Thomas E. Catanzaro, DVM, MHA, FACHE, Diplomate American College of Healthcare Executives
A client should perceive a higher level of service and caring when they contact a veterinary hospital (the pet health experts in the community), and, in most team-based healthcare delivery practices, 70-80 percent of these contacts have become paraprofessional staff duties. It is the caring and knowledge of the nurse technician and client relations specialist that allows the client to form that "first impression" and "practice image."
Man is a dog's ideal of what God should be. Holbrook Jackson
The veterinarian's charge goes back to Noah -- the Lord said to tend to the animals of the land. It is the responsibility of the veterinary healthcare team to speak for the needs of the animals we care for -- to be their advocate! Concurrently, we must give the client the right to make the informed decision, which means we should take the time to explain the animal's needs and, on deferral occasions, the alternatives available to meet those needs. The higher the client's knowledge of the healthcare needs (veterinary I.Q.), the more often the animal will receive the needed care. The patient advocate ensures the client is aware of the needs to restore or maintain wellness and allows the client to make the informed decision.
Waivers and Deferrals
The AAHA standards, and the New Zealand and Australia Hospital Certification Standards, require an overt deferral or waiver be recorded for all needed care not performed. This simple action covers a major liability concern, but also initiates the follow-up programs.
Good - Better - Best healthcare recommendations carries a liability for the practice, since the levels are economic in nature, rather than clearly identifying the needed care for the client. Clients are not professionally trained, and medical courts have stated repeatedly they cannot be asked to waive or defer as a form of "informed consent".....this is the accountability of the provider, and must be documented in the medical record.
Waiver (W) - this is the client who is definitively saying no - as with, "I do not brush my teeth, and I will Not brush my dogs teeth."
Defer (D) - this is the client who is asking for time - as with, "I need to talk to the family" or "I need to think about this" or "Not today, Doc".
Note: all deferrals need to be followed with the time of deferment agreement, such as 72h for many X-ray needs, 3w for dental hygiene needs, 6m for next life cycle consultation.
Appointment (A) - this is a deferral turned into a commitment, usually when the deferment was based on discretionary cash availability.
Do It (X) -this is the client's decision to access the needed care, and it can be either immediate treatment, or an immediate admission plan.
Most all healthcare needs can be categorized into one of these four categories, which facilitate tracking by the practice staff (+/- veterinary software) as well as enhancing continuity of care between providers. It is critical to understand that "needs dental", "need X-ray" and similar healthcare plan notes do not tell the next provider what the client said, and if you do not record what the clients says, it is called poor communications.
The patient advocate desires the best care possible, but the economy of the household often can afford only part of what is needed during any given pay period (proof of this is in your own paycheck each pay period). It is the paraprofessional healthcare provider who can keep contact with the client and negotiate a return next month for some of the other care needed. The enthusiasm and caring of the nurse technician or client relations specialist can help make this return decision a practice reality. When a staff member becomes a healthcare team member, client communications improve. Many clients feel more comfortable discussing concerns with the nurse technician because: 1) they don't want to take the doctor's time, 2) they don't understand the terms the doctor uses, or, simply, 3) they feel it is easier to talk to the nurse technician or the client relations specialist. The client's concern must be answered first if the practice wants to keep the client returning, and the client concern (patient's need) is first told to a staff member, not the doctor. This is why the staff member has such a great influence on the number of clients entering a practice. The urgency or need is established with the first contact.
The nurse technician team needs to work with the client relations reception team to ensure the narratives and understanding exists about every practice program and service. When a client calls about a flea or tick problem, is there an urgency? Can't fleas and ticks be handled with a bath and some dusting powder from a pet store? What level of in-service education for effective narratives has been conducted for the staff members at your hospital? Do they know the other diseases for which the animal needs to be screened in a tick or flea case (e.g., Lyme disease, tapeworms, etc.) and how to best communicate this need to clients? Some veterinary practices have initiated a "nurse technician hot line" just to ensure the client can reach someone who has the time to care. What are the client education skills your practice has developed within the staff members who talk to clients on the phone, at the front desk, or in the exam room? How are they reinforced? Who is the patient advocate?
