The basic premise in a professional service industry like veterinary practice is to establish the core values, which the owner states are inviolate, and there are never exceptions to a core value. This is a very hard premise as a practice grows. After all, during the early years, owners do almost anything to make the front door swing and to stay solvent, even if means to live off depreciation and amortization dollars. As a practice grows, the original total control must give way to delegation, because no one can be in all locations at one time, although some try, like in our on-going true story throughout this chapter.

The value of a principle is the number of things it will explain; and there is no good theory of disease which does not at once suggest a cure or treatment. - Ralph Waldo Emerson

Core values must precede delegation, because whoever has the accountability for the outcome needs to know the limits and latitudes. We do not delegate process anymore, just the outcome. A good leader shares the "why", and then jointly sets the "time-line" with the program manager for the expected outcome. Before delegation can occur, a few different styles of leadership come into play during effective teaching. All are explained in more detail in Building the Successful Veterinary Practice: Leadership Tools, Appendix B.

 A "discovery" occurs. This is a teachable moment. Something gets the person's attention, either fabricated or actual. The person wants to prevent that from recurring. Effective adult education only occurs at the teachable moments. It still requires a plan with three to five outcome-based learning objectives. Nevertheless, the "start time" requires a teachable moment.

 It starts as very directive. The standards of performance, as well as the definition of "competency" within the skill, is clearly shared. This is called teaching/learning in the effective teaching model.

 A persuasion style of leadership follows the directive phase, where the person is coaxed into trying the new procedure or knowledge application. This is also called teaching/learning in the effective teaching model, since replication is a required outcome.

 A coaching style of leadership follows persuasion, since we are now fine-tuning the knowledge to allow variances to the single system thinking. This is critical for delegation, since we only delegate outcomes, and the person must be able to make the change in process to reach the outcome agreement in the desire time. This is called application phase teaching/learning in the effective teaching model, since independent thought is a required outcome.

 If the evaluation of the effective teaching shows the person is now competent, then we celebrate and delegate. If the evaluation of the process reflects we have not achieved the learning objectives of the session, and the person did not get the idea and/or skill the first time, then the trainer must recycle the person through the skill training.

 In training or retraining, it is the trainer's accountability to ensure the participant learns to a level of competency. In healthcare delivery, there is no grading curve, no one to ten rating, and no A-B-C-D-F bell curve. Either the trainee is in the vein for that IV, or are not. Either the trainee restores breathing, or the patient dies. Either the trainee stops the bleeding, or the patient dies.

 Once delegation occurs, no savvy leader ever takes the outcome accountability back. The leader may mentor, and may consult, but leaders do not revert and make the person feel untrusted. If the person, who has been delegated the outcome, exceeds expectations, the leaders and trainers can join-in and be one of the masses. Harmony and balance have been reached.

 The challenge at this point of group development is that when a new task, or a new person, is added to the team, the above sequence must start all over again. That is why we say a staff member costs about $25,000 to $30,000 to replace, due to the training and reduced competency during the ninety days of orientation and training required to determine a team fit, competency level, and ensure productivity.

What you do speaks so loudly, that they cannot hear what you say.
and/or
Never do anything for the group that the team can do for themselves. - Lord Robert Baden Powell, Founder of the Boy Scouts, on Leader's Behavior

The concepts of group development are consistent, as are the sequence of the four phases: Forming, Storming, Norming, and Performing. They cannot be avoided, and they cannot be ignored, but they can be accelerated through "Storming", with astute application of the first five leadership skills discussed earlier.

Scouting has had many valuable years to develop cutting-edge leadership training for volunteers. A veterinary practice is filled with "volunteer-like people": staff members, who are not there primarily for the money, although a living wage would be nice. Rather, they are in the practice at underpaid wages and stressful hours for their own reasons of self-worth.

The Group Development and Styles of Leadership, called situational leadership, when applying the various styles, are separate leadership skills. However, they usually work in unison, during group development by the team trainers and practice leadership. As discussed earlier, these two leadership skills are categorized as "advanced" team and group leadership skills. If the basic group skills are not yet operational within the team, the advanced skills will have nothing on which to build. So, please stop right here, and reassess the state of training on the basic group leadership skills: effective teaching, planning, and evaluation.

