MARIANNE BISKUP: So I want to welcome everybody to today’s session titled The. Science of Tackling Same Day Add-ons, No Shows and Cancellations. You may see Katie McDermott up on your screen, but in reality, My name is Marianne Biskup, I’m the events manager for LeanTaaS iQueue. So before we start, we have a couple logistical points to cover. If you want to contact us, you can you can text a question to 630-884-5493 or you can email us at email@example.com.
Now you’ll also notice that you’re all muted. But you can still ask questions. So if you have any questions during the presentation, please enter them in the Q&A box, which can be found in the corner of your screen. And I know you’re eager to get a recording of the post webinar. Well, we will send out a link– a recording– a link to the recording shortly after we conclude. Now I’d like to introduce our presenter, Chris Koh. He’s our product manager for iQueue Infusion Centers.
CHRIS KOH: Thank you,. Marianne, much appreciated. And thanks everyone for their time today. So as Marianne said, I’ve been with LeanTaaS and iQueue for about six months. I’m the product manager on infusion side. Prior to this, I worked in tech at a software company and also in finance. All right. So we’ll start with a quick drive into the sunset here. On the first slide is a metaphor for your infusion operation. Hope many of you can relate. Like many other things in life, you try your best to plan things out well with good intentions. In the case of an infusion operation, you schedule patients in a way so that they can get their treatment delivered accurately and in a timely manner. However, also like other areas of life, unexpected things happen.
An existing patient needs an additional treatment, a new patient needs an urgent treatment, or a patient is too sick to treat or doesn’t show up for other reasons. These same day patients add-ons, cancellations, and no shows can wreak havoc with your best laid plans from a scheduling perspective, particularly the add-ons. And how you adapt to those unexpected things can impact your entire day. The goal of this webinar is to help you pick the best times to place those add-on appointments so that your day can proceed smoothly. Let’s spend some time going over the different types of unexpected appointment changes and how they can impact your day as an overview.
One thing to note is that we are focusing on same day add-ons and cancellations. Since add-ons and cancellations that occur the day before or earlier give you at least a little more time to react and plan for, and thus, are generally less disruptive than same day changes. Same day add-ons probably have the most direct impact on your day in that they represent extra volume coming in that you have not planned for. So they tend to add risk to your daily operation. One unexpected long infusion at the wrong time can have knock on effects on staffing and wait times for the whole day. Because of this, we’ll spend the most time on how to handle and place add-ons.
Same day cancellations, depending on when they occur and the type of appointments that get canceled, have the opposite effect. They clear out space in your schedule, and thus, often have at least a partial offsetting effect on the smoothness of your day. No shows are the worst of both worlds, as a patient is not getting seen and treated. And they are taking up chair space that you have reserved for them waiting for them to show up. This impact can be mitigated but can definitely also caused some headaches. On the next slide, we lay out a framework for you to think about how to manage same day add-ons, no shows, and cancellations for your infusion center.
The three main steps are to measure and quantify, day-of response, and planning and remediation. Starting with measure and quantify, you will want to gauge the impact of add-ons and cancellations on your infusion operation over time. Do you have a large number of add-ons? When do they typically come? How do they compare to no shows and same day cancellations? How have these numbers trended over time? And do they deviate significantly or are they stable? Once you get a sense of how these metrics trend over time, you can create a baseline from which to act. Second, after getting a sense of how add-ons and same day cancellations impact your infusion operation, you’ll want to understand how to best react to each situation on the day-of.
How do you decide where to put a– where to best put an incoming add-on? Will you have chair space or will your nursing team be able to handle the patient flow? Will same day cancellations and no shows sufficiently offset the incoming add-ons? These day to day responses will hopefully serve as an aid to minimizing potential bottlenecks each day, particularly on busy days. Lastly, you also want to think about how you can respond to longer term trends– longer term to the trends that you see. If your add-ons are persistently high, is there anything you can do to redirect the add-on flow to a different day? How much flexibility do you have to try to change the flow? If your cancellation or no show rate is high, why is that? And how could you potentially impact that? We will go into each of these components and more details over the next few slides.
Drilling down into the measure and quantify part of the framework first, you probably have a sense of whether more of your patients tend to add-on unexpectedly or cancel unexpectedly on the day of their appointment. But the actual delta in consistency over time matters. The goal is to get a quantitative sense of the impact. Here we have an example of the measurement of the impact of same day add-ons relative to the impact of same day cancellations. The purple line above here represents same day cancellations. And the blue line underneath represents same day add-ons. Over about a two month period here, as you can see, this particular center tends to have more same day cancellations than add-ons very consistently, which is a fortunate outcome since you will wind up with more chair space, assuming that the patient hours associated with the add-ons are fewer than the patient hours associated with the same day cancellations.