It takes two to speak the truth - one to speak and one to hear. Thoreau
Clients are not well informed consumers of veterinary healthcare services. They do not understand the levels of quality and training that are so variable between the suppliers available. Very few clients understand the difference between different blood chemistry tests, so why do new graduates keep using the 'alphabet soup' explanations? As a profession, we haven't helped this situation that much. We still deal in "quotables" on a daily basis, and we call comprehensive healthcare plans "estimates", just as mechanics use for grease and oil changes. Even out software vendors are plotting against us, starting with "presenting complaint" instead of "client concern" and then they lock in the "Form Heading" as estimate, instead of allowing an open field so the practice can use Healthcare Plan......from first touch to last, our software vendors have been training your staff with inappropriate terminology...... what is your practice's plan to alter this communication disservice?
Communicating to win is not selling a service or product. It is listening to the client and recording their reason for accessing veterinary care on the first line of the medical record. It is ensuring that same client concern is the first issue of the Assessment (problem oriented medical records use S-O-A-P or H-E-A-P to stimulate the diagnostic thought process). It is answering the client's concern first, adding our professional assessment, and then letting people buy. The only thing a caring veterinary practice "sells" is 'peace of mind', all else, the client is allowed to buy. Look at the world around you. People are not sold newspapers, they are buying information (or comics, or sports). You don't want to be sold circus tickets, but you want to buy the thrills and entertainment. When someone parks a new car in his/her driveway, the first statement is "Look at the neat car I just bought...", but when something goes wrong, the phrase becomes, "Look at the lemon they sold me!
If we assume listening to the clients is a given (which it seldom is unless we train ourselves to do so), then we meet their needs and wants first. In veterinary healthcare delivery, we often discover additional needs of the patient during the physical examination which must be prioritized into the care plan. Communicating to win has four basic steps that any practice can learn to follow:
1. Make the client aware of a pre-existing condition that needs attention.
2. Educate the client about the changes in the veterinary profession that now allows us to address the condition.
3. With caring and enthusiasm, offer your practice's program to address the client's concern (patient's problem).
4. After the client replies, validate the response, regardless of what it is, and set the expectation for the next encounter.
Be ready for the client to ask the basic buying questions: What is it? Why do I need it? How much is it? Is it really needed now? What is the value to me? As you can see, the client bases most decisions on the emotion of the moment, while the average veterinary practice addresses the logic of the need. Logic will seldom answer the emotional need, but staff members who care can! The pet owner wants to know how much you care, not how much you know. Clients expect professional excellence when they contact a veterinarian's office, so don't disappoint them by recommending a "tincture of time" brush-off. They also want the caring, so never disappoint them in this area!
The opening contact with a client should be non-threatening (avoid questions which require only a "yes" or "no" answer) and a time to gather information. A "phone shopper" should be mailed a hospital brochure, newsletter, or flyer the same day of the call, so an address is also an important piece of information. A "price shopper" should be asked about pet insurance, provided wellness rider information, and even offered Care Credit's, 90-days same as cash qualification. You need to stress that you treat the whole animal and care for the whole family, not just one part of the animal. When healthcare recommendations are made, they need to be stated as "needs." Be clear about the needs of the animal or of the practice. For instance, a pre-anesthesia laboratory profile is a professional need so we can ensure there isn't something going on that we cannot see which may cause anesthetic complications. There is a need to explain the entire wellness approach of the practice. Health is an entire project, for animals as well as for their owners.
Need vs. Recommendation
The term "recommendation" is a legacy from production medicine, where the producer understood the economics and health needs of his herd/flock, and needed to weigh the veterinary costs against the resale values. In companion animal healthcare, the rules of the pediatrician come into play, where the Pet Parent is told clearly 1) what is needed, 2) who would be do it, and 3) when it needed to be completed.
This production legacy is also the source on a single column appointment log, since veterinarians could only work on one place at a time, a very linear process.
In companion animal healthcare, the paradigms of the dental profession come into play, where the Pet Parent is told clearly 1) what is needed, 2) how the staff can do it economically, and 3) when the care needed to be completed. Most dentists have multiple chairs for hygienists to do dental cleaning and whitening, and also have three chairs for restorative care by the dentist supported by higher skilled staff members.
