Recently, Novant Health’s nurse managers Lisa Rioux, RN, BSN, OCN, CRNI and Susan Perrella, RN came together to discuss addressing the operational bottlenecks at their system’s Presbyterian Medical Center in Charlotte, NC. iQueue for Infusion Centers, which uses machine learning and predictive analytics to solve the math underlying optimal appointment scheduling, improved schedules, and resources so effectively that Novant could open a whole new center with minimal patient waiting areas. If you missed the conversation, see the summary below, our recent blog post, or view the webinar recording.
Mallory Hufford: Hello everyone, I’d like to welcome you to today’s webinar, “How Novant Health was able to open a large infusion center with a small waiting room,” presented by the association of community cancer centers and sponsored by LeanTaaS. Today’s speakers include Novant Health Nurse managers Lisa Rioux and Susan Perella, joining LeanTaaS panelist and product implementation manager Mike Casteel.
If you have a question or comment, please enter it in the Q&A box at the end of the presentation. This discussion is being recorded; you’ll receive an email with the link to the recording as well as other useful information after the webinar. If you’d like to estimate the ROI on iQueue for Infusion Centers, please check out your ROI calculator in the chat box.
Thank you all for joining us today. With that I will hand it over to Lisa to get started with the presentation.
Lisa Rioux: Hello, good afternoon. We’re going to spend the next half hour or so telling you about our journey and preparation of going from a 32 to an 80 bay infusion center, and how iQueue impacted our success.
First we have to tell you a little bit about Novant Health and Presbyterian Medical Center (PMC). Then we’re going to go over the pain points and why iQueue; the implementation process; our infusion expansion; and the results of our implementation. Then we’ll share some best practices in our ongoing process improvements and goals, and then we’ll have a brief Q&A session.
So, a little bit about Novant Health and Presbyterian Medical Center. Presbyterian is a part of a large not-for-profit healthcare system in North Carolina, South Carolina, and Georgia. We’re a 576 bed Regional Hospital located in uptown Charlotte, North Carolina, and we’ve been a cornerstone of Charlotte since 1903, when it started as a 20 bed hospital. In 1997, Forsyth Medical Hospital and Presbyterian Hospital merged to form what is known as Novant Health. Since that time, nine hospitals have joined Novant Health, and five hospitals have opened, and it seems like we have a new hospital every year. Presbyterian in particular has about 7,000 employees and more than 700 physicians on medical staff.
Presbyterian Medical Center provides many specialized services. We have over seven centers of excellence, with cancer being one of them. In 2008, Presbyterian was honored with the prestigious Methodist designation, which we all know signifies high quality care and is the highest honor in nursing, with only 5% of hospitals nationwide earning this designation.
Our seven story cancer outpatient facility that also includes cardiovascular care opened in October 2020. Every detail of this building was designed with a patient in mind, reflecting an environment of healing.
Susan Perella: PMC is one of the country’s largest cancer centers. We are an accredited Cancer Center by the network Commission for Cancer. We currently treat over 100 types of cancer, we have 32 cancer specialists here in our building with us, and 12 specialty clinics. We offer surgical, medical, radiation oncology, integrative medicine, cellular therapy, genetic testing and counseling, nurse navigators, a palliative care program, and our fabulous Cancer Wellness Center.
For the purposes of this talk, we’ll talk about the two infusion centers that fall under PMC. We refer to those as the Charlotte Infusion Center, which is actually based in the hospital, which is where we used to be, then our current infusion center is the Elizabeth Infusion Center. The Charlotte Center, as I said, is hospital based. They currently operate using 17 chairs, three beds and one injection chair. That injection chair is just for lab draws and shots. Depending on the volume of the patient schedule there’s typically two nurses, a CNA, one scheduler and a charge nurse. They are only open Monday through Friday, and they take the non-oncology patients. We have a very large neurology practice that sends the majority of their patients to the Charlotte infusion center, so there’s a lot of Lemtrada infusions and other treatments. We also see a lot of GI patients, and pulmonary and primary care, a lot of blood transfusions, IBIG. They also perform monoclonal infusions for COVID positive patients.
Very few of the patients that come to the Charlotte Center have seen the equipment, because it’s in the hospital, and they’ve come through their doctor’s office. The pharmacy that their medications come from is located right on the unit with them, and the labs are sent to the central lab in the main hospital.
The Elizabeth Infusion Center, in our lovely building that you can see in this slide – that’s one of our nerve cells, we actually have four, and they all have a spectacular view. Currently we are all utilizing 43 infusion chairs, six beds, and one injection chair. All the patients that come to us are oncology and hematology patients, and about half of them have seen the appointment, so they’re seeing a physician somewhere in this building, a radiation oncologist, and coming to us on the same day. We have that small waiting area that we mentioned earlier. Our goal is to move people through quickly and that’s what LeanTaaS helped us do. We have a vascular access area where the patients come and get their peripheral IVs, and ultrasound technology, or port access. Then they’re moved on through the infusion center. We do have a lab here in this building with us, and the pharmacy is here on the seventh floor with us as well.