This will also lead to a lesser nursing workload than planned for, which can help reduce pressure on any potential bottlenecks during the day. However, even if the broader trend is favorable, as it is in this case, there can still be a number of days where the number of same day add-ons exceeds the number of same day cancellations, as you can see on. September 5th here. Or it could be a situation where the length of the cancellations you have don’t match the length of the add-ons. The question when encountered with these cases is, how can you best manage your add-ons for those days? Next few slides, we’ll go over on how to best respond to the day-of for these types of situations. There is also a case where your add-ons may be consistently higher than your same day cancellations, which is the opposite of what you see in this chart.
In that case, you may want to take longer term steps to plan for and remediate that pattern in addition to understanding how to best respond in the day-of. We will revisit that case later. Moving on to the day of response part of the framework. Here we provide a couple of visuals that can help you decide the best place to place your same day add-ons. The key concept before we get into the specifics of this example is that you should consider both your chair capacity and your nursing capacity together rather than in isolation. The reason for this is that an available chair with no nurse available to treat the patient still results in a patient that is waiting for treatment. And available nursing capacity with no chairs to put incoming patients in leads to the same result. Either scenario can lead to bottlenecks. And one bottleneck can lead to a waterfall scenario where the entire day becomes difficult.
So it’s important to consider both variables when deciding where to put an add-on. On the left hand side here, we can see a view of the chair utilization for September 5th. It looks like there is some chair capacity from 7:30 to 9:30 in the morning and from 4 PM onwards, relative to a level loaded schedule, which is what this green line here represents. On the right-hand side, you can see the starts by half hour throughout the day. If you look– and that’s on right here, on this side. If you look at the difference total column here on the right hand side, you can see time slots where you’re overbooked for the day, which are signified with red numbers. In this case, you can see five overbooked at 8:00 and one overbooked at 8:30 and six at 9:30. Meaning that your nurses are likely to be very busy at those times. It would exacerbate the bottlenecks for the day if you were to try to put add-ons at those times.
Better times to put add-on appointments would be early in the morning at 7:30 in the morning, where you are underbooked by five, as you can see by this yellow minus 5 here. Or at 4:00 PM where you are underbooked by two appointments. You’re more likely to have both a chair and a nurse available simultaneously at those times. To reiterate the point, when you’re looking for the best time to put an add-on consider both your chair capacity and your nursing capacity, and look for times where there is expected to be availability for both. Sometimes, even after you’ve made your best efforts to put add-ons in places where they would cost the least strain– cause the least strain on your resources, you’re simply just overloaded with too many patients. And in those cases, overbookings will be unavoidable and you just expect a busy day.
However, even in those cases where you are already overbooked, there are still better ways to overbook than others. Here, we go back to the chart that we were looking at with over and underbookings by half hour for September 5th. The clusters of starts at particular start times represent high risk frames. And they can generally be avoided by spreading out the overbooked times as much as possible. Having one or two overbooks every half hour for a few hours is better than having six overbooks at 9:30, which is the case here and as we saw on the last slide as well. The same can be said for the five starts at 8 o’clock, the four starts at 10:30, and the fourth starts at 11:30. Plus ones instead of plus fours and plus fives are also better.
The reason for this is that just as uncertainty can work against you with regard to creating bottlenecks, it can also work in your favor if a patient ends early or doesn’t show up. So by spreading out the overbookings, you give the math the chance to work in your favor as well. Having a large cluster of patients show up at a given time reduces the chance of natural variability working in your favor and increases the chance of a bottleneck. On the right hand side here, we see that there were two add-ons on this day at 10:30 and 11:30. Right here and here. And given that these wound up having forced overbookings at those times, it would have been better in this situation to put those appointments in other time slots where you are underbooked to reduce the risk of bottlenecks.
Part of what you can do to avoid these types of clusters is to proactively offer patients times where you know you have both chair and nursing space as opposed to asking patients when they would like to come in. As things will tend to cluster into peak hours, generally, between 10:00 and 2:00 if patients are given an open ended choice. So far, we’ve gone over some things you can do at the point of scheduling to alleviate the pressure that same day add-ons might put on your day. There are also some tangible actions that you can take day-of when you’re anticipating that a day will be busy and that the patient flow and workload could be particularly susceptible to bottlenecks from add-ons.
You can see from this chair utilization chart that this day is scheduled to go over the chair capacity of the center, which is 30, as indicated by this horizontal max capacity line. And the red bars are how you can tell it’s going to go over capacity for about three hours in the middle of the day. When faced with a day that looks like this, any add-ons at all could create a problem and it can be very difficult to place even one. These are cases when you can take an all hands on deck approach, which some of you probably do already. Hopefully, not as frequently. But actions such as calling in your float nurses, advising nurses to take early rivals back as efficiently as possible, can help create a little bit of extra chair space and hopefully alleviate some of the red bars in the peak hour of busyness. So that was a rundown of things that you can do day-of to respond to add-ons.
