MARIANNE: Hello, everybody, and welcome to today’s a webinar, titled. Ready, Set, Grow! Strategies for managing increasing patient volumes. My name’s Marianne [INAUDIBLE]. I’m the Events Manager for LeanTaaS IQueue. I’m going to go over some brief housekeeping items, and then we’ll go straight into today’s webinar. So, the first thing is you’ll notice that you’re all on mute. However, we do encourage engagement. So, if you look at the right hand corner of your screen, you’ll see the Q&A icon. Click on that at any time. It will capture questions, and we’re more than happy to answer your questions at the conclusion of the webinar.
I also would like to introduce our– well, actually one thing before. I introduce Dan, our presenter, I want to remind you that you can email us with any questions, or contact us for a demo request, and that’s at email@example.com. And now I’d like to introduce. Dan Hoff, who’s our product manager for IQueue Infusion.
DAN HOFF: Hello everyone, and welcome to LeanTaaS’s monthly webinar on Infusion center operations. In today’s webinar, we’ll be discussing a topic that we cover with many of our customers, some of which I believe are on the line here. And that topic is, how do I absorb increasing patient volumes? Maybe you’re planning on growing your volumes, moving to a new center, or linking up with a new physician group and wondering, how do. I keep all my centers running smoothly. Maybe you even had that growth already, and are now feeling that pressure.
Either way, we’ll talk through a couple of strategies and their underlying tactics to help you accommodate more patients. Before we dive into today’s topic, a bit about myself. My name is Dan Hoff, and. I’m a Product Manager on the IQueue for. Infusion Centers product. Before joining LeanTaaS,. I served as a Health for America Fellow, and worked for several early stage digital health companies, as both an early team member, and as a consultant. At LeanTaaS, in addition to my work building the product, I also help manage implementations at our newest customers, and provide ongoing support to some of our oldest customers, too. Having experience with both small and large infusion centers, what I’ve noticed is that, regardless of size, nearly everyone considers how to balance operational efficiency, and growth at some point.
So, let’s dive in. As we see it, there are two main strategies to consider when grappling with this question of, I have increased, or will be increasing, the number of patients. I’m seeing, so how do I make room for them all? The first set of tactics we’ll talk about is capturing more chair hours, which really boils down to growing your chair utilization trapezoid so in a few different directions. Why trapezoids? Well, if you’ve had a chance to talk to any of my colleagues, you’ll know we’re a big fan of trapezoids, because they illustrate a smooth day of infusion center operations. And why is that, in particular? Well, because a trapezoid shaped chair utilization means you’ve steadily ramped up patients in the morning, attained an even flow throughout the bulk of the day, and then smoothly ramped down patients in the late afternoon or evening.
If you’re looking at your chair utilization chart right now and saying, gee, ours looks more like a pyramid, or maybe, eh, it kind of resemble the trapezoid. But that plateau in the middle there, it’s pretty choppy, then the good news is that you’re already at a good starting point. Your main focus should first be getting to that trapezoid shape, as doing so will naturally increase the share of your share hours used. You can find recommendations on how to accomplish this in some of our past webinars. But today, we’ll discuss what happens next, once you already have that ideal trapezoid shape.
The first strategy we’ll review is expanding that trapezoid, by either increasing the share of chair hours used, or increasing the total number of chair hours available. Our second strategy we’ll discuss is reducing your cycle times. If you haven’t previously heard of this term, cycle time, this basically describes the total time it takes for a process to complete from start to finish. If we conceptualize a standard appointment from when a patient arrives to when that patient leaves as a process, we can then ask questions like, how do we reduce the waste of time between when one appointment ends, and another begins? As well as, how do we reduce the wasted time within the process itself?
We’ll discuss all that and more in the second half. But for now, let’s focus on that first point of capturing more chair hours. So, before we get too excited by specific tactics, it’s important that we first pause and consider what metrics are involved here. Accommodating more patients means they’re going to have more appointments. So, appointment volume is obviously a handy number to refer to, but what else is there? Chair hours, also referred to as patient hours, is probably the second most important number to consider when pursuing growth strategies. This is because chair hours convey the area of the trapezoid we talked about earlier.