Pain points and why we chose iQueue — previously when we were across the street, as I mentioned, in the Charlotte Infusion Center, we were all together. We have developed a crosswalk, our spreadsheet so to speak, with all of the drugs that we gave. We scheduled infusions on the hour and all the injections on the half hour. As you can imagine, that created a lot of bottlenecks. We would have anywhere from six to eight patients all coming in at eight o’clock, and then again at nine o’clock. So that created a bottleneck for the nurses and the pharmacy, because then we were notifying the pharmacy that we were ready for eight patients in a cluster, which caused a lot of backup. All our chairs were full, patients were there for appointments who we weren’t able to bring back, which caused a delay in our waiting room as well.
We weren’t able to accommodate very many add-on patients, because if they had a visit with the doctor earlier in the day, they weren’t able to come directly to us. We could usually accommodate them at the end of the day, which required them to sit in our waiting room and wait, or go home and come back, which if they weren’t feeling well, really isn’t ideal.
Our nurses struggled to get lunch. We had blocked out a time from 11 to 12:30 for lunch. But it wasn’t always practical for everyone to get to lunch at the same time. So that was a challenge as well. We did an assignment, myself and the other CULs on our unit, and that typically took us about one to two hours, which was a challenge. So we knew moving into our new space, which was going to need three times the size, that we needed to make some type of a change, that we would have bigger problems on a larger scale if we didn’t fix it then.
One of the nurses that worked with us at the time had been working at UVA and had experience with iQueue, and was able to arrange for us to learn more about it. About a year and a half later one of our service line executives had a personal experience with us in the infusion center and saw the delays in getting back and getting the treatment. He spearheaded the planning and implementation of iQueue in the infusion centers based here in Charlotte. Our goal was to decrease the patient wait time and hopefully increase their satisfaction and also twofold increase the satisfaction for our nurses here in the unit. We wanted them to feel like they could step away and not feel like they were handing off too much to one of their coworkers. iQueue really, really helped us work with that.
Lisa Rioux: So here’s the timeline of how we implemented iQueue in our infusion centers. In February 2020, we identified who our stakeholders would be and we began our planning. The stakeholders were service line leaders, clinical informatics, infusion scheduling, infusion nursing, referring providers and their office staff. Then in April, our team reviewed the iQueue generated templates based on our historical data, and began building those templates within Epic, which is our EMR system.
Prior to iQueue, we had a crosswalk, which Susan mentioned, that listed when our infusions could be scheduled. But they were scheduled based on how long they were. So the morning part of our day was usually typically very busy. We reworked our crosswalks to get them more accurate tracking of the cycle times, so that iQueue and Epic could build a more accurate template for us to rely on and depend on for learning, or trends.
We communicated our purpose and goals to our referring providers, nurse and scheduler training began, and then we provided scripting to our nurses and schedulers so that patients that have been coming to us for weeks or months or years even, suddenly if their appointment time was a little bit different than it had been before, the why behind that hopefully to get them in and out of the infusion center in a more efficient way.
Then in May, the schedulers spent the weekend moving existing appointments into the iQueue templates in preparation for our go-live, which was actually June 1 of 2020. In August we began planning for our new Elizabeth location that was scheduled to open in October. We use the predictive volumes of the oncology patients we were currently seeing, as well as the growth we expected to have in our next 12 months.
Then in September, the scheduler started moving appointments and scheduling future appointments into that Elizabeth scheduling template. Then October 26 of last year, the new Elizabeth building opened, and we started scheduling. We continued the schedule with that template and schedule system. In April of 2021, we made some changes to our scheduling durations, tweaked our template based on our compliance data, which we’re going to talk about – some of the data tools that came out of iQueue.
Susan Perella: As Lisa mentioned, we opened the building in October of 2020. We then divided it into two separate centers. Our center was only going to grow, because we had so much space, but initially we only utilized 49 of our total 80 chairs. Because the Charlotte Center was losing all their oncology patients, they cut back and were only using 17 of their 32 chairs. So our initial templates that iQueue designed for us were based on the predicted volumes from the previous year.
As we continue to grow – when we moved here, have weekly meetings with iQueue, and any changes we needed we were able to – pretty much in real time, they worked with our IT department. We were able to adjust the template to allow adding more, longer infusions and more one-hour visits where we saw that it was helping us more. It was very flexible, and really freed up our schedule, and we were able to spread things out further, so we didn’t have the bottleneck.
Lisa Rioux: So our early successes. We mentioned iQueue – we went live in June of 2020, with only having that Charlotte location open. This slide is comparing iQueue’s impact, using the data leading up to our launch and then post-launch. The numbers here on the left cover June 2019 through May 2020, which was our historical data, and then the post data was June 2020 through May of 2021. You can see our volumes were pretty steady. They were pretty consistent. But you can see over a 41% reduction in the average infusion wait time post iQueue implementation, as well as almost a 10% decrease in the average drug wait time.
But what was impactful to us, especially, was that we had free chairs. Those patients that were coming to their appointment weren’t waiting in a waiting room, or in the physician’s office that was calling to get their added appointment. They can more easily get those appointments made and patients weren’t waiting in a waiting area for a freed-up chair.
