Thomas E. Catanzaro, DVM, MHA, FACHE, Diplomate American College of Healthcare Executives
A Look at Changing the Focus of YOUR Veterinary Medical Healthcare Delivery
So if a companion animal practice has been trying to doing their very best, most of the preventive medicine care has already been offered most all clients. Concurrently, the curative medicine cases have actually decreased with leash laws and better informed stewards of companion animals. Do a self-assessment of a baker's dozen of basic wellness program factors, from a team-based perspective:
Are the basic wellness items being tracked? Vaccines, flea/tick/heartworm protection, nutritional history, PCR screening as appropriate for genetic predispositions, and master problem list are the minimal factors for tracking.
Can you find a Temperature, Pulse, and Respiration recorded with each visit of the animal (in a retrievable format)?
Can you find a Sequential Weight with a Body Condition Score (BCS 1-9) recorded with each visit of the animal (in a retrievable format)?
Can you find a Dental Grade (DG 0 - 4+) recorded with each visit of the animal (in a retrievable format)?
Can you find a twelve system physical exam (PE) recorded with each visit of the animal (in a retrievable format)?
Can you find a Blood Pressure (BP) recorded with each visit of the animal (in a retrievable format)?
Can you find a Lead II Electrocardiogram (ECG) recorded with each visit of the animal with a need (in a retrievable format)?
Is there a pre-emptive pain management score (1-10) assigned with each outpatient visit?
Does every admission have a risk assessment (1-5) recorded with each inpatient visit of the animal (in a retrievable format)?
Does the Risk Assessment drive the pre-anesthetic laboratory evaluation (non-waiverable and included in the fees), and does it change when atypical conditions are found?
Is pain management used before every surgery (non-waiverable and included in the fees)?
Are inter-operatory fluids established as required (included in the surgical fee, and non-waiverable)?
Is discharge planning documented, and always includes at least one of the three Rs (recall, revisit, remind)?
Blood Pressure by Nursing Staff
The above thirteen (Baker's dozen) elements are simply good medicine and essential for team-based healthcare delivery. They are a part of the diagnostic quest for wellness, yet are listed above as 'continuity of care' issues (in the medical record for the next person). Most veterinarians learned to write medical records for their own memory jogs, and most of the USA software taught us to write it for the sake of the invoice. Medical records are the foundation of continuity of care, should be written in a S-O-A-P (subjective, objective, assessment, plan) or H-E-A-P (history, exam, assessment, plan) format, and need to be written for the next person when embracing team-based healthcare delivery programs. There is no such thing as leaving "medical records for tomorrow" or "taking them home" in other healthcare professions; they are completed before the provider goes home from the shift, and are left with the patient or in the facility for the next person needing them.
Probably economics made dentistry a major emphasis for most practices by the new millennium, but in reality, it was actually just a new wellness program which worked well in human healthcare. Yet, in the 2003 AAHA Compliance Study, the average practice was losing over $300,000 a year per doctor in undelivered dental care; seems not everyone got the word on 'brown teeth = bacteria = bad breath' or 'red gums = pain'. Early in this Millennium, Purina published their research that companion animals on premium diets live 22 months longer, so while all companion animals 'deserve' to be on premium diets, at least 50 percent 'need' to be on premium diets for age, weight, or other medically-driven reasons. In most veterinary practices, while they acknowledge the research and dietary scientific logic, the patient medical records do not show this level of commitment to quality care. In fact, Hill's reports that while about 35 percent of the patients are put onto a premium diet each year, less than 7 percent stay on it. Vetcentric reports that people coming into a practice to buy pet food average 3.1 months of keeping their pet on the prescribed diet, home delivery moves it to 8.9 months of compliance. In the real world, while practices say they need to sell premium prescription diets to ensure client return rates, most do not assign a nutritional counselor, nor do they handle the case as a medical follow-up.....they do not walk their own talk!
