OBEHI UKPEBOR: All right. Thanks, Marianne, and welcome again everyone. Thank you for joining our monthly webinar on infusion center operations. My name is Obehi. Before we get started here, just to give everyone a little bit of background about myself, I’ve been with LeanTaaS for about a year now as a product manager, and I worked with over 20-plus infusion centers using predictive analytics to improve their scheduling practices and their daily operations.
Before I joined LeanTaaS,. I spent a couple of years as a software engineer streamlining QA operations for a database server company here in the Bay Area. And before that, I got my master’s degree in manufacturing engineering from MIT. And then I spent a couple of years working in operations management. During one of those years, I also spent some time analyzing data to develop a scheduling tool for semi-conductor manufacturing plants. OK. All right, let’s get started here now.
So today, we’re going to be talking about nursing assignments, the different strategies you can use for managing them, and the pros and cons of each of these strategies that you can use. But first of all, I spend a little bit of time talking about some of the factors that need to be considered when balancing nurse workload and how iQueue templates take these factors into account. So assigning patients to your nursing team in a way that balances nurse workloads early is often very time-consuming. And quite frankly, it can be a very, very difficult thing to get right. There are quite a number of elements that you need to consider.
For example, how much time does each nurse need before they can take their next patient. In some centers, this time could be 20 minutes. It could be 30 minutes, or it could even go up to an hour. Does total acuity load that each nurse can take is also another factor that comes up quite often? Does this number vary from one nurse to another? Or is it pretty much the same for every night that day? The timing and length of each treatment– those are also very important factors that need to be considered because throughout the day, there are so many different treatments that are happening, and each of these treatments have different lengths or expected duration.
So accounting for all of these factors plus a few orders that may be center-specific can be very quite challenging. iQueue templates take many of these nursing factors into consideration by taking as inputs what your typical staffing is on any given day. What is your nursing shift? How many nurses work during each shift? iQueue also takes into account any requirement for specialized nurses needing to take care of specific treatment type. In some centers, for example, you might have LPN to only do injections. You might have NAs, are they able to take some patients as well? How much capacity do your charge nurses have to help with patient load. In some places, charge nurses might– they might not be able to help out with load.
So all of these factors are then translated into nursing parameters that are used in the mathematical model to represent nursing capacity. Nursing capacity is another resource that gets optimized whenever iQueue templates are being built. Chair capacity is obviously another resource that gets optimized in order to make sure all of your chairs are being effectively utilized. But going back to nurse capacity, there are three main nursing parameters that are being used in the mathematical model. These include, one, set number of patient a nurse can treat at any single point in time.
We typically call those numbers the nurse-in-ratio. And across most inpatient centers we worked with, that number is typically around three to four. It also includes how much one-to-one touch-time a nurse has with a patient at the start of their treatment, in the middle of their treatment, and also at the end of their treatment. There are also some treatments that might be one-to-one touch-time. You might have a four-hour treatment where a nurse has to be with that patient for all four hours of that treatment. The last parameter and arguably one of the most important one is when do nurses take lunch. And virtually almost every infusion center we worked with, one major pain point is nurses not being able to take their lunch break.
The algorithm takes this into account. It takes as input what nurses– or when nurses– what time nurses start taking their lunch breaks. How many nurses also go to lunch at a time? How long do the lunch breaks last for? Are they 30 minutes, 40 minutes, an hour, and what time do they need to be completed by? In some centers, maybe 11:00 to 2:00 might be the time window for nurses to start taking their lunches. So these are all inputs that go into the template build process. So with all of these constraints, iQueue is then able to generate level-loaded template such that [INAUDIBLE] appointments at the– exactly to match the slots on the templates.
The result is this really flat green chair utilization line on the chart on the right versus the [INAUDIBLE] profiles that we typically see at most infusion centers prior to implementing iQueue. The chair utilization line, so this green line here, it shows the expected number of patients in chairs at every point in time during the day. In the morning, we see a very smooth ramp-up. And in the evening, we also see a smooth ramp-down, matching your nurses’ availability based on whenever they come in for their shift and when they leave at the end of their shift. And then in the middle of the day, we see a flat chair utilization, which evens out the nurse workload throughout the day. All right.
