In multi-tasking techniques (high density scheduling), The doctor and outpatient nurse work as a team. They have two or three consultation (exam) rooms, and no one is allowed to divert the nurse from supporting the doctor and clients in these two/three rooms. With another nurse, the doctor can cover three/four consultation rooms. Multi-tasking/high density scheduling is based on overlapping the last ten minutes of one appointment in one room with the first ten minutes of the next appointment in the other room. The staggered schedule just means the outpatient nurse loads the other room and does the 3 to 5 minute asymmetry screen ten minutes before the end of the preceding appointment, puts the record with findings on a rack outside the rear door of the exam, then returns to the room with the doctor. When the nurse enters, the doctor knows it is time to disengage and transfer the client education and close out to the nurse, immediately! Then the doctor moves to the other room, reviewing the wellness screen recorded in the medical record by the outpatient nurse and left on the rear door of the examination room. In many practices, there is a pharmacy float, to draw meds, place prescription labels, deliver the drugs to the consult rooms and act as another set of hands for holding animals.

Marketing Advantages

As yellow page advertising and media marketing increased, the quality practices centered on service to differentiate their facilities in the eyes of clients. Phrases like, "evening hours," "emergencies welcomed any time", "walk-ins welcomed", "Visa, MC, American Express and Discover." "weekend hours," "Care Credit Accepted", "Pet Insurance Honored" and other improved client-access factors appeared. This was very effective for the well-informed or well-bonded clients, but the less-bonded and poorly informed clients still pursued the cost savings with vigor. Interestingly, the lower end (discount-type) practices have been most susceptible to failure during the recent recession. For the first time in history, the 1990s saw veterinary practices closing in response to hard times (reportedly at a ten percent rate in Toronto, Colorado Springs, Oregon, etc.); in 2000s, walk-aways were occurring in other communities as a Gen-X and Gen-Y response to adversity and low client flow.

The annual Pfizer client research at the turn of the millennium showed that Saturday hours were still the most popular, but as more practices offer early evening hours, the pressures of Saturday are being shifted to 5:00 p.m. to 8:00 p.m. during the week (second most popular time) and then commuting clients look to Sunday hours. While this is not all bad, the tendency during these hectic appointment times is to just treat the problem and not the patient. The need for return visits are overlooked, the more intensive diagnostics are waived or deferred, and some concurrent or underlying problems are never addressed. Shifting away from quality veterinary healthcare costs the practice net income, even if it increases the gross due to volume. There are quality of life options available, even with only two doctor scheduling: Two unique, extended time off, options are shown below:

Asymmetrical Two Week Schedule

or

Asymmetrical One Week Schedule

In the later case, the new associate (usually recent graduate who "hates mornings") is given four "party" evenings a week, as well as weekday access to ski runs, beaches, hiking trails, malls, and shopping, during minimal tourist/family traffic times; the single owner who has been working 24/7 for years is now rewarded with three day weekends to get to know their family again. The best aspect of this later "new associate" schedule is the new doctor has the highest productivity times, so with multi-tasking, team-based, high density scheduling, they can drive $1,500 to $2,500 in personal production each day (that is $6,000 to $10,000 per week, or $300,000 to $500,000 per year, which at 20% productivity pay, does well to pay school debts). Our consulting firm established the VPC Brokerage at the turn of the century to prepare practices and owners to have "smarter" hours when employing new associates at a livable wage, and after four years, the systems we promoted became mainstream, so we could close the brokerage. We use the same type "leverage the doctor time" logic as we assist in placing practice administrators in the larger or specialty practices.

There are companion animal practices established with appointment hours only from noon to eight p.m. They support a "bedroom" community of commuters. There are practices which have morning appointments until 10 a.m. and do not schedule appointments again until after 3 p.m.; surgery is a mid-day activity, as are mobile home calls. New companion animal veterinary facilities are being built with an odd number of exam rooms, so the doctor - nurse pairs can work two rooms and the odd room can be used by the inpatient team to see walk-ins and emergencies in a timely manner, without disrupting the high density scheduling. In August 2007, the first Dr. Tom Cat designed, team-based multi-tasking veterinary hospital opened in North Nowra, New South Wales, in Australia; they are still being amazed at the ease of multi-tasking and staff leveraging of veterinary healthcare delivery. This is supporting the emerging multi-doctor practice business profile, emerging as the standard during this past couple decades, capitalizing on team-based healthcare delivery.

The profitable one-veterinarian practice has all but disappeared; relief doctors, needed for quality of life, greatly eat into the profit margin (paying a quality relief veterinarian for an average of two days a week actually equates to a full-time associate's compensation). There are still single doctor practices, usually caused by established practices that do not want to build colleagues or succession plans, so we see the store front start-up situations, where emergency practices are already established. Mature companion animal practices are averaging 2.6 veterinarians per facility, but we are seeing more larger facilities in metroplex locations.

