Thomas E. Catanzaro, DVM, MHA, FACHE, Diplomate American College of Healthcare Executives
Since I am a Charter Member of the Delta Society, I was strongly influenced by Dr. Leo Bustad (the true founder of the American human-animal bond movement) from the very beginning of my quest to embrace the bond (over three decades ago). I still remember many of the words he shared, sometimes over a quiet dinner, and more often, when he was promoting the bond in the "early days", when most people did not understand. His passion is what we all need to find, so here are some thoughts by Leo that he wrote in 1988:
For as long as I can remember, I've been thankful I had extensive exposure to a variety of animals and that my parents impressed on me the importance of treating animals gently. During my professional career, I've observed the many benefits that contact with animals has on people of all ages and conditions. As Dean of the College of Veterinary Medicine at Washington state University, I studied the significance of animals throughout our society, and I am deeply distressed by the casual disregard for animals' well-being manifested by many people. Irresponsible pet ownership is widespread. I am also disturbed by the lack of behavior training: such training benefits both animals and people in numerous ways.
I realized something had to be done. The relationships between people and animals are important and beautiful. We link ourselves with the world of nature through the animals that share our lives. We marvel at the sheer physical appearance of animals - their eyes, coats, fins, feathers, and their movement. We feel enriched by the obvious pleasure our pets take in our companionship, and we are touched by their sensitivity to our moods. We also derive many practical benefits from our animal companions. In caring for our fellow creatures, we express some of our finest qualities and it is normal to develop bonds of love with animals that are as powerful as those we experience with people.
In regard to our place on planet Earth, my views, like other authors in the human-animal bond literature, are consistent with those of many Native Americans. I live in the Palouse of eastern Washington and western Idaho - the land of Chief Joseph and the Nez Perce. These ancient Native Americans, who refer to themselves as "The Real People", have a profound comprehension of reality and truth. The word "religion" is not in their vocabulary, for everything has sacred significance. Nature is Mother Earth, and the minerals within her, the vegetation that springs from her, and the animals that roam over her, are sacred. They, along with other groups of enlightened inhabitants of our planet, believe that animals, plants, and the earth are like vital parts of our body - if these parts are compromised, we seriously harm ourselves. To remain healthy, we must maintain a respectful relationship with all the elements of our environment. A strong people-animal-environment bond is crucial to a healthy world-wide community.
The new millennium will see many claim to be "bond centered" veterinary practices. Some will implement the programs listed herein that make them money, but will not change their approach to staff nurturing or veterinary healthcare delivery; these are not "bond-centered" veterinary practices. Some will endorse the Delta Society, join the American Association of Human Animal Bond Veterinarians, and attend all the VetOne meetings, but will not become the patient advocates willing to take a stand and tell clients what is needed; these are not "bond-centered" veterinary practices. So where do you start?
The human-animal bond is impacted by the environment, sometimes even with feral and wild animals; we usually cannot control the environment, but we can appreciate the relationship. The human-animal bond is impacted by the community, and there is variable influences a veterinary practice or it's professional team can contribute (pet population control activities, leash laws and other regulatory interaction, pets by prescription in the school system, humane society support, animal impoundment activities, abuse/neglect expertise (Title 9, CFR), assistance animal support, etc.). The major impact of the bond-centered practice is the client-centered healthcare delivery as patient advocates.
The combination of quality veterinary healthcare delivery programs and a caring heart begins the process, and there are a mixture of steps and elements that must come together to form the "bond-centered" practice. There are less than a dozen elements in the basic "bond-centered" formula, and they are not listed below in any specific order or priority. The offered list is not all inclusive, it only provides a set on common elements, and the expansion beyond these elements is what makes the healthcare delivery of client-centered, patient advocacy, in any veterinary practice an art and science:
Understand the quality required in veterinary healthcare delivery, including the Standards for Veterinary Hospitals as offered by the American Animal Hospital Association (this is not a push for the certification, this is the utilization of the new 2003 Standards, with updates, in daily operations whether you are a member or not; they are available on www.vin.com). Understand that the leadership, programs, and innovation described and developed in the Blackwell Publishing three volume series, Building The Successful Veterinary Practice:, are minimal expectations of practice excellence. Ensure every member of the practice embraces the concepts of patient advocacy, clinical competence, and celebration of the human-animal-veterinary bond. The American Veterinary Medical Association, www.avma.org, keeps publishing position statements and clarification of emerging community issues on their web site, yet most veterinarians do not take the time to stay informed (this could be assigned to an interested staff member for monthly staff meeting reports).