Most dentists will reject managed care casualty insurance programs (risk transfer), yet seek indemnity insurance programs (risk sharing) to support their clients. Most all pet insurance is indemnity insurance, and many have $2 reimbursement for every $1 of premium cost interestingly, practices which use pet insurance for their staff make more net than those that give their staff deep discounts, and the insurance concurrently allows subsidy of the referral to specialists or when accessing emergency care.
After the low-key conversational greeting, the information gathering, and the valuation of total wellness, the client must make the decision to buy. If the smart technician or receptionist offers two "yes" alternatives, the ability to "buy" is assisted. The best way for someone to close a sale varies with the service, the product, and the individuals involved within the discussion. There is no one best way. Regardless of the closure method, one additional step is needed. A caring practice will ensure it comforts the buying decision. Whether the client has opted for full service, partial care, deferred service, or simply waived the care, the client must feel comfortable with the decision if you want a return to the practice another time. Return visits make a greater net for the practice than the search for new clients, so to establish the expectation for their next visit is part of the "comforting" action. If the dental decision was "......not today......." assign a nurse technician to the client/patient and set expectations for the telephone follow-up to ensure the "red gums (red = pain)" are resolved. Your practice team must accept the clients and their decisions, and ensure they know that you want to see them again!
These ideas do not guarantee success; they only allow you to add to the practice's success. How you approach the client service and the patient care will make the difference. How the practice empowers the staff to extend the veterinary caring will make a difference, but the caring delivered by you will be the real difference.
Education makes people easy to lead but difficult to drive.
Most veterinarians find themselves giving a standard set of instructions to their clients concerning common animal problems. It is usually repetitious, monotonous, and time-consuming for the practitioner and for the client, who may even perceive the boredom in the doctor's presentation. It is usually all too soon forgotten. There are better ways to inform the client about conditions and concerns, more effective methods to ensure retention of important information, and, most important, proven techniques to decrease the monotony and time involved in conducting "client education."
Effective educational tools can ease the burden on the practitioner in the consultation room, strengthen client appreciation and referrals, and expand the market for veterinary services - if - the message is delivered by an informed and caring staff member.
For many veterinarians, printed and audio-visual client education materials appear to be the answer. Indeed, most practitioners already rely on some form of instructional materials in addition to verbal advice but in an inconsistent manner.
The staff member must be added to the equation to make any "system" effective. With careful thought, preparation, and some investment, the right type of client education materials can be an effective practice builder resulting in client appreciation and referrals. Every veterinarian and staff member needs to weigh the benefits of expanding the practice's client education resources and delivery methods against the cost of producing and/or acquiring the material to be used. The benefit analysis should include:
Saving Time -In the U.S.A., less than 10 percent of the practices never distribute tailored educational material of any kind. Most practitioners agree that handing out materials that deals with common animal problems saves time and eases the monotony of repeating instructions to clients. A caution is in order though, since an over-reliance on printed or audio-visual materials may cause the client-practice bond to be broken. Clients deserve verbal communication time; less is often resented. It is best when a staff member presents the handout with a narrative that point out the key elements to ensure successful understanding.
Customizing - More practices that put together their own materials often blend a few manufacturer resources with their own flyers. To add a bonding factor to the literature, these must be explained one-by-one by a caring nursing staff member. For instance, a handout titled, "Traveling with Your Pet," allows a practice to identify local parasite and health problems and still warn the client of the dangers that lie outside the community environment. This customized approach is also very important following a surgery or inpatient stay since each practice has different expectations for the clients. The customizing and outreach by informed team members allows the practice to differentiate itself in the eyes of its clients, which may detract or add to the quality perception depending on the effort expended in the client education piece.
Client Response - There has been a generally positive response whenever a practice has augmented its client education material, sometimes to the extent of receiving thank you notes and additional referrals. In high volume-lower price type practices, the client acceptance rate drops. Almost 40 percent of the price shoppers seem disinterested in being educated. Almost every practice which employs staff supported client education techniques reports the procedures pay for themselves as a practice building device.