In the new millennium, in response to the emerging "shot clinics" vaccines, most companion animal practices have unbundled their vaccines, and now have fees for consultations as well as vaccinations. This helps with the vaccine sarcoma panic, and vaccines were becoming seen as a "necessary evil" rather than just great protection. In WA and OR, the Practice Acts have been changed to allow nurse technicians to administer vaccines and even sign rabies certificates. Now the extended duration of immunity (DOI) vaccines are being introduced, which will reduce the preventive medicine income of most practices......or will it? PCR testing is emerging, and genetic markers are now known for 450 animal predispositions. Human healthcare have found 5000 DNA markers, and the genome of dogs and people are 95 to 98 percent similar, so it si expected that PCR screening will expand greatly in the next few years.
Wellness surveillance focuses on risk assessment and planning for the future to enhance the quality and extend the duration of our patients' lives. As a diagnostic quest, the twice-a-year for life consultations provide a starting point for the diagnostic quest. It is client-centered patient advocacy at its best. With 89% of our clients feeling that their pets are family members and a full 1/3 of those giving them child status, practices still focusing mainly on curative medicine are not doing enough and the pet parents are "voting with their feet."
Wellness-centered healthcare surveillance means a pet will live longer and the family will have better companion experience. This matters to pet parents. Client-centered Patient Advocacy focuses on meeting needs that change with the various maturation stages and life cycle situations:
Community and lifestyle risk factors
Client surveys show that 66 percent of the pet parents will accept wellness screening (in the $50 to $60 range) to help their animal live longer.
Client surveys show that 54 percent of the pet parents will accept wellness screening for early detection of disease or debilitating conditions.
Practice management surveys show that the top 30% of a practice's client's leave about 80% of the gross sales (so why worry about the bottom 20% who will never be satisfied, even if it is free, and have virtually no net income value to the practice?).
The only thing a veterinary practice 'sells' is peace of mind; all else the client is allowed to buy.
Training to a Level of Trust
By horizontally including wellness surveillance to all levels of the practice operations, it requires a team approach, since it is primarily husbandry surveillance; new narratives need to be developed within all operational zones of the practice. This means going back to square one and redesigning the Orientation & Training program for new staff by putting the entire team through the new training program(s). In this new world, all "job descriptions" become training plans, and are integrated into a time-line of personal skill development; this is a defined period of "at will" employment, and in most jurisdictions, people may be released for any reason without unemployment consequences. Training actually establishes "recognition points" for staff' members individually credentialed at specific levels of competency, or maybe as skill-based trainers for specific learning objectives. At the end of 90days "at will" orientation and training, the candidate will be evaluated for team fit, competency, productivity and client-centered patient advocacy; the annual wage will then be set based on demonstrated performance.
In the Signature Series monograph, Orientation & Training, there are four sets of individual checklists (client relations, outpatient nursing, inpatient nursing and one for technical assistants/animal caretakers) already developed to act as the skeleton for tailoring and developing a practice specific set of expectations (e.g., nursing checklist evolves into outpatient nursing services, inpatient nursing evolves to surgery, imaging, dentistry, metabolic care, etc., and technical assistants, and/or animal caretakers evolve with Title 9, CFR guidelines, boutique services, maintenance, and other ancillary functions which are practice specific). Appendix C of the Signature Series monograph, Orientation & Training, reference explains self-directed training, a key concept in developing a team-based healthcare delivery program. There are four basic checklist phases for new staff candidates:
Non-Productive (entry training wage)
Phase D - Data -1 week - rotation between zone coordinators while gaining an understanding of the employee manual, vision, and core values
Phase C - Communications - 2 weeks - rotation with every member of the staff and each doctor, inpatient and outpatient, while gaining an understanding of the Standards of Care, Mission Focus, and zone inter-dependence.
Productive (small pay raise to recognize new status)
Phase B -Basic Skills - 3-5 weeks - learning operations within the zone, including working each shift, and gaining appreciation for skills needed to ensure appropriate achievement of outcome expectations.
Phase A -Advanced Skills - 4-6 weeks - while working each shift, gaining appreciation for inter-zone coordination needs, develop operational skills needed to timely outcome excellence.
