High-density Scheduling

Extract from Zoned Systems & Schedules in a Multi-doctor Practice, a VCI® Signature Series Monograph, with disk, Veterinary Consulting International®, 2003 (www.drtomcat.com)

Geography

1.  Any ten-minute interval log will work (paper or computer). Most practices use twenty minutes as their basic appointment, while a few ignore the Pfizer study that states eight-seven percent of the clients want to be and out in twenty minutes or less, and they schedule three blocks of ten minutes each per appointment. In both cases, the first ten minutes of the subsequent appointment in the adjoining room overlaps the last ten minutes of the original appointment.

2.  The practice schedules available consultation (exam) rooms, rather than doctors, with multiple rooms per doctor. We start with two per doctor, but have seen as many as six per doctor for the well-staffed and experienced doctors.

a.  We prefer to use to foci for starting the schedule. For example, 9:30 a.m. and 4:00 p.m., then offer open slots to either side of the foci for scheduling appointments in a stair-step, slowly expanding fashion.

b.  We want to give clients two "yes" options when scheduling: "Morning or afternoon? 9:25 or 9:35?... That is fine, we have you with Dr. Smith at 9:35 a.m., Tuesday, June 12th. Do you want me to send you an e-mail to remind you?"

c.  When talking to clients, we do not recommend scheduling doctors by their name initially, we want that saved to the very end. At the very end, we verify when and with which doctor the appointment has been made, unless the client specifically has asked for a doctor by name. In that case, we again offer two "yes" alternatives: "Dr. Jones has an appointment at 4:05 this afternoon, or you can bring in White Fang this morning with Dr. Smith, for a drop-off admission, and we can schedule a discharge appointment with Dr. Jones. Which do your prefer?"

3.  We prefer odd number consultation (examination) room arrays, so at least one room (odd room) will remain available for walk-ins, technician appointments, and/or emergencies.

4.  The client relations team (receptionists) will control access within the following guidelines:

a.  A "standard" appointment is twenty minutes.

b.  A second/third pet gets one additional ten-minute slot added.

c.  An exotic case, ophthalmology, or other atypical case gets an extra ten minutes.

d.  A new client gets an extra ten minutes added to the standard twenty minutes.

e.  A new veterinarian graduate gets an extra ten minutes added to everything.

5.  A doctor-nurse team, both of whom have completed the five phases of training, has two consultation (examination) rooms scheduled concurrently, but out of sync. The last ten minutes in one room overlaps with the first ten minutes in the second consultation room.

6.  The nurse loads the room and does a three to five-minute asymmetry exam, and then returns to the original room and does the last three to five minutes of the appointment after the doctor prioritizes the veterinary healthcare delivery plan.

7.  See samples attached.

Foci scheduling, from the "E" (emergency) block

Effective start for one doctor practice, since doctor will maximize open mid-day time for inpatient cases

This format requires a very skilled client relations staff to "fill the gap" early morning, before scheduling clients into later slots in the morning.

High-Density Schedule Sample

Ten patients in two hours. And no one gets less than twenty minutes! Please note the sixty minutes of nursing "catch-up" time in that two hours. Nurse catch-up time can also be suture removal, sequential lab blood draws, etc.

 Plan#1: Fill one exam room column per doctor on outpatient.

 Expanded: Go to high-density, when shift is full for one room. Schedule second room. Concern: Last ten minutes in one room overlaps with first ten minutes in second room.

 Notification: High-density schedule requires technician nurse alert.

 Additional: Pharmacy float person will be important technician assistant.

 Note: If full, inpatient doctor comes forward to take walk-ins and emergencies.

 Plan #2: Fill one room and can't do second, due to doctor speed limitations.

 Alternative: Inpatient doctor takes walk-ins, as well as emergencies in other room.

Alternative "Balanced" Staffing Schedule Draft

General Considerations

Schedules done six weeks ahead, swaps preferred over rotation changes. Flexibility is based on season, doctor skills, and caseload, but not on type of case. Transfer of cases from outpatient to inpatient is the rule and alternative systems are by exception only.

 10:00/11:00 a.m. doctor is inpatient with drop-off, walk-in, and emergency with 10:00/11:00 a.m. technician. Back-front float.

 This doctor starts three-case surgery load by 11:00 a.m. Reverts to outpatient at 1:00 p.m. until close.

 7:00 a.m. doctor is on-line by 7:30 a.m. morning outpatient with 7:00 outpatient nurse. Two exam rooms out of phase.

 The afternoon outpatient doctor is also by "high-density scheduling" of rooms, not doctors.

 Elective surgery: M, Tu, and Th. Cases prioritized by doctors on treatment room board in early a.m.

 10:00/11:00 a.m. doctor starts surgery at 11:00 a.m. and out by 1:00 p.m. Reverts to outpatient at 1:00 p.m. until close. Food break at about 4:00 p.m. is scheduled into appointment book.