If you think about that trapezoid shape for a moment, the horizontal axis is the time of day, while the vertical axis is the number of chairs used. So, it follows that the area, then, would be the utilization– would be the number of chair hours. Whether you’re trying to grow that shape, or pack more appointments into that same area, chair hours is the metric you’re going to want to watch here. Another good metric is the number of chairs used during peak hours. Or, in other words, when your center has ramped up its operations for the day, how many chairs are filled? This not only tells me the height of your trapezoid, but it also gives you a sense for how close you are to being limited by the number of chairs, or rooms.
Connected to this is the percentage of days where you ran out of chairs, which can be a metric to track if you’ve experienced growth and want to know how efficiently you are forwarding those new appointments into your schedule. There are other numbers that you can probably come up with, but these four are the most important to track. Now that we know which metrics to keep an eye on, let’s talk about the tactics that are actually going to move the dials on these metrics. The first strategy you can employ in capturing more chair hours is to use what you already have more efficiently. What this means can take two forms. The first is to estimate your durations more accurately.
The second is accounting for daily add-on and no-show patterns. If embarking on this first path, you should start by talking with your nursing team, and asking them how do the expect durations of existing appointment types line up with reality. Your nurses are going to be the ones that feel the pain immediately when an appointment runs longer than scheduled. After talking with them, we recommend using qualitative feedback as a starting point for your quantitative analyses. By looking at your timestamp data, and comparing the actual and expected durations of different appointment types, you can identify whether changes need to be made, and if so, which durations should shift. In the world of. Bayesian statistics, we call this updating your priors.
Essentially, incorporating new information into your expected probabilities on how long each appointment will run. Whether you find you need to increase the duration of a couple appointment types, or decrease them, or both, all of these changes are for the better, as it allows you to more tightly pack appointments in. Now, you may be thinking, I totally get that I need to account for shrinking appointment durations. This means I get to avoid holding the chair for longer than I need, and I can also pack in more appointments at that point, too. But why does this still work if it turns out that I need to increase the length of some appointment types? Well, the simple answer is that by giving your nursing staff more time on that appointment, they’re less likely to be late coming off of that patient.
This not only avoids creating additional wait times, but also promotes smoother utilization, and improves your center’s ability to accommodate same day add-ons. I’m sure we’ve all had busy days before, where your first thing went long, and then you spend the rest of the day chasing to get back on time. The same principle applies here. By scheduling for that delay that you know is coming, suddenly you’re on top of things throughout the day, and can handle not only your own schedule, but potentially pop-up requests of your time. This also brings us to our next point, which is accounting for add-ons, no-shows, and same day cancellations. If you take a look at your data and see that every day the actual number of appointments your center sees is less than what’s scheduled, you can use that in your favor, and technically overbook your chairs.
Airlines have actually perfected this tactic. They’ll overbook their flights with the knowledge that there’s a high probability that no-shows and cancellations will bring that number within their flight capacity before the cabin door is closed for takeoff. You can apply that same logic if your probabilities align similarly. The alternate case to consider is when you add-ons exceed your no-shows and same day cancellations. We advocate closely looking at your chair utilization and bookings to see if you can squeeze those appointments in on the day of. If this remains a problem, another tactic we’ve seen some success with is blocking a few appointments for that day of, so that you’re accounting ahead of time for those probabilities.
As is with duration estimation analysis, this won’t directly help you add more appointments. But by striving for steady operations across the day, you’ll have a much better chance at accommodating the maximum number of patients possible. If you find that maximizing how you’re using your existing chairs doesn’t quite get you to where you need to be, then it follows that the next strategy to consider would be increasing your total number of chair hours. There are three different levers that you can consider pulling to accomplish the strategy. They involve staffing, hours of operations, and your chair count.
Let’s consider each one in detail, starting with staffing. When we talk about staffing here, we primarily mean your nursing staff. However, many of these same principles can apply to your pharmacy staff as well. So, the immediately obvious option you might think of is, let’s hire some more people. That might be the right plan, but it really shouldn’t be your first course of action. What you should consider first is whether you can better stagger your shifts to match when your appointments occur. You might consider this if your center starts labs early before infusions get going, and a large share of the nursing staff is actually on call, but not yet taking patients. In this example, you should consider keeping only the nurses you need in the early morning, and then having the rest of the team come in once infusions begin.
This would allow nurses to work later, which, depending on your hours of operation, could expand your options. Speaking of hours of operation, another potential tactic is to expand with your center is open to match that of your lab, pharmacy, and clinics. You can also consider having one to two nurses arrive early for morning injections and port draws. Depending on the injection, you might be able to do this without pharmacy even being open. This helps pull your short appointments forward, and opens up space for either more appointments, or if you didn’t have a fast track area setup, frees up chairs to be used for infusions. Returning back to the hiring piece, short of going out and actually hiring a nurse, another way to increase your total nursing hours is by upgrading existing shifts.
