Client Compliance: The Key Factor in Providing Exceptional Patient Care
World Small Animal Veterinary Association World Congress Proceedings, 2008
Clayton MacKay, DVM
Hill's Pet Nutrition Canada, Inc.
Mississauga, ON, Canada

Introduction

When one considers what parameters are used for measuring success in a veterinary practice, the list usually includes a combination of: providing care to sick patients, providing preventive care for healthy patients, having satisfied clients and the financial stability and growth of the practice.

Therefore, in order to meet some or all of the goals above, one needs to be able to measure the success in all of those areas. In general, veterinary clinics have tended to measure their success most often by tracking the results of services, products and procedures performed. By performing more services or sales of product measured against the previous year, we use that figure to imply we have been successful. Recently, however, there has been growing concern that simply increasing the number of things done, while increasing gross income, has not improved net income. When attempting to sell a practice today, the buyer is more interested in the net income (or how to finance the buy-in from the practice proceeds) rather than simply the gross income generated.

The other major obstacle in managing a veterinary practice (or any medical facility) solely on income generation is that it may alienate a large proportion of the people working there. The majority of the veterinary health care team is motivated by their desire to help animals and their owners. Income from the practice, while important, is often of secondary importance in job satisfaction. Altruism in helping these patients plays an important factor in how the veterinary clinic team views itself.

Veterinarians and their teams believe they are offering high quality medicine and surgery services to their patients. They work very hard at trying to keep up-to-date with the rapidly advancing science of veterinary medicine. Continuing education for all members of the health care team plays a major role in today's modern practice.

Compliance Study

To make the kind of advancements we, as a profession, desire for our patients, we need to assure ourselves that our clients are utilizing the products and services we offer to them every day in practice. There has been some suspicion that client compliance for our recommendations to their pets is not as high as we think it should be. In order to assess that situation, the American Animal Hospital Association has produced the first ever compliance study for companion animals supported by a major educational grant from Hill's Pet Nutrition Inc.

This 18-month study included:

1.  Industry analysis. Existing data included those from veterinary pharmaceutical and biological companies, pet food manufacturers and large national corporate veterinary practices.

2.  Benchmarking. Human medical and dentistry fields were examined for potential parallels or experiences that could benefit veterinary medicine.

3.  Practice diagnostics. Fifty-two practices were visited or had in-depth interviews with their health care teams to evaluate their processes, systems and staff activities that related to client compliance.

4.  Attitudinal and behavioural study. Veterinarians and practice managers agreed to lengthy interviews that probed their thoughts and beliefs and the steps they felt could be taken to improve compliance.

5.  Pet owner survey. Over 1,000 pet owners were surveyed regarding the care they provided for their pets, their desire to receive more information and care from their veterinarian and their actual compliance with these health care recommendations.

6.  Quantification of the opportunity for better health care. Data from 240 practices including 1400 dogs and cats were used to quantify compliance and then to highlight the potential improved health care by increased client acceptance of practice recommendations.

The study looked at six areas:

1.  Heartworm testing and prevention

2.  Dental prophylaxis

3.  Therapeutic diets

4.  Senior screenings

5.  Canine and feline core vaccines

6.  Preanesthetic testing

Because of the size and scope of the study, it would have been impossible to track every routine recommendation made by clinics routinely. However, there was no directional evidence to suggest greater compliance would be found in any other areas.

The compliance data in this study is only for dogs and cats that had been seen by a veterinarian at least once in the previous 12 months. It is, therefore, easy to conclude that compliance rates for the entire pet population are substantially lower than those quoted in this study.

For the procedures listed above, only practices that made recommendations in that area were measured. For instance, if they did NOT recommend senior screenings, that practice was NOT included in the data. This also highlights that the medical recommendations were that of the individual practice, not ones suggested or imposed from an external source.

Compliance

Compliance means that the pets in your practice are receiving the care that you believe is best for them.

Compliance Gaps

Measurement of the percentage of pets that did not receive the care, products or services that the veterinarian believed was best for the pet.

1.  Core vaccinations: 87% (leaves 12,400,000 dogs and cats under-vaccinated)

2.  Heartworm testing: 83% (leaves 7 million without testing)

3.  Heartworm prevention: 48% (leaves 21 million partially or completely unprotected)

4.  Dentistry: 29% (15 million dogs and cats that would benefit from a cleaning, scaling and polishing at the minimum)

5.  Therapeutic diets: 7% (52 million dogs and cats with a diagnosis that would benefit from the appropriate dietary intervention

6.  Senior diagnostic screening: 33% (18 million dogs and 16 million cats have not had a senior screen)

Compliance Formula

C=R+A+FT

 C = Compliance

 R = Recommendation (effective) and reinforcement by veterinarian and health care team

 A = Acceptance by the client for the entire protocol (duration, dosage level, etc.)

