Thomas E. Catanzaro, DVM, MHA, FACHE, Diplomate American College of Healthcare Executives
Millions of U.S. pets aren't receiving the best care and treatment available. Compliance is essential to a patient's health and well-being...... the biggest obstacle to compliance is the veterinarian's own misconceptions about pet owner's willingness to act.
Dr. John Albers, Executive Director AAHA
"Compliance"..... wouldn't you know this profession would use a phrase that blames the client, while the very expensive AAHA study specifically identifies the veterinarian as the primary culprit in the delivery of substandard care.
Where Does it Start?
Most of us entered veterinary medicine because we cared about animals, and most every staff member entered this profession because they care about animals. Pet owners have become stewards to their companion animals because they care about those animals and access veterinary care because they want assurance of health as well as personal peace of mind. Remember the numbers from recent surveys in this millennium, 89% of Americans, 85% of Australians, 75% of Kiwis, 81% of Canadians, and 91% of the UK pet owners consider their pets members of the family or best friends, and a third of those give the pet child status. This is the era of veterinary practices serving "pet parents".
Then veterinary school influence occurs. People who have lost contact, or do not understand anything about private general practice train the future veterinarians. They are specialists or specialists in the making, are supported by the state in most cases and they want 45 minute appointments (the recent Pfizer studies of 35,000 to 37,000 clients, three years in a row, showed 85% to 87% of the clients want to be in-and-out of the general practice's consultation room in 20 minutes or less).
Most veterinary teaching hospitals have twice the expense as income, yet no one seems to care. A private practice could never operate with this ratio, yet this is the environment where students are "educated" about the business of veterinary medicine. Students are told, "You cannot afford to do this in practice!" or "Only specialists can do this, so you must refer these cases." And we wonder why most veterinarians seem to discount as a matter of course? We just consulted with one New York practice doing $1.5 million a year, but they had no cash flow (liquidity); they had discounted $200,000......and not charged for $300,000 of work during the same $1.5 million year. No one can give away one third of their earned dollars and expect to stay in business.
Then there is the paradigm of practice reality. The VTH is not the location to learn business, human resource management, profit center development, or even effective case mix management. In human healthcare, private practitioners go together and hire a skilled, and often board certified, medical administrator to manage their practices, human resources and business affairs (www.mgma.org).
The first practice a veterinarian works at usually sets the "business sense" barometer; therefore most veterinarians try to do it all themselves, or worse, make their spouse accountable, who is less skilled than they are in healthcare business operations. That "first practice" experience is where the new veterinarian learns about time-motion-productivity (or ineffective doctor-centered scheduling in most cases), as well as how to utilize the staff (or not utilize, as in most cases). The doctor-centered veterinary healthcare delivery system has successfully perpetuated ineffectiveness as a management model, and then we wonder why a practice cannot leverage their production capabilities.
Only veterinary accountants dare provide a business with a Profit and Loss Statement (Income Statement) that only shows "Sales" under revenues. Every other business in the world knows how much of what they are selling.
Only veterinary accountants dare mix cost of professional good expenses into a single pile of useless information. No one else would take a 2.2-2.5 mark-up item (resale pharmacy), and mix it with nutritional products (30-40% mark-up), then add in flea/tick/heartworm products (60-70% mark-up) and medical supplies (at wholesale cost). It is the relationship of income to expense by line item that shows the profit margin.
Only veterinary accountants would ignore the industry standard Chart of Accounts and tell their clients to use some un-calibrated system which defies comparisons.
When comparing yourself to any published National averages, never forget the definition of "average":
Average = the best of the worst - or - the worst of the best!
There is virtually no veterinarian who wishes to be either.
In a recent employer survey of the new veterinary graduates, the number one shortfall (barrier to success) was the lack of "life skills". New graduates did not know how to talk to clients, they did not know how to show respect to the staff, and they did not understand the relationship between performance and pay check. Regardless of what the accountants told us in the expensive AVMA's Mega Study in 1999, this has proven to be a generational issue, not a gender issue. This generation wants a balanced life from the first day of employment, and are unwilling to practice the hours which practice owners did 20 to 30 years ago. In the "golden years" of veterinary medicine, a new graduate would go work with a practitioner and learn about the business of veterinary medicine (often it was the "James Harriot" cigar box on mantle system, but it worked when there was minimal debt). Today, the new graduate has enormous debt, as does most start-up practices, and there is a critical need to know net income relationships to services and products, yet most current practice owners do not know how to quickly and effectively assess net income and liquidity.