If you have six, eight, and 10 hour shifts, bumping some of the nurses up from the 6 hour to the 8 hour or 10 hour shift helps add capacity, provided you are not currently limited by the number of infusion chairs. Finally, if all else fails, increasing your chair count is an option. Sometimes, after you’ve made all the necessary changes you can, and have your center running as efficiently as possible, you just need to be bigger. If you do pursue this route, be sure to check what your staffing levels are first. You’d hate to invest in new chairs, or put in a request to move to a larger area, and then discover after the move that your effective number of chairs hasn’t changed because you don’t have the nurses to staff those extra chairs. So, let’s talk for a minute here about analytics.
Before our review of the tactics to capture more chair hours, we previously talked about a few utilization metrics. It’s worth mentioning that while utilization metrics are great, they tend to focus on the output of your operations, which is good for tracking the progress of your top line. However, they don’t get into the weeds of what is going on internally, and what the specific changes are that you need to make. To this point, we recommend a few different types of analytics that can help guide you through the process of debating, is this the right tactic to use, to change my utilization. What’s displayed on the slide is the right way to look at these analytics, which you can pull the data for and create manually, but which we also conveniently offer in IQueue.
In particular, looking at your median scheduled volumes across a given weekday gives you a sense for how you regularly schedule, and how your day turns out. In this example, we see that chairs are actually used less than they are scheduled, suggesting we might look at adding another appointment at that time. If the chart had instead looked like the nursing staff was delayed in starting those patients, we would have looked into either shifting nursing staff, or decreasing the number of appointments given in the first few hours of the workday to prevent those delays. Comparing cycle times to their expected durations can also help you pinpoint where refining your– where to expect durations. In the middle chart here, a quick look suggests that the majority of the appointments are within the expected range.
However, zooming in on the zero to one hour appointments at the bottom of the bar chart shows that this appointment group routinely runs long, so we could investigate those appointments further to understand why that is, and what corrective action is needed. Finally, a running history of add-ons and no-shows by day gives you a sense for whether you can book more appointments than your schedule currently allows. In this example, we see that no-shows and same day cancellations occur more frequently than add-ons. This opens up the space, but occasionally add-ons are higher, so we should be careful about assuming we’ll always be gifted a few extra appointments worth of capacity.
Now, this data’s all hypothetical here. However, the anecdote that’s mentioned very much come from real situations in which we have helped customers navigate in the past. So, moving on to cycle times. I’ve mentioned cycle times a few times now, and want to spend the rest of our time today digging into not only what they are, but also how you can apply your understanding of them to your own advantage. Returning back to what I mentioned before, a cycle time is the total amount of time it takes for a process to run from beginning to end. In this instance, the process we’re talking about is a specific appointment type, which begins when the patient sits down in the chair, and ends when he or she leaves.
Whereas in the last section, we referenced tightening up the estimate durations of appointments to better match the actual duration, the focus in this section is on how you can actually bring that actual duration down. The intended outcome of this is that by eliminating wasted time, we can shorten our appointments, and by extension, fit more of them into a fixed number of chair hours. Which begs the question, how do we decrease cycle times? In thinking through our options, we can consider how we shift our operations to minimize both wait times, and wasted time. It’s worth mentioning that pushing meds faster to make your appointments run faster is clearly not an option due to safety reasons.
That being said, it’s worth keeping an eye on the NCCN guidelines in case standards do shift. Although standards won’t change frequently, we have heard of a couple of cases over the past few years where there has been a meaningful update to the recommended push times. With that in mind, let’s dig into our other two options for reducing cycle times. Much of what we have to consider when trying to eliminate waste between appointment centers around how we manage our infusion chairs, when we don’t have a patient sitting in them and receiving an infusion.
So, what should we do? We should try to maximize the portion of time that meds are being administered relative to the hours that someone is staffing that chair. In the very hypothetical world of perfect efficiency, a patient sits down, immediately starts receiving their infusion, and then get up as soon as that’s complete, and then another patient sits down for their infusion. Doing this begs the question, what about schedule constraints, or delays from labs and clinic visits? This is convenient, because these are actually the two things we should focus on in improving our processes around the appointment. Starting with labs, many of you have patients come in, have their labs drawn in your center, and have all of this occurred before the appointment begins.
