Phil Seibert, Jr., CVT, and I have run hospitals together before, the largest being a central facility with nine satellites, an impoundment facility, eighteen veterinarians, sixty full-time paraprofessionals, and a bunch of part-timers. Here's a little practice philosophy from our hearts, and our experiences:

The Goal for the Outpatient Nurse Technician (OPNT): Allow the examination room encounters to go smoothly, to increase the doctor's productivity, and to give the client another healthcare provider to talk to, in the exam room and on the telephone. - Phil Seibert & Tom Catanzaro

The OPNT is responsible for escorting the patient into the exam room, completing the interviews required for baseline client and patient information, doing the history review of the client's concern, conducting the TPR and asymmetry exam, as "wellness exam" is not used and seems to be a "diagnostic" term, and providing the delivery of healthcare information, as directed by the veterinarian. Like the IPNT, the skilled outpatient nurse technician provides whatever else the client may need, acting as a friend to the client and having genuine concern for the companion animal.

OPNTs must always act, dress, and look like a member of a superior healthcare team. They must always remember that they are "on stage" and that their actions, appearance, and words are not missed by owners. They are impressive, simply because they are friendly and they "know their stuff".

The Mission of the Outpatient Team

With the above philosophy, it must be obvious that we believe technicians are critical to effective healthcare delivery. Both Phil and I have said it many times, in many seminars, throughout many areas of this country and internationally, "Veterinarians are accountable for producing the gross, but it is the staff who can produce the net!"

The effectiveness of the staff is directly proportional to the level of trust for which they have been trained. As stated before, if they have not been trained to be trusted, or if the doctor corrects them in front of clients or other staff members, the healthcare delivery team system will be non-functional.

The concepts of operation stated herein are built on the premise that the provider trusts the team, that training has occurred, and that the team members feel "nurtured" rather than controlled. Nurtured means they know the outcome desires and accept the accountability for getting there with the client and patient. They concurrently understand that the choice of process is theirs and the "boss" does not care, as long as the philosophy of the practice is not violated.

Authority and responsibility are outdated terms on this team, since accountability for outcome means doing the right things for the right reasons at the right time. Doing things right was a training concern, not an operation control. The measurements of success are the controls on this team: happy clients, harmony in the team, and net income for the practice.

What are the three basic OPNT concepts that must be addressed during the nurturing process and skill development sessions? They include the following needs, but are not limited to the examples provided:

1.  Meeting client needs.
This is "job one", as Lee Iacocca might have said. Effective technicians are able to pick up on client needs for the pets, inform the doctor, usually verbally, and always document it in the record with a "need box". They are knowledgeable about products, programs, and services, and how they may benefit the pet, for that is "job one" for the clinic. Example:

2.  Meeting the doctor's needs
The most useful, as well as the most useless, technicians are the ones who always seem to be around the doctor. The great ones seem to know beforehand when the clippers, or an otoscope, or a woods lamp, etc., is needed. They are seemingly always available for the doctor. The poor ones wait to be asked. In other words, the focus of the OPTNs is the outpatient doctor-client encounter. They make it run smooth and easy. They do not get "lost" in cleaning up the back or assisting in surgery. Other things can be done, but only with one eye on the lookout for the doctor. By keeping this focus, a good OPNT can make the most crowded and complicated day run smoothly.

3.  Meeting client relations specialist's needs.
The OPNT must also have an antenna up for the client relations team and the reception room. This is especially true when completing the "New Client Welcome Form" or the "Patient Data Cover Sheet". These are often consultation room interview requirements to keep things flowing.
The skilled OPNT always knows how many clients are waiting (none, hopefully) and which consult rooms are empty. The great OPNT is always "chomping at the bit" to get the clients into the room!
The OPNT escorts the patient-client pair to discharge and verbally transfers their care to a willing client relations specialist before leaving them there. They realize how upsetting it is for the client relations specialist to have a client wait, either for a discharge or for an appointment.