 FT = Follow through usually done by the health care team

Where's the Compliance Gap?

 Protocol: Compliance levels will never improve unless a practice has clear, concise written protocols that all staff members understand and follow.

 Recommendation: The next most common reason for poor compliance is the client never receives an effective recommendation from the practice team. All too often, the client is faced with information overload plus distractions in the exam room or reception area. Recommendations need to include not only verbal, but visual and written information to take home. At times, practices believe the client is overly concerned about costs and therefore does not offer all of the services available ('sticker shock'). This has been refuted by many other studies as well. Clients wish to receive all of your advice and recommendations.

 Acceptance: Study showed that the client is generally not a barrier to compliance.

 Follow-up: The practice team must take steps to ensure that the patient receives the recommended care, by scheduling further appointments, providing at home instructions, sending reminders for all services and products recommended (not just vaccines) and making follow up phone calls to help the client understand the importance of following through and therefore improving compliance.

Six Steps to Improve Compliance in your Clinic

1.  Measure current level of compliance. Most practices overestimate compliance and therefore have no solid idea of where they are. Contact the American Animal Hospital Association to acquire the booklet "The Path to High-Quality Care".

2.  Involve the entire health care team. Establish protocols that must be followed by everyone in the practice and utilize the veterinary health care team to effectively reinforce all of the recommendations suggested by the veterinarian.

3.  Set compliance goals. The entire practice team should discuss and agree on quality-of-care goals they want to achieve. These goals when achievable and specific will be a great source of motivation to everyone that they are making a difference in that patient's life.

4.  Implement the new compliance protocols. Important to have a "compliance champion" or "patient advocate" to make sure the tasks and protocols are assigned and carried out.

5.  Measure and track results. Those practices that measured compliance for specific areas achieved significantly higher compliance in those areas.

6.  Celebrate victories! Celebrating success will continue to motivate everyone to focus on compliance issues in many aspects of practice care.

Why Should You Try to Improve Compliance?

Compliance is clearly a quality-of-care issue. If you truly believe that the protocols and recommendations you make, as a practice, are in the best for the patient, you need to be firm in the delivery of that message to the client. Our patients in veterinary practice have no hope of receiving the products and services that are needed for them, if the client fails to hear, understand or follow through on our advice.

Veterinary medicine needs to strive toward 'outcomes assessment'. Human medicine is now becoming very focused on outcomes of treatment. Not only does the clinician need to be concerned about handling the immediate problem as presented, but the length and quality of the patient's remaining life. That is just as true in veterinary medicine. The quality of life of our family pets is often more important to the owner than the actual length of life. This should highlight for us the reason our preventive care protocols and getting client compliance should play such a significant role in every day practice. In the "user pay" world of veterinary medicine, it is significantly cheaper for the owner to provide high quality preventive care, than to deal with the problems caused by lack of client compliance.

Financial Benefits to the Practice of Better Client Compliance

While not the primary focus of this study, it was shown conclusively that better client compliance meant significant additional net income to the practice. Having written protocols, ensuring effective recommendations, sending home written materials, follow-up phone calls and auditing records can often be accomplished with no additional staff. Adding an additional person to focus on compliance, will show a substantial improvement to the bottom line of the practice because of the additional patient care provided. This money can be invested in additional equipment, training, continuing education, higher wages or more benefits for everyone on the health care team.

Considering that many owners equate their animal's health as equal to their own, and that an increasing number of them regard pets as family members, it is incumbent on veterinarians to engage the owner in being part of the team that makes good choices for their pets (getting them to be part of the decision making team).

The veterinary profession needs to recognize how many opportunities exist for raising the standard of medical care. By recognizing this, we will improve quality of life and enhance the family-pet-veterinarian relationship. Family and pet may have a very strong bond but without the veterinarian, it may not be in favour of the pet's health.

Compliance Success Means Everyone Wins!

 Clinic will see healthier patients, happier clients, higher revenues and a happier practice team.

 Clients will be more educated and their pets will have improved quality and length of life.

Reference

1.  Compliance facts are from The Path to High Quality Care, AAHA 2002.

Speaker Information
(click the speaker's name to view other papers and abstracts submitted by this speaker)

Clayton MacKay, DVM
Hill's Pet Nutrition Canada, Inc.
Mississauga, Ontario, Canada


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