The first thing to consider, operationally, is to avoid holding the chair between the lab and the infusion. In other words, patients should be sent back to the waiting area while the labs are being processed. I know that having patients remain in the infusion room might feel like it improves the patient experience, because a patient is in the chair, and is seeing these operations, but in truth, you’re locking down the chair and your patient unnecessarily. If you have a good sense for what the turnaround time for the lab is going to be, you can actually communicate that to the patient, and suggest an activity or two to pass the time.
An example of this might be walking over to the hospital cafeteria with their family. With patients no longer sitting in the chair from the start of the lab to the end of the infusion, this leads us to our second suggestion, which is to pull out the labs into a separate chair, or chairs. We have a whole webinar on this topic of creating fast tracks, which I suggest you check out if you’re considering pursuing this. In short, this works because a specialized chair helps focus the other chairs on what they’re intended for, which is infusions. Now, we normally recommend you not pull out specific appointments types or chairs, but in this instance we make an exception, since labs are significantly shorter, and operationally different than the infusions.
To paraphrase, using an example that uses cars as infusions, and bicycles as labs, you wouldn’t separate cars into different lanes on the highway by color, but you do separate out bicycle is into their own area. An added benefit of the fast track area is that you can staff it with a nurse in training. That nurse can’t administer chemotherapy when they haven’t completed the necessary certifications yet. However, they can do port draws, and other low risk activities. This is particularly great, because more nurses are now available to work to the top of their license than before when we had everything just mixed together.
Switching over to linked appointments, we find similar dynamics apply. It is important to remember here the standard recommendation of not holding a chair for a patient that hasn’t yet arrived. Even though these patients are coming straight from a provider visit, it’s important to your operations to chair them the same as you would other patients coming in. In particular, this means not holding the chair for them, even if they’re running late. Having walked through how to decrease the waste between appointments, let’s discuss reducing wait times within the appointment itself.
Depending on the time stamps that you use, you can come up with a few different ways to measure wait times. Since we’re trying to minimize the delay between when an appointment starts and when the first med is administered, drug wait times are actually what we want to focus on here. There are a few different options for reducing drug wait times. However, the common thread is having your meds and pre-meds ready to go as soon as possible, while avoiding wasting drugs due to late or no-show patients.
The first area to look at is how you communicate with your pharmacy. As certain drugs need to be mixed right before they’re administered, you can imagine that the faster you can notify your pharmacist about an arriving patient, the sooner those meds can be sent back to you. Given the cost of mixing certain drugs, it is generally not advisable that you mix your chemo treatments before your patients arrive. The risk here are a potential loss of efficacy, if the patient shows up late, or a sunk cost if the patient misses their input appointment entirely. Beyond improving communication, which is always a good thing, pre-meds offer another place to work for a decreasing drug wait times.
If you have pre-meds that aren’t time sensitive, you can stock them in your center using a Pyxis, or similar style of mobile secured cabinet. This allows you to start those pre-meds as soon as the patient sits down, which the huge time saver, especially when your pharmacy is not co-located in your center. Along similar lines, if there are pre-meds that you can tolerate being mixed the evening before an appointment, or even the morning of, you should consider talking to your pharmacy about preparing these in advance. Ideally, you then will be able to store these on site, but even if not, and then store it at the pharmacy, this will still save you and the pharmacy plenty of time.
A point worth emphasizing here is that you should only pre-mix the minimum number of pre-meds you might need in a day. The reason for this is that you want to avoid pre-mixing something you only have– or, sorry, pre-mixing something only to have it go to waste. This same principle applies to other areas of your center, including locking down chairs or nurses to focus on fast track appointments. The saving of time for these activities is worthwhile, only so long as you’re not creating waste or inefficiency elsewhere in your center. All of these potential changes should be guided by the input of your nursing team, as well as the data that we collect.
Let’s look at a couple ways to consider displaying that data. As we stressed before, wait times are what you’re going to want to focus on here. We have the average drug wait times by date displayed on the left, which is the most immediate measure of improving your operations. Note that we’ve called out wait times for the whole day, and wait times during those 10:00 to 2:00 peak hours. Looking at these two metrics and comparing them is a great way to identify whether your wait times are primarily happening once you’re center is up and running for the day, or if it’s during the ramp up and ramp down period.