This is a slide showing our infusion wait times. Again, wait times went down across the board, even during our peak hours. Pre-iQueue, patients had a consistent high wait time throughout the day, with a slight peak at 8am, which was when we opened the door. So the patients that had to drive an hour to get here were sitting in our waiting room. Then there’s that 12 o’clock hour, still waiting to get into the infusion center, because of possible bottlenecking that was happening earlier in the day.
Post iQueue, you can see the numbers are lower, significantly down from the pre iQueue data. We saw about half as many patients that were waiting more than 15 minutes before they got back to their chair, as we did prior to iQueue.
The drug wait time also went down across the board. We still had a spike midday, around noon, which is consistent with what we were having before. There’s still some amount of wait time that needs to happen for drugs to be delivered, so we would expect some gap in time, but we still have some internal workflows we’re changing and adopting to improve that as well.
Here’s our flow right now. Once the patient comes and gets checked in with the scheduler, we send them over to the lab area for their IV to get placed, with their port to be accessed. If they hadn’t had labs drawn, they’re drawing labs, then they’re brought back to their infusion chair, they’re getting measure, height and weight, we’re calculating their body surface area (BSA). Then we’re doing our two-nurse calculation, based on that day’s body surface area, the nurse is performing the physical assessment and the toxicity assessment. Then we actually have the luxury of having nurse practitioners within our infusion department that may address any issues that have come up once the patients come to our infusion center. That’s probably a good reason why we’re still having that 45 minutes before the drug is actually started with the patient.
This graph actually shows the max chair occupancy. The pre-iQueue data, you can see we were maxed out between 11 o’clock – every infusion center has those witching hours, 10 to 2, where you’re slammed full and sometimes you run out of chairs. That’s what was happening with us, that Susan was describing. Now post-iQueue, given the template that we had created, we never ran out of chairs, and we always had availability, even during that highest peak in the day when we typically would have been completely full.
Remember how Susan was saying that when we were using our own scheduling template, we had long infusions scheduled on the hour. So you can see these tall bars. The bar graphs show five patients coming in at eight o’clock, five more at nine, five more at 10, so on and so forth.
Then the smaller graphs in between are what our short visit appointments are on the half hour. You can see after we implemented iQueue, how that is more evenly smoothed out throughout the day, so that nursing can keep up with the flow of patients coming in, the pharmacy’s able to mix the medication and deliver that in a more timely manner, rather than getting all bogged down with multiple patients coming in at the same time.
Susan Perella: So the innovations and best practices that we would like to share with you today. As we mentioned in the beginning, the small waiting room to keep the patients moving – that hasn’t been a problem, our waiting room hasn’t been full. Every 15 minutes have really spread things out for us, and our immunocompromised patients are not forced to all sit together in the same space. We’ve updated our crosswalk and made it a little bit simpler to follow. We’ve learned to be very adaptable and flexible.
Especially during COVID, in our old Charlotte infusion center that I mentioned, that’s still under operation – last year during COVID, they were doing monoclonal infusions for COVID positive patients. Depending on how many patients rescheduled, they had to adjust their schedule for upstairs in their regular infusion center. Some days they were only open in the afternoon, and iQueue was instrumental in helping us with that and changing that on a weekly basis, as to what appointments were open, and what was blocked and what was available. That really helped the flow over there, and allowed them to be flexible and accommodate those patients. It created a more spread out time for nurses to go to lunch, and to hand off to one another and cover for one another, which wasn’t happening before.
One thing that’s been very wonderful for myself and the CULs is we use the nurse allocation tool, which is how we do our assignment. We plug names in and iQueue runs it for you and we have the ability to tweak it and shuffle things around, but it really gives you a great baseline to level of the assignment so nurses aren’t overwhelmed. That also gives us the availability when we have add-on calls for same day appointments, we can see where there’s gaps when the nurses have – if they’re at lunch, when they have free time, this person should be going. Or if we need to adjust an assignment, if one nurse is getting behind, she’s had a reaction or someone now needs TPA, it’s a great tool for us to use to look back and see, “Okay, we can shuffle these patients around, it gives us a nice view to be able to do that”. And we’ve used the schedule to help. If we don’t have an available spot, we can see that we can jump up to another spot to accommodate fitting chemos, like last minute chemos, onto our schedules.
Lisa Rioux: One of the things that was very exciting for me was all the data that was coming out of iQueue. There’s a daily huddle I use on a daily basis to, just as a quick glance to the days; and the future days; volumes, and the mix of patients that are coming, based on their predicted chair time. So I could see if the schedule looked really heavy on Sunday, but it was lighter on Thursday, or light on Sunday but busy on Thursday, I could adjust staffing, and pull a nurse off Sunday scheduled to work Thursday, when I knew that was a higher workload for that day.
Using the daily huddle to steer the same day add-on appointments that Susan spoke of, or just shipping an appointment time, if it looked like we had a lot of patients that were coming in early in the morning, because they have doctor’s appointments, perhaps we can move an appointment from nine o’clock to one o’clock, when it was going to be a little bit lighter. The diagnostics reports that have come out are great for us, just internally, but they’re also really good tools to use during our leadership meetings, so we can inform them on how our chair utilization and our volumes are going in our department. We can trend wait times throughout the day or even day-to-day, we can observe our number of add-ons and no-shows that we’re having, look at when patients are arriving early or how many patients are arriving early or late. It’s very useful and with lots and lots of data that we continue to look at.