Compounding the scheduling problems of extended hours has been the inherent fear of client fee resistance, usually unfounded (except for quotables) in an established practice. As a rule, during the 1990's, veterinary practices found their gross slightly increasing, but the net was often decreasing. The client's ability and willingness to pay for services had been put to the test, and as practices raised their fees, and the average transaction charge was going upward, many practice owners felt they had started to reach a discretionary spending ceiling. After the 1999 Mega Study (price was the #9 decision factor for clients), and NCVEI fee profiling, the ability and willingness to pay appropriate fees appeared to have been veterinarian based and not client demanded. The smarter practices developed discharge planning programs that increase the client return rate rather than the centering on the average transaction fee. Using more "smaller ticket" visits, over a period of time. Often with nursing staff, supported the perception of lower costs; it is the client/patient return rates, not the infamous Average Client Transaction (ACT), that made veterinary practices successful. NCVEI shifted from fee profiling to communication enhancement in 2006, reflecting the realization that it is how the programs are shared, rather than the price, which provides program successes.

The greatest "demand" for extended hours is usually competition from other practices (fear of losing clients). The United States and Canada have increased the number of graduates during the latter part of the last century, and Australia is expanding teaching hospitals during the first decade of this new millennium (although OZ already have the largest density of veterinarians per capita of the English speaking countries). Almost every suburban and urban animal owner, regardless of country, now has multiple veterinarians to select from when they need local veterinary healthcare services. For this reason, the fear is real. If you close Saturday, the clients will find a different practice. If you take a vacation without a relief veterinarian, clients go elsewhere, and some never return. Inversely, in an inner city Denver practice, we noted clients often came in for urgent care at the 5:30 p.m. closing time, keeping the doctors and staff busy until about 7p.m.......so we sent announcements to all the clients stating that they were shifting to early evening hours (open until 7p.m. for commuter convenience) and ceasing Saturday hours, so staff had time to relax and recharge....... from first 100 clients surveyed, 10 gave accolades to the owner, and one stated disappointment, the other 89 stated it was equitable and okay. In communities without competition, Saturday hours are less important. If you are the only game in town, you set the table rules!

To get a multi-veterinarian practice into a quality of life program, we often use the basic prototype of a two-week scheduling cycle for the professional staff (as shown above). Simply, the starting sequence for planning is two days on, one off, three days on, one off, four days on, then a three-day weekend. The second veterinarian starts the same schedule, but a week later. In a two doctor practice, this single staffs the practice on Friday-Saturday-Sunday, but double staffs it on Monday, Tuesday and Thursday (Wednesday is church night in many communities, so we recommend not fighting it); multi-tasking of the higher density scheduling resolves the lower access seen with linear thinking scheduling. The double staffing days allow for evening hours because one veterinarian can come in later (e.g., 11:30 a.m.), start with desex surgery (OHE and castrations are time scheduled elective surgeries, and with reversible/low residual induction agents and gas anesthesia, they are fully awake within a hour of the surgery time), do food and phone from 3 to 4 p.m., then work high density, multi-tasking, outpatient appointments until 7:00 or 8:00 p.m. with evening appointment hours.

The bottom-line is that we are a caring and dedicated profession, a group of healthcare professionals which respond to the obligation which started with Noah tending for the animals on the ark. The obligation to serve must be matched to the obligation to live (or sleep in the case of farm calls), and the compromise is a personal decision. As the profession expands, the need to cooperate with our competing colleagues will outweigh the need to draw clients away. Be the first in your area to generate professional conversation concerning meeting the community's needs through rotating office hours. Meeting the needs of clients while meeting the needs of your staff and self will be important in the latter years of this decade.

Veterinary Practice Effectiveness Begins with the Appointment Log

The Geography

 If you cannot make your computer do multi-tasking, high density, scheduling, call your vendor. For a written example, review the Signature Series Systems & Schedules monograph at www.v-p-c.com

 The "Surgery Column" allows the client and patient to be scheduled for an early morning arrival (before 7:55 a.m.).

 The "Drop Offs Column" are for early arrivals, whether they are early appointments, drop-offs, or day care (insert your own times as desired).

 Most practices have core appointment hours within the 9 a.m. to 6 p.m. period, with some form of staggered lunch break.

 There are appointments over the lunch break (usually single staffed with a doctor), so use the full width if "lunch time" appointments are desired.

 The "5-minute" schedule endings cause far greater client compliance in arriving on-time since it sounds so exact (please don't disappoint them).

 The after-7:00 p.m. appointment needs could be scheduled into the "Call Back" columns (times inserted as desired).

 With 2.6 doctors per clinic, the third "doctor" column can be for technician outpatient time (nutritional, parasite, dental, behavior, etc.).

 Ensure ten minutes are blocked each two hours across both columns as "emergency space" for the client who wants to be "seen today." It is enough time to admit for day care, regardless of the reason (or it serves as coffee time or catch-up for the doctor when not scheduled).

The Schedule

 Initially discussed in Building the Successful Veterinary Practice: Programs & Procedures (volume 2). After guidance, this should be the front staff's duty (not doctors).

 A standard "sick call," with a full doctor's consultation, for an established client, is seen as 20 minutes (two spaces).

 A practice can add ten minutes to the "standard appointment" for: exotic pets, a second animal, each new client, an ophthalmology problem, etc.

 An extra ten minutes can be scheduled as a senior citizen benefit. Social time is often more critical to them than the traditional ten percent discount.

 A single ten-minute space can be used for: recheck, suture removal, vaccine clinic, heartworm screening clinic, etc.

 Add 10 or 20 minutes to each appointment for a new graduate. Only ten extra after 90 days, and no extra "orientation" time after six months.

 Non-availability of doctors is monitored by the receptionist team and the log is annotated (long lunch, surgery, late arrival, early departures, etc.)

Click on the chart to see a larger view.

High Density Scheduling Example