Modified Tidal Wave Scheduling at NWP

I see this question all the time from Pediatricians looking to update their clinic schedule template:  "What do you all do?".   My reply:  We use a Modified Tidal Wave Schedule Template.  And I love it.

When I first started in private independent practice, it was in a rural setting and we had 10-minute slots.  Now, this was over 25 years ago, and there were no electronic health records (everything was on paper) at the time.  It wasn't unusual for us to have over 30 patients scheduled in a day with more being added in-between the scheduled ones - sometimes seeing around 50 patients a day.  Our notes were a few scribbled lines, the practice I joined did not follow Bright Futures guidelines, we did not use standardized developmental surveys, there was no POC testing, and patients were literally with us for less than 10 minutes.  

Fast forward a little over a decade.  We had opted for Office Practicum as our EHR.  I created new appointment types and tried to "assign" times to each type, eg 20 minutes for an adolescent routine, 15 minutes for certain problems (behavioral/mental health concerns, longstanding problems), 5 minutes for same-day sick visits, 10 minutes for most everything else, etc.  We had a list for the front office team of things to assign a longer amount of time (depression, headache for a year, abdominal pain for a month, etc).  There was no guidance or limit on who could be "worked in".  We were still seeing 40-50 patients a day.  It was insane and it was not unusual for there to be wait times of 2 or more hours in the busy winter season.  

When my older partner retired and my other partner decided to leave independent practice to work for a hospital system, I was left as the sole administrator and owner for the practice and depended a lot on the AAP's Section on Administration and Practice Management (SOAPM).  It was through SOAPM that I found out about Paulie Vanchiere's Pediatric Management Institute (PMI) and I started watching some of his learning videos (they're free!).  This one, in particular, caught my eye about wave scheduling:    https://pediatricsupport.com/learn/scheduling-in-pediatrics.  I ended up using a modified version of a wave system utilizing "long" and "short" appointments.

Let's back up just a little, though, and discuss what a basic wave scheduling system is:  an appointment scheduling method that involves assigning patient appointments at the same time typically at the top and bottom of the hour.  This is different than double booking which is a standard system with slots at timed intervals (every 10 or 15 or 20 minutes) and more than one patient booked within those established intervals.  

The advantages of a wave schedule?  

• Maximizes the clinician's time 
• Improves efficiency
• Reduces patient wait times
• Minimizes staff downtime

Here's how it works in my practice:

We only have 2 appointment types:  long and short.

We do not "assign" time to the visit
In the long column, you'll see how we define a long visit which includes patients with >4 problems on their problem list, new ADHD/mental health visits, new headache/abdominal pain visits.
In the short column, these will be newborns, same day acute visits, well visits, etc.
Procedures get 1 long + 1 short or 2 sick slots.

The modified wave system accommodates patients who show up early, late, or end up needing a little more or less time.  All of that time is "recaptured" for the clinician to use and is not wasted.  Think of it as:  here are 4 patients, you have 60 minutes.  You decide how much time you need to spend with each one instead of locking them into a 15 or 20 or 30 minute amount of time.  I think a schedule wrecker is when complicated patients or patients with complicated symptoms are "crowded" together.  By stacking long and short visits together at the top and bottom of the hour, it allows the clinician to have the option of spending more or less time with a patient and reduces the need to try and guess who needs more or less time. A complicated patient who is well managed doesn't *always* need more time compared to an uncomplicated one.  Sometimes they do and the modified wave schedule takes that complicated patient and mixes that patient in with ones who are (hopefully) less complicated and reduces the chances of scheduling several complicated patients in a row.

Here's what the schedule looks like in Office Practicum for my PA.  She works Monday through Thursday and has Fridays off.  You have to remember to reset the "start time" to see the entire schedule and then change the increment to 5 minutes.  Keep in mind, patients aren't scheduled for a 5 minute visit.  We've basically created a 60 minute time span for 4 patients to be seen:  one more complex patient (long slot), two routine/follow ups/med checks, and one newborn visit for that first hour of the morning (refer to the picture above to see the rest of the day's schedule).  The long slot didn't actually need extra time?  No problem, you've got 2 or 3 other patients in the queue (assuming they all show up!).  Need more time with that newborn?  You're not boxed into a time limit.

