Thomas E. Catanzaro, DVM, MHA, FACHE, Diplomate American College of Healthcare Executives
In the absence of knowledge, most all decisions are based on money. Clients list fees as the #9 concern when selecting a veterinarian. Practice need to differentiate themselves in ways other than prices. Client-centered patient advocacy by a caring healthcare team is step one! Dr. Tom Catanzaro
Today we are told we must work smarter, not harder. Some consultants have their favorite solution: "Give me your current office call and I can set your prices to the appropriate level which will increase your net"......or.......Profit centers must be developed"......or......"This new equipment/system will save you money in the long run"......or......"Send your people to this school/seminar to increase your profits".......or......"Subscribe to this newsletter for all the management answers". Regardless of the consultant pitch, the unspoken bottom-line is good medicine is good business.
Most all practice staff entered this profession to "tend to the animals". Good medicine is what we were all trained to provide. Yet, somehow the day-to-day crush of practice squeezes the professional juices from our souls as well as our treatment plans. Couldn't happen to you? Try this quick test: Pull the first five records from any position in the first half of your hospital patient files (the "S" file is in the last half and has been overused already). Now systematically review each record for your patient advocacy. Here are some questions to ask:
Were vaccinations, fecal, heartworm testing, FELV, Giardia, offered and/or recorded at the first contact?
Have you kept current on PCR testing for genetic predispositions? Have you incorporated laboratory screening for genetic predispositions into your Standards of Care?
Is the problem list active and reflective of existing conditions which deserve to be followed by caring professionals?
Does every client leave with a Recheck/Recall/Reminder entry (every client meets at least one of the three Rs).
During the following visit, does the outpatient nurse routinely screen the problem list and note some form of resolution or review need of the previous problem(s) before the doctor enters the consult room?
Can you determine how many animals are in the household, and is there a separate record (separate prongs in same file folder is adequate) for every patient in the household?
How often are dental grades recorded and/or dental condition needs recorded with the client's response (W-D-A-X)?
Are there sequential weights recorded for every animal, has each been quantified with a "body score", and what have been the actions when there have been weight changes?
Where do you record the pre-emptive pain score, and how is it used by the staff as a case management tool? What is the consistent pain management program that emerges on review; are there recurring pain scores for all inpatient cases?
Concurrent with admission, how is risk assessment (1-5) of anesthesia candidates recorded and what is the practice consistency on pre-anesthetic laboratory screening?
Does the practice's I.V. IOF (intra-operatory fluids - TKO: to keep open) policy match the VIN and VECCS guidelines of low levels of IV fluids running for all anesthesia cases? Are they 'appropriately' priced as staff-operated protocols?
Can the practice's imaging philosophy (x-ray, ultrasound, endoscope, etc.) be established by the client concern (misnomer: presenting complaint) review; is there a diagnostic consistency for grade 3+ dentals, limping, chronic gut problems, moist rales, cardiac murmurs, and similar positive indications for imaging?
Are client refusals (W = waivers) or deferrals (D = deferral) recorded?
Are handouts noted on the record so we remember which ones we have explained? No handout should ever be given without some form of personalized professional overview of subject.
Were all the previous medications given for the full duration and did they work? Is there a practice policy concerning clients who say, "Oh, we have some of that medication at home - can we use that for this?"?
Can you determine if a client who hasn't been back "on time" has been contacted? Recovered Client and Recovered Pet Programs are described in greater detail in the Signature Series monograph, Client Relations Zone Operations.
Do other animals in the same household get prophylactic treatments? Are medications divided between records when the client states one package will be for multiple pets?
Does Client Relations Specialists catch up records on all pets belonging to a client at every visit?
How many times have you found yourself making excuses because the above answers were less than professionally satisfying?
".......an advocate is defined by Webster's Dictionary as a person who pleads another's cause......."
I have found it much more difficult to teach a practice staff internal marketing than to help them become caring patient advocates. We no longer talk in "shoulds" or "recommendations," but rather, we speak in terms of "need," as in, "Fluffy needs to be tested for heartworms after your winter vacation down south." At the same time, we need to infuse our staff with the respect for the client to waive or defer any needed treatment. Waivers or deferrals are recorded, occasionally with their initials just to reinforce the severity of the need, right after the plan in the medical record.
Good medicine starts when the client makes the first phone call (answered within three rings). Good medicine means never putting someone "on hold" without their verbal consent. Good medicine means for each veterinarian every fifth appointment space is left blank for same-day emergency services ("E" annotation or shaded space). Good medicine means an emergency is as perceived by the client, not by the receptionist. If unused, the "E" space becomes catch-up time, or a coffee-break rest period, or a recall, or just a time to observe the rest of the team delivering quality healthcare.
Good medicine means introducing yourself upon entering the room, and touching the animal early. Only nerds lean against the wall, cross their arms, and question the client at length while the animal is suffering (in the client's opinion). You only have 17 seconds to touch the pet and make a friend, and about three to four minutes before your body language makes the client decide on your concern. Is your reception area a "waiting room," or has it been a good client experience where smiles and concerns have "hosted" the client into the consult room within 5 minutes of the appointed time? If you teach yourself to listen to a client (not just hear what they are saying), you will be able to detect the concern, frustration, anxiety, or maybe even confidence in what they are saying. As you examine the pet, do you convey the good news (the specific normals, the good care) or do you silently skim the animal and give just an overall "okay" at the end? Clients enjoy hearing that the eyes are clear, the bladder feels normal, the intestines palpate healthy, the coat is glossy, the lungs are clear, both ears are clean, or whatever.
Does your receptionist (probably soon to become the 'client relations specialist' after Chapter One) offer to reschedule late arriving clients or on-time clients when your "schedule has been interrupted" (don't ever just "run late")? Good client relations specialists automatically shift to a day-admit option when things are getting jammed up. Many clients would prefer to come back for a discharge appointment from day care, or even a different appointment after they do a few more errands, than wait for 45 minutes while you "catch up."
The curb appeal, the dog access/relief areas, and the first impression of the receiving desk all set the tone for the visit. Look at the first impression the client sees, smells or hears (the three senses clients have security using). Most companion animal practices only come in three flavors: cat urine, masked (lemon/orange/Lysol) or clean. Only the latter is acceptable. Look at the reception area. Are plants alive and well (comfort to clients) or are they brown or dying (worrisome to clients); I generally use quality silk plants and dust often. Can a nervous cat and owner find a corner of protection? Can a lady safely tie her dog while she goes to the rest room? Are your displays framed (or do you just tape things to the wall like a teenager)? Neatness counts. Brightness and cheer have led to open receiving desks, bright wallpaper, and smiles. The days of dark paneling and small windows for "plush luxury" have yielded to "bright and cheerful." Old magazines are not needed in the reception area. There are many quality handouts and booklets available for free that can be read. 'Behind the Scenes' scrapbooks (ensure people and pets are in the pictures and actions labeled), practice