Gauging patient satisfaction can be an effective means of pinpointing and correcting problems in your dialysis treatment process. Addressing a recurrent complaint can not only lead to more satisfied patients and staff, but also boost efficiency and reduce costs.

The staff and clinic managers at Mercy Medical Center’s dialysis center in Cedar Rapids, Iowa undertook a strenuous process improvement effort starting in August 2012 after finding that the top patient complaint in the clinic was delays in treatment start time. One patient’s delay caused a domino effect, as other patients scheduled at the same time had to wait for their dialysis session to start. Some of these delays were up to 30 minutes.

We tracked this problem with out own metrics and found out that only 62% of patients started treatment on time.  A survey we completed also showed staff satisfaction with the process scored only 3.3 out of 7. With that data in hand, we started a process improvement project with the objective of increasing punctual start times to more than 90%, while also increasing staff satisfaction.

Time for a new approach

Traditionally in dialysis settings, a patient care technician and an RN handle all the steps in getting a patient started on dialysis and monitoring their session. All 20 patients in our unit are started at the same time; at least, that was our approach. “That was the way we did it for 27 years,” notes Tawnya Salsbery, MSN, RN, CNN, director of Mercy’s outpatient dialysis unit. “The standard was to allocate 15 to 20 minutes per session to get a patient started on their treatment.”

Fadi Yacoub, MD, the clinic’s medical director, adds, “Historically, dialysis is done over two or three shifts a day. All patients start at the same time and end at the same time. But by doing all the procedures at the same time it’s nearly impossible to stay on time.”

Staff members’ stress level was high using our system because they were trying to prioritize and finish multiple tasks, leading to errors and delays. The time allocated was not sufficient for completing all the steps of dialysis treatment.

It is important to remove waste in the scheduling process to ensure we are meeting patient demand in the most efficient way. With that in mind, we worked to match a support system and staff capabilities with maximum process efficiency. We believe that ties in with achieving the best outcomes possible and using the most cost-effective methods.

Reviewing treatment steps and time allocated

Beginning in August 2012, our team reviewed each step in the process. We created our current value stream map with estimated process lead times to identify how many minutes in a day were budgeted against the number of patients we could see in that time. We identified the current patient rate of demand and determined the ideal time that each process step should take. As we re-examined our process, we found we could allocate more time overall by dividing and standardizing tasks among staff members. This gave us a 12% decrease in the total time needed from when the patient arrived to when they left the center.

We determined that getting patients started and then off the machine were the steps requiring the most time. In between, the other steps took less time so staff responsibilities were minimal. Staff knew the activities and tasks that needed to be completed before putting a patient into treatment but tasks such as taking patient vital signs, weighing the patient, and doing a machine saline flush were not performed in a specific order. Also, if a patient needed assistance to get on the treatment chair, a mechanical lift was needed in some cases, requiring extra work to find the lift and wait for another staff member to help transfer the patient into the chair.  “There was a lot of wasted lateral movement and inefficient methods,” Dr. Yacoub noted. “We decided we ought to do something with our approach that was ‘out of the box.’ ”

We also evaluated our personnel costs and worked to find the most efficient use of staff time. We developed standard process steps to ensure staff understood and performed tasks consistently.  We listed all the activities and times necessary to place a patient into treatment. Once we had all the activities identified, we grouped them into six “care cells” to have similar total times of approximately 15 minutes. We selected that time because that was our rate of customer demand or the time that we could spend on each task in order to treat all of our patients during a day. Each care cell consisted of a group of tasks that needed to be performed by a staff member to meet the customer rate of demand.  Care cells and estimated times helped develop schedules that supported starting treatments on time. The schedules were provided to staff to keep the process on time and focus on high quality care. This eliminated the need for double and triple verifications to prevent errors.

Enacting new approach

With the new care cells identified, we assigned a staff member per each care cell to work in tandem. Each staff member is asked  to complete all the tasks assigned within the time allotted, and at the end of the tasks another staff member will start work as defined on the following care cell. This allowed the staff to focus on a predefined set of tasks and avoid errors and distractions.  Staff with a care cell identified to set up machines was tasked with having machines ready for patients as soon as the previous patient was done with the first two care cells. This helped to have the machine ready by the time the patient was ready and avoid spending time preparing the machine while the patient was waiting in the chair.

Our next step was to develop guidelines for scheduling changes. We staggered patients’ start times and staff scheduling accordingly to allow for time defined on each care cell.  We established a new LPN position called the circulator who assists where needed if staff or a patient was having a problem. That helped keep the process on time. The charge nurse was also tasked with stepping in to help, as needed.

Will it work?

When we presented the changes in task distribution to the staff and the schedule changes to the patients, we were met with a lot of skepticism. “The patients’ reaction was like ours: ‘How is this going to work?’” Dr. Yacoub recalls. “When I looked at it, it looked impossible and too complex. But we told everyone to give it time. We believed the benefit would outweigh the inconvenience.”

We improved our dialysis supplies management, making supplies more easily accessible from rolling carts with drawers of supplies needed in treatment. The carts are kept in the office area just off the floor to save time and steps. At the end of the day, the staff replenishes the supplies.


We looked at the impact of the new process in December 2012 to measure improvements. We found substantial gains.

  • The amount of time staff uses to complete tasks is now less, requiring fewer man-hours. We have exceeded our goal of 90% on-time start times, and some days we have 100% of patients start on time (see Figure 1).
  • Feedback from our patients has been positive. Our staggered shifts have brought more flexibility in staff scheduling. We also now need less time for training new employees. We recently hired two new employees and under our new system, we were able to cut two weeks off our training time.
  • The cost impact of our changes was significant. There were supplies and staff savings through more efficient use of staff and standardization of process and materials.  Also if there is a need to treat more patients, we can increase capacity to treat 16 more patients a day by extending hours of operations by just one hour.
  • Our new survey shows that staff satisfaction has increased from 3.3 to 4.7 (scale from 0 to 5; 0=less satisfaction, 5=high satisfaction). Patient satisfaction with the new process ranks 4 on a scale of 1 to 5. Of that, 68% strongly agree or agree that they like the new start times.

One of the first changes we noticed was how quiet the unit was with our new approach. There were fewer machine alarms going off, fewer patients using their call lights to summon staff, and less chaos on the floor. “Delays were considered a part of the process in dialysis,” Dr. Yacoub adds. “It’s very unusual to schedule this way. But this change has made all the difference.”

We continue to track our performance on a daily basis. When we identify a problem, we are now able to review the process and troubleshoot to pinpoint the cause and solution.

Support from upper management was critical to our success. “We have better interaction with patients now,” Dr. Yacoub says. “This change was not easily achieved. But staff did take ownership of the process. I credit them with implementing this and making it work.”