and though they saw volumes drop in the early stages of the pandemic, volumes are coming back as the shelter-in-place orders are being relaxed. Having to manage high levels of patient volumes with reduced chairs has brought new headaches for centers, especially as they try to engage in smart infusion scheduling.

Overbookings often cause significant delays because patients have to wait on both nurses and chairs to become available before beginning their treatments. Even if a chair and nurse are available, having too many patients at once reduces the ability of the center to bounce back when patients arrive late, delays occur in pharmacy, or treatments run long.

Although many of these issues are unavoidable, infusion centers can put in smart processes around overbookings to make sure that they are conducted in the least disruptive way by establishing a booking pathway. This will help centers lower wait times, optimize space to accommodate add-ons, and respect staff needs and workloads while continuing to serve a consistent number of patients.

Creating a booking pathway

No two infusion centers are the same; therefore, there is no one-size-fits-all solution. But there are some common guiding principles that inform decision-making based on each center’s operations, capacity and priorities.

Overbooking policies should be informed by:

• Who is allowed to participate in how the center addresses overbooking appointments: There are a number of different stakeholders — infusion schedulers, front desk staff, lead schedulers, clinic schedulers and staff, in-patient schedulers and staff, infusion charge nurses, and patients themselves. As such, each center needs to determine how much of a say each group has as well as establish a pecking order.
• Why appointments can be overbooked: There are a number of reasons why appointments can be approved for overbooking. Some include: required coordination with clinic appointments, center capacity limits, time constraints on treatment times, and limitations from the pharmacy. These reasons should be established and potentially ranked based on their importance to the specific infusion center.
• Where overbookings should be directed: Once a center’s leadership determines the “who” and the “why” pieces of the puzzle, figure out the best options to route them in order to cause the least amount of disruption. For example, most centers want to place overbookings in the early morning or later in the afternoon. Off-peak times are key — or other times when both chairs and nurses are available. Another option is to look at other dates or locations.

After figuring out each of these pieces, centers can construct their booking pathway. It might flow something like this:

A same-day add-on is needed. The charge nurse can book according to clinical needs.

1. If that doesn’t work, the scheduler will try to fit into an existing free slot, and the appointment is booked.
2. If an appointment is not available, the next step is to search for an alternative time or location for the infusion.
3. If the patient or center cannot make that swap work, the scheduler can look for an alternative, meaning there might be a time reserved for a different type of treatment that is not currently being utilized. If the requested treatment requires the rough equivalent of time and resources, the charge nurse can override the booking system and claim that spot for the needed treatment.
4. If no alternatives are available, the infusion center might opt for a front-line overbook, which means the front-line scheduler overbooks at the time of day that causes the least disruption.
5. If the center does not feel that every scheduler is capable of making this determination, based on their knowledge or experience level, Step 5 could be skipped, heading straight for an escalated overbook, which means that a senior scheduler looks for the best possible spot.
6. If this still doesn’t work, the final step in the pathway is to look at the consequences of a scheduling decision and decide whether it puts the center over capacity and creates a bottleneck for the day. If it does, the center can do some schedule grooming in which it may proactively shift one or two appointments to ensure the schedule runs as smoothly as possible.

Most bookings should fall in the first couple of steps of the booking pathway, with only a small minority resulting in overbooking. When that happens, there is a clear process in place to minimize problems. That process often includes establishing guidelines, rules and permissions according to priorities and dictated by circumstances.

When failure strikes

There will be times when there is no avoiding overbooking issues, even following the booking pathway to a tee. Pitfalls can pop up before scheduling, in the pathway, and after scheduling, but with awareness, even these moments can be reduced and improved.

For example, a scheduler may not receive the right information because clinic schedulers are unaware of the next day’s infusion staffing, or the front desk staff might not have the clinical information to know if an appointment can be moved to a different time. Another common scenario occurs once a request enters the booking pathway. A center might have 15 add-on appointments per day, but there is only one charge nurse available to approve them all, which wreaks havoc on the system and causes delays. Additionally, appointment requests may be incomplete or have conflicting information about dates or treatment duration. And suppose a schedule is overbooked according to the process in the pathway, but then nurses call in sick. Myriad things can happen that are beyond an infusion center’s control.

But the best defense against such issues is a good offense. It is possible to arm schedulers with options that can lead an appointment back on course. If only one charge nurse has permission to approve add-ons, maybe expand that responsibility to four nurses, reducing the number each has to approve from 15-20 to 4-5. Centers can also script interactions with patients differently to drive them toward accepting appointments at harder-to-fill times. For example, instead of asking when they want to come in, a scheduler might say, “Great! For your treatment on Monday, we can book you at 10 a.m. or 3 p.m. Which do you prefer?”

Another possibility is to work with clinic staff to ascertain whether an add-on appointment is based on clinical need or the patient’s desired appointment time. If it is based on the patient’s requested time, the scheduler can work with the patient to come up with a preferred outcome, such as explaining that the patient would have a shorter wait at 2:00 p.m. than at noon, and he might actually want some time between his clinic visit and infusion appointment to take a break or grab lunch, rather than being faced with a long wait in the lobby of the infusion center.

By establishing a process for and alternatives to overbooking, schedulers are better prepared to avoid the problems that accompany overbooking. They can also effectively set expectations with patients and drive long-term changes in scheduling culture, which is to everyone’s benefit.