While the Signature Series monograph, Orientation & Training, is based on individual development, the Signature Series monograph, Zoned Systems & Schedules, is formatted to ensure multi-tasking team-based development. The increased efficacy part of the wellness integration comes with multi-tasking skills, and the five-by-five, team-based, training plan matrix in the Signature Series monograph, Zoned Systems & Schedules, provides that practice developmental plan. Again, the 5x5 matrix is provided to ensure the time-line development of programs, staff, and operational flow occurs concurrently in all zones of the practice. If implemented concurrent with the Orientation & Training Program described above, some integration of the Orientation & Training checklists will be needed, specifically:
Phase 1 is integrated into Phase B
Phase 2 is integrated into late Phase B or early Phase A
Phase 3 is integrated into mid-to-late Phase A
Phase 4 and 5 are multi-tasking and cannot be attempted until everyone has completed the four phases of the Orientation & Training sequence.
Team-Based Veterinary Health Care Delivery
Knowledge is doubling every 24 months in veterinary medicine, and continuing education, at all levels of the practice team is essential for staying current. The old adage of "not having the time to train" only reflects a doctor-centered practice which cannot leverage it's time or schedule it's clients effectively.
Adult education requires a different format than the traditional classroom centered systems we all grew up experiencing. Gen-X and Gen-Y expectations are far different than those of Baby-Boomers and Traditionalists (the pre-Baby Boomer generation). Self-directed training, in multiple short duration episodes, is far more effective, since adults need to be "ready to learn" before they engage a new subject. The concept of "Effective Teaching" requires:
an established lesson plan for each issue, focused on only 3-5 outcomes, with resources matching the handouts of the practice as well as the established standards of care
a teachable moment be created, a discovery be capitalized upon, or some other event triggers the need for the adult to have new/more information
healthcare excellence requires the instructor ensures learning occurs, not just be satisfied with teaching a subject
there must be an application phase, to ensure the participant can demonstrate proficiency and understanding of the healthcare delivery outcomes desired
if competency (which is also excellence in healthcare delivery) is not achieved at the application, the instructor must recycle the participant using new styles of development, or refer the participant to a new trainer, to attempt development of proficiencies
A celebration/recognition is needed to meet the Gen-X and Gen-Y expectations, and allows the recognition/reward to occur to start building the respect needed before assigning accountability for new outcome(s).
The second part of this staff development equation is a recurring training time, which should be the same day each week, since it requires closing the front door and giving people concentrated self-development time. Many practice owners cannot bear to be closed from 11 a.m. to 3 p.m., once a week -they are afraid they will lose the sale of a bag of dog food. These are the practices where staff development is stagnated, doctors are stressed and overworked, and delegation is of process only, seldom outcome. Practices that do not take the time to train are destined to become outdated and be behind the power curve when the wellness issues are raised by clients (remember, the AVMA initiative, www.npwm.com, is gong direct to clients-over 300 media releases each October alone). AAHA showed there was 29% flexible time in most every staff member's day, and since nature abhors a vacuum, staff vibrated to fill that time. These are often the practices where the job description ends with, "Other duties as assigned", which often translates into, "Stand in one place and vibrate until someone tells you to do something." It would be far better if all duty area Performance Standards ended with:
See the problem, solve it!
Find a challenge, meet the needs!
In the progressive practices, three hours a week, same day every week, are set aside for staff development (in non-retirement communities, this means stop appointments at 11, train from 11:30 to 12:30, have a lunch break, and then train again until 2:30 p.m., restarting appointments at 3 p.m.).
First Week - ALL staff meeting 11:30-12:30, followed by lunch then planning time (coordinators, program managers, and DIG teams) - doctors do reciprocal medical record audits for standards of care
Second Week - individual training with designated trainers
Third Week - zone training
Fourth Week - individual training with designated trainers
Fifth Week - inter-zone invitational training
Adults learn best when it is one-on-one, in twenty minute blocks, when they are ready to learn (i.e., self-directed training model). In most cases, new concepts must be reviewed seven times in the 21 days following the first exposure for retention and integration.