So now let’s move on to the different strategies that can be used for managing nurse assignments. There are three main strategies and workflows that we’re going to talk about. These are what we typically see being used across most infusion centers. Do you think [INAUDIBLE] one, booking to nurse templates in the EHR? Two, triaging patients as they arrive on the day of treatment. And three, assigning patients and nurses prior to patient arrival using the iQueue nurse allocation tool. Understanding when and when not to use any of these strategies and also just having a really clear understanding of the trade-off between one versus another is very important when it comes to deciding what method you should use at your center.
Take for example booking to nurse template. Booking to nurse template is less operationally efficient, but it might be the only option available to you. Maybe this is how things were set up in the EHR, or if the team has limited IT sources and there is no personnel available to make any sort of changes to the existing setup. And in such a case, typically, the operations team just have to leave with the setup as is even if this ends up with a less optimal flow throughout the day, but you’re very limited at that point and there are very few options you have. On the other hand, triaging patients as they arrive on the day of treatment is a widely preferred option. It is the most efficient from an operational standpoint.
However, it may not be feasible if there is no charge nurse to coordinate nurse assignments on the day of service. Or perhaps, if that center uses a primary nurse and model to ensure continuity of care, it may not be feasible. And then the third method which is assigning patients prior to arrival can be very useful when nurses need to review that patient’s orders hours or days ahead of time. But nothing ever really goes as planned, and assigned patients may not show up. So all three of these strategies have their own pros and cons which need to be carefully considered before a decision is made.
But now let’s take a closer look at each one of these just to give a little bit of more detail about them. OK. So booking to nurse templates. With booking to nurse templates, “Resources” in the EHR are typically set up to represent an individual nurse, and iQueue template starts are set up within that resource. For some of you who are seeing this for the first time, on the left is what a typical iQueue template looks like. The first column all the way on the left is showing the time slots from when the center opens to when it closes. If you notice, this is using a 15-minute interval right now that is based off of what that center uses.
So we see 15-minute time slots every 8:00, 8:15, 8:30 and so on. In a center that uses 10 minutes, it will be 8:00, 8:10, 8:20, 8:30. Each of the “Auto” columns represents a different block types or appointment duration groups being used to fill half-hour, one-hour, two-hour, three-hour, and four-hour. And then each of the ones that you see there represents whenever a start is available for that appointment duration group. So, for example, at 8:00 AM, there is a half-hour start available. And then at 8:15, we also see there is a one-hour start available. So in a center that’s booking to nurse template, as I mentioned earlier, a resource is set up for each nurse. So on the table on the right, nurse 1 will be a separate resource in the EHR. Nurse 2 will also be a separate resource. And so we’ll [INAUDIBLE] nurse 3 as well.
So what happens then is all of these starts on the iQueue templates are then transferred to these individual nurse resources in the EHR. So, for example, that 8:00 AM half-hour start on the iQueue template has been set up as that half-hour starting block at 8:00 AM under nurse 2. And then that one-hour, 8:15 on the iQueue template is that 8:15 one-hour on the nurse 1 resource. And the process goes on until all the starts are then transferred to the nurse template. All right. So given how messy that set up might look where all of the iQueue starts have to then be transferred to each of these individual nurse templates, you might be wondering when is it a good time book to nurse templates, right?
As briefly mentioned earlier, sometimes this is just how things are set up in the EHR, presumably since the EHR was first implemented. And if there is limited iQueue to make any changes to the set up, iQueue may just need to live with this as well. And every time a new iQueue template is built, maybe you have a template update or a refresh, maybe your provider’s schedules changed or something like that, all of the individual nurse resources will need to be modified as well to match the new templates. In some centers with very low variability, booking to nurse templates can actually work out really fine. If the volumes are very consistent and patients tend to arrive on time– and that just means the system is very stable and very predictable– and everything should work just fine.
So although– all right, my slides skipping here. So although it seems like booking into nurse template could be optimal and fair, it really isn’t. One drawback is that it assumes the same schedule of nurses per day, and it does not account for sick days or leave, so if nurses don’t show up that day, for example. There is also no guarantee that patients will show up as planned, or that all of the appointment starts on the template will get booked. And when it does happen that they don’t show up, it can end up leading to a very unbalanced workload across the day for a nurse. Although booking to nurse template in theory works best, it actually works really well when there’s low variability and volumes. If only one appointment on the schedule, like, say, the 9:30 one-hour appointment in nurse three’s schedule gets canceled, it can lead or end up in really long gaps between appointments for that nurse.
