Structuring Your Practice and Team
World Small Animal Veterinary Association World Congress Proceedings, 2007
Carole J. Clarke, MA, VetMB, CVPM, MRCVS
Mill House Veterinary Surgery and Hospital
King's Lynn, Norfolk, UK

What do we mean by team structure? Teams and practices are never static. Practice, staff and clients all have changing needs and expectations, and the need for innovation has never been stronger. Each member of your staff has their own skills and attitude and harnessing their enthusiasm is essential for success. Practices must adapt their structures to fit their people as well as the other way around, and a hierarchy which worked a few years ago may be entirely inappropriate today. Similarly, a structure that works in one practice may not work in another. This is often one reason why recruiting skilled staff can be so problematic--they may be used to a structure and relationships they have become comfortable with, and moving into a different team environment can be at least unsettling and at worst a sources for major stress--on both sides!

Recognition and Challenge

Many practices start out with a hierarchical model, but as the staff develop knowledge and skills, the hierarchy blurs and a flatter team-based structure may become more appropriate. The aim of induction is to develop essential skills and confidence in your staff to the point where they can self-direct their learning and their work. Ultimately, if they can work independently to meet and exceed your expectations, and those of your clients, you will have succeeded in integrating them into the practice. If, with their colleagues, they can move the practice forward, develop new ideas and services and improve profitability, you may ultimately find that you can stop worrying about directing your staff and start to think more strategically. You may even find the practice can manage itself without you! A structure that traditionally was vertical with information cascading downwards, now becomes flatter with information travelling in all directions. Maintaining efficient communication and consultation in the flatter structure can be a challenge, and may require some creative thinking.

Job titles can be very important in the development of your people--people thrive on recognition and their own job satisfaction, and so how they are referred to within the team and to the outside world can be extremely important. On the other hand, titles can impede progress. Having one 'Head Nurse', or 'Senior Vet', for example, can mean that someone with aspirations may have to leave to achieve that recognition elsewhere. An 'Assistant' title can stifle creativity or empowerment. Finding a way to recognise responsibility without elevating just one person to a senior position can be very liberating and motivating for your staff--and keeping experienced people is becoming one of the major challenges in veterinary practice. Of course, individual personalities can have a huge effect too!

Historically we have been fortunate as a profession in having a ready pool of enthusiastic young people who would love to work with animals. They have been willing to work for relatively little reward and veterinary practice has been a fantastic opportunity for these people to grow and develop into skilled and confident young men and women. The problem is, where do they go from here? If we cannot offer them meaningful work challenge, genuine job satisfaction and appropriate recognition, they will leave for pastures new. The loss of our trained assistant staff is not necessarily a sign of failure--it may indicate the level of opportunity we have opened up for them in the wider world of work. To address the issue of staff retention, we must look at ourselves, our practice philosophy, and the needs of our clients to open up these opportunities within our own workplaces. It is much better to give the responsibility and recognition that an employee craves within our own structure, than to make them look for this elsewhere. It costs more to keep experienced staff, but they will make the practice much more money if used effectively.

Core Values

In our practice, we see successful interpersonal communication as paramount within our teams. Structure is secondary to this, and our philosophy is that everyone in the practice has an absolutely equal role and responsibility in the success of our business. Although some people lead more than others, everyone has their opportunity to lead, to initiate ideas and actions and to be recognised for their efforts. Our structure follows the activities of our people, not the other way around. So what do we value?

 Continual improvement in our technical skills and knowledge

 The means to use these to benefit our clients and the patients in our care

 Assertiveness (everyone receives assertiveness training and coaching)

 Flexibility

 Cross-training

 Mutual respect

 Understanding of everyone's job roles and day to day work responsibilities

 No barriers (free trade)

 Individual responsibility and accountability

 No blame culture

 Problem solving skills

 Standing in the customer's shoes

These values are introduced from the first day of induction, and we all sign our very own 'Code of Ethics' by which we work day to day. The code was developed by the whole practice, is reviewed regularly and is a valuable self-help guide for when things go wrong or relationships may appear strained--the answers are usually there (or in the assertiveness training!). If our own animals are sick, we make an appointment like everyone else. At work, we behave professionally, and take our work seriously. Apart from an annual evening practice meeting, all our meetings, discussions and training are in working time. We continually review working time and rotas according to need and to accommodate part time returners, CPD and other demands on our time. Cross training is part of induction and equal opportunity to work in different areas is essential.

In our own knowledge based business, we keep our professionals on the front line, dealing directly with clients, and our support staff (admin, IT, cleaning etc) behind them, helping them do their job. This is the opposite to some practices and businesses who hide their professionals behind a wall of customer service personnel or reception staff. Our professionals are directly responsible for customer service at all times, and we have recruited them to be enthusiasts. We are very fortunate to be in direct contact with our customers every day--we can listen to their concerns, talk to them about their expectations and act directly to influence the service they experience at the time it is given. This is a fantastic opportunity to manage our activities on a daily basis and really achieve excellent customer service. We can do and learn things in our day to day work that other businesses have to achieve with huge marketing and survey expenditure, consultant activity and process and outcome monitoring. If each individual is managing the customer interface in this way, and communicating information with others, we reduce the requirement for formal protocols, rigid systems and unwieldy communication processes. Buy-in is automatic.