The Central Thing About The Central Thing Is The Central Thing
We need to address some paradigms and bias, mine as well as yours. As I was thinking about how to make this a concise section in this second edition, I was also having my annual physical. A Medical Assistant (less than 10 weeks training, uncertified, but they still call her a 'nurse' in that office) called me from the waiting area and escorted me to the scale (body score 7.5 on 9 point system, but she did not dys' me) and height (let's assume I was just under-tall for my weight). Then the urine sample stop was in route to the consult room; she pointed out the consult room, handed me a specimen cup, pointed out the bathroom, said "Fill it and put it on the shelf", and said she would meet me in the consult room when I was done. In the consult room, the medical assistant did the blood pressure, pulmonary function, and seven lead ECG, then "went to get the doctor" (except for the pulmonary function, this is just what we expect a veterinary outpatient nurse to do as part of the asymmetry exam). The doctor came in, did his exam, and we discussed his recent experiences at the veterinarian (an Akita decided to chomp on his Peek-a-poo, and fractures resulted). He noted that the veterinary staff was better than his staff in client relations. He scripted my medications, then turned me back to the medical assistant for two vaccinations and a lab tech for the blood letting (just what we expect an outpatient doctor to do). This team-based perspective is offered to shatter some of the long-standing traditional veterinary paradigms......it is designed to introduce the reader to models that have worked successfully in veterinary hospitals across the United States, Canada, Japan, Australia, New Zealand, and around the world where we have consulted (our consulting partners), using the core principles of team-based veterinary healthcare delivery which have been derived from other healthcare professions.
"The best way to begin is to begin."
Let's set the scene, the practice's physical environment, so we all are thinking alike. The change from a one doctor, one or two examination/consultation room system, to a two doctor system is usually minor, the owner just takes more time off. Usually we find that the two doctors just divide the longer one-doctor shift into two, continue to work in the traditional linear fashion, and never give it another thought. When a practice moves beyond two doctors, beyond 1000 transactions a month, or when they expand into five or more consultation rooms (the need for an odd number of outpatient rooms becomes evident below), or in the new AVMA wellness initiative (www.npwm.com) where practices integrate wellness surveillance into the traditional curative and preventive medicine programs, there are psychological, physical, and problematic issues to address in the basic operating premises.
Wellness is a team-based effort, since most maintenance aspects are basically applied husbandry.
The doctor is always accountable for prioritizing care, as well as training his/her staff in narratives and delivery systems.
Staff members become accountable for outcomes, not just process; personal pride develops. Clients perceive pride as quality, and it supports higher levels of client-bonding.
Scheduling becomes a team effort, no patient leaves without at least one of the 3 Rs being scheduled (Recall, Revisit and Remind). About 70 percent of the recalls (we always call them, they never are asked to call us) and revisits (always appointed and seen in the consult room within 7 minutes of the appointed time) are staff functions.
The practice style of two doctors working two or three consultation rooms, flowing erratically front to back, cannot be done in a practice that doubles in size. Zones must be established in a larger facility, to concentrate the doctor resources on the client needs; the nursing staff must concurrently accept veterinary extender roles. To allow us to start on a level playing field, with hospital zones operated by staff and respected by doctors, let me to offer a diagram and a few basic definitions, as well as some "optional" references:
Click on the chart to see a larger view.
The operational zones for the new systems and schedules would usually include the following five areas (the 5x5 matrix) of staff accountability:
Client Relations Zone
Scheduling facility, not doctors
Coordination with IPN and OPN for capacity estimates
Veterinary software operations
Editing/sending newsletter, health alerts, and timely reminders
Front door swing rate
Recovered pet and recovered client programs (Signature Series monograph)
Client/patient outpatient movement
Keeping the Outpatient doctor on schedule
Coordination with client relations for capacity scheduling
Outpatient client education
Behavior management assistance to clients
Sequential laboratory sample collection
Client recalls for outpatient follow-up
Outpatient zone maintenance and cleanliness
Wellness and husbandry issues for Pet Parent Awareness
Supervision of technical assistant pharmacy float
Accountable for their own '3R' (recall, recheck, remind) clipboard
Inpatient White board for prioritizing multi-tasking operations
Treatment Room, with Imaging, Dentistry, and Surgery
Keeping the Inpatient doctor on schedule
Coordination with client relations for capacity scheduling
Cages, Wards and Runs
Nursing Rounds (before 8 a.m. and by 1 p.m.)