Access Rates - The informed client has a greater access rate (more visits per year). It is more visits at "community standard" average client transaction (ACT) rates which bonds clients - rapidly escalating ACTs can break the client-practice bond for mid-range clients. Informed clients seem to better understand the need for preventive healthcare, as well as becoming more alert for the signs of disease and discomfort in their pets. These clients are more likely to ask about dental hygiene, elective surgery, and parasite control.
It is amazing, but most every practice I enter (about 1900 to date), there are brochures and handouts, many in client areas. That is not the amazing aspect-what amazes me is the number that do not match the practice's Standards of Care, or do not meet the needs of the client. Dental brochures are a great example: some advertise products and have no pictures of teeth (these brochures need to be trashed yesterday); some have great pictures of dog teeth in each of the four levels of deterioration, but the doctor/nurse narratives use different terms than those in the handout (narratives must match the brochures you send home with clients - alter the narrative or make your own client education brochure); some have cat pictures, but the practice does not grade cat teeth, sending a mixed message to clients.
The other aspect of brochures and handouts is that they are never handed out as a replacement for one-on-one client education; they follow the nurse's client education, and are provided "for the folks at home".......the value is in the narrative the client hears and discusses in the consult room.
One picture is worth a thousand words, so ensure the pictures are those you believe in and want to share with clients.
Weed out the brochures that are not targeted to your practice's Standards of Care, and do not "waffle" when it comes to a consistent message for clients.
The selection of client education material varies from practice to practice and the better practices use a mixture of techniques to ensure there are methods compatible with the specific needs of most clients. The recurring cost may be minimal for those practices that use exclusively vendor supplied resources, or can range into the hundreds of dollars per year for those practices that customize most of their client education material. Clearly, the importance of client education to veterinarians (and affordability) differs substantially between practitioners. The basic components of a client education program are a combination of custom material (e.g., practice brochure), vendor references (e.g., vaccination literature), and audio-visual resources. There are benefits to each of the options:
Audio-Visual - Most practices in the U.S.A. have now changed to the videotape, audio-visual format of presentation, and a few have web-based capabilities. Some still use a self-produced computer slide presentations. The early veterinary videotape programs were ineffective because of the length and too much technical information. Clients do not need to become professionally educated, they just require an increased awareness of the needs. While the initial cost was traditionally expensive, especially with a viewing system in each consult room, the ability to utilize the systems for staff training pays for the system in saved leadership time. The selection of short (less than 5 minutes), client education videos has increased, as have the staff training video resources. The advent of PetCare TV started a new era, and while there are now mimics, and there will be more, it is the "ad" inserts that make the difference for client friendliness.
Practice Brochure - This one piece of "emotional" promotional material needs to be an educational effort as well. Most clients are unaware of the scope of services, the technical expertise, or the diversity of training available in a veterinary practice. Beware -- a brochure is not a client rule book; it needs to be a client enticement. This applies to food animal and equine as well as companion animal practices. Practices differ by more than appointment hours and location, but most clients are never told anything further. A well illustrated practice brochure goes a long way to tell and show clients what happens "behind the scenes" in their veterinary hospital. Credit systems available, staff's special interests, and descriptions of what the practice really provides add to the usefulness of this practice building tool, but the presentation must be addressed to the feelings and emotions of the client, not just the logic of the practice. The website used by most practices starts as an electronic practice brochure, but need to become dynamic web sites with client benefits.
Practice Web Site - This is Gen-X and Gen-Y mandatory, but remains an "emotional" promotional communication system. The material needs to be an educational effort as well as an informational resource. Many clients would like a second opinion, so linkages to your favorite specialists are useful. Many practices link to the AVMA client site www.npwm.com to reinforce their shift to a semi-annual life cycle consultation format. The genetic predisposition web sites (www.upei.ca/cidd/intro.htm or www.vetsci.usyd.edu.au/lida) are highly useful for promoting the need for routine laboratory screening (urine, blood, PCR, etc.). We have practices that have their Wellness Standards of Care programmed against a weight/breed/age breed profile, so clients can insert their pet and find out what is "needed" for appropriate care. As a problem solver, linking your web site to www.PracticePartner.com provides great information at the client's level of reading comprehension. The use of an in memoriam for deceased pets often helps resolution, since clients get to enter their own thoughts under the pet's picture. A new pets pictorial (with client approval) also provides a changing set of "cute" pictures that many clients really like to visit (insertion of occasional placebo pictures, e.g., a prehistoric raptor, often excites the younger family members). Some practices have even linked to a dinosaur coloring page website to increase search engine hits by younger family members. Beware -- a web site must change regularly to keep it interesting and provide clients reasons to return.