One of the other best practices that was really important to us before we went live with this system is obtaining provider and patient buy-in. Because sometimes when we would get before iQueue, you would get a provider office, that would call and say, I have a patient that I need to add on or send over, and they would request a particular day or time. This system helps us make those decisions and we need to explain that to the providers, so that they would understand – if a patient typically came in at 10 o’clock on Tuesday, well, it may be better for that patient to come in Tuesday at 10:30. Then they would get started quicker and they would go home earlier.
The patient buy-in, we actually talked about that during previous appointments, and we also sent out a letter to our patients, informing them of our new process and to be patient with us, but nurses and schedulers all received that scripting on helping us stay on track with our templates so that we wouldn’t sabotage it immediately when we went live with iQueue.
So we still have work to be done, we still have goals we’re trying to accomplish. We continue to track our data. We’re looking at appointment groups, as Susan had mentioned. If we have to make an adjustment to a template, it’s because we see that maybe we don’t have enough two hour appointments available, but we have too many three to four hour appointments. We can make adjustments based on that data,
Looking at the number of add-ons and cancellations and no-shows, and why is that happening, maybe we need to dig a little bit deeper to find out why those are happening day to day. Observing the chair wait times, does it look like we’re trending beyond the 15 minute wait time, or the drug wait time of 45 minutes? What processes need to happen to get us back on track?
One thing we’re working towards, which will help us with that drug wait time, is scheduling a lab appointment earlier than 15 minutes ahead of the provider appointment. This way the patient can have their labs drawn, see their physician, and before they leave the physician’s office they already know what their labs are. Then they have the time to make adjustments to their treatment plan, rather than sending the patient to infusion and having them wait in our infusion chair, or in our waiting room, until those labs have resulted. So we’re working on that.
We continue to hardwire that daily management of using iQueue for our schedulers, to actually use those empty spots to schedule patients in, especially with the same day add-ons. The more daily management and the use of the iQueue diagnostics, the more we use it, the more familiar we get with it, and the more information we can glean from it. So we’re continuing to work on that.
One internal thing, one of our goals is to build an acuity tool that would actually work in conjunction with iQueue, which would actually give a wait to a patient’s infusion appointment. We all know that it’s not always about the numbers or the duration that they’re there, but it’s about the complexity of the patient and the complexity of the infusion. So that is something that we’re working on internally.
Then, our overall goal obviously is to have that patient chair ready, so once they arrive to their infusion, we get them checked in, do all of our cross checks, sit them in their chair and begin their infusion.
This is actually our last slide, and at Novant, all of our things that we do we try to tie back to our strategic imperatives, and I think iQueue fits in this very nicely with several of the imperatives that we have. The “team resilience” is kind of an understatement about nurses not being able to find time for lunch. They may run back and get 10 minutes of real quickly putting the snack in their mouth. Since we’ve gone live with iQueue, nurses truly, truly are able to go to the break room, and have 30 minutes of downtime, and just enjoy their lunch without feeling stressed to get back and take care of the patients. That’s been huge.
The operational excellence, patients starting and finishing on time, will only improve the patient satisfaction with their experience in infusion. Innovation and advanced analytics is a mathematical analytics program, to place the patient in the right appointment at the right time. And then the industry growth, as we continue to grow, as cancer continues to grow, scheduling for an 80 bay infusion center requires us to work smart and efficiently, and iQueue has helped us to do that.
That actually ends our presentation and our story at Novant Health. We’re happy to take questions about Novant or iQueue, and then Mike can also help us answer any questions,
Susan Perella: Lisa, if I can add one thing that I think was really important and helpful for us. You mentioned the letter that we sent out to our patients. We started talking about it early on with the patients, because I think by nature, everyone’s resistant to change. We talked to the patients about it and explained to them it was going to be to their benefit. We knew it wasn’t the times or the days that they always wanted, but it was going to make things move faster. I think we started talking about that well in advance. By the time we moved, they’re all in that mindset and it made it a little bit easier for our patients to share it with them early on.
Lisa Rioux: Absolutely. Good point.
Mallory Hufford: All right, great. So we will move into Q&A. We’ve gotten a lot of really great questions. So, Lisa, Susan, Mike – I’ve tried to group them by similar questions. To start I’m going to read both, and then I think the answers will be similar and we can work them in together. So:
- Did you schedule by time to chair to resources, or did you schedule the nurses in Epic?
- Then do you schedule to the chair, or do you have pods?
Susan Perella: Our appointments are actually scheduled in Epic, using that process, we have an allotted amount, and we do a pre assignment. I did see one of the other questions earlier was, does the patient have the same nurse? And yes, we do try to do that just for consistency for our patient. We do have the pods that we use, but the nurses are in the pod, and then we’re assigning the patient specific to them in that pod, if that answers your question.
Mike Casteel: So as far as scheduling, into certain resources – with iQueue we typically set it up as scheduling into a pooled resource, so we’re not scheduling into individual chairs, or scheduling into nurses, we’re actually scheduling into a pool of resources. So that looks a little bit different depending on what your EHR looks like. But effectively we built in, what your chair limits are, what your nurse limits are when we build out those templates, and then we give you a pooled resource that you schedule them to in your EHR. In making the template, it’s making sure that your chairs are available, your nurses are available. It helps make operations run more smoothly too.
