We are well aware that any building is built on a sturdy foundation, and if even one footing of the foundation starts to break down, the structure becomes unstable. We have many "foundation publications" in this profession, and most of them are economic in nature, focusing on the economic concern of the current practice owners. While this is noble and normal for the veterinary profession, responding and operating by a doctor-driven set of values, it is not being client-centered, nor is it being patient advocates. Good medicine is good business.

One can lay a good foundation, using the text Building The Successful Veterinary Practice: Leadership Tools, where there are only four chapters:

 Chapter One: "The Foundation: Attitude of a Leader"

 Chapter Two: "The Framework: Skills of Leadership"

 Chapter Three: "Closing The Structure: The Glue That Holds it Together"

 Chapter Four: "Inside Finishing: Sharing the Vision and Power with Others"

The Introduction is "Nurturing Your Leadership Competencies", and Appendix B provides the "Pillars of CQI", showing the fourteen key leadership skills.

The frequently referenced 1999 Mega Study, sponsored by AVMA, AAHA, and AAVMC, gave us the key factors for client selection of their veterinarian, ranked in order:

1.  Veterinarian is kind and gentle.

2.  Veterinarian is respectful and informative.

3.  Reputation of veterinarian for high-quality.

4.  Past experience with veterinarian.

5.  Range of services.

6.  Location.

7.  Convenient hours.

8.  Recommendation from friends or neighbors.

9.  Price.

While the above nine factors were published as part of the survey data, they were NOT included in the six major summary findings of the Mega Study. As previously mentioned, the National Commission on Veterinary Economic Issues (NCVEI) was the offspring of that major study .The NCVEI provides the Internet access (www.ncvei.org) to the EXAM ROOM, an economic site for comparing your veterinary practice on multiple fiscal and operational factors. They started with the ninth most important factor for client selection of veterinarians, which seems unusual, until you look at the above list .It is the ONLY issue easy to quantify by traditional means.

The AVMA publishes the Economic Report on Veterinarians and Veterinary Practices, as well as veterinary-specific pet ownership and demographic studies, and AAHA publishes Financial Productivity Pulse Points, as well as a Veterinary Fee Reference survey.

AAHA is dedicated to Healthy Practices: Healthy Pets, and its purpose is to enhance, support, and cultivate a veterinary community that offers the highest level of companion animal care and career satisfaction for all practice team members. They have published three distinct elements in their mission:

 Enhance the abilities of veterinarians to provide quality medical care to companion animals.

 Enable veterinarians to successfully conduct their practices and maintain their facilities with high standards of excellence.

 Meet the public's needs, as they relate to the delivery of companion animal veterinary medicine.

Finally, someone is addressing the first eight criteria for clients selecting veterinary practices, and they have done it without invoking "small animal" into their nomenclature. Let's review the major sections of the AAHA Standards for Accreditation:

 Quality care:

 Anesthesia.

 Contagious diseases.

 Dentistry.

 Emergency.

 Pain management.

 Patient care.

 Surgery.

 Diagnostic and pharmacy:

 Diagnostic evaluation.

 Diagnostic imaging.

 Laboratory.

 Pharmacy.

 Management:

 Client services.

 Continuing education.

 Human resources.

 Leadership.

 Safety.

 Medical records.

 Facility:

 Exam room.

 Housekeeping.

 Satellite.

AAHA also offers accreditation in eight specialty categories: avian, dental, feline, mobile clinic, central hospital, emergency and critical care, house call, and surgical.

We are not promoting joining AAHA that is not our intent. The Veterinarian Information Network provides a current set of the AAHA Standards. The AAHA Standards are a cutting edge, reputable subpoena document, developed by a committee of your peers. AAHA, as a veterinary professional organization, addresses the eight leading factors for client selection of veterinarians and veterinary practices. Yet, AAHA has less than fifteen percent of the practices in North America as members. All these facts mean that while practices say they want breakthrough performance, true "benchmarks" have not yet entered veterinary medicine.

Benchmarks

Environmental pressure to cut cost and to increase productivity has given a new face to practice improvements in the form of continuous quality improvement and a need for effective benchmarks of excellence. Globalization has forced different types of production industries to resort to reducing operating cost and maintaining production cost to a level where it remains competitive.

Human healthcare was forced to look at its efficacy by an insurance disaster called managed care. Veterinary healthcare delivery must look at its efficacy based on too low a client access rate, a poor fee structure, underpaid staff, and underpaid professionals.

 The exponential rise in the cost of delivering veterinary healthcare services, price competition, and market realignment are the major factors that are forcing practices to scrutinize their business processes and to redesign them in a manner that would not only help keep the prices competitive but help deliver quality care to the patients.

 In the early 1980s, service environment design and service process design were more focused on clinical effectiveness and technical efficiency. In the late 1990s, the focus included patient customer service excellence, along with clinical components. The methodology of veterinary healthcare purchase is gradually shifting from the traditional cash and carry model to third-party supplementation, such as Care Credit®, Veterinary Pet Insurance® (VPI®), etc.