Are there downsides to a modified wave program?  Sure.  Is this always going to translate to a smooth clinic day?  Of course not.  We can't predict who is going to be late, no shows, same day cancellations, who is going to show up early, who is going to bring a tag along, etc.  Here are a few of the other downsides we have found: 

1. Scheduling siblings together was tricky.  There was confusion about giving each sibling a different time slot and then the parent receiving text message reminders with different times. They didn't know when to show up.  And there was the issue of hunting for 2 slots next to each other.  We started putting both siblings in the same time slot (both at 0900) and then blocked a slot with "blocked for sibling" in a later time slot.  That way, the parent got their appointment notifications for both siblings at the same time slot and a later slot was blocked to recoup that time back for the visit.
   
   
2. Not every parent completes their Phreesia intake before arriving at the office - especially new patients.  This created an issue where parents sometimes took up to 30 minutes to finish Phreesia and mixing them in with other patients showing up at their appropriate time slot(s). It was just as though the family arrived 30 minutes late which creates a problem with a modified wave schedule. We now schedule newborns and new patients 15 minutes early and then block a slot with "blocked for NB" or "blocked for new patient".  This seems to have helped with the flow.
   
   
3. Scheduling a procedure (circumcision, ear piercing, wart removal) was also tricky for the same reason as above - it was oftentimes hard to find 2 slots near each other but we use the same approach as siblings - scheduling in a slot and then blocking another slot.  
   
   
4. The front office team has to remember that the same day slots and nurse only slots shouldn't be filled until the day of.  Similarly, we don't fill the newborn slots unless scheduling a newborn.  If a newborn slot isn't filled 2-3 days in advance of the date, we can use it like an encounter slot.
   
   
5. Occasionally, the sun, moon, and stars all line up together and we have several patients who show up late, siblings arrive, and several patients who show up early and then the OP tracker looks like a train wreck with 7 or 8 patients in the office simultaneously for one PCP.  I understand that creates anxiety (honestly, it doesn't bother me - it's a marathon, not a sprint) but fortunately, this doesn't happen often.  

2025 Switzer Family Christmas Newsletter

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Switzer Family Christmas Newsletter 2023

 

Day 0-1 (Saturday/Sunday, May 13-14, 2023) - OKC to Rome, Celebrity Beyond 12 night Mediterranean Cruise

Background

“6F Travel Club”: Eve (54, pediatrics) and Seth (55, ER/family medicine)
Lisa (57, Domestic Goddess) and Tim (59, orthopedics)
Wade Hodge (57, retired pharmacy tech) and Charlie Vorndran in spirit.

The Retreat Suite class – sunset sky suite 7327 (deck 7, aft)

For the TL;DR summary

This cruise marks a number of firsts for us. It will be the longest cruise we’ve ever taken at 12 nights. It will be the first time we’ve flown in the night before the cruise boards. It will be the first ocean cruise for our friends, Lisa and Tim. It will be the first cruise we’re taking without Charlie.

We left Oklahoma City on a Saturday afternoon flight to Charlotte so I spent the afternoon on Friday packing and getting ready and finishing up on Saturday morning throwing a few more things in my bag to bring along. We had a bite to eat at the Vino Volo in OKC but our first class flight to Charlotte did include lunch – a surprisingly good beef short rib but after 2 pm which was kinda weird. We had a fairly short layover in Charlotte and then boarded our flight to London. The food in business class on American was just okay. The Latin Shaved Beef was really good but the herb roasted chicken breast was super dry.

Customs/security was straightforward at Heathrow because we were flying business class on British Airways and got to use the “Fast Track” line, which was great given our past experience, but this time we had about 3 hours before our connecting flight and got to hang out in the lounge for about 1.5 hours.