In short, the OPNT is the "glue" that holds the continuity of the outpatient schedule together. This is no small feat. The OPNT must know what's going on in the client relations specialist's mind, the client's mind, and the doctor's mind, then see to it that all their needs are met. They never become diagnosticians, but they are always counselors and "hand holders" for those needing someone who cares.

Outpatient Nurse Technician Development Plan

Phase 1: In the treatment room, learn how to do a "value added" asymmetry exam, nose to tail, including manual TPR, blood pressure, if it is a standard of care in the practice. Share more good news than bad within the three to five-minute lapse time. Narratives must be non-diagnostic, such as:

 Grade 2+ dental plaque: "Red gums mean pain and brown teeth have bacteria that can cause bad breath. I have made a note so the doctor will remember to talk to you about it."
The OPNT writes in the "O" field, "dent 2+[ ]", into which the doctor will later enter the client's response.

 Overweight pet: "There seems to be a little extra flesh over the ribs, so I have made a note so the doctor will remember to talk to you about it."
OPNT writes in the "O" field, "35lbs/6 [ ]", into which the doctor will later enter the client's response.

Phase 2: In the consultation room with the doctor for four-hour shifts. Traditional linear scheduling, doing the asymmetry exam, while the doctor is in the room, listening and learning the doctor's patter. Eventually, after training, the doctor will have the OPNT close the session with the client continuing education, including puppy/kitten programs, nutrition, house training, parasite prevention, dental hygiene, over-forty surveillance, elder care, and other routine or recurring messages.

Each OPNT-doctor pair will be tested and retested until the narratives are uniform and the doctors are comfortable with the skill levels. Initial training subject narratives include:

 House training (add more behavior, after the OPNT develops confidence).

 Quality diets' basic benefits (smaller stools, less odor in cat boxes, etc.).

 Traveling with your pet concerns (parasites, heat stroke, cold shocks, etc.).

 Dental grading (four stages, 1+and 2+ are "bacteria", 3+ and 4+ are "disease").

 How to present a healthcare plan, often called "estimates" in past.

Phase 3: Four-hour, outpatient-only shifts, in the new dual consultation room schedule environment, where the last ten minutes in one room overlaps with the first ten minutes of the other room. Continue cycles and recycles of doctor-OPNT pairs until all permeations and speed bumps are out of the system. After each four-hour block, OPNT, doctor, and front desk client relations specialist retire to assess the shift, using three core questions:

 What worked very well?

 What do we need to do better next time?

 What do we need to change to make this more effective?

Phase 4: With new skills, link a.m. and p.m. shift changes, so the four-hour, outpatient only shifts, with dual consultation room schedule environment, and where the last ten minutes in one room overlaps with the first ten minutes of the other room, cover an entire day. After each day, the morning and afternoon OPNT-doctor teams, the IPNT, and the respective front desk client relations specialist(s) retire to assess the shift, using three core questions:

 What worked very well?

 What do we need to do better next time?

 What do we need to change to make this more effective?

Phase 5: Just do it! This is the point that internal resistance will no longer be allowed by doctors or staff. Inappropriate behavior is cause for discharge.

Outpatient Nurse Technician Duties

The following is a list of duties and expectations for the OPNT. We've grouped these into three categories:

 Before.

 During.

 After (the doctor's time with the client).

The list within each category is in no particular order as to which is done first, second, third, etc., during each visit. This is client-specific and is also based on practice preferences. When in doubt, meet the client's needs, then handle the variance from the practice paradigms later in the privacy of a one-on-one setting.

 Before -- setting up the room:

 Erasable board is always cleaned before the client comes into the room. Other areas are checked to make sure the exam room is immaculate before a client comes in:

 Floor (no hair, nails, blood, urine).

 Walls (no blood, dirt).

 Consultation table clean on all sides.

 Drawers (K-Y fully stocked to the top).

 Full bottle of cleaning solution.

 Paper towels.

 No water on counter tops (this is where we place the record).

 Cabinets stocked.