Information Technology

Our IT system is a member of staff. We effectively pay it an annual salary and expect it to support our work with a minimum of fuss. Effective use of IT doesn't just give you good management reports--it makes communication easier and reduces the work of the customer interface--appointment booking, arrivals, waiting lists, record keeping, payments, stock, lab and referral reports, client information leaflets etc. Many of these actions can be carried out directly by the professional vet or nurse without an intermediary--much more efficient and also client friendly. Our clients are often on a tight schedule with children, work and other commitments. They want an efficient face to face service with someone they know and can trust will give them the right answer and meet their individual needs, not follow an inappropriate protocol. They do not want superfluous information.

Stress

A year or two back, we worked on a practice stress risk assessment and strategy for reducing or avoiding stress in the workplace. Everyone completed detailed questionnaires, and we discussed the issues thrown up by this project as a whole practice. Everyone had their own stressors and attitudes to stress at work, but there were some common themes. Predictably, one of the main sources of stress for veterinary surgeons was the inability to control work flow. When everything went according to plan, things were fine--but unexpected cases, emergencies, complications and unexpectedly long procedures were all contributors to stress. Flexibility within the team was a helpful strategy--easy negotiation with others to cover and take over work at stressful times was one major way of handling the stress. This can be the veterinary equivalent of production line stress--where factory workers cannot alter the speed of the conveyor belt and have to maintain a set speed of work to keep up. Structuring the team and the day rota to allow vets to plan their work, communicate their plans and allow some flexibility is helpful, as is mutual respect and cross training--all in our core values.

Our nurses found that their main stress factor was conflict of expectation. As excellent customer advocates and service givers, they find it very difficult if they are not party to all the information they need to give what they consider to be excellent customer service and information. Sometimes, when following up a veterinary surgeon's discharge, their lack of direct knowledge about a case can produce feelings of insecurity and worry which is exacerbated by their desire to be able to answer every question without having to refer to the clinician. None of the veterinary surgeons really understood this conflict until we discussed it as a result of the questionnaires. Clarifying expectations, as well as communicating information is a valuable strategy for reducing stress which is often the result of trying to give the best customer service both to clients and within the team.

Encouraging Development of Your New Staff and Keeping Them

Induction is just the first step--next, the practice has to be sure it is aware of each individual's strengths and weaknesses and is using these to achieve real results and job satisfaction for that employee. In general it will take six months to a year for a new person in the practice to reach full productivity, and for those acquiring professional technical skills this timescale may stretch to three years or more. It is important to allow time to settle in and gain initial skills, but not to leave further development too long--as that initial enthusiasm your new vet, nurse or receptionist had on day one must be harnessed before it wanes away. Finding small areas for developing responsibility allows people to gain confidence and organisational skills, so they can move into more difficult areas. Make sure you have thought through what you are trying to achieve and give adequate training. If people are promised responsibility, only to be undermined or have it taken away later, they will quickly become demotivated and may leave. People given responsibility with which they are uncomfortable or for which they are not prepared, will become stressed, unhappy and suffer loss of performance. Every practice has some untapped potential.

What happens to your own people as they progress through their first year or two? What is your staff turnover, and why do people leave? Are some teams more of a problem than others? Is low staff turnover holding other practice members back? Is there any reluctance to take on new ideas, or are your long-serving staff still driving the business forward with the same enthusiasm they had years ago? Are there any members of staff with a can't do attitude or a reluctance to discuss issues, take up new ideas or mentor and encourage newer members of the team?

Now look in the mirror--which category do you fall into? Are you eternally positive with a mind open to new ideas from outside and from your own staff and clients? Are you delegating sufficiently to your staff, and are your nurses nursing or just assisting? Your staff will mirror your own attitude so start with yourself and look at your own motivation, work pattern and work-life balance. Now ask yourself how much you really know about your staff. What motivates them to come to work every day? Are they more productive outside work than during the hours you are paying them? Are they using skills outside work that you are not harnessing for the practice? Are they hanging their hearts and minds on the cloakroom peg along with their coat when they get to work? What other demands do they have on their time, commitment, loyalty and emotion?

As time goes on, job roles may change--with or without your knowledge. Keep on top of the issues and encourage change where it is indicated. If you feel your practice needs a shake up to get the best out its people, involve them in the process. This requires trust and space from you as the boss, as well as acceptance of the values listed earlier. Post-it note brainstorming techniques can be helpful here as can noting down every issue which seems to hamper effectiveness. At the end, review to ensure all the issues have been addressed or are programmed for discussion at a future date if you run out of time. Facilitation skills, negotiation and problem solving skills are outside the scope of this paper, but professional training in these areas is strongly recommended for all your staff. Let your staff surprise you by giving them the opportunity to sit in the front seat!

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

Carole J. Clarke, MA, VetMB, CVPM, MRCVS
Mill House Veterinary Surgery and Hospital
Norfolk, United Kingdom


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