High Density Scheduling = Effective Time Management
Thomas E. Catanzaro, DVM, MHA, FACHE, Diplomate, American College of Healthcare Executives
"The best way to begin, is to begin."
The dilemma of many practitioners is there are no more hours left in the day. In the article, "Management Woes Got You Down?", published in Veterinary Economics, May 1991, a colleague and I discussed the need to identify areas that can be delegated, the need to train staff members to a level of competency, and then the concept of assigning accountabilities rather than tasks to increase staff impact on the practice. There is no need to replicate the delegation concepts here.
Time Management Concepts
The premise that we can manage time is silly . . . it will keep on ticking just like a TIMEX, regardless of what we attempt to do with it. What we need to manage is ourselves; we need to take control of our lives and our daily activities. This will be the concept discussed below.
People do have individual energy cycles, regardless of what the practice needs. Some people are most effective in the mornings, some are afternoon people, and a few are night folk. The majority of Americans have their prime energy time in the morning, a low slump at lunch time, a moderate energy boost mid-afternoon, and another slump about supper time. A good practice manager will utilize each staff member during his/her specific prime times for highly productive tasks and save the routine tasks for the individual's slump time. But again, the purpose of this article is inward looking, so we will not expand on this perspective of time utilization.
One of the "most unique" concepts we introduce into multi-veterinarian practices, and one of the most exciting for practitioners, is that a work cycle is two weeks, not one week. This is important because it allows a three-day weekend once every two weeks for each veterinarian. Here is an example for a typical "open three evenings" small animal practice:
This schedule assumes we use "high density scheduling," as shown in the attached samples, so it reduces the overlap between the veterinarians to Monday, Tuesday, and Thursday afternoons (considering Thursday afternoon (1-3) should be reserved for training and staff meetings). A "high density schedule" allows a full day's case load to be seen in the four morning hours (and an increased workload if the morning outpatient "day care" admissions are seen by the same team as the inpatient doctor team in the afternoon).
The second benefit is when veterinarians are on a clinical performance percentage compensation (18% to 23%, with the owner at 24%), the two associates seldom compete for clients due to the lack of overlap. In the previous sample plan, note the evening shift starts "after lunch," an important psychological advantage. The single Wednesday off is preceded by a short day and followed by an evening shift which allows a "longer break" than a single day off. The other way to look at the schedule is that each veterinarian works two days, then is off a day, works for three days, then off another day (but on call), then he/she works four days and get off for three days . . . no more five- or six-day weeks!
If we look at the impact of a third veterinarian in this schedule, let's assume an owner who has built this practice with blood, sweat and tears (not to mention family sacrifice and fiscal hardships). Tom Cat's first scheduling rule is, "Life is equitable, not fair!" The owner has invested a lot more in the practice than the associates and can have an alternative schedule, still with three-day weekends (since some Mondays will be business needs):
As you can see, the owner is "optional" for full coverage, but provides the double coverage for an aggressive inpatient and surgery program without sacrificing the outpatient program. The other important factor to note is the associates get the "densities," those times with high client counts, evenings and weekends, allowing them the most advantageous times to increase their productivity percentages.
When we address the paraprofessional staffing for either option, empower the technicians and receptionists to develop their own schedules to ensure adequate coverage, just provide the specific needs such as:
1. Target full-time hours at 39 scheduled hours per week, to allow for the "need" to finish up without causing overtime.
2. On surgery days, we need a "clean" inpatient technician as well as the outpatient technician. If there is an inpatient technician doing dentals or abscesses, they cannot be the "clean technician" supporting the surgical suite; but the laboratory technician could be the "clean technician."
3. Receptionists know when client densities occur, use split-shift scheduling to ensure client-centered service, including coordination with the outpatient technicians to assist client flow and receptionist back-up.
4. We need an outpatient technician to support the receptionists and exam rooms whenever there are appointment times scheduled.