So, for example, nurse 3 would get a patient at 8:45 but wouldn’t get another patient until 10:15. So booking to nurse templates, it can also be a little bit biased or unfair to nurse 1 or whoever is the first name on the list of nurse resources in the EHR. So typically, nurse 1 will just get the head assignments. And that’s just because there is a natural tendency for schedulers to always look up the first name on the list when scheduling. It’s just the easiest option. So now let’s move on to real-time– real-time triaging of patients to nurse. This is a widely preferred option, as we mentioned earlier. It is being used across many centers. We also really like it here at iQueue because it is the most optimal from an operational perspective because your nursing resources can be pulled together. And as patients begin to arrive throughout the day for their treatments, they can be assigned on the fly to the most available nurse.
Again, think about it this way. When you book a hotel room, you reserve a room of a given size on a given day, but you would never call. Hilton Hotel, for example, and ask for a specific room, say, Room 125, except if you are like a drug dealer or something and you want that room for a particular reason. But when you show up, you get assigned to an available room that fits your needs. Using these same strategies can result in lower patient wait times, improving the overall flow of patients throughout the infusion center. Using live scheduling is very efficient, and it works pretty well for many reasons. Your nurse resources can be pulled, and your schedulers don’t have to think too much or bother themselves right at the point of scheduling about which nurse will be taking which patient. And it also works really well when there is very little predictability of a center’s operations.
So, in a sense, it has the most flexibility when it comes to dealing with variable patient arrival times, especially in centers where patients always tend to run late from their prior clinic provider. That’s one problem we see that’s very persistent across a lot of centers. Providers are always running late. So this strategy has the most flexibility when patient treatments always tend to run over their expected durations. So if you keep track [INAUDIBLE] cycle times, then you’ve seen how variable they are. This strategy is typically the best for handling variable cycle times or treatments. And when your nurse in shift always change as well everyday, real-time is the best way to go. One more benefit of real-time triaging is that a patient always goes to the nurse who has the most capacity. And you will never really sign up patients just waiting for a pre-assigned nurse to be ready. So it is helpful [INAUDIBLE] with patient wait times and patient satisfaction.
So real-time is very effective, but sometimes it doesn’t work. So when does it not work? Sometimes it’s just not feasible. For example, [INAUDIBLE] center, the stated center where nurses must check their patient’s orders days or hours in advance, you cannot use real-time here because a nurse might review a patient’s orders today. But when the patient arrives tomorrow, that nurse may not be available when the patient arrives for their treatment. And you wouldn’t want to keep that patient waiting when there aren’t nurses available. So if there is also a primary nurse shift model being used, where nurses are preferentially assigned patients from the same clinic provider or patients that they’re typically used to working with, and it’s most likely the case that the next available nurse may not match with the next patient that arrives for their treatment.
Another variable that real-time assignment doesn’t perfectly factor in as balancing the planned nurse workload by acuity. Some centers typically try to balance acuity on the fly by writing down acuity numbers and keeping track of the amount of the load that a particular nurse has been for that day. The sum or acuity load that a patient– that a nurse has seen so far is then taken into account when deciding which nurse should be assigned to the next patient that arrives. This could work well. It could work when there are many nurses available and not too many patients waiting. In such a case, it’s easy to use simple math to say, for example, oh, nurse A has seen a total acuity of six so far. Nurse B has seen only four. Since both are available at this time, let’s give B the next one.
All right, so you can balance between nurse A and nurse B. However, this may not always be the case. What if nurse B, who has a lesser acuity of four so far, might not be available for another hour? You’re not going to keep that patient waiting for an hour. You’re going to give that patient to nurse A who has seen higher acuity patients so far. So, in a sense, this is not a perfect solution given that assignments are done on a first-come-first-served basis, and there is some variability in when the patients arrive for their treatments. Also, given patients have different treatment lengths– some may be long, some may be short. There is a very, very high chance that some nurses will end up treating more difficult patients with longer treatment length throughout the day, while some other nurses may end up treating mostly shorter patients or either patient.