When dealing with others, respect life and respect opinions of others. Do not accept "euthanasia" as an initial treatment in cancer, kidney dysfunction, or chronic care. Understand respite care, hospice, and senior friend screening programs for wellness and support in medically stressful times; the study of thanatology can be augmented by review of Chapter 4 on the aging pet, Healthcare of the Well Pet, by Hartcourt Brace.
Never allow pain or puking in any patient. We have too many medications available today to allow any patient to "endure pain" or any client to experience recurring vomiting in their companion animal. Respect the hospital staff, their feelings, and their opinions; monitor their pride as a factor of the quality of the practice.
Ensure staff members are assigned responsibilities for outcomes rather than just process. Accept the responsibility to ensure clients feel good about the treatment modalities, including ensuring they know how and what to feed their companion animals. Don't tell people what not to do, tell them what they can do; help them learn to help people be winners on their own terms.
Cease making healthcare "recommendations" to client.......start clearly stating what is "needed" and learn to then be quiet and listen. When you state what is "needed", write the need with a box, e.g., X-ray [ ] (instead of "recommend X-ray"). Then, after listening, enter the client's response in the box: W = waiver, D = defer, A = appointment, and X = do it! After and "D" or "A", enter the time until the recheck, e.g. X-ray [D]72h (as in, ".......if the limp has not resolved in 3 days, I need you to bring Spike back in fro the X-rays!"). An expanded explanation of effective medical record documentation is offered in the ISUP text, Building The Successful Veterinary Practice: Programs & Procedures (Volume 2).
Become an advocate of quality preventive health care, including the AVMA/FDAH 2004 initiative, http://www.npwm.com/, which is simply, "Since one dog year is 5 to 7 people years, your pet needs to visit your veterinarian twice a year for life." Since the majority of practices are accessed by the female of the family unit, and they have an annual OB-GYN appointment tradition for wellness screening, as well as being "feelers" in the decision process, the initiative automatically makes sense. This also puts the "over 40" physicals (anthropomorphic comparisons are permitted and encouraged) and senior physicals into the flow rather than just an arbitrary "change in practice concern/attitude" at some longevity point of time. The "over 40" physical is a well known healthcare standard in human healthcare in the USA, and should become equally well accepted in companion animal care (Canada, Australia, or New Zealand do not publicize it as well due to the access limitation encountered with socialized healthcare programs). For veterinary practices, this "over 40" physical should include awareness of genetic predispositions: thoracic X-rays, abdominal X-rays, CBC, blood chemistry profile, ECG, plus breed-specific needs (e.g., thyroid and blood pressure in cats, gout in Dalmatians, ocular pressure in "bug eyed" dogs, etc.). Also, the bond-centered practice will stand for standards of excellence, such as: pain scoring, body scoring, dental scoring, nutritional scoring, pre-anesthetic blood screens, pre-anesthetic risk assessments, vaccine protection, flea & tick protection, zoonotic disease screens (e.g., fecals and blood tests), and annual life cycle consultations, which include traveling with your pet and assessment of nutritional needs.
Never quit learning, personally or as a practice. Never defer educating clients in becoming better stewards of living entities; they need professional assistance in learning these new skills. Embrace and support Continuing Education for the practice staff. This includes distance learning for staff members who want to become "certified" in their disciplines (e.g., CVT/RVT/LVT for technicians, CVPM for managers, etc.),. Strive to find new ways to extend the quality of life of all living things, including Subchapter A, Chapter 1, Title 9, Code of Federal regulations (implementation of the Animal Welfare Act). Never quit striving for the next level of excellence.
Manage the veterinary practice from the heart (Bracey, et.al, Managing From The Heart. New York, Delacorte Press, 1990):
H = hear and understand the team members
E = even if you disagree, don't make them wrong
A = acknowledge the greatness within each person
R = remember to look for their caring intentions
T = tell them the truth with compassion
Give recognition, specifically and regularly, so appropriate behavior will be repeated (behavior rewarded is behavior repeated). Appreciate the quest for a balanced life by healthcare providers, and recognize individual contributions for performance during realistic shifts, not excessive duty hours.