 To show how low veterinary fees actually are, VPI payments through their insurance premium reimbursement schemes accounted for about sixty percent of the paid premiums in 2001, while human healthcare reimburses one hundred three to one hundred five percent of the collected premiums, and survives off the float money investments .That is one of the main differences between the "risk sharing" of pet insurance (indemnity insurance) and "risk transfer" of casualty insurance.

 In such an environment, a problem-solving approach is needed that emphasizes radical redesign of business process to achieve dramatic improvements in critical contemporary measures of performance, such as cost, quality, service and speed. The elements of the Six Sigma concepts previously provided are constrained by past economic bias, as well as a lack of total service experience. So, a veterinary practice should start to focus on seamless service to clients across various functional areas of practice.

 The process of breakthrough improvement of performance is to obtain gradual, incremental improvement in Six Sigma procedures, before launching a major attack on bias, prejudice, and paradigms of our veterinary traditions. In the veterinary healthcare industry, the most dynamic change has been technology. With each change in technology, the methodology of service delivery changes. For example, the VCI® Signature Series Monograph High Tech and Diagnostic Intensity Need High Touch in Program Delivery discusses how new technology acquisition brings new capabilities to business, thereby raising the competitive bar and the need to improve client communication on the benefits and services now available. High touch caring becomes more mandatory with increased technology.

 The major factors that are forcing practices to utilize new concepts are:

 Delivery of improved service quality to clients.

 Reducing bottlenecks in delivering timely care to patients.

 Improve financial performance by leveraging professional time.

 Improve clinical performance.

 Need to increase doctor and staff compensation.

 Adopting a competitive benefit program for all staff.

 Pressure to comply with forensic and regulatory requirements.

 Need to remain competitive with other practices.

To initiate a foundation set of standards, a veterinary practice team must jointly establish inviolate core values, quality-based standards of care, and an innovative future vision, based on benchmarks of the "best of the best". The use of "average" in veterinary literature is a pathogenic management concept, which needs to be eliminated from existence. But since it is easier than really making the determination of excellence, it will likely remain.

As an example, the Veterinary Economics© reports on the Successful Practice Profiles reflect numbers that have been generally exceeded by most all of VCI's® consulting partners (clients) during the first year of their transition plan implementation of team-based quality healthcare delivery. So what needs to be done first?

Before seeking outside benchmarks, a practice must establish its own baseline, so meaningful measurements beyond gross and average client transaction value are needed. New metrics are needed for new programs. Review the VCI® Signature Series Monograph Strategic Assessment & Strategic Response for details on establishing new metrics.

If a baseline set of measurements has not yet been established, also consider using the VCI® Signature Series Monograph Profit Center Management and its accompanying CD for a baseline set of key factors. Once you know where your practice is, then you can determine where you want to go. That is where benchmarks and breakthrough performance start to come into play. Let's look at the benchmark process:

 Identifying benchmarks:

 Very few veterinary practices have the ability, or the management skill, to seek out the "best-of-the-best" to benchmark.

 Based on cost center analysis and revenue generations in various programs, it becomes very important to identify which programs or habits need benchmarked. For example, waiting time is high in clients' minds, but seldom a major practice issue.

 ISO-9000, ISO IWA-1, NCVEI, and AAHA offer only starting points to develop CQI to become a veterinary industry benchmark for others.

 Objectives of benchmark indicators:

 Increase service level to existing clients.

 Adopt a recovered patient/recovered client program.

 Increase new client outreach for after the first visit.

 Reduce total appointment process cycle time.

 Enhance patient advocacy for deferred and symptomatic care.

 Community awareness of services available.

 Increase visits of per pet per year for all client companion animals.

 Reduce waiting time for doctors by high-density scheduling.

 Increase day care drop-offs for dual income families.

 Reduce specific low productivity activity cost.

 Reduce inventory handling/maintenance costs.

 Methodology definition:

 Practice teams to undertake project. Tools to be used for problem analysis and solution testing are to be decided next.
For example, in case of problems relating to waiting time for outpatient appointment, the team, comprising the key players, such as client service specialists, OPNTs, project manager, an associate doctor not tied to paradigms of the past, and maybe even consultants, should be constituted.

 A variety of tools are available for business process assessments, ranging from the foundation references provided above, to Six Sigma, to workflow diagrams, to computerized simulation models.
For example, in case of high density scheduling, the team can actually work from the VCI® Signature Series Monograph Zoned Systems & Schedules, with the five phase skill and confidence-based development plan contained in the Appendix and on the accompanying CD, to find an alternative process sequence.

 Standardizing new processes and their strategic analysis:

 Some benchmarks are made available in veterinary literature for various activities carried out by practices. These benchmarks can be analyzed for application to individual practice projects.

 A number of practices in the USA have implemented concepts of breakthrough performance, and have been recognized in the professional periodicals, as well as at meetings and roundtables. These case studies can be utilized for learning and to avoid repeating mistakes.