In the Signature Series (30-plus single-topic publications, about 50 pages, each with a topic-specific CD-ROM tool kit, available from www.drtomcat.com) there are many monographs which develop business skills, including but not limited to: Fundamentals of Money Management, Profit Center Management, Leadership Action Planner, Performance Planning, Inventory Management & Maintenance, as well as Models & Methods Which Drive Break-through Performance (written for the top 40% of veterinary practices who cannot use National averages as a yardstick). Okay, once we know where we are, and we can measure what we are doing, we can move forward and change what we do, or how we do it, for better business and practice outcomes.
So What is Compliance Then?
Compliance is the doctor and staff having core values and standards of care that is inviolate. Compliance to core values and standards of care means they are inviolate, that all staff and all doctors say the same thing to clients, especially for wellness care and professional needs. Without a consistency between doctors, staff cannot be effective extenders.
In the U.K., they speak of clinical freedom, and while we agree there is a need for this in case management (curative medicine), there is no reason wellness standards of care (SOC) should not be established by protocols and be very consistent between providers in a practice.
A practice which also variation in wellness screening causes two things to happen:
1. Confusion between clients when they have seen different providers
2. Frustration in the staff when they have been contradicted between providers
Neither of the above options is how a practice bonds clients or staff to the practice, nor how they can get increased consistency in the SOC applications. The choice is yours - think about it!
Veterinary practices are no different than any other business, except most of us feel it is a calling rather than a job. There must be protocols and common expectations if the staff members are to become veterinary extenders. The staff cannot have trepidation when it comes to stating the wellness standards, pre-surgical protocols, or preventive medicine expectations. Example questions to ask yourself include:
What animal, what species, what breed, what age, what sex, is it always safe to induce anesthesia without some form of blood screening? Answer: None! (So why has pre-anesthetic laboratory screening been optional?)
When is it humane to leave an animal in pain? Answer: Never! (So why has pain medication been optional?)
What percentage of companion animals (cats & dogs) need to be on heartworm medication? Answer: All! (So why are less than 60 percent currently protected?)
Which animals need to be screened for internal parasites, including the protozoa threats, at what frequency? Answer: all that have ANY outside access or reside with other animals in the household! (So why do some practices state the heartworm medication treats for all internal parasites?)
Shouldn't clients who come in more often, and keep their pet's dental conditions treated, be afforded a lower cost for a grade 1+ dentistry (about 2030 minute procedure by a staff member) than a client who has let it progress to a grade 3+ oral surgery (about a 60 minute procedure by a doctor)? Answer: yes! (So why doesn't every animal have a dental grade in the computer?)
Sequential weights are a diagnostic aid, so shouldn't each have a body condition score (BCS) associated to them so we know what the previous provider stated? Answer: yes! (So why are there no fields for BCS, and why doesn't the practice track BCS on each animal?).
Research shows that pets can live up to two years longer when on highly digestible premium diets, so shouldn't clients be told this? When an animal has a 10 percent weight change, is that significant? Answers: Yes to both questions! (What has been stopping you from assigning a nutritional counselor to each adult patient?)
As animals live longer, genetic predispositions begin to show up more often. We recommend one of the following sites be hyperlinked to your practice's web site, as well as being provided clients as part of the life cycle consultation explanation (only the first one is NOT a university site):
www.upei.ca/cidd/intro.htm (Preferred in North America)
www.vetsci.usyd.edu.au/lida/ - (Australia)
Regardless of the site your practice has selected, ensure you review the site on a regular basis to ensure it continues to say what you think it does.
The emerging diversity available with PCR testing needs to be part of your wellness Standards of Care; which ones are being offered by your practice this year?
Urine tests are routine in human healthcare surveillance, yet when we finally get a urine screening test (Heska's Early Renal Damage), academics say it is not specific for renal disease, so it is "bad". When does a kidney shed microalbumin normally? Answer: never! Granted, about 70 percent of the positives are non-renal in origin, but this test is just an indicator, pre-signs, to look further! When do you get a false positive? With RBCs, which are also not normally shed, so you must look further also! (So what is stopping you from adding urine screening from your life cycle consultation, except your own paradigms of the past dark ages?)
Aren't the inpatient staff members accountable for patient safety and wellbeing when hospitalized? Answer: yes! (Then why are pre-anesthetic risk assessment scores (1-5 per AAHA) so seldom recorded in the medical record at admission and on the white board in treatment to help ensure the animal's safety?)