 The following resale products should always be in every exam room: dental care aids, vitamins, shampoo, etc.

 Diet samples stocked. OPNTs have full authority to give away samples (limit two per animal) and coupons.

 All pets are always called by name. All clients are addressed by appropriate title and name. The wellness screen by the OPNT includes a nose-to-tail palpation for asymmetry and a TPR and weight, with body score, recorded in the medical record.

 For a new client, the OPNT is also responsible for ensuring the entire sheet (client information) is completed. If "referred by" box is blank, ask as to how the client heard about the practice. If "shots previously given" is blank or stated as simply "current," write a close date estimate, so follow-up can be initiated. Same with "birth" date. "Age" requires too much computation each time. All of this information is essential.

 If the animal is "well", any vaccines to be given are made up before the doctor enters the room. Remember, we do not want any invasive procedure done to the animal until after the doctor has prioritized care.

 All OPNTs should be fully aware of all infectious diseases that can be prevented, as well as all wellness programs. Currently, the most common OPNT programs include:

 Puppy/kitten programs (vaccines, fecals, preventives).

 Life cycle consultation programs (see www.npwm.com).

 Twice yearly (bi-yearly) parasite checks.

 Golden years (geriatric), or over-forty work up.

 Cardiovascular evaluation.

 Arthritis programs.

 Dental disease work up.

 Parasite prevention and control.

 Nutritional supplementation programs.

 Behavior management capabilities of practice.

 Each of these programs need concise, community-specific, handouts. OPNTs and client relations team will build the new client-friendly handouts, within the practice image, then be ready to talk about them. All know where restocking supplies are kept.

 All vaccines have company brochures. Make sure you use only those that accurately describe your programs. OPNTs and client relations team should have, as a minimum, the knowledge contained in the brochures. These are preventable diseases, and your goal should be to prevent disease, but the owner must be educated.

 As with the other programs, the OPNT must know how to explain the brochures to clients. Only give a brochure to a client after you have taken the time to explain the brochure to the client. Another word about brochures: never hand out a brochure you haven't read. Also, when you hand the brochure to the owner, ensure it has the practice name and phone number on it, then write the pet's name on the brochure. This personalizing has been shown to incline the owner to read it.

 The goal for everyone in the practice is to ensure that every pet owner leaves better educated than before arriving. Brochures are one easy way to do this, and can be used with phone shoppers seeking information. They help differentiate the practice.

 Product knowledge. The OPNT must know the advantage of each product on the shelf and better than the competition, whether the competition means the other doctor or another clinic. What are the benefits, how long does it last? Is it safe for puppies, kittens? Listen to a doctor detail the product, have the senior technician explain the selling points, or request that a staff training session with a vendor be scheduled. This is often good for free pizza, too.

 Fill out the folder for vaccinations and preventive care, and hand out a health maintenance folder pointing out:

 Commitment.

 Practice philosophy.

 Emergency telephone numbers.

 Clinic brochure.
The client can read it while waiting for the doctor. These four items should be stressed for client information and for client bonding reasons. The folders are made to fit into a filing cabinet.

 OPNT time is always written on a travel/circle sheet, so their value is shown. Adjustments can be made at the bottom of the form, but ensure they are perceived as having a value. This is critical if you are ever going to provide behavior management "service" to a client, since behavior management services use devices or aides that are only "net producing" items when sold with the first visit. Time is worth money from any provider in the practice.

 Weight, with body condition score (BCS), is written on the medical record and travel sheet for the computer.

 When discharge requires a view box, get the films as well and put into the hopper. Don't set them in the consultation room.

 For all ear cases, have otoscope ready; mineral oil, a scalpel blade, and slides for all dermatology cases.

 During the doctor's visit:

 Report fecal, HW , and other lab results. There are usually three areas into which the OPNT reports:

 Write in the record.

 Lab log.

 Verbal report to doctor and client.