Planning

"Done by the staff members, for their programs"

Remember Always the Roots of Planning Include:

 Client-centered service with patient advocacy and concern.

 Practice philosophy, vision, and inviolate core values.

 Consistent standards of care => continuity of care.

 Continuous quality improvement (CQI) by all.

 The power of the entire healthcare delivery team.

Planning allows more than one plan to be written to achieve a similar outcome, so the team hitting operational road blocks and speed bumps always has alternatives that can be tried without going back to the boss with a failure.

Problem solving is applied planning, and shown on the VCI ^®Veterinary Leadership Pocket Guide:

 Clearly identify the problem/task.

 Review available resources.

 Jointly select alternatives for this situation.

 Have the two in conflict jointly write a Plan A and Plan B.

 Jointly establish measurements for determining success.

 Implement the plan, take action, and stay flexible (ARF!).

 Jointly evaluate outcomes to previously established success measurements.

The bottom line of planning is actually exciting for most teams. It has been shown time after time, for every fifteen minutes of dedicated planning, the user usually gains at least an hour back during the implementation process.

See the following "Effective Teaching" diagram:

 Learning objectives are for the trainer, not the participants. They are usually outcome/action-oriented, and kept to only three to five-outcome expectations for any session. If the learner replicates the learning objectives, without being told, after teaching learning, then effective teaching has occurred.

 Discoveries are opportunities, artificial or actual, to have the team ask to know more, and are often called teachable moments. Mini-discoveries should recur continuously during teaching/learning, with the facilitated discussion method of sharing knowledge.

 Teaching/learning means competency of performance in the application expectation. When a team member does not adequately learn, it is the trainer's concern to find an alternative teaching method that works better.

 Application is the demonstration of the competency, or the train to trust, level of practice performance.

 Evaluation is based on the outcomes set in the learning objectives, and that have not changed during teach/learning or application. Recycling means the trainer did not get the concept/skill across in an adequate manner for replication.

At this point, if you need to review the following topics, please turn back to Chapter One:

 Peculiarities of Adult Learning

 Emotion and Gender

 Figure 4: Trainer Lesson Plan Matrix

Evaluating

The goal is to provide positive suggestions for growth and improvement. Critiques, exams, and appraisals must give way to coaching and persuading, to vision building and reinforcement of values, and to performance planning, rather than fear of failure.

The values of the individual, the ethics of the situation, and the core values of the practice need to be the consistent evaluation criteria. In this light, the six basic leadership questions that need to be answered in every evaluation are:

Task Balance

 Are we getting the job done?

 Are we doing it right?

 Are we on schedule?

Group Balance

 Is everybody involved?

 Are they working well and satisfied?

 Do they want to continue?

It is always a balance between the needs of the practice (task), needs of the group (harmony and team-pride), and needs of the individual (self-pride and safety). A skilled leader, as with the transitional skill of reflection, knows they are always going to be restoring balance. Life in healthcare delivery is not so predictable as to always have it just one way. Therefore, restoring balance is the continual quest.

Evaluation, with reflection-type questions, phrased to the future, helps the leader keep the efforts operational and the team harmony in balance within the group dynamics.

Keep the group together and get the job done. There isn't anything else.

To a caring leader, evaluation is a continual process. It is not the "grading process" of academia. That is for teachers, not trainers. In healthcare, performance competency is delivery excellence! There are no shades of skill competency, when restoring an airway, stopping bleeding, interpreting radiographic images, or pursuing other diagnostic or medical/surgical objectives.

Do it right, for the right reasons, and at the right time. Keep it positive and make it a building experience.

So, if you have assessed the state of training on the basic group leadership skills as previously discussed, and you are now a happy camper, you can look past the basic group skills of effective teaching, planning, and evaluation, as apply to group development and situational leadership to the team's skill set. Figure 7 below shows the interrelationships in graphic form.