5. Schedules with the names and times are provided to the office manager the Thursday before the work week; don't expect others to cover your areas of responsibility unless you coordinate it yourself.
These scheduling concepts have been provided as an example of an implemented "time management" system for mental hygiene as well as client service support. These ideas are only the implementation of some basic principles of time control, which are discussed below.
Seven Principles Of Control
1. The telephone is an optional life support device.
Identify when you will be available to return calls and keep to that schedule. Teach your receptionist to say, "That sounds like a case the doctor needs to see; please come in right away and we will admit your pet into our emergency day care program.", or, "Dr. _____ reserves from 1 to 2 p.m. everyday for returning client calls. What number can she/he reach you at during that time?"
2. All choices have consequences, regardless of which one is selected.
List and prioritize your weekly activities into three categories:
A = must do (critical items, client requirements, deadlines, key success, or advancement opportunities),
B = should do (medium value, improvement of performance, not essential to survival),
C = nice to do (interesting, fun, and personally rewarding but easily postponed, rescheduled, or eliminated).
When you look at the consequences, today's "B" may be tomorrow's "A," and today's "A" may become tomorrow's "C" if the deadline passes.
3. Most crisis situations can be renegotiated.
Deadlines are generally human-made and arbitrary based on agreements made before the disasters set into the daily schedule. Resources can be reallocated to reduce impact. Substitutes are available, to include colleagues. Most important, you may be able to narrow the scope of the demand, meet the critical element(s), and/or provide alternatives for the balance of the situation that do not require immediate reaction.
4. Mail, like telephone calls, won't go away but can be managed.
All unsolicited mail should be opened by staff members and placed into at least two piles: "information only" and "action." Good staff members will ensure the "lost cause" pile is eliminated before anyone else has to touch the two piles; they will also route the elements that require staff input BEFORE the boss has to read it. Information-only mail should NEVER be read when the practice is operating. It is not that important.
5. A place for everything and everything in its place.
Each key management team member needs at least five categories in his/her personal file drawer (this includes the boss):
Ideas -- things to investigate further at a later date, usually to improve the operations.
Projects -- details about ongoing projects, kept individually by project.
Instant Tasks -- little jobs that need doing when you have a few minutes.
Self-development -- folders in this area include training, books, articles, etc.
Background Information -- separate folders by topic for later reference, including statistics, trends, examples, quotations.
Color coding these major categories would be helpful to most, as would a monthly screening time to ensure folders are kept current.
6. Frequently ask, "What is the best use of my time right now?"
The inability to say "NO" is the major cause of doing the wrong thing at the wrong time. Learn alternatives to saying "NO" that fit into your life style, such as:
"I can take care of that right now, but what I'm doing right now will be delayed . . . is your request that important?" OR
"I'm sorry I don't have the time right now, may I call you when my schedule clears?" OR
"I'll be happy to do that, but with the rest of the jobs I'm doing, I won't be able to get back to you until . . . ." OR
"I appreciate you asking me, but I am over committed . . . have you considered asking . . . ."
When procrastination occurs because of boring, difficult and unpleasant activities, consider a proactive training and delegation program for someone on the staff.
7. Do it!
Keep a daily time log for a typical two week period (whatever "typical" is). Record activities by 10-minute intervals. Be specific. Identify who visited and record duration and topics of conversation. Be honest, you are the only person who accesses this information. Write a brief comment after each activity, to include the impact of interruptions and importance to your personal schedule. At the end of each day, summarize your feelings about the day in general: typical, busier, slower. Add the time, by day, in each category or major activity and show totals. At the end of the two weeks, identify those activities that can be delegated and train people to do them effectively.
Tests Of Time
The above time log will provide some of the answers, but you need to ask the right questions first. There are four "test questions" that seem useful when assessing any time log information:
THE TEST OF NECESSITY - Was the activity necessary, by the person, for the practice, for success . . . how will the results be used tomorrow?
THE TEST OF APPROPRIATENESS - Did the right person have enough authority to do the right job in a competent manner . . . was someone working below (or above) his/her appropriate skill level?