Last, but not the least important, is the tone and feel of the practice. When we celebrate the bond, we are celebrating the ability to extend the quality of life of a family member within a stewardship. Every staff member is empowered to embrace the opportunities to extend the quality of life, every patient has the right to access the best veterinary care, and every provider speaks for the needs of the animal at every opportunity. I have discussed client-centered patient advocacy, which is one approach to showing appreciation to the Human-Companion Animal Bond felt by clients and staff. Clients are treated as stewards of living entities who want the best for their family member; healthcare and wellness decisions are not made unilaterally by the practice team.
As the human-animal bond increases the value of the pet in the family, there are inherent and concurrent impacts. Courts may start to award "pain and suffering" findings against veterinary practices who do not fully inform clients of the consequence of the healthcare delivery decisions. In human healthcare, informed consent seldom includes protection to the provider who allows clients to defer or refuse care; courts have found clients do not have adequate knowledge to put themselves into that position of jeopardy. Healthcare standards at veterinary facilities will increase as a systemic expectation, including more aggressive pain management, intra-operatory fluid (IOF) therapy during most all surgeries (e.g., I.V.TKO - To Keep Open), and pre-anesthetic blood screening; the lack of these programs in a practice's standard delivery will become liabilities. The trend will increase the cost of veterinary healthcare, so pet health insurance use probably will increase (some European communities are already seeing in excess of 50 percent pet population insurance coverage). Practices will no longer be able to offer coupons and cut corners (or do "bait and switch" sales), nor will they just absorb the costs of increased quality healthcare; veterinary practices will need to share the value of services with the stewards of pets and charge according.
The "bond-centered" practice.......it may not be well defined in the veterinary profession literature or the family household, but when a client experiences it, they know they have discovered something special. The bond-centered practice can be the differentiation in the community that builds the word-of-mouth reputation, but that is not the primary goal, it is just an additional outcome. The bond-centered practice does not ask, "What's in it for me", as an initial assessment, but concurrently, charges appropriate fees for the exemplary services it provides; we see a referral by word-of-mouth in excess of the magic 60 percent of all new client transaction.
The bond-centered practice is not for all people, some staff and some clients will not "get it". Many people were raised with "barn cats" and "farm dogs", and their basic values do not include patient advocacy for all animals; accept this diversity in the population and be happy when they seek another practice to visit. The bond-centered practice embraces the opportunity to offer a special environment for staff and clients who want to experience patient advocate healthcare delivery. The client-centered service of a bond-centered practice listen to the client and allows joint involvement in decisions; it does not mandate or abdicate in the joint decision process.
The "Z" Story - Zillmere Veterinary Surgery
Australia, Queensland, north side of Brisbane, a depressed community where welfare was the rule, wrong side of the tracks (physically), average family household income was less than $500 a week for over a third of the households, the practice was on a dead end street, in a store front, with no hot water, and the loo was an outhouse behind the facility (but the outhouse was made of brick). When the practice was purchased, it was one 900 sq ft bay, but it was close to the purchaser's mother's house, which is why she was located there. She bought the practice cheap (it had been a shot clinic with desex services) and doubled the gross turnover, then she expanded into the second bay of the store front complex for a better surgery and ward area (still no inside plumbing or hot water), as it plateaued at about $250,000 gross turnover per year.
She had graduated in 1983, had a successful partnership in north Brisbane, left that practice when her second daughter was born so she could commit more time to the children, became a single mom of three girls, and when they entered high school, determined she needed to own a practice again to have the flexibility to support the girls in their school and social activities. She is a clinically astute veterinarian, stays current with a multitude of CE courses, as well as monitoring VIN on a nightly basis. She had been a locum, and then part-time, at Zillmere Veterinary Surgery, to also be close to her ailing mom, so it was natural to buy the practice since she knew the clients and area (it was a single bay, 750 sq foot, converted meat market). In fact, for her entire life, due to family commitments, she had been inside a small walking triangle bounded by her childhood home, her current hone, and the practice location.