Figure 7. The Situational Leadership Model

In reality, the storming phase is what usually kills a new project or program. It is very stressful for most people to leave their comfort zones and change. When storming occurs, those who avoid confrontation tend to revert to their "fur-lined rut". For those few who love change, the staff resists. They have learned "this too shall pass", as most change agents have moved on to a new project, before the previous system has been integrated into the practice culture. It takes careful planning and staff nurturing for at least ninety days to get a new program to become part of the revised culture. Application of the situational leadership skills can reduce the time spent in the storming phase, but it cannot be avoided.

To be conscious that you are ignorant of the facts is a great step toward knowledge. - Benjamin Disraeli

This chapter was originally titled "From Then to Now". However, as we wound our way into the leadership skills, some readers may have already realized that the "now" for Veterinary Consulting International®, and the VCI® consulting partners, has not been in your past, nor is it in your "now". While you wish it could be in your future, you doubt that it will work in your practice culture and community.

The other small realization that possibly emerged from this chapter is that sometime in the past ten years:

 Small animal has been replaced by companion animal.

 Variable whims of the owner are being replaced by inviolate core values.

 Customer has been replaced by client.

 Expense control has been super-ceded by income production.

 Doctor-centered decisions have become client-centered decisions.

 Staff is assigned to a practice zone, rather than to a doctor.

 Doctor preference is being replaced by standards of care.

 Receptionist has been replaced by client relations specialist.

 Technician has been replaced by nurse technician or nurse.

 Kennel kid has been replaced by animal caretaker.

 Boarding has been replaced by critter camp, Pet Lodge, etc.

 Strategic planning has become strategic response.

 Recommend has been replaced by need.

 You should consider has been replaced by your pet needs.

 Wallet medicine has been replaced by true patient advocacy.

 Male graduates have been replaced by female graduates.

 Higher ACT has been replaced by higher return rate per animal.

 Equity investment has been replaced by invested Return on Investment (ROI).

Veterinary healthcare delivery in a veterinary teaching hospital is usually defined as curing an animal. To a surgeon, a chance to cut is a chance to cure. To an anesthesiologist, it is animal recovery without any pain. To an internal medicine doctor, it is that definitive diagnosis. In a general companion animal practice, veterinary healthcare delivery means keeping the animal well and free from disease. It means keep a client satisfied, so she or he will refer neighbors to your practice. It means a practice culture of harmony and pride. Coming to the practice needs to be something to which each staff member and doctor can look forward, rather than dread, as with the rounds during your senior year in veterinary school, with a sharp-shooting intern.

The team-based veterinary healthcare delivery means the doctor-centered practice is becoming a client-centered practice of patient advocates. Being a dog person or cat person is no longer the stigma of the 1970s. It is a "classification" used in social circles, and is a complement in most all communities.

Staff no longer follows doctors around, to be ready when they call. Staff runs the hospital and schedules. And when a doctor enters a hospital zone, Doc reports to the nurse-in-charge and verifies that the schedule will be adhered to, as delineated by policy and precedent, and as listed on the schedule the nurse presents.

The "social contract" with a client, as in making an appointment, is maintained, with staff surveillance and cooperative doctor compliance. Standards of care drive the continuity of care between providers and for staff. When a treatment protocol is questioned by nursing staff or other doctors, it enters peer review until a single standard of care is established. It is not violated again. It may be reviewed again after the ninety-day test, but never before the ninety-day test is completed.

Nothing in life is to be feared; it is only to be understood. -Marie Curie

Most veterinary practices do not get to see outside their own little boxes. The demands of the practice are such that the practice model the owner started with years ago has very few modifications that were not "tweaks" by the owner himself. Most of these came from sound bites in the periodicals, a management session at a conference, or a "word-of-mouth" idea heard at some veterinary dinner and/or the bar. Most veterinary practices that try small tweaks or "gimmicks" from outside their practice sphere of influence seldom get the idea to stick, because it has not been integrated into the practice flow or long-term plan. Nor has there been staff buy-in to the idea. In most consults we do, the GREAT ideas that work are the ones that have had staff support, but poor implementation planning in the past. As a consultant, my main job is to mobilize the ideas of the staff, and integrate them into the existing practice flow to reach the next level of performance excellence.