Mallory Hufford: Susan, you touched on this a little bit, but I’ll ask a few other questions in the same realm. Are you pre-assigning patients to your nurses or are your nurses taking patients as they arrive?
Susan Perella: Our goal is to take them as they arrive. As Lisa mentioned earlier, one thing that we need to accomplish is being chair ready. We haven’t reached that goal yet. When we do, then we will take them as they arrive, but currently we are pre-assigning the day before we are doing the assignment. When the nurses come in the next day, the nurses are assigned to them and they know who they’re going to have and they can look at the charts and look up their orders and know what it is you’re going to be getting ahead of time.
Lisa Rioux: I was going to add to that – I think Susan spoke to it – there’s a nurse allocation tool that actually will help assign patients to nurses, based on the hours that they’re scheduled to work that day. It used to take Susan and the clinical coordinators up to two, two and a half hours to make a nurse assignment for 60 patients, let’s say. Now, using the nurse allocation tool, they run it, they do a little tweaking, it may take 15-20 minutes max. So, huge, huge assistance to have that.
Susan Perella: It’s been helpful for us when we’re doing that. We have some nurses that are not yet chemo certified so they’re not hanging any chemo, and in that nurse allocation that we referenced, you can choose an option for or non-chemo, so then the allocation won’t assign any chemo patients to that nurse.
Mallory Hufford: A few more nurse allocation questions. So that tool is a product through iQueue, that comes to iQueue for Infusion Centers. Is it based on regimen acuity, or do you have a nurse-patient ratio, and what is that ration?
Susan Perella: We currently don’t have any acuities. As Lisa mentioned, that’s another goal that we would like to get to. It’s just the nurse-patient ratio. We do look at the regimens that were assigned to them, to try and keep it even. Today most of the nurses have five or six patients apiece,
Lisa Rioux: That is a manual shuffling. The system doesn’t know the experience of the nurse necessarily, but the person that’s shuffling assignments around will know what a particular nurse can handle in their day, and that’s where you can move assignments around a little bit.
Mallory Hufford: And then a clarification on the five or six patients per nurse per day, or at one time?
Susan Perella: No, throughout the day, that’s how many patients they will have.
Mallory Hufford: Great, thank you. For an eight hour shift?
Susan Perella: We have varying shifts. Some of our nurses are nine, a few that are 10 and the rest are 12.
Lisa Rioux: So the nurses that work 12 hours, obviously they will have a heavier nurse assignment, but they also will take on any patient that is still there when the nine-hour shift nurse leaves. So they may start off with six or seven patients, but they’re going to pick up two or three at the end of the day,
Mallory Hufford: Then another on the same thought. How many chairs are each nurse assigned at one time, if assigned by chairs?
Susan Perella: They’re not really assigned by chairs, and nurses are each in a nurse huddle, and the patients sit wherever they would like. There aren’t chairs assigned to a specific nurse. Our desk is kind of central, with the chairs and rooms spread out so you can see most of the spaces from the nurse’s station, so they’re not assigned any specific chairs. If you’re looking in Epic, it has a chair assigned to them, but in reality there isn’t that certain chair that that nurse is treating patients in.
Mallory Hufford: Shifting gears to provider appointments, linked appointments. Do your patients have provider exams and treatments on the same day?
Susan Perella: Yes they do, and sometimes they have radiation oncology, which is also in this building with us. Over half of our patients have same day appointments within this building.
Mallory Hufford: Great. Then in terms of clearance, do your patients do labs, including for treatment day before by the provider or the same day for clearance?
Susan Perella: It varies by provider. The majority of the patients are seen day-of. Our GYN oncology practice prefers to see them the day before, so that they have labs results and can make any adjustments, but for over half of them it’s the same day. So they’re drawing labs, they’re seeing them and sending them to us.
Mallory Hufford: A few more questions and reiterations on volumes – average volume of patients treated per day? A few questions on that.
Susan Perella: Today we have 72 patients on the schedule. Usually our volume is in the 60s lately. There were originally 80 on the schedule and some got cancelled. But I would say, typical recently is in the high 60s
Lisa Rioux: Yeah, that’s been our average, and that’s been open from 8am till 7pm, Monday through Friday, and then we’re also open on Saturdays and Sundays. But the hours for the weekend are only 8 to 5.
Mallory Hufford: Okay, great. That was a question as well as the operating hours. I think that’s a great segue as well. There’s several questions on add-ons, cancellations and no-shows, and how iQueue has helped with that process.
Susan Perella: It’s helped tremendously with add-ons. It’s allowed us to accommodate a lot more patients in the moment, that are in the office, that need to be seen same-day.
Lisa Rioux: We can see from that daily huddle, what available appointments are in. And if we have a patient cancel or no-show, once that’s marked, that slot now becomes available, and we can slip a new patient in if needed,
Susan Perella: And even to add on to what Lisa was saying, even if there isn’t an available slot, using iQueue in the allocation that I referenced, we can still see where we have wiggle room to safely add someone to the schedule, that’s not going to overwhelm the patient or the nurse or cause the patient to wait.