This was also the first time we were traveling with a fold-up wheelchair for Lisa. It was a good investment as some of our connections were really far apart. Tim gate-checked it during each of our flights but what we discovered was a real variation in how gate-checked items are handled. It was pretty straightforward in Charlotte – dropped off and picked up at the end of the gangway just before getting on/off the plane but in London, he was told to pick it up at “the top” which was confusing and not correct. In Rome, it was sent all the way to baggage claim.

We were traveling heavy this time around since we were going to be gone for almost 2 weeks. Seth and I each had our large Monos suitcases weighing in at between 45 and 50 pounds each. Luckily, come to find out, that the weight allowance for first class is 70 pounds – not 50. My suitcase was 50.5 at the airport even though I weighed it before we left and got 49 pounds. We also had a 3^rd check-in – a large rolling duffle bag where we put all of our shoes. Shoes are so bulky so this left a reasonable amount of room in my suitcase and I didn’t have to sit on it or expand it to shut it.

We reached Rome and picked up our luggage, breezed through customs and security, and found our driver from Merkava pretty easily. We had a short hike to the car which just fit all of our suitcases, carry-ons, and the folding wheelchair. It took a while and a lot of “squeezing” to get the van to the front of our little boutique hotel. Sunday is super busy on the streets of Rome near the Trevi Fountain and it was slow going waiting for pedestrians to step aside and allow the van to pass – often having to flatten themselves against a storefront so we could squeeze by. Our flight landed in Rome right around 2 pm and we reached Harry’s Bar Trevi Hotel at around 4 pm. Check-in was pretty straight forward and our hotel rooms were very comfortable with king-sized beds. We checked out the view from the hotel’s 3^rd and 4^th floor terrace then had cocktails in the bar.

On the way to the hotel, our driver told us about the “best pizza in Rome” - Piccolo Buco which was just up the street from our hotel. We decided to give it a try instead of eating in the hotel restaurant because it didn’t even open for dinner until 7:30 pm. Most of the restaurants I had looked at for dinner were closed on Sundays. We walked 400 or so feet to Piccolo Buco and couldn’t figure out the sign on the door (with patrons seated inside) until we looked around and noticed the line that had formed across the street in the alley just to get into the teeny restaurant. There were probably 15 people in line already so we decided to just duck into a small Italian hole in the wall closer to the hotel.

We were seated immediately and enjoyed some wine with the fried burrata special and pizza Diavola that Seth and I shared. It was just the right amount of food. 

We were all wiped out when we got back to our hotel and went right to bed - I was asleep as soon as my head hit the pillow but what felt like a long stretch of sleep was only about 3 hours. We were jet lagged and both Seth and I were up watching Netflix and YouTube at 1 in the morning. I fell back asleep at around 5 am and woke up at 8 am.

Next post:  Day 2 - Monday, 5/15/23 – Rome to Civitavecchia

Day 14 (Saturday, May 27, 2023) - Civitavecchia to Rome, Italy, Celebrity Beyond 12 night Mediterranean Cruise

Day 14 – Rome (May 27, 2023)

We had one last breakfast in Luminae where I had the Eggs in Purgatory one last time. It’s still my favorite breakfast of the whole cruise. They were sweet enough to store our carry on bags near the entrance so we didn’t have to keep them with us during our meal. We thanked our waiter, Alvin, and our hostess, Oktarina, for the wonderful job they did and promised to fill out a cruise survey.

We headed down to deck 4 for disembarkation and then located our luggage pretty easily. Lisa and Tim found a porter for their luggage and, after locating Wade’s lost garment bag (didn’t have a tag so it was put in the “untagged” pile), we found our driver that took us to the same hotel in Rome we stayed at in the beginning: Harry’s Bar Trevi.