 7:00 a.m. doctor becomes outpatient doctor on arrival, then does inpatient/surgery after 1:00 p.m. in afternoon. For example, lunch at 1:00 p.m., surgery catch-up, then inpatient and telephone from 2:00 to 5:00 p.m.

 Non-elective surgery: W and F. Done mid-day during slow times.

 Dentistries done daily by nursing staff.

Same "Hate Mornings" Staffing Schedule Draft

General Considerations

Schedules done six weeks ahead, swaps preferred over rotation changes .Flexibility is based on season, doctor skills, and caseload, but not on type of case. Transfer of cases from outpatient to inpatient is the rule and alternative systems are by exception only.

 7:00 a.m. doctor is on-line by 7:30 a.m., morning outpatient with 7:00 a.m. outpatient nurse. Two exam rooms out of phase. The afternoon outpatient doctor is also by "high-density scheduling" of rooms, not doctors.

 7:00 a.m. doctor becomes outpatient doctor on arrival, but could do inpatient/surgery after 1:00 p.m. in afternoon. For example, lunch at 1:00 p.m., surgery catch-up, then inpatient and telephone from 2:00 to 5:00 p.m.

 11:00 a.m. doctor is inpatient, with drop-off, walk-in, and emergency with 10:00 a.m. technician. Back-front float

 This doctor starts spay/neuter surgery load Noon to 3:00 p.m. Reverts to outpatient at 4:00 p.m. until close.

 Elective surgery: Tu and Th. Cases prioritized by doctors on treatment room board at 11:00 a.m. 11 a.m. doctor starts pet population control surgery at Noon and is out by 3:00 p.m. Reverts to outpatient at 4:00 p.m. until close. Food break at about 3:00 p.m. is scheduled into appointment book.

 Non-elective surgery: W and F. Done mid-day during slow times.

 Dentistries done daily by nursing staff. Grades 1 and 2, while doctor is on outpatient. Grades 3 and 4, when inpatient doctor is available.

Sample Three-week Staffing Schedule

Code Key

Premises

 Doctor and nurse pairs in paired exam rooms - one technical assistant float in lab pharmacy whether one or two teams.

 Travel sheet has 3Rs. Start one every time a client arrives.

 Doctor works with one nurse, never pulls another. Two rooms out of sync and doctor pace is controlled by nurse.

 The following are inpatient cases: X-ray, laboratory, ear flushing, tails, IV fluids, etc. Receptionist keeps doctor schedules filled, shifting walk-ins and appointments between doctors to keep wait time down.

 Appointments stay within ten-minutes of target (promised) times. Receptionist and nurse accountability.

 Receptionist puts ready records into rack in reception. Do not leave the front area.

 The outpatient nurse technician moves the records and clients from reception to exam to reception/discharge

 After healthcare is prioritized by doctor, the inpatient or outpatient nurse technician can do exam room discharges.

 Discharge invoicing from the travel sheet requires entry of 3 Rs for next visit by nurse.

Requirements

 Better continuity of care in medical records[ ] = need, W-D-A-X is client response inside box).

 High-density scheduling.

 Start training doctor-nursing staff immediately and start "test periods" to see how teams work.

 Outpatient nurse technician training centers on three-to-five-minute asymmetry check, without diagnostics or doctor talk

 Increased nursing telephone surveillance for symptomatic and deferred care

 Doctors respect staff, staff keeps them on schedule (social contract with clients).

Always -- No Blame -- No Yelling -- No Public Negatives -- Just CQI

Sample Three-Week Staffing Schedule

Code Key

Premises

 Doctor and nurse pairs in paired exam rooms. One technical assistant float in lab pharmacy whether one or two teams.

 Travel sheet has 3Rs. Start one every time a client arrives.

 Doctor works with one nurse, never pulls another. Two rooms out of sync and doctor pace is controlled by nurse.

 The following are in-patient cases: X-ray, laboratory, ear flushing, tails, IV fluids, etc.

 Receptionist keeps doctor schedules filled, shifting walk-ins and appointments between doctors to keep wait time down.

 Appointments stay within ten-minutes of target (promised) times. Receptionist and nurse accountability

 Receptionist puts ready records into rack in reception. Do not leave the front area.

 The outpatient nurse technician moves the records and clients from reception to exam to reception/discharge.

 After healthcare is prioritized by doctor, the inpatient or outpatient nurse technician can do exam room discharges.

 Discharge invoicing from the travel sheet requires entry of 3Rs for next visit by nurse.

Requirements

 Better continuity of care in medical records.

 High-density scheduling.

 Start training doctor-nursing staff immediately and start "test periods" to see how teams work.

 Outpatient nurse training centers on three-to-five-minute asymmetry check without diagnostics or doctor talk.

Alternative Staffing Schedule

Code Key

Less than Optimum Staffing Schedule

Code Key

*This schedule attempts to balance the shifts and the special needs previously committed. Inherent in the transfer of cases at the end of shift is the continuity of care requirements (need =[ ], with client response and time delay for any "W" or "D" entries). On-coming doctor must release off-going doctor after case transferred.

Sample Weekend Rotation

Staff Schedules