Mallory Hufford: Great. Back to the provider side of things, what’s your typical end-of-provider time to beginning-of-infusion?
Susan Perella: That can be five minutes –
Lisa Rioux: To three hours.
Susan Perella: It’s an elevator ride up. So, sometimes they will finish in the provider clinic, and immediately come to infusion, and that is the fine line of scheduling these patients. I always make the analogy of catching a flight. You know, you don’t want that layover to be so long that somebody gets stuck at the bar. You don’t want it so short that you have to run to your next plane. So we really try to get our schedulers to make that gap between the provider visit enough time, but not too much time to get the patient to us earlier than what their scheduled appointment is.
Lisa Rioux: We have some patients that are arriving when there’s a big gap. We try not to have big gaps between the office visit and hours, but sometimes it happens and the patient will arrive two hours early. Using iQueue and using that allocation, we can adjust the nursing assignment and accommodate the patient two hours early, and just change someone’s assignment a little bit and still be able to see the patient.
Mallory Hufford: Shifting gears to the pharmacy side of the house, does pharmacy use iQueue as well to schedule pharmacists and techs?
Lisa Rioux: No, pharmacy can see iQueue or they can see our appointments, and that helps them prepare for their day because they know what medications that they have to prepare for that day. Mike, you might need to answer or jump in.
Mike Casteel: Pharmacy obviously has access to all the things – they can see nursing assignments, they can peek at what sort of stuff is coming down the line for them. They can take a look at what the schedule is going to be like, see where they’ll see a lot of demand. Currently there’s no iQueue product for a pharmacy. In our current iQueue products we have iQueue for Infusion Centers, iQueue for OR, iQueue for Inpatient Beds. We don’t have that product directly for pharmacy, but pharmacy is still able to use those tools, and a part of the solution for iQueue is making sure that we aren’t overloading pharmacy.
Obviously we’re in charge of those templates, of how patients are arriving into that infusion center so, you know, if we’ve noticed that a certain times of the day where we’re overloading pharmacy, they can’t take this many patients at a certain time, what we can do is work with them and make sure we back off on that, and we’ll see that in the data and also just through talking to them there.
Mallory Hufford: Right, and I know iQueue is also in research and development stages with pharmacy, and seeing what more we can do from that aspect. There were a few more questions on helping improve the drug mixing time, I believe Mike touched on that, but anything else to add there?
Mike Casteel: I think part of the drug wait time that we see, that’s really considering when that appointment is scheduled to start and when the patient checks in, up until the point where they received that first drug. Part of that big thing is you know how quickly they’ll be able to be seated. But beyond that, there’s also an added effect of, how is my pharmacy not getting overloaded? If we are making sure that we’re evenly spreading patients through, or orders through into the pharmacy. Then the pharmacy can have a more steady flow of orders coming through, instead of like how we were, where we’re getting eight patients to come in, on the hour, pharmacy’s basically just now stuck with eight orders consecutively. As opposed to, if we can give them two orders every 15 minutes it’s much more manageable. These patients are now arriving at eight o’clock, they’re now arriving at 8am, 8:15, 8:30, and it just helps basically just level load throughout the day.
Mallory Hufford: So Susan, I know you touched on this a little bit, but can you talk a bit more about how the implementation impacted patients, and maybe some tips and tricks to help patients and even providers get through the implementation process?
Susan Perella: The most important thing is letting them know as soon as possible what’s going to happen and how it’s going to look, and getting that letter out to them. We kind of talked about our patients as they came and prepped them way in advance, so when we transitioned, it was really a smooth transition for them. They immediately saw the impact that it had, and even people that I thought were going to be difficult and give us a hard time were really very impressed by it. We got a lot of positive feedback, very little negative feedback from the patients.
Lisa Rioux: The provider feedback that we received also has been much, much less resistant to getting those same day add-on appointments added, as well as getting their new patients on the schedule sooner. So it’s freed up a lot of available chair time that we did not have before, so it’s been a win-win.
Susan Perella: Especially with a lot of the chemos, because with the hematology practice a lot is very urgent, and they get put on our schedule the next day. So we’ve been able to accommodate the majority of those.
Mallory Hufford: Two that kind of go hand in hand, maybe a mix of Mike and Susan and Lisa, how do you coordinate the OB time and the infusion time, and then is chair time being kept track of? What percentage of available chair hours is being used?
Susan Perella: I’ll let Mike speak to that. One of our graphs in our iQueue is very helpful, we can see that trend, but I’ll let Mike speak to that.
Mike Casteel: So one of the things that we’ve tracked, is basically how well you’re using your center, so what percentage of your chair hours you’re using. And obviously we’re never going to quite get to 100% there, unless we have staffing, you know, as many chairs we have nurses and patients throughout the entire day. There’s going to be some little drop off there.
There’s always some golden zone where you want to try and find that balance between what staffing you have, how many chairs are actually utilizing and things like that, which are operating as ours are. So it’s a little bit of a complicated question, a little bit more case by case but, does that help answer it?
Mallory Hufford: I believe that’s great. There are a lot of questions coming in so I do have them queued up, but if we don’t answer anything please feel free to resubmit in the Q&A or the chat box.