We’ve spent quite a bit of time on those since they require more resources instead of fewer. Now we’ll move on to same day cancellations, which typically help loosen up your day. In these two charts, we’re looking only at two to three hour appointments by day. With add-ons on top and no shows and same day cancellations on the bottom. If there is a same day cancellation and an add-on of roughly the same length, you can plug the add-on where the same day cancellation was originally scheduled. So as I mentioned earlier, you can tell in this case, we filtered out all the appointment lengths except for the two to three hour ones.
So this chart, you can see that on December 13th and 14th, we have one add-on of two to three hours and one cancellation. So that’s a case where it does match up very well. And you can probably just plug your add-on into where the cancellation was, assuming there aren’t other variables like a linked visit that may create some inflexibility there. And also, for January 8th, we have a similar situation where there are three add-on appointments and then three matching same day cancels. So that’s generally favorable as well. Now in the cases where the durations do not match up as well, you can fall back on the process that we outlined in the earlier slides. We’ve talked a good amount about the day-of responses.
Now let’s move on to more strategic longer term methods you might consider for responding to your same day add-on and cancellation metrics. If you’re infusion center has specific characteristics, it may be beneficial to make structural adjustments to the way you book. Here, we’re looking at a chart that represents median share utilization over about a month of data, where the blue line is the schedule chair utilization and the pink line is the actual chair utilization. So right here is the schedule. This is the actual. We can see that this center consistently books about three chairs worth of patients more than wind up showing up. So you can see that by looking at the gap between the blue line and the pink line.
The ramification is that you can afford to book a little more fully when you need to for the center in anticipation that the actual outcome will require fewer chairs than scheduled. This is the more favorable case where same day cancellations tend to work in your favor. If you’re infusion center is in a state where you consistently have more add-ons than cancellations, where the pink line is above the blue line instead of vice versa, and as we touched on back on slide six, you would take the opposite approach. Scheduling more conservatively with some chair buffer below your capacity so that you allow for additional chair space that the anticipated add-ons will take. Moving on to some other longer term corrective actions you can take.
If you find that your add-ons are persistently high, we found in our interactions with our customers that it’s frequently caused by patient flow coming from clinics or like water trying to go through the Hoover Dam. You might try to impact the flow from clinics by various methods, including moving certain providers from busy days to slower days, steering patients toward having their clinics and labs on a different day than their infusion appointment, or asking scheduling to schedule only the most urgent add-ons for the same day. We also understand that these types of actions can take a while to implement, quite a while to implement. And in some cases, might not be feasible at all. But they’re just a few options to think about.
For no shows and cancellations, even though they typically help the flow of the day, we don’t want everyone to become our favorite truant, Ferris Bueller here. And no shows waste valuable chair space. If your center has a high no show rate, outreach to patients to understand the root cause, maybe a starting point to address that problem. Same day cancellations can also be a problem if they’re consistently too high, which would also, perhaps, require process changes likely unique to your center.
To wrap up, let’s take a look at how a future infusion operation might look like. Some of the visuals we used today were from the current iQueue application and are designed to do some of the things we discussed. This includes providing a view of your day before it begins, tools to help you manage add-ons on the day-of, and analytics to help you identify longer term trends. Our goal in a future state is to allow for data feeds to be updated multiple times per day or in real time to provide intraday visibility.
This will not only allow you to plan for your day at the beginning of the day, but enable continuing visibility throughout the day. And allow you to respond even more nimbly to incoming and canceled patient flow. Another potential enhancement after that is to actively provide suggestions to put add-on appointments to further streamline the process and to make it even easier to decide the best place to put an add-on without having to conduct a manual inspections every time. Now I’ll turn it back to. Marianne to take any questions.
MARIANNE BISKUP: All right. Thanks, Chris. So a reminder, if you’re interested in submitting a question, you can use the Q&A function in the corner of your screen. And we already have a few questions. So the first one is, we often face patients who arrive late. In these cases, we try to fit them in where possible. But they still can lend to significant bottlenecks. What recommendations do you have for patients who arrive late from a delayed clinic or a late arrival?
CHRIS KOH: Yes. So that’s an excellent, excellent question. And I think there’s only so much you can do to respond to that in many cases. But I would go back to the framework that we showed on slide seven and eight, which is you kind of take an inventory of whether you have any open spots or not. If you don’t have any flexibility and the patient needs to go right then and there, then you manage it the best way you can in response to that addition.