Our rooms weren’t ready so we stowed our luggage and waited for our tour guide. Seth and I went next door to the cafe to have some coffee and a donut. We got back to the hotel well before our 10 am tour but when our guide hadn’t shown up yet at 10 after, I called Kensington and was told that our tour wasn’t until 10:30 am.

We met our tour guide and can’t, for some reason, remember what her name was. Probably because we really didn’t care for her style and even I was super annoyed by the end of the tour (which we ended early) by her methods. Our first stop was the Vatican museum which was really interesting. Our guide was clearly knowledgeable and very passionate but the constant commentary with a ton of minutiae which we’ll never remember got annoying very quickly. The Vatican was super crowded and it was getting a bit warm outside. We stopped at a couple of pictures to discuss what we would be seeing at the Sistine Chapel since the chapel is quiet and tour guides are expected not to say anything while inside the chapel. The explanations of the different pictures was very interesting.

When we entered the museum, we got “in line” and followed this line through multiple rooms and displays. Our tour guide was annoyed (and so were we) that there was no way to bypass seeing every single room of the museum and going straight to the chapel. It was bad enough having to follow the masses into every single room but what made it worse was that our guide was pointing out every little thing in each room and talked constantly into our whisper devices that, for a period, we were taking the ear piece out of our ears just for a break. She also had a really bad habit of charging forward without us and we had to fight other tourists to try and catch back up to her.

The Sistine Chapel was amazing, bigger than I thought it would be. There was no talking allowed while in the chapel and they didn’t seem to be very picky about tourists wearing shorts or women with spaghetti-strap tops. We hung out in the chapel for a little while and I was glad that our tour guide explained the different depictions before we got into the chapel – it made more sense.

We fought the crowds to get to St Peter’s Basilica next – the largest cathedral in the world. It was really impressive and so interesting to see the different styles of the artists who were in charge of depicting the different popes through the ages. Marble was everywhere and the grandness of the basilica can’t be overstated.

We walked for a bit and then met up with our driver who took us to Piazza Navona for lunch – she recommended a restaurant called Tre Scalini and when I asked her what the name meant, she didn’t know and asked one of the waiters who pointed toward the 3 steps coming out of the building where the kitchen was. I was so happy to see parmigiana di melanzane (eggplant parmigiana) on the menu again. It was delicious and I ate every bit of it along with a glass of white wine.

We walked to the Pantheon and then over to the Roman Forum where we could see the forum ruins. We were pretty worn out by this point and it was only 4 pm and our reservation for a tour at the Colosseum wasn’t until 5 pm. We decided to call it a day and just had our guide and driver go by the Colosseum and then take us back to our hotel. Our tour guide was quite offended that we wanted to end the tour early even though we explained that we had dinner reservations at 7:30 and wanted to get back to the hotel to change and freshen up.

We both took a shower and changed for our dinner reservation at il Pagliaccio. Wade decided he didn’t want to join us for dinner but we met downstairs for cocktails before dinner. We said our goodbyes to Wade and had the hotel call a taxi for us which we met down at the end of the alley. The ride was like being in a Mario Cart – fast/slow, stop/start, and very very bumpy. I’ll never understand why anyone would want to be a taxi driver in Rome – it’s absolutely crazy.

We got to il Pagliaccio at around 7:10 and had to awkwardly wait outside until they opened at 7:30 pm. When we were let into the restaurant, we let them know that Wade couldn’t make it so they converted our table to just 4 and pulled the other table away. They set it up for 2 people and, surprisingly, that table got filled a little later.

We did the 10-course tasting and pairing. The service was super good, the food presented like art, and most of what we had was wonderful. There was one chocolate-covered candy interlude that I’m still not sure what was in the center but I had to wash it down with water. The rest was quite good.

We had the restaurant call us a taxi to take us back to the hotel and repacked a few things then went to bed. Pick up in the morning was going to be at 6:30 am.

Next post:  https://kidoctr.blogspot.com/2023/06/celebrity-beyond-mediterranean-cruise.html