Split Scheduling for Chemotherapy Increases Efficiency, Reduces Costs

With community cancer centers facing rising costs and declining revenues, finding more efficient ways to run a practice is critical. In this interview, Cathy Maxwell, RN, OCN, director of clinical operations at Advanced Medical Specialties in Miami, Florida, discusses how community cancer centers can make the most efficient use of chemotherapy nurses by efficient scheduling and how this not only increases nurse and patient satisfaction but also reduces costs.

Because chemotherapy nurses are usually among the higher paid employees, it is important to use them efficiently. You don’t want to have them doing tasks and duties that do not require a registered nurse (RN), and you want to schedule them in a way that you’re not wasting them as resources. That all translates into dollars. There are different ways to staff an infusion suite to make optimal use of nurses’ time.

The scheduling of the treatments is crucial because you want to make sure that your schedule reflects what is actually going to happen as much as you possibly can predict. I’ve found that in many cases, the schedule is already set up to fail before the first patient walks in the door because it doesn’t reflect what time the patient is actually going to be sitting in the chair. For example, say a patient has an 8:00 AM appointment but first the nurse has to get a blood count, the results of the blood count have to be interpreted, and the nurse has to get a doctor’s order before the infusion can begin. So if you have that patient scheduled in the chemo chair at 8:00 AM, your schedule is already set up incorrectly. One of the best ways to use your nurses’ time efficiently is what we call a “split schedule.” This means that the patient comes in the day before the infusion for their blood count, for their office visit with the doctor, and for assessment of their readiness for the treatment; then he or she gets treatment the next day.

Many people think their patients won’t accept split scheduling, but we do this in the three sites that I’m responsible for and it is very successful. In this day and age when you have to control your inventory of drugs, this is the best way to predict what you’re going to need for the next day, which is especially important when you’re talking about expensive drugs. We used to carry $800,000 to $1 million worth of drugs in our mixing room every day for three locations. We are now at $400,000 with the split schedule, and our goal is to get even lower than that.

How would you achieve that?
My goal by the end of the year is to get the doctors’ orders 48 hours ahead of time, because we would be able to tighten up our inventory even more. In most places around the country, you have until about 6:00 PM to place your orders for delivery by 10:00 AM the next morning. If you have that ability, you don’t have to house expensive drugs; you can order them as you need them. If you have same-day scheduling, you don’t know for sure whether the patient is going to get their chemotherapy until after the office visit. Meanwhile, the patient has an appointment in the chemotherapy infusion suite and the nurses are waiting for the patient. If there is a delay in receiving the patient or the treatment is canceled, it wastes resources and costs the practice money. When the doctor orders a change in treatment, in our practice we need 5 business days to run it through our financial department to make sure the patient’s out-of-pocket costs haven’t changed, that it’s not an off-label regimen, and that we don’t need prior approval from the insurance company.

What changes have you seen in your practice as a result of the implementation of split scheduling?
With the split schedule, patients’ treatment begins as soon as they arrive at the infusion suite so you can stay on schedule and staff the suite for what you truly need, not what you think you might need. This way, you can use your nurses more efficiently, not waste resources, and free up chair space. Another thing that we noticed when we started split scheduling was that overtime was practically eliminated. In centers where the nurses are paid hourly salaries, eliminating overtime can result in huge savings.

Keeping on schedule increases both nurse satisfaction and patient satisfaction. Studies of patient satisfaction showed that patients most dislike waiting. So even though with split scheduling patients have to come in for two visits, their actual time in the office is less. They’re not wasting time waiting. They go in, see the doctor, and go home. Then when they come back for their treatment, they get in on time, know how long it’s going to take, and go home. They’re much happier because of that.

We had an independent group do a patient satisfaction survey a few months after we started split scheduling in a new satellite office. This satellite office was opened in an effort to decompress our original office of 15 doctors. We split the schedule at that time because all of the chemotherapy was prepared at the remote site and we needed to be certain the patients were going to get their prescribed doses and drugs. We interviewed those patients who had experienced both same-day scheduling and split scheduling. We found that patient satisfaction was higher for the split schedule than the old schedule, and patients believed the wait time was better at the new office. That made it easier when we decided to start split scheduling in a larger practice. We basically told the patients that we had no choice, because with split scheduling we found we could lower inventory, cut costs, and reduce overtime.

Did you meet with any resistance from patients when you introduced split scheduling?
We distributed a letter in our waiting room about 2 months before starting that explained the reasons for the change, but we still had a lot of angry patients and family members at first. I had to do a lot of damage control. I called every patient or caregiver who requested to speak to someone and explained to them that we were doing this to stay in business. When we were honest with them and explained why we did it, they were extremely understanding and cooperated.

Anyone thinking of starting split scheduling has to realize it’s going to be rough at first, but after you get through that period, it’s a piece of cake. In addition, within the next month, we saw the change in inventory and change in overtime, so you get instant financial gratification from making that change.

What are some other ways practices can increase efficiency?
To run efficiently, you have to schedule your nursing staff so that you have the bulk of your nurses there at the busier times. I recommend having flexible nursing schedules with staggered starting times and a per diem pool of nurses to help you cover vacations and other time off.

Cancer treatments today are much more complicated than they used to be, and it takes more interactions from the nurse to take care of the patient. A nurse who works 10 hours probably shouldn’t take care of more than 10 or 11 patients who are getting chemotherapy. In our practice, we separate patients who are coming in for shots and blood counts and other non–infusion- related services from those who are getting infusions. They’re seen in the rapid treatment area where a nurse looks at their blood count and a medical assistant gives the injections. That way the nurses who are in the infusion suite are doing infusions. In most cases, you don’t need an RN to give an injection. But you do need an RN (in some states an LPN) to give chemotherapy.

Our challenge every day is to keep everybody safe and happy. As things change in our field, we have to be flexible, we have to change. We have to stay efficient, save money, but at the same time we have a huge service to deliver.