 Some veterinary-specific consultants offer assistance in developing practice change models, strategic assessment and response models, and/or creative program-based services to enhance quality healthcare delivery. Some other consultants often appear as "gimmick of the month", or only fee schedule-based mentors. Some consultants have even published books, so the leadership of a practice can review the philosophies and approaches most often utilized.

 Developing the solution:

 Once the problem is analyzed and all key decisions are taken, the team can then start working on solutions.

 Test programs and alternatives are conducted. Predetermined standards for measuring the outcomes are monitored.

 In the case of appointment waiting time, the new sequence of activities in the process can be tested in a modified planning/test environment, to have an approximate idea of new waiting time.

 Implementation:

 If using the Six Sigma prototype, the project Green Belt coordinates the implementation.

 In case of an appointment exercise, the training and development plan in the VCI® Signature Series Monograph Zoned Systems & Schedules Phase One is "behind the scenes", and Phase Two is simply the doctors allowing the nursing staff to do more, under their developmental guidance. As we explained, at the end of each Phase, the doctor statement of "We trust you at this skill level" is the requirement before the next Phase of development is initiated.

 In case of an appointment exercise, in Phase Three of the IPNT and OPNT development plan, the new process models need computers implemented and a computerized module for appointments developed.

 Implementing computerized modules may take a small bit of overtime, if the mid-day slow period does not occur as usual. The process can be shifted from manual to completely computerized, only when the system settles down.

Factors that contribute towards a successful benchmark:

 Perception and awareness of practice leadership on benchmarks.

 Measurement process can only succeed if the top leadership is committed.

 Bottom-up acceptance of new Six Sigma measurements to monitor the breakthrough performance is the key to implementation success.

 Six-Sigma is a contemporary tool to breakthrough performance.

 Information technology, computers, and communications will be needed.

 CQI is a necessary pre-requisite for the more intense process of breakthrough performance development.

 Organizational redesign will likely be necessary to support breakthrough performance and the new statistical measurement systems.

 Standards of care, and commitment to developing statistically sound measurements for measuring performance, are top-down led.

Common factors responsible for unsuccessful breakthrough performance:

 Lack of leadership development/commitment in the knowledge and skills of the "Models and Methods for Breakthrough Performance".

 Lack of cooperation/buy-in from staff, often inadequate acceptance lead time.

 Insufficient staff training and skill development.

 Lack of "practice culture" enthusiasm and interest in change.

 Lack of access to information, such as benchmark data.

 Lack of new resources leads to problems in acquiring technology and skills.

 No top leadership support in trying to implement solutions generated by Green Belts and Six Sigma teams.

 Low practice priority for change or improvement.

 Selecting and training employees in Six Sigma is time consuming.

 Internal control is not well defined under the new Six Sigma process.

 Benchmark goals are set too low, or not measured accurately.

 Staff turnover is a major distraction, because new staff takes time to undergo the basic orientation and training before they are asked to understand the Six Sigma process, benchmarks, and drive to breakthrough performance.

 Implementation becomes difficult if the staff is too new to understand the core values, standards of care, continuity of care, and the pillars of CQI.

Breakthrough simulation of service-based processes:

 This is very difficult, when the leadership defines everything by "money" or "doctor needs". The practice must become client-centered patient advocates.

 Both the practice flow and resources, to an extent, are human-based assets. Each person must be identified as having essential strengths.

 In case of most practices, the arrival of new clients is highly variable and current clients arrive as trained by the practice. In most all cases, the consequence of being late for an appointment needs to be "two yes options", such as next available appointment, inpatient admitted emergency, or a day drop-off, if it is an established patient, rather than a "squeeze in.

 In the last few years, a few facilitation tools have been published to aid implementation of service-based processes. AVMA, AAHA, and the VCI® publications at www.drtomcat.com are excellent resources. The staff must be given the resources and specific training to fully participate.

 Discrete, event-based, service-based, practice tests are a powerful tool that use experiential data to allow the team to monitor the client/patient flow through various practice programs, services, or systems. The practice culture must accept the new measurements as essential improvements to client-centered healthcare delivery by patient advocates who speak only of "needs" of the animal.

In a service industry like veterinary medicine, good process management can provide practices with the requisite cutting-edge, which can become a competitive advantage over other service providers in the market. Business process benchmarks may not be necessarily easy. They can be labor-intensive in the initial Phases, especially if there is no experienced consultant to facilitate the process.

In case of computerization changes in the practice, such as for admission and appointments in a practice, the cost of installing appropriate computers and implementing a software package can be very high. But at the same time, computerization reduces processing time, saves human power, and also helps in strategic control, which may not be possible in a manual system. Computerization can help save the practice money, while developing breakthrough performance programs.

In the VCI® Signature Series Monograph Leadership Action Planner we introduce a series of tools that help the leadership develop their core values, then provide the same tools for future project planning by the practice teams, so there is a continual reinforcement of the core values and vision with each program developed.