THE TEST OF EFFICIENCY - For the tasks remaining, are you doing what is most effective for the practice, is there a better way, a person with more aptitude or interest, or is there a technology replacement that will allow the veterinarian or staff to touch more clients or patients?
THE TEST OF CONTINUOUS QUALITY IMPROVEMENT - The continuous need to empower every person to improve his/her work environment, his/her client service or his/her personal pride in performance must override the "tradition" of habits . . . because it was a good system yesterday does not always mean it needs to be maintained for tomorrow!
Grading The Tests
After evaluating the seven principles and applying the above tests, there are only three ways to make better use of the available time. In any given period of your life, you can only:
1. Discontinue low priority tasks or activities;
2. Find someone else to take some of your work; or
3. Be more efficient at what you do.
Time, like money, goes farther when we have less of it. It is the busy person who finds additional time to pursue excellence. In the final evaluation, remember the words of Mae West, "He who hesitates is last!"
Recommended Reading (Iowa State University Press):
1. Building The Successful Veterinary Practice: Programs & Procedures (Volume 2)
2. Building The Successful Veterinary Practice: Innovation & Creativity (Volume 3)
Recommended Reading (www.v-p-c.com):
1. Signature Series monograph, Systems & Schedules (w/diskette)
2. Free Management Newsletter
3. Free Veterinary Facility Safety Newsletter
HIGH DENSITY SCHEDULING
VETERINARY PRACTICE EFFECTIVENESS BEGINS WITH THE APPOINTMENT LOG
# A perpetual appointment log (sample by ProFiles, AVS log is tailorable), with the entire day visible and room to write, is VERY receptionist friendly; ask the front staff for their preference!
# Most quality computers can be configured with the same system, but the computer must make the first appointment column the doctor's name, then have the two exam room columns following (leave space between doctor columns).
# A "Surgery" column allows the client and patient to be scheduled for an early morning arrival (before 7:55 a.m.).
# A "Drop Offs" column provides spaces for the before 7:55 a.m. arrivals, whether they are early appointments, drop-offs, or day care (insert your own times as desired).
# Most practices have core appointment hours within the 9 a.m. to 5 p.m. period with some form of staggered lunch break.
# There are nine appointments over the lunch break (usually single-staffed with a doctor), so use the full width if "lunch time" appointments are desired.
# The "5-minute" schedule endings cause far greater client compliance in arriving on-time, since it sounds so exact (please don't disappoint them).
# The after-7 p.m. SPECIAL appointment needs could be scheduled into a "Call Back" column (times inserted as desired).
# With a 2.4 doctor clinic (with an adequate inpatient load), the third "doctor" column could be for emergencies or walk-ins (both handled by an inpatient team) or technician outpatient time (nutritional, parasite, dental, behavior, etc.).
# We prefer to book examination rooms rather than doctors, since even a new doctor should be able to work 1.5 exam rooms at a time, and a seasoned veterinarian with a good outpatient technician can work two or sometimes three at a time.
# These concepts were initially discussed within "Client Options" article in the January 1993 Veterinary Forum; after guidance, maintaining the log and appointment durations should be the front staff's duty (not the doctor's).
# A standard "sick call," with a full doctor's consultation, for an established client is seen as twenty minutes (two spaces).
# A practice can add ten minutes to the "standard appointment" for: exotic pets, a second animal, each new client, an ophthalmology problem, etc.
# A single ten-minute space can be used for: recheck, suture removal, vaccine clinic, heartworm screening clinic, etc.
# Add 10 or 20 minutes to each appointment for a new graduate; only 10 extra after 90 days, and no extra "orientation" time after six months.
# Non-availability of doctors is monitored by the receptionist team and the log is annotated (long lunch, surgery, late arrival, early departures, etc.).
High Density Appointment Scheduling Sample
(two exam rooms, one doctor with one outpatient nurse - OPN)
ACVC Contact Information