Not pictured here, but another great way to get at that particular insight, would be charting average drug wait times by hour. We showed a prior version of the cycle times earlier in this presentation, but I wanted to service another format for your consideration. This examines whether your actual cycle times are within the range of your expected durations. We all allow– or, we allow some buffer on either side of the appointment duration groups, since we’re probably fine if an appointment runs 15 minutes long, but 45 minutes may be a cause for concern. Here, the operational focus should be on minimizing the number of appointments that run long before considering the appointments running short.
Appointments that run long lead to delays, which are immediately bad, and can affect your ability to pursue other capacity maximizing strategies. while appointments that are chronically shorter than expected don’t immediately create problems, they are a sign of inefficiencies, and should be corrected to reclaim capacity. So, that’s it. We’ve talked today about increasing your capacity through capturing more chair hours, and through reducing your wait times. If you have more questions after this webinar, feel free to reach out to our team. We’d be more than happy to start a dialogue with you. I’ll take the next couple of minutes to answer any questions submitted.
MARIANNE: All right. Thank you very much, Dan. We have a couple of questions that have come in. First one is, our center has 3/4 of their appointments visit the clinic beforehand, and those patients are coming in consistently late, which forces our staff to stay late since we fall behind in the afternoon. We started taking even more patients from another physician group last month, which has only made matters worse. What should we do?
DAN HOFF: Well, I’m sorry to hear that things are busy, and not in a good way. It sounds like the linked appointments are a pretty big pain point– or rather, the spacing between the provider appointment and the infusion center are tight. What I’d recommend is looking at the difference in timestamps between the clinic appointment time, and the infusion appointment arrival time. There should be some distribution here, and my sense is that the schedules aren’t factoring in enough time for the patient to finish their clinic and make it to the infusion center.
I’d look at the data and see how much spacing you’d need between those two appointments for the majority of patients, and use that to tell your schedulers, hey, linked appointments, give the patient a minimum of 90 minutes, or whatever, for between the clinic visit and infusion appointment. This change in scheduling should help more patients arrive on time, which should help lead to less delays, which should also help reduce the likelihood that your nurses have to stay late, and hopefully avoid overtime, too.
MARIANNE: OK. I see another question’s come in. We’re moving to a new center with nearly twice as many chairs, and are wondering how many more nurses to hire. How do we figure out how to staff up for this move?
DAN HOFF: That’s a great question as well. So, there are a few assumptions you have to think first before diving into an analysis like this. For one, you might not have doubled the volume in your new center on day one. So, you should think through what your growth is going to look like. Of course, it’s going to take some time to train nurses, and hiring might also be pegged to your budget cycle, so you’ll probably also want to take those timelines into consideration. These are all questions about how you ramp up to max capacity, assuming that’s what you want, but I imagine what you also want to know is what that peak number actually is.
So, to do that, I would talk to the nursing team, and look at that data, and figure out what the average number of patients a nurse can comfortably see per day is. The other number I’d look at is how many patients you’re currently seeing per chair, per day, when your current center is running at full capacity, assuming it does. If you multiply this patients per chair number by the number of chairs in your new center, you’ll get a rough estimate of the max capacity there. If you then take that number, and divide your number of patients figure by your patients per nurse ratio, you’ll get an equally rough estimate of the nurses you’d need at that max capacity. The next step here is that you want to confirm and validate all of this.
You would do that by building templates, and adjusting the inputs as needed, and those inputs would be number of nurses, total number of appointments, as well as the mix of those appointment types. It generally helps to have a tool like IQueue to do this last part, which I can definitely attest to having done this analysis before. It is quite helpful. Yeah, I think that’s probably what my recommendation would be.
MARIANNE: Well, thank you Dan. Unfortunately, I see we have another question, but we’re really up against the clock right now, so what we will do is we will make sure– we have a couple more questions. We’ll make sure that we respond to these questions via email, because we’re just completely out of time today, unfortunately. But I’d like to thank Dan for presenting today’s webinar. It’s actually his first official [INAUDIBLE] webinar, so it’s a big day here in IQueue land.
DAN HOFF: Thank you.
MARIANNE: And I’d also like to thank all of you for tuning in. Please keep an eye out on your inbox. We’ll be sending out a link to this webinar recording. It will also include the PowerPoint deck. You should see that in your inbox in the next 24 hours or so. Also, if you wish to contact us post-webinar, you can do so via email. That’s firstname.lastname@example.org. Or you can text us. That number is 630-884-5493. And again, thanks for joining us today. Thanks everyone.