Discharge Planning and delivery
Sequential laboratory sample collection
Supervision of technical assistant float
Title 21, CFR (controlled substances and prescription drugs)
Accountable for their own '3R' (recall, recheck, remind) clipboard
Resort (boarding) Zone/Animal Caretaker Zone
Maintenance and cleanliness
ABKA Standards for kennels
Chapter 1, Sub-chapter A, Title 9, CFR
Clear Standards of Care
Timely (daily) and adequate completion of medical records
Integration of AAHA Standards (regardless of membership)
Respect practice protocols
Embrace Core Values
Maintain provider commitment awareness to programs
Nurturing & respecting staff & schedules
Owner's Accountability Zone:
Exist ONLY between falls of the gavel
Strategic Assessment & Strategic Response with Community
Policy, Precedent, and Quarterly Budget Guidance
Exemplary leadership in ensuring appropriate practice culture
Respects administrator, managers, coordinators to be implementors
The what and the why is a leadership-to-staff communication which must precede every new program or initiative.....assignment of clearly defined outcome expectations rather than process mark a true leader.
The who and how is a zone responsibility, based on expected outcomes, and is staff organized by Zone Coordinators (not supervisors/managers).
Individuals and teams are self-directed, client-centered, patient advocates, embracing the practices Vision, Core Values, and Standards of Care.
The when is a joint discussion between leadership and operators, with milestones and completion date, as well as clear measures of success before the program/initiative is undertaken.
Even a partial accomplishment is celebrated as a success, never a failure, since learning has occurred. A well-led team celebrates the accomplishment(s) and fully faces failure(s) as meaningful learning events.
The functional zoning of the hospital allows the respective zone coordinators to become accountable for the new systems and schedules. They are accountable for staff competency (training) and productivity (schedule effectiveness within the zone) within their training role. Each coordinator and staff member must have a client/patient advocacy, whether they are "in their zone" or scheduled to work elsewhere. Once a practice starts to schedule the facility based on client and patient demands, and empowers the staff to be advocates for the client and patient, the linear thinking of a doctor centered practice will start to disappear, and the productivity will become enhanced.
The Veterinary Hospital Managers Association offers a certified veterinary practice manager (CVPM) designation by examination by your peers; there are only about 100 CVPMs active in our profession today.
Currently, Dr. Tom Catanzaro, President/CEO of VCI, is the only veterinarian to become Board certified in Healthcare Administration by the American College of Healthcare Administrators (30,000+ members), and achieved fellow in 1996 (less than 10% of ACHE members achieve this distinction); he still must recertify every three years.
There are some MBAs, and few MHAs, within our profession, but these are not board certified designations. We even have a few with JDs, but again, many have not "passed the bar", the basic certification level for attorneys.
Would you trust a DVM who could not pass the boards?
In the Signature Series monograph, Standards of Patient Care, we provide the Five Step of coordinator development that overlies the skill development in the Signature Series monograph, Zoned Systems & Schedules. In the Signature Series monograph, Building the Bond-centered Practice, we provide the soft side techniques to expand upon the 26 staff-friendly appendices of the Blackwell text, Promoting the Human-Animal Bond in Veterinary Practice. This all sounds good, the references are abundant, and it all sets the stage, but as they say ion the hamburger commercials, "where's the meat?"
The meat is sitting in every practice's medical records. They are gold mines of opportunity, waiting to be harvested. Tom Cat started sharing this perspective when he was hospital service director at AAHA, and increased membership satisfaction, as well as AAHA consulting services. Since 1991, our consulting firm has been promoting team-based healthcare delivery, wellness surveillance and screening for the other pet(s) in the household, to enhance practice growth without external marketing (a very ineffective method for finding quality clients). It was not until AAHA published their compliance study in 2003 that the veterinary profession at large started to embrace the reality of more comprehensive service for better compliance.
If you have not seen the new generation of electronic medical records, you are outdated; they are now legally sufficient. You do not need paper records or major storage areas. Compare RxWorks, Cornerstone, AlisVet, AviMark and your current system, and it should be an awakening.
Paper 'forms' are a crutch, but very useful in training new habits. Notepads are variable resources, depending on speed of linkages. Key stroking is usually a staff function; learn to dictate.
When we take the doctor off the key board and make staff accountable for data entry, and initiate a gain sharing program based on commitments to SOC, an increase of 12-15 percent is common, even on equine ambulatory trucks.
Doctors are to diagnose, prescribe, surgicate and maintain caring client communications; all else belongs to the staff.