VECCS states that 80 percent of all surgery patients deserve to be on fluids (interoperatory fluids, IOF), what is the rate in your practice? Answer: why don't you know? Every trauma/stress case should have an I.V. TKO (I.V. to keep open), in case there is a circulatory misadventure, what is the policy in your practice? (So why have the benefits of IOF and I.V. TKO fluids been ignored for as long as they have?)
There are many more drugs available for treating chronic conditions, and with our new knowledge, we know there must be a surveillance program for organ damage. Idexx and Pfizer have excelled in giving the practitioner consolidated lists of which organ system(s) need to be tested for which chronic use drug. Are the specific surveillance tests linked to your pharmacy prescription/dispensing software so they automatically enter your reminder system? Answer: if you want liability protection as well as good medicine, it better happen this month!
Are veterinarians allowed to do anything that is not needed by the State/Province Practice Act? Answer: No - they are only allowed to do what is needed for that patient at that time! (So why do students learn the word "recommend", which puts the client in to the position of determining/selecting the animal's needs?....... why don't we clearly state the "need" as a "need", and then shut-up and listen to the client about decisions to access that care?)
The Standards of Care Signature Series monograph provides two spread sheets in it's CD Tool Kit, one for birth to 18 months, and the other from 2 to 12 years of age. We do not expect any practice to take a text book answer for what is "needed", or "what the pet deserves", but we do want each Medical Director to verify the current state of the art for their respective practice. Please access Veterinary Information Network (VIN), www.VIN.com, and do your research with referred boards and real practitioners. VIN is a fee for service web site for veterinarians, while Veterinary Support Personnel Network (VSPN), www.vspn.org, is free for staff. For clients, www.petcaretv.com has over 100 streaming videos, and VIN also offers the free site, www.veterinarypartners.com; both provide a good site for staff learning client friendly narratives.
Review the Signature Series monograph, Standards of Patient Care in a Bond-Centered Practice, and/or the Human-Animal Bond Scoring Pocket Card (which is provided at the Veterinary Consulting International exhibit hall booth for free at most major meetings, www.drtomcat.com), and determine what you really want to stand for in your practice and your community.
Most bandaging is strictly a nursing function.
AAHA Estimates of Compliance Gaps
In 2003, the American Animal Hospital Association (AAHA) commissioned a survey of practices to assess the "shortfall" in wellness care in the average companion animal veterinary practice. The data base assumptions included: 63.7 million dog population with 54.3 receiving regular care (85.7%); 74 million cat population with 50.1 receiving regular care (67.7%); and 34,261 companion animal Full-time Equivalent (FTE) veterinarians. The compliance (practices delivering the needed healthcare elements - actually standards of care issue) included:
Canine Core Vaccines
Feline Core Vaccines
3% compliance (dogs), 1% compliance (cats)
Heartworm K 9 testing
37% compliance (annually), 74% compliance (biennial)
34% compliance (canine only)
Total Additional Revenue Opportunity per FTE doctor per year: >$639,700
Note: Revenue opportunity was calculated using average fees compiled from the AAHA Veterinary Fee Reference (www.aahanet.org)
What did the AAHA study show about existing practices and their patient follow-up? The results were dismal:
23 percent of the pets with grade 2 dental disease or higher had NO recommendation for dental prophylaxis (ask yourself why didn't they survey grade 1+ dentals, since NO gal or guy can ever get a second kiss if they have grade 1+ mouth).
27 percent of pets with medical conditions needing therapeutic diets did not receive recommendations from the veterinary provider(s).
53 percent of seniors' pets did not have a recommendation for any form of senior screening.
13 percent of the pets were not in compliance with the veterinarian's recommended vaccine protocols.
11 percent of the dogs in heartworm endemic areas had not received a recommendation on heartworm testing.
Only 10 percent of the clients felt veterinary recommendations were based in a profit motive; only 7 percent said cost was a barrier to access of care.
78 percent of veterinarians surveyed said they were satisfied with their compliance, and 63 percent of those said they felt their client's compliance was high.
Now ask yourself, why was everything in the AAHA survey addressed as "recommendations" rather than "needs"? Why are the major associations in our profession not changing the nomenclature to ensure clients are not confused about the needs for quality healthcare delivery and protection? Answer - the compliance problem is ours, not the client's. The clarity of needs greatly resolves this entire issue.
Pet Parents come into the practice stressed, concerned for the pet's welfare, and unsure of the associated costs. Some practices like to offer options, requiring the client to have either 1) a veterinary education or 2) a crystal ball. Stressed clients do not want options, they want clear answers, or statements of need, for their peace of mind!