So, in a sense, real time is not perfectly optimal when it is important to balance planned nurse workload. And that’s where iQueue nurse allocation comes into play. In many of the centers we work with, the iQueue nurse allocation tool is being used daily to assign patients to nurses prior to patient arrival. In some centers, nurses may work closely with a particular provider to ensure continuity of care. But in some other cases, we see nurses may also take time to check their patients orders hours or days in advance. And there are some cases where we see both of these happening at the same time in some centers. The images you see on the right here are screenshots from the iQueue nurse allocation tool. We’re going to use a short demo of the tool in action just in a little bit. But for now, we’re going to quickly give an overview of what the results look like and how to use the tool. Whenever you run nurse allocation, the output is a nice visual timeline.
During the day, showing each nurse’s assignment are these color-coded horizontal bars indicating when appointments are expected to start and end. Each bar also has labels identifying the appointments, and these appointments can be labeled or color-coded by a number of options, including visit types, clinic provider names, or it could just be appointment times. All the way at the bottom of the output is the overload area. In some cases, a center might overbook the schedule– not in some cases. In most cases, centers will overbook their schedule in such a way that nurses could get double-booked. These appointments are caught early whenever you’re using the tool. And these appointments that are double-booking nurses, they end up in the overload area. And if needed, these appointments can then be manually dragged and allocated to a nurse who might be more experienced to handle some extra load, or some of these may end up just being seen by a charge nurse or a float nurse who may be available to see those patients.
Using the nurse allocation tool is a very simple three-step process. A user typically first sets up the nurse in shift for that day, so how many nurses are coming in, what are their shifts. The user then runs and reviews the result and then prints them if needed to be handed to the staff on the treatment floor Viewing, during the set up, the dates are run, the allocation for is selected by the user. The nurse and model, is it primary nurse in or non-primary nurse in? You have to select that option as well because if you select primary nurse in, then nurses will be preferentially assigned patients with the same clinic provider. The nurse in shift is then adjusted, and the allocation is run. It takes about a minute or so to generate the results. And then when the nurse in assignments are generated, some appointments may end up unallocated.
As we mentioned earlier, the algorithm determines that. It is just impossible to allocate without double-booking a nurse’s time or just even break in some of the other constraints like the nurse shifts, the lunches, or the max number of appointments a nurse can see at a time. So these appointments that are unallocated can then be dragged and dropped into the preferred nurse’s schedule or just lessen the overload for a float nurse or the most available nurse at that time to treat Once the results are finalized, you also have the option to view them in a sortable table, which you can order by number of fields, including appointment time or the nurse names. And that’s in a list view, which we’ll show in a little bit once we demo. But then there’s also the Gantt chart view as well that you can print and then handed out to staff on the treatment floor. All right.
Now we’re going to quickly demo the tool in action. You should have a little red icon at the bottom media. You might need Flash. Player for it on board. Just going to go ahead and do that, and I’m going to share my screen right now. OK. So now we’re in the iQueue– now we’re in the iQueue nurse allocation tool. On the top left is the unit you’re in, the date– were just going to run nurse allocation for tomorrow, Halloween. On the landing page is the set up. How many nurses do you have for that day? What times are their shifts starting and ending? When is their shift lunch? You can go ahead and add a new nurse if you want. But, say, we want to add one nurse who comes in at 9:00, and let’s say the nurse’s shift ends at 6:00 PM. Go ahead and add that. That’s nurse E1. Again, the user has to select or unselect Primary Nurse In if that the center uses primary nurse in model in how you want to group your nurses by clinic provider.
Once that’s been set up, you can– so typically, this will be pre-populated with what your typical nurse in shift and standard is, and then you can go ahead and modify daily based on what the shift is for that day. But once all of your nurse in shifts are set up, you hit Run Allocation. It typically takes less than a minute. While that’s loading,. I’m just going to give you a quick overview of some other sections of the app. You know, the application is very– it’s very useful for schedule planning. So you can plan your day off. You can see how much volumes you’re expecting that day. You can use the huddle calendar to see up to a month what the chair utilization graph’s telling you, what date could be problematic, where can you move patients from, or one day or another, or one unit to another.
