Infusion Center Practice Considerations of Business Impact and Scheduling

Disclaimer

--Any patient receiving care should be treated with respect, dignity, and the highest quality of care available regardless of the price or length of treatment. Treatment scheduling should NOT be based solely on maximizing economic impact, needs of the patient should always be the paramount priority.--

For this thought exercise, we will be using a model of a medical oncology infusion center that has two providers on site: 4 exam rooms, 12 infusion chairs, and 3 blood draw chairs. This size format has been chosen as it closer reflects the reality of many satellite/branch/community infusion centers that far outnumber the larger cancer centers. Other limiting factors such as nursing shortage and offsite pharmacy delivery will not be explored in this instance to allow for a more focused discussion of the impact of scheduling.

The largest consideration for scheduling is time, both for the patients and the center. A treatment that takes 3 hours to infuse cannot be started 30min before the infusion center closes without additional staffing accommodations. This leads commonly to the longest treatments being scheduled at the beginning of clinic hours to maximize available time but also allow for buffer time at the end, to protect against unforeseen delays. Some “unavoidable” delays associated with treatment are waits associated with drawing bloodwork and provider visits on the same day as treatment. This can be “unavoidable” as although the waiting time in the clinic can be decreased by the bloodwork and provider visit being completed prior to day of treatment that feasibility may not be available to patients with unreliable transportation or limited day availability due to caring for others or if the patient works.

For the schedule to be effective it must have available seats for the patients on the schedule. Filling all your treatment seats with hours long treatments then scheduling infusions in the next block 30min later is doing nothing but causing schedule congestion and decreasing patient satisfaction. Blocking of seats for multiple schedule blocks for treatment is a valid solution and as long as it is visible to other scheduling staff can help “fill the holes”. Being creative with the schedule is the true art of creating economically sustainable infusion center.

In the current oncology landscape immunotherapies tend to have much higher compensation rate but a shorted infusion time and usually an extended period between infusions. This allows for greater positive business impact, higher chair turnover, and an opportunity for the clinic to sustain a higher patient population with them visiting less often. Traditional chemotherapy such as carboplatin/paclitaxel on the other hand are less expensive but also take longer to infuse, needs longer premedication, and sometimes requires the patient to come in more frequently. Moreso they are the standard of care but resulting in longer chair time and decreased business impact. Between immunotherapy and traditional chemotherapy, chair time is often occupied by injections and iron infusions. Injections for oncology regularly take a few min, often do not require as robust bloodwork if at all, and usually don’t require taking up a full chair. Iron infusions more commonly require a chair, but the treatment time can range from IV push to 90min depending on the iron used. An additional consideration of iron is many of the formulations are multiple administrations weekly based on the product, further congesting scheduling. In its favor the compensation for injections is aggressively higher than for iron infusions.

Common infusion center care items that require chair space and time but do not create as positive business impact are IV hydration, port flushing, blood transfusions, and phlebotomy. These factors are essential to patient care, but the compensation is based on the nursing effort, not with any pharmaceutical consideration. These nursing effort charges are present on infusions as well but does not have a strong driving business impact.

Above all its important to understand where your limiting factors are when considering an infusion center workflow.

• If it is nursing, then the schedule is overleveraged for staff or not staggered enough for effective time flow.

• If its patients time management them considerations need to be met with regards to the provider-patient relationship and involving other professionals to help assist with pinch points like transportation.

• If it is waiting for labs then moving more of the bloodwork offsite being drawn days before would be beneficial.

• Pharmacy delays can be related to poorly staggered scheduling or miscommunication of scheduling.

• Provider delays tend to have the most oversized impact as they impact multiple steps in the process that can inadvertently delay smooth workflow. As much as providers need to have rooms full of patients for them to see when they start their day, this intrinsically creates a limiting action for the infusion center to bring the treatment patient in in the morning, room and wait for the provider to see them. Therefore, occupying a chair that could have been occupied by a patient receiving a shorter treatment that could have been completed in the time the bloodwork resulted, provider met, and orders signed by the first patient.

• Other important distinction are patient not seeing the provider that day but receiving bloodwork and not having their orders signed. “Chasing” down a provider to sign the orders for the patient can create another extended wait time where other patient could have been treated. These small missed opportunities are missed business and missed patient care. In the 30min it takes to wait on a delay is a full infusion of Nivolumab that could have been given, missed revenue, and missed rebalancing of the days schedule.

Perfect days and perfect scheduling do not exist nor do perfect patient or prefect providers.

To think of a clinic day as a brick wall with the bricks being a patient’s full treatment, the larger the brick the longer the treatment. To add stability to the wall and fill the holes in between we use injections and iron infusions as mortar to optimize time and keep the whole thing stable. Delays are like waiting for a brick to cure from clay when it could have cured the day before, not properly adding injections and irons are like waiting for mortar to mix. Too many large treatments together are like haphazardly stacking large bricks into the sky. Optimizing time and scheduling is not about being perfect but is about minimizing the limiting factors available to you wile optimizing the process and business impact so that it may be sustainable. If we have the ability to safely and effectively treat more patients in a day by minimizing negative factors we are doing ourselves and our patients a disservice.