Less than fifteen percent of the veterinary practices seek diagnostic professional practice business help from a skilled veterinary-specific consultant. I have offered to nominate every national veterinary consultant to take boards at the American College of Healthcare Executives. To date, no one has taken me up on sitting for the orals and written exams, and the exams must be repeated every three years now, instead of five. I've also challenged consultants to pass the Certified Veterinary Practice Management (CVPM) exams of the Veterinary Hospital Manager Association. Very few have earned the CVPM designation, and those who have actually do stand out above the rest. Take, for instance, Jim Guenther, DVM, MBA, MHA, CVPM; Peter Ainslie, CVPM; Karyn Gavzer, CVPM, MBA; Tom Kendall, DVM, CVPM; Marsha Heinke, DVM, CPA, CVPM; Roger Cummings, CVPM; Jim Remillard, MPA, CPC, CVPM; Karen Feldsted, CPA, MS, DVM, CVPM; Shannon Pigott, CVPM; Joan Robinson, CVPM; Owen McCafferty, CPA, CVPM, DABFA; and only about one hundred and thirty more have earned this coveted designation. In the text Veterinary Management in Transition, Preparing for the 21^st Century we clearly stated these people are worth the extra money to have them on your team.

The practice leaders and association leaders of today play at management, fake leadership, and endorse "risky business" management approaches. There is a leader-follower disconnect in most veterinary associations, be it culture void, generation gaps, and in some cases, open warfare. There is not a "best defined management system" being provided. Measures are dollars, rather than client satisfaction. And management by objective has been tied to belonging, rather than prospering. We have deficient craftsmen, absent task masters, and a basic lack of management professionalism.

All it takes to be listed by the new Association of Veterinary Practice Management Consultants and Advisors (AVPMCA) is someone to nominate you. There is no skill delineation, no certification or degree requirement, and self-ordained "experts" are listed in common with those having achieved higher learning credentials in their chosen field(s).

There is strong lemming behavior, where practices imitate others, even if the performance of the others is substandard or a community-specific abnormality. Forming non-standardized "systems" is common, creating an empire without building a business.

Most all veterinary computer software vendors title their programs "practice management software". Yet, the most basic business premise, Income minus Expenses equals Profit, cannot be computed, since there is no expense side to the software.

There has been too much internal focus, and virtually nothing done about the client attraction and bonding. We are not minding the store when we do not address the front door swing rates. Even for a standard practice, most have a very ill-defined market position. They have not learned to differentiate themselves from the other practices in town.

The basics have been proven and stated in many forms and within many forums, yet we are still trying to invent the new wheel. The new approach veterinary practices need to embrace include:

 Know your own numbers.

 Stay focused on client satisfaction.

 Speak for the patient in single "need" terminology, and offer timing options only.

 Differentiate yourself with quality the client can understand.

 Keep your costs within reason.

 Become the employer of choice for the best people in the market.

Many veterinary practices are riding a dead horse. Dakota Indian tribal wisdom says, "When you discover you're riding a dead horse, the best strategy is to dismount."

In veterinary medicine, and with the writings of many management gurus, most practitioners have been provided a wide range of advanced strategies to keep riding that dead horse (or outdated program, or poor employee), including:

 Buying a stronger whip.

 Changing riders.

 Threatening the horse with termination.

 Appointing a committee to study the horse.

 Arranging to visit other tribes to see how others ride dead horses.

 Lowering their standards, so that dead horses can be included.

 Reclassifying the dead horse as "living-impaired".

 Hiring outside contractors to ride the dead horse.

 Harnessing several dead horses together to increase speed.

 Providing additional training to increase the dead horse's performance.

 Doing a study to see if lighter riders would improve the dead horse's performance.

 Rewriting the performance expectations for all horses.

 Promoting the dead horse to higher management.

 Declaring that, since the dead horse does not have to be fed, it is less costly, carries lower overhead, and, therefore, contributes substantially more to the bottom line of the economy than do living horses.

Do not bet your career, or your practice's future, on the above alternatives!