There is also the daily huddle which shows you what– so on the top left, we’re going to see the allocation was run for Wednesday, October 21st. We see when it was last run, and who ran it, so it was run by me. You see the total number of appointments that were allocated for that day. And remember, we briefly talked about overload. So these are appointments that couldn’t be allocated to nurses because they disobeyed some other constraints or they just double-booked nurses. And then we see how many nurses you had total for that day. So we’re viewing the. Gantt chart view. In a little bit, we’ll talk about the list view. But then– so for each nurse, so nurse E1, you can go ahead and also rename the nurses if you want based on who showed up that day.
So let’s just call this Obehi. Let’s call this Ed, for example. And then it’s going to sort them by alphabetical order. But what’s going to show for each nurse? So Ed, for example, four appointments were allocated to Ed. Ed will get their first appointment at 8:00. This is an infusion 3-to-5– a three to five-hour infusion, and the clinic provider for Ed is Obehi. You can also change the labels and colors you see for each of these appointments. For example, you could label by appointment time. You could label by iQueue appointment group. You could label by length visit. You could also label by appointment time. So length visit, if that appointment has a lengthy visit or not. You could also color-code by length visit, pretty much similar fields, so iQueue appointment group or color-code by clinic provider. Right at the bottom, there’s legends to see what each color represents based on what you decide to color it by.
So let’s go over to the overload area. So we talked a little bit about the overload area. So these are appointments that couldn’t be allocated because they broke some constraints. It’s easy to identify some of these constraints. For example, if we look at this– let’s change this label back to a visit type or appointment type. If we look at this one-hour infusion that is scheduled for 4:30, what we see is that this appointment ends up really late. It ends up running past the last nurse shift. So if you see, the last nurse here leaves at 6:05, so any appointments that’s is scheduled to go past 5:00 will get unallocated. So typically, that’s an indication that there was some issue in scheduling where it wasn’t considered what time the center is closing or what time a nurse is going to be available. So in these cases, should you move that appointment to a different center that’s open later or should you have a nurse stay later?
Some of these appointments you can drag and drop. So, say, I want to reallocate this appointment to Obehi. Obehi will be there to take this appointment right at 15:00 or 3:00. And let’s just move this to length visit. You can color code by clinic provider. And once you drag an appointment from the overload to assign to a nurse, that number decrements. So before, we had nine appointments in overload, and now we have eight. And the total number of allocated appointment is 43. Now, in some cases, you may not be able to allocate these unallocated appointments. So what you do is you just leave them there and plan for a charge nurse or a float nurse to take them. Or as the day goes on, you figure out which of these nurses is most available to take an additional patient. OK.
Now, if we go over to the list view, you can sort– pretty much, it’s just a list view of all of those appointments. You can see for each nurse what appointments they’re taking, what time those appointments at clinic provider, the expected duration of that appointment, the appointment type if it’s a length visit, if there are any notes that were on that patient’s appointment, and the date of that appointment. So you can click on any of these to sort the duration. Appointment type, you can search by length visit or the date. And then once you’re done, you can go ahead and then print the results. You can download a CSV, or you can just print directly. You can download a CSV if you want to go in and modify and add some more notes. So that’s pretty much the iQueue nurse allocation tool-specific overview. Now let’s go back to quickly wrap up these slides. OK.
Now what are– now you’ve seen the nurse allocation tool, what are some of the benefits of using the iQueue nurse allocation tool to assign nurses to patients prior to arrival? When using iQueue nurse allocation tool to assign your patients, nurses can do their prep work prior to their day of treatment or even during the late afternoons, for example, when things start to ramp down and they feel they have more time to then go ahead and start looking at who they’re assigned to for the next day or next couple of days. With the tool, your center can also preserve their primary nurse in model while gaining additional load balance and benefits. So you can preserve primary nurse in model and also balance by acuity or balance by treatment lines or however you consider balancing a nurse workload. And if there aren’t too many changes to the schedule on the day-off, the balancing of the templates can be more ideal than taking patients on a first-come-first-served basis. And it’s easier to factor in things like acuity and patient hours.
So acuity is a sensitive issue for some centers. Some centers may not really carefully consider acuity, but the concept of acuity sometimes is often correlated with treatment length. But not all four-hour treatments, for example, are equal. Some could be more or less difficult based on the patient or the medication that is being administered or where the patient is in their treatment cycle. It could be cycle one, two, three. Some cycles, typically, earlier on, you might be having more difficult cycles, and then later on, once they’re more stable, things get easier. All right. Some centers already capture acuity as a score in their EHR system. Typically, they have it inbuilt into the patient’s regimen, and they’re spending this information along with the data for each appointment. Some other centers, they’ve developed acuity charts for each visit type or regimen, and then they’re providing us with a mapping to use to factor in acuity into the nurse allocation.