Newsletters - The regular newsletter gained popularity during the 1980's and lost favor as we entered the 1990's. This was a mistake, and most have corrected their oversight. The newsletter is one of the five to six exposures leading to the call for action - it is an informational resource for caring Pet Parents. When a postcard or e-mail call to action reminder comes to the client, those who have had previous information (e.g., seasonally targeted newsletter), immediate response rats are increased. Each contact is a bonding activity, and a newsletter offers enhanced knowledge. It provides each client with the written word to be read at leisure. When a client is "listening" to the veterinarian, the comprehension is generally below that of reading similar written material. The written word has power -- it can be shared with a spouse at a later date. The newsletter in a food animal practice is a very good way to increase producer awareness of changes in the industry and wellness standards which may increase yields. A "new client" newsletter could be developed and maintained at the reception desk to introduce both new clients and phone shoppers to the practice team, the practice facilities, and the practice philosophy of excellence and care.
Handouts -as discussed previously, explanatory handouts have become critical to practice communications. Besides the promotional literature by the vendor, there are books of individually tailor able handouts available, as well as computer-driven narratives, to insert into the final invoices. One practice developed an "Owner's Manual" for households with new puppies and kittens which follows the format of new car booklets. Instead of "thousands of miles" between check-ups and maintenance, they used "pet ages" and got a great client response.
Veterinary Staff - The delivery of all of the above is best done by a veterinary nurse or nurse technician in the quiet retreat of a consultation room. This person has the client's ear, does not talk "doctor's talk" too often, and has both the compassion and the time to spend with the clients. If the doctor does not routinely use an outpatient technician nurse, then the doctor is either: 1) doing technician work or 2) shortchanging the client on information. Neither is profitable!
The tail will keep wagging if we can give clients an economical way to spend the small amount of discretionary income on their pets. When the client calls, they do not want to hear the laborious explanation of an untrained receptionist of why the practice's prices are so high; the good pet owners want the best value for the best price. This is where the well-trained client relations specialist decides to keep the call or pass it to a nurse technician. So please, answer their question directly, using ideas from the following:
Q - How much is a dentistry?
A - Do you have pet medical health insurance?
Q - No why?
A - Because if you did, our adolescent dental is less than $80 after reimbursement!
Q - How much are the annual vaccinations?
A - Do you have pet medical health insurance?
Q - No why?
A - Because if you did, our booster vaccination, with a nurse's consultation, is less than $20 after reimbursement!
Q - I saw the Purina ad about semi-annual blood testing; what is the cost?
A - Do you have pet medical health insurance?
Q - No why?
A - Because if you did, our full life cycle screening blood chemistry is less than $30 after reimbursement!
Supplemental & Optional Statements
Since you are worried about cost, let me send you a couple of pet insurance brochures, and if it looks right for you, please call the respective companies or visit there web sites. It is not practice exclusive, so if you need to use an emergency practice, or we need to refer your pet to a specialist, the insurance is still in effect.
Since you want the best price, the wellness care portion of these wellness rider policies provides over $2 of reimbursement for every dollar of premium...... two dollars back for every one spent is the best deal on the street today! Both VPI® and Pets Best® have been industry leaders, and there are four others who have entered the American market; they also have monthly payment plans.
Pet insurance premiums are age dependent, so for $15 to $25 a month, you can receive coverage for sickness, injury, and wellness care, and with over $215 dollars of wellness care reimbursement available a year, even if your pet does not get sick or injured, you can receive more reimbursement that what you paid in premiums.
Care Credit® offers a pet credit card with 90-days same as cash........if you use that in conjunction with pet insurance, the pet insurance reimbursements usually comes to you before the first credit card payment, so you are using float money to pay for the pet care......it is worth looking into the program.