So taking a turn here for injections. Do you have a separate, central line or injection room, so each nurse really has five to six infusion patients, and then you have a nurse assigned to injections only?
Susan Perella: Yes, we have a nurse that is just doing injections. We have two areas set aside, a chair and then a room, because a lot of the injections require privacy. So we have a designated space for the person that is giving all of those. And for instance, the nurse that’s in that space today has 16 patients, short visits, and then the five or six that I mentioned are actually all chemos and infusions. They are separated. Occasionally we’ll have a day where there aren’t a lot of injections and then we just divide it among the nurses, but typically there is a nurse assigned to the short visit areas we refer to every day.
Lisa Rioux: Then we also have our phlebotomy area that we do the IV starts and the port accesses and labs, if need be. On occasion we’ve also put some infusions or short injections in that space. It does have its physical limitations because we don’t have an automated medication distribution equipment in that space, so they have to go to another medication room. But if it’s a simple IV fluid replacement or something, we’ve used that space as well.
Mallory Hufford: Digging back in there, what times do you typically schedule those injections?
Susan Perella: It’s throughout the whole day.
Lisa Rioux: It starts at 8am, and I think our last appointment is 5:30pm for a short visit. iQueue figures all that out so they tell us where we can have those appointments.
Mallory Hufford: A few more questions have come in as well around nursing protocols. So, first one being, I know we talked a little bit about this. Do you see a lot of unbalanced nurse assignments due to no shows and holds?
Susan Perella: Using iQueue when that happens, we can see the no shows, and we readjust the assignments to keep it fair.
Mallory Hufford: So for those patients, who are unable to accommodate consecutive appointments, maybe the provider or lab before infusion, do they leave and come back or do they wait for those scheduled appointments?
Susan Perella: Usually, then the patient’s prefer to wait.There’s actually a cafe downstairs on the first floor, so there’s other things in the building for them to do. But most of them, if we can’t accommodate, which doesn’t happen very often, they wait.
Mallory Hufford: Do your patients wait in the chair for lab results or in the waiting room?
Susan Perella: If we’re drawing the labs, they go to our vascular access area that Lisa mentioned, and then there is a waiting room there. Or sometimes, depending on what they’re here for and if they need to be in a bed, they’ll be brought back into the treatment area while we’re waiting for the labs to result.
Mallory Hufford: Thank you, Susan, Lisa. We’ve rapid-fired lots of questions, so I appreciate it. Do the same scheduling staff, schedule physician appointments and infusion appointments or are those separate staff?
Susan Perella: Typically we have a scheduler here with us. Usually offices are scheduling their own appointments and our schedulers are scheduling infusion, but they all see one another’s appointments. Even nursing, we can see any appointments within our system. So even if nurses are making the appointment, you can see when the doctor’s appointment is, so you’re not creating that big gap in time.
Mallory Hufford: We have someone who’s looking for specific feedback – “So is this for oncology patients or other infusions such as dermatology? This particular center has 14 chairs, and sees 50-60 patients per day. Some are same day clearance and some are one to two days prior to get cleared, and then chemos premix in the morning of treatment. The first nurse in the office calls the patient to clear one more time for premixing, and the pharmacy starts mixing even a day prior for stable drugs. Pharmacy’s in another part of the hospital, deliveries are delayed, standard volumes have been running overdue to overbill, we have issues with patient travel. All patients want to come in during the off-peak travel hours. Was there any feedback for those patients not wanting to travel during the peak hours?”
Susan Perella: It was a lot of a learned adjustment period for our patients. A lot of them were very set in their ways, always had the same time. We even had some patients say, they always came at nine and we scheduled them at 11, they still come at nine. And we would say “no, your appointment at 11.” So it took a while for them to adjust, but we were able to work that out. It was a challenge at first.
Mike Casteel: One of the best practices that we’ve learned, is as you’re offering these times to these patients, have it be more of a conversation where you guys are starting to offer time. So obviously, if you ask everybody when they come in, they’ll all tell you when they want to. And it’s just impossible to do that. So you’re not necessarily trying to move every single patient outside of those hours, you’re still going to have the bulk of your patients coming in during those peak times.
But you really want to try and offer people times outside of those, so you can basically say “Hey, we’ve got times available at 8am, at two or three,” and give them the choice. So they still have an input into when their visit is. Because if they do have any issues, they can’t make it at a time, they really do need to come in in the middle of the day, they’ll let you know. You’ll be able to accommodate them that way. So that helps.
Mallory Hufford: So I know we talked about nurse-patient ratio a little bit. Can we clarify as well how many nurses do you have on an average day?
Susan Perella: There’s typically at least 14 nurses here on a day.
Mallory Hufford: Do the nurses do a QA check that everything is an order for the treatment to proceed, orders signed, any changes to vitals, etc.?
Susan Perella: It’s actually a double check if it’s for chemotherapy. Two nurses review the labs, two nurses review the orders and there’s a valid consent. So it’s actually a two person check.
Lisa Rioux: That’s the reason why we do the pre assignment, so that they have that time before they start seeing patients, and all that information is in the chart that they need.
Mallory Hufford: Do you perform any radiation therapy?
Susan Perella: That’s on the first floor in our building.