When a need is stated by the provider, the room needs to fall silent. In most cases, the client will respond with one of four types of replies: W = waiver (no way doc), D = defer (maybe later doc), A = Appointment (cannot afford it until after payday), or X = do it......if there is not a client reply within 17 seconds, the provider asks, "Is this the level of care you wanted for Spike today?"
All unresolved presentations must be listed on the Master Problem List, logged into the veterinary software and assigned to a veterinary nurse for tracking.
All atypical laboratory screens must be listed on the Master Problem List, logged into the veterinary software and assigned to a veterinary nurse for tracking.
For anything on the Master Problem List, a nurse must be assigned to the case, logged into the veterinary software for tracking, and it must be followed until the condition is resolved.
If there is deferred or symptomatic care provided, it must be logged into the veterinary software for tracking and a nurse must be assigned to the case and it must be followed until the condition is resolved.
Nothing is resolved until the Master Problem List has been annotated as resolved, and the follow-up closed-out in the veterinary software.
The average clinician learned his consult room narratives from the first practice they worked for after graduation. A few examples:
The term recommend came from production medicine, where the producer 1) knew what was appropriate for his stock, and 2) had to do a cost-benefit assessment, The term need is similar to pediatricians, where the patient cannot tell mom or dad what is needed.
Two door consult room, sort of like a cattle chute, run them in - treat them - run them out, unlike physicians who have one door. Actually it is because physicians have always used nursing staff to load the room and finish the treatment plan, while veterinarians knew they had to do it all themselves.
A physician concurrently uses 4-5 consult rooms, a dentist has 4 -11 prophy chairs and three restorative chairs, and a veterinarian, one room operated in a linear fashion (since they have not yet learned to use staff as extenders).
Medical Records for Continuity of Care
What medical record documentation should look like [each "need" is a box [ ] or if electronic record, a CR-__ (client response -__)]:
Before client/per arrives, client relations specialist or Outpatient Nurse (OPN) enters the needs:
"pet deserves" items from written Standards of Care (SOC) (e.g., C3 CR-__ , PH CR-__ , deworm CR-__ , etc.)
Other pet - name (if open issues) (e.g., OPN - Spike CR-__ )
(This is actually just referred back to OPN at end of appointment)
OPN escorts the client/patient to the consult room and does an asymmetry exam:
weight/BCS (if other than 5, CR- __)
Dental Grade/DG _+ (if other than 0, CR- __)
Pre-emptive Pain Score __
T ___, P ___, R ___, BP ___, ECG II ____, Risk Level if admission ____
12 body systems (if atypical, OPN has written CR- or placed [ ] to alert doctor)
any PCR screening needed by this breed/age/sex
Client concern first
Atypicals prioritized for later or day admit
Plan (according to SOC - pet deserves):
Veterinarians have established the SOC for the common presentations:
X-ray CR- __
CBC CR- __
FNA CR- __
Blood Chem CR- __
etc., etc., etc.
Problem List (for all unresolved, deferred or empirical treatments)
Revisit ____ Recall ______ Remind _____ (SMS, e-mail, snail mail)
Attending nurse moves 3Rs from History/medical record plan to her own clip board, and follows case accordingly (about 20-30% will be marked for Vet to retain)
* CR- , means client response (W-D-A-X), the doctor must get something behind every CR-, and we must make whatever they said okay for today!
Life Cycle Consultations
The direct-to-client AVMA initiative, "Think two visits a year for life" was started in 2004, in partnership with FDAH for funding. They used in excess of 300 media releases in a month to get clients attention. In the subsequent years, new programs were added, and the web site has been expanded concurrently, with free training kits offered AVMA members for in-clinic training.
2004 - One dog year is 5-7 people years, see your vet twice a year!
2005 - genetic predispositions need professional assessments
2006 - zoonotic diseases can be identified and treated
2007 - behavior issues
2008 - pets are at risk too
By the end of 2007, the 1.9 visits per year of 2004 had expanded to 3.3 visits per year for clients/practices following www.npwm.com philosophy. Yet only 50 percent of the companion animal practices had enrolled for the free training kits.
All it takes to start the twice a year doctor consult process (2xFL) is look at the client and state, "We will consider this visit the first life cycle consult for Spike, and in six months, we will send you a reminder to come in with Spike and a fresh urine sample so we can start checking for what Spike is eliminating." If you are really confident, then add, "We will then start to alternate a blood screen to see what is happening inside the body with urine tests to see what is being eliminated by Spike."