If you do have a little flexibility where the patient can come in an hour or two later, you pick the spot where you have both the chair space and the nursing capacity. And so that’s where you would use both the chair utilization and the over and underbooking table together. The best places are where you have the white space in the chair utilization and the yellow space in the over and underbooking table. Now if you’re in a situation where you’re overloaded, as we discussed on slide eight, that’s when you resort to, OK, if anybody does work in your favor, you can take him back a little bit earlier, you call an extra nurse.
Again, if this late in the day, that probably doesn’t help you very much. But generally, if you adhere to the let’s take a look, get some visibility into our schedule and see if there’s any like looser spot to put them, that would be the best way to go.
MARIANNE BISKUP: Next question. What time period of data should I look at to determine that a trend exists?
CHRIS KOH: So statistically, an n of about 30 is what would be considered a large enough data set to be able to pass a judgment on. Typically, more data is always better to help you confirm patterns. You can’t do this in isolation. It needs to be corroborated by reasons that you can point to operationally. For example, if you see your volumes going up, is it because you’ve added providers? Or was it a holiday spike? If it’s because you’ve added providers, then, you know, at that point, you can say that’s probably going to be a persistent trend and we should be adding staff or extending hours. If it’s the latter case, that might be a spike.
MARIANNE BISKUP:. Another question. What if I have a short appointment cancellation and an add-on that is a long treatment? Can I just plug the add-on into the short appointment cancellation?
CHRIS KOH: Yup, that’s a good question. At the risk of sounding like an economist, it depends. This is not necessarily a clear cut answer and it is a dilemma the schedulers often face in our experience in our conversations with them. In general, the first thing you want to do, similar to the framework, is to go back and check to see if you have chair space and if you have a nurse available at that time.
Generally speaking, you will have a nurse available since a start time was recommended for that short slot. And if you need to plug a long one in, that the nurse should be available. The question is, will you also have chair space available at that time and then hopefully a little bit afterwards. So if you take kind of those two variables together, you can make a judgment of is it safe or is it less safe or is it risky or less risky to slot that longer appointment into the shorter slot. In general, it is designed to take into account the nursing starts. So if the option is, you know, pile it on top of a place where you’re already overbooked or put into a short slot, we would put it in the short slot.
There is also the things specific to your infusion center to consider, which is, if you know you’re going to need the long slots or you tend to have long slots come in late, then you might just pick the least bad place to overbook if you need to. But in general, we would say, first thing to do is check to see if you have some chair utilization but use up the start times because we know that there will be a nurse available at that time.
MARIANNE BISKUP: It looks like this is our last question. We have a significant problem with our first patients of the morning always being late. Even if we tell them to be 15 minutes early for check in, we still have problems with this at many of our clinics. This puts the whole day behind. What would you do?
CHRIS KOH: So, appeal to empathy. Say that you being late causes our nurses to have to be more stressed during the day and also causes other patients, including yourself, possibly, to have to wait later on in the day. That is a somewhat tongue in cheek answer. I would say that, going back to one of our slides, that’s what I would consider a long term problem. I would say patient outreach is the best way. You might need to train them over time. You know, if it’s only 15 minutes late, maybe you kind of move your template by 15 minutes. You might shift your operating hours a little bit.
So there’s a few things you can do. You might say something like, if you show up on time, we’ll give you chocolate. I don’t know, that usually seems to work pretty well. Pizza. So yes, these long term behavioral changes though, I think, are usually pretty infusion specific and do need to be implemented over time. The iQueue kind of math answer would be, try to shift your hours is probably the most legitimate way to respond to that. Just by a little bit.
MARIANNE BISKUP: OK. Well, speaking of empathy, I’m going to allow one more question to slide in under the wire here.
CHRIS KOH: OK.
MARIANNE BISKUP:. Does this system take into account adverse events that may occur and how?
CHRIS KOH: Adverse events. So if you’re talking about like somebody was unexpectedly sick, there are some tools that allow you to tweak those kinds of things. I think I’d certainly want to take that question offline. We’d be happy to talk in more detail offline about what types of adverse events you’re thinking of. But we do have mechanisms for something like, if I have a half day meeting and I know I’m going to be short staffed, we can rejigger that the templates and the schedule suggestions to account for that.
MARIANNE BISKUP: All right. Well, our time is up for today. Huge thanks to Chris Koh, who did a stellar job in his rookie webinar. Yay, Chris.
CHRIS KOH: Thank you.
MARIANNE BISKUP: Keep your eye on your inbox, where a link to the recording of the session as well as for announcements about future webinars. Also, you’ll see a pop up window at the end of this webinar. Please complete the survey that will be that’ll be presented to you. It takes about 15 seconds. So it’s pretty quick. Also, please remember you can text your email address to us at 630-884-5493 or send us an email for a demo request, firstname.lastname@example.org. Thanks again, everyone.