Mallory Hufford: Does this integrate with iQueue?
Mike Casteel: We can integrate with it. So one of the things that we take a peek at as we are building templates is what we call linked visits, which has a little bit of a broad definition. Typically it’s just your clinic visits that are on the same day. So if I have a provider visit in the morning and then an infusion visit we consider that infusion visit a linked visit.
Typically we consider just clinic visits because schedules are a lot more restrictive. It’s really hard to find some time on the provider’s schedule. But for some other areas like radiation oncology, you typically have a little bit more flexibility in the schedule, so we don’t necessarily consider those linked a lot of the time. But if you’re at a center where maybe the radiation oncology appointments are very restrictive, you really can’t fit much time into the schedule, we can definitely factor this in.
The way we do that is when we’re building your templates we look at your demand. You know, historically, where do you see a lot of those appointments coming in? If I see a lot of them coming in the middle of the day, I want to make sure that I have enough space at that time that I can accommodate those patients. Because finding a time for those linked appointments is a battle of finding the timings available on the infusion side and the time it’s available on the other schedule, the clinic schedule, the radiation schedule. We just want to make sure we’re making it as easy as possible when we’re building up these templates for you.
Mallory Hufford: We have a question on chemo education, how it’s handled in the clinic for first time patients or changing treatment patients. This is done at the chair side and planned in the infusion time.
Susan Perella: Now we used to do our chemo teachers but it became kind of a barrier for us. So now it is done prior to their appointment, it’s usually done by a nurse practitioner in the office. On the offshoot that it isn’t, the nurse practitioners that are here in our infusion center will come and teach chairside. We obviously reinforce the education on every visit, but they’re doing the initial teaching.
Mallory Hufford: Alright, so a few more questions on the linked visits. Was coordinating the office visits and treatment visits a concern before starting templates? Does this coordination make scheduling difficult with templates?
Lisa Rioux: Was that question coordinating the office visit with the infusion visit?
Mallory Hufford: I believe so, yes, the treatment visits are the infusion visits in that case.
Lisa Rioux: I think with us joining into one building, it’s made it more important for that to be looked at by the schedulers, but when we were creating our templates, it was purely based on the amount of time that patient was expected to be in their chair. It didn’t account for an office visit, ahead of time. It is in a separate space in our building. So they’re going from one department to another. Now for those provider practices that have infusion centers within their practice, I would think they would want to create that together.
Mallory Hufford: Great, I have a few more, but I do want to encourage the group to please submit questions that I may have missed. There’s been quite a lot and I’m trying to get to all of them. We do have about five minutes left and are happy to connect with you all afterwards as well.
The last two I have on my plate may be a little bit more geared towards Mike. Is iQueue best for smaller infusion centers or is it capable of providing the same service to a larger facility? “We see about double the number of patients.”
Mike Casteel: We can handle any size of facility. Like we said, LeanTaaS is a data science focused company, so we’ve got the tools to basically take any size infusion center. We’ve got some with just a handful of chairs and we’ve got some that are getting close to double what we see here. So we’re able to handle any sort of volume, any sort of structure you guys have, we’ve got a lot of flexibility with a lot of customers right now. So we’ve probably seen something similar to what you have right now. We definitely encourage you to reach out, we can definitely be of use to you.
Mallory Hufford: Is iQueue actually working with any EMR vendors to have this tool integrated versus being an external application? “Scheduling is a huge part of our practice, not sure why an EMR would not already offer a better scheduling tool?” Which I laugh about, is because we hear the same thing every day.
Mike Casteel: We’re definitely used to hearing that question. So to answer your first question, yeah, iQueue will work with any EHR. We consider ourselves “EHR agnostic”, so we can basically work with your team to build out our solution into your EHR.
Now the reason that your EHR may not be able to give you the solution, is because they aren’t quite looking at the same things as you are or as we are. We factor a lot of things when we’re building out these templates. We’re factoring in what your cycle times are, what your demand that you typically see is, what your current setup is, how many nurses you have, how many chairs you have. Some of that stuff can be built into your EHR, like your chair counts, maybe your nurse counts as well. But to get the customized templates where we’re building an optimized schedule for you, something the EHR just can’t offer. It’s a level of data science that they really don’t have available to them.
I think it’s what really sets us apart, that we are able to work within the EHR to basically build these optimized templates that will help your center run a lot more smoothly. And within the EHR you’re really kind of set to setting your own templates up, with really that solution on your own. We can be the tool to help you get to that solution.
Lisa Rioux: I would say that before we implemented, when we were going through the training, I was skeptical myself and I’m sure our informatics folks were as well. Why couldn’t we just start scheduling patients in 15 minute increments and come out with the same results? And it really doesn’t, it’s completely different. So, I was a skeptic. But it truly has – it’s not just, every 15 minutes. There’s a lot of it that they work out.
Mallory Hufford: Alright, great. We had a ton of engagement today. I thank everyone ,and thank you so much, Lisa, Susan and Mike, for presenting today to everyone for joining us.
We hope this presentation was beneficial to you and your organization. You’ll receive an email with the link to the recording if you’d like to revisit anything. For any additional questions, feel free to email us at email@example.com, and with that thank you and have a great rest of your day.