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.