 All positive fecals will cause the client to be given a handout or brochure, circling the type of parasite, zoonotic potential if appropriate, and discussing prevention and control with the pet owner. Most folks have no idea what the differences are in these worms, so remember to write the name. Similarly, have brochures for tapeworms, Giardia, Lyme disease, other tick problems, heart worm, etc.

 A good OPNT is always checking up on the doctor for any help needed. It's inappropriate to assume the doctor never needs help. Whichever doctor is in the back on IP duty will always understand if you simply say you're the OPNT. He/she may still want you to do a job, but the duty will be abbreviated.

 Also, the doctors may need to be reminded of who is doing what duty.

 All little puppies and kittens need to be held for the doctor when vaccinations are given, unless the doctor releases the technician of that duty. Similarly, assume the doctor needs help with hyperactive dogs for shots, skin scraping, and most dogs requiring a muzzle (black tongues are a hint).

 The "What can I do to help?" statement is reserved as a sign for "We're getting backed up, Doc!" Use another statement when asking the doctor if assistance is really needed.

 After the doctor leaves:

 Other than prescriptions and products, nothing else should need to be entered into the computer. Check the master problem list to see that all problems/issues were addressed by the attending doctor. If not, recall the doctor to finish, using whatever code phrase you have established to maintain respect. However, if anything is entered, put an "S" next to it to alert the client relations specialist that it is already stored.

 When you give HWP to a puppy or kitten, tell the owner that "We'll do the heart worm test at (state the time of that visit), the time of the next refill," and follow up by saying "We will check for heart worm once yearly, as well as intestinal parasites twice yearly." Whenever you perform a heart worm test, remind the client that HWP is needed, and ask if a refill or injection is needed today. Record it on the travel sheet, if dispensed, and in the record with a checked box.

 OPNTs are allowed to worm puppies and kittens. Mark in the record and leave the empty syringe on the counter to prompt the veterinarian that it's been given. Also, mark the travel sheet. Mention at the time you worm the animal that the Center for Disease Control (don't say CDC) says all puppies and kittens need to be de-wormed and that twice yearly fecal exams are needed for the pet's lifetime.

 Go over all prescriptions clearly with owners. Make sure that they know how to give pills by an inoffensive question like, "When was the last time Fluffy received pills? Would you like me to help you give the first one now?" Many of these drugs are expensive. Reinforce the purchase by adding some information on Cestex, Baytril, Torbutrol, and Fulvicin. Also, some practices believe in a pill popper promo: reason equals better compliance. The pill popper must be demonstrated.

 If the doctor hasn't completed the recall, recheck, or reminder on the travel sheet, ask for it! Do it for the doctor if necessary. No one leaves without being assigned at least one of the three Rs. The OPNT is accountable for following up by phone all nutrition, dental, parasite, and behavior notes.

 OPNTs must check the travel sheet against the medical record for missed charges.

 Finally, if you receive a compliment, simply hand the client a practice brochure and say, "Thanks! Please tell a friend!"

A Comment on Using the Outpatient Nurse Technician

School trained or home grown, trust comes from nurturing your team. The ability does not lie within the title, it lies within recurring training to a level of competency that can be trusted. By the Practice Act in Colorado, if a veterinary assistant is not school trained, they cannot be called a "technician". We then call the home-grown veterinary extenders a "nurse", an acceptable definition from dictionary.

Inversely, the Minnesota VMA capitulated to some noisy nurses from human healthcare, and have stated the practices cannot call the veterinary extenders "nurses". Registered nurses are not all registered nurses, since most "nurses" in a physician's office are only nine-week medical assistants, but are referred to as "nurses" in front of clients. We expect the Minnesota VMA to rename veterinarians next, since they have started down the slippery slope of arbitrary nomenclature capitulation, and will bend under a challenge from the RDs (real doctors/physicians). It is not the school that makes the OPNT successful, it is the practice that makes the veterinary healthcare delivery team successful. Believe they can and they will. Believe they can't and they won't. The difference is in the leadership's belief, trust, and accountability. Hire for attitude and develop the environment to nurture the attitude. Everyone will win!