In July 2004, she attended a local seminar where Dr. Tom Cat was the speaker. As one of the first Aussie's subscribing to VIN, she knew his name, and decided to take her part-time nurse to the seminar (that was 50% of her staff, which was two part-time nurses).
She knew she was going to hear USA marketing that she could not accept, but went anyway. The seminar surprised her, it was actually on wellness care and building the bond-centered practice, but she kept peppering the "annoying yank" speaker with clarification requests anyway. Afterward, she stopped me and said she was looking at leaving the profession, there were 5 veterinarians within 5 minutes of her front door, a new local discount spay/neuter clinic draining off the desex business, and she had been plateaued for 18 months, and her net income was being eaten away by inflationary trends. I asked her to try wellness care first, starting with addressing bad breath that she already knew was in her patients, but also, she knew clients could not afford dental care, so she hesitated to offer the service. She committed to stating a 'need' when she saw a problem, and then fall silent to listen to the client.
Long story short, step-by-baby-step, she verified whatever I recommended with VIN searches, adopted appropriate pricing strategy for staff-delivered services (e.g., dental cleaning, nutrition, etc.), added one program at a time and cemented it into her delivery system, then as liquidity increased, she added staff and shifted toward team-based healthcare delivery. At the end of the first `12 months, she had grown her practice 43%, and at the end of 24 months, she had four full-time staff and two part-time staff, she had virtually doubled her gross turn-over, and amazingly, we never asked her to increase her fees due to the community economic profile.
Her practice was recognized nationally as a "successful practice" by the end of her first year, she was recognized as a community "visionary leader" in her second year, and now has doubled her new client rate due to word of mouth and community image. In the third year of her evolution, we got her to subscribe to e-Vet Suite, from VIN, and she is now keeping her web page current and exciting without major webmaster costs. This year she is finally addressing her fees, using small incremental steps again, at her normal conservative rate.
Her practice is still growing, often accelerating when she adds new programs. Last year she expanded into behavior management, this year she is adding Canine Photonics Cold Laser non-invasive pain management. She now knows it was her mind-set, not the clients......... as she offered every new program, about 80% of her clients accepted that new level of wellness care; they were in fact part of the 85% of Australians who considered their pet a family member or a best mate.
She is having fun again in practice. She is even considering expansion, with a second practice in a better part of town.......not a rush, not a mandate, just a desire to share her discoveries with other communities on the north side of Brisbane. She is now the visionary and role model for single mom veterinarians, although she does not flaunt her successes. She has shown that success is a matter of mind-set and good medicine, promoting wellness care with the same intensity as acute care. I am so proud of her evolution as a bond-centered practice, using proven American techniques in Australia, and proving clients are Pet Parents, and Pet Parents are similar world-wide.
The bond-centered practice is a wonder to behold; it provides a very special feeling to all who enter. The family-pet-veterinary bond is one aspect to be appreciated, while the people-animals-environment relationships are another aspect of the increased awareness of the bond-centered veterinary practice. This reference text was the beginning in 2001, not the end, of the discussions about "how to get there" with a practice team that cares enough to follow a bond-centered leader in the veterinary profession, community, and greater healthcare delivery system. This is now the second edition, expanded in the wellness programs, and having been an operational cornerstone resource for many practices around the world.
In a Bond-centered practice, the client-centered patient advocate has a workplace filled with harmony and celebration. The new Association of Veterinary Family Practitioners (AVFP) has considered starting a certification program, but it will never replace the bond-centered practice approach to client service and patient advocacy.
The old saying. "Try it, you'll like it", should apply in most every environment, but the fact is, many practitioners want a guide across the void to this new horizon. Please, when seeking a guide, do not accept a cheap imitation - I have seen many come and go, flashes in the pan, especially with VetOne, since it had deeper vendor pockets, and many self-defined consultants follow the dollar rather than the calling. Take a serious look at their credentials (training as well as experiential), their historical involvement in the leading HAB organizations, and ensure their personality matches with the practice culture.
Now go and have a long, heart-felt staff discussion on the potentials outside your practice walls, and how to entice the practice primary providers to start embracing the reason we all enter veterinary medicine - to celebrate the human-animal bond.