So using the nurse allocation tool, it has its [INAUDIBLE] load balance and benefits, and it is very useful when nurses have to review the patient’s orders ahead of time. But nothing really ever goes perfectly as planned especially if there is a big difference between the schedule and what actually happens due to things like add-ons, for example, or patients not showing up or just even late arrivals. There could even be patient reactions as well. So things most likely may not go as expected or exactly as planned. So because of this variability, it is possible for the pre-assignment to end up leading to an uneven spread of patients for nurses. So to summarize things here, we’ve talked about three main strategies for managing nurse assignments; one, booking to nurse templates; two, real-time triaging; and three, using the iQueue nurse allocation. Booking to nurse templates works well when volumes are consistent and you have patients tend to always arrive on time.
Real-time triaging is the most efficient, and we see this used everywhere or in most centers. It has the most flexibility on the day-off because it utilizes a pool of users of nurses. And using the iQueue nurse allocation tool, it works really great when balancing nurse workload and maintaining continuity of care. So whenever those are really important and high priority for a center, nurse allocation tool is the way to go. However, we also discussed some of the downside of some of these methods. For example, booking to nurse templates, it dramatically performs really bad once a small distraction happens, like a patient not showing up. Real-time is not very optimal when it comes to balancing workload– plans nurse workloads early. It may require the charge nurse to be available to coordinate assignments on the fly.
And then lastly, the iQueue nurse allocation tool, it could lead to an uneven spread of nurses whenever there’s a big difference between what is scheduled and what ended up actually happening. So when deciding what strategy to go with, it is very important to just take a step back, analyze if there are any EHR constraints in your system, what are the specific nursing constraints that are used for that center, how predictable your operations are, and what overall strategy is being adopted for patient interaction as well as patient satisfaction. So that pretty much covers off all the main content here. We’re now going to open up the floor for questions.
MARIANNE BISKUP:. And it looks like we have a couple of questions that have already come in. And let’s see. The first one is, if I can read that, for the strategy of the assigning on the fly, how do you recommend balancing acuity?
OBEHI UKPEBOR: OK. Good question. Good question. So strategy of assigning on the fly, how do you recommend balancing acuity? We touched a little bit on this before. One strategy that [INAUDIBLE] have found helpful is to have the triage or charge nurse keep track of which patients are currently assigned to each nurse so that as a patient comes in, the nurse doing the assignment will be able to see the current nurse workload for each nurse on that floor.
So this could typically be done maybe by just writing down the number or maybe they have an Excel spreadsheet somewhere where they keep adding and keeping track of what’s happening that day. They can then use their best judgment to assign the patient to the most available nurse based on how recently a new patient just got assigned and look at clinical factors as well, such as acuity. Our recommendation is to estimate the patient’s acuity via a numeric scoring system, sort of keep track of each nurse’s current running acuity sum. That way, when a new patient with high acuity comes in, it can go to the most available nurse who also has one of the lower acuity running sum.
MARIANNE BISKUP: OK. And a reminder to those of you participating in this webinar, if you want to submit a question, you can use the. Q&A widget, which is located on the bottom toolbar of your screen. Looks like there’s one more question so far. How does nurse allocation take acuity into account?
OBEHI UKPEBOR: OK. Good question. Acuity is one of the factors that the nurse allocation can use to spread the patient assignments across nurses. But the algorithm will only consider it if it’s been sent to us in the data feed. So we typically get a data feed from the customer every day. We recommend having a numeric scoring system for acuity recorded somewhere within the EHR so that it can be sent to us.
But if you don’t have that, something that some centers are doing is giving us some rules for us to derive an acuity score during the data processing and load step, sort of a mapping. Once the algorithm has the score, it will then try to keep the total sum for each nurse roughly balanced while also still considering the timing, the length, and the provider if primary nurse in is turned on for each appointment.
MARIANNE BISKUP: OK. Well, I don’t see any other questions in the window. But, again, if you want to reach out to us, you can still use the Q&A widget. It will capture that question, and we can respond to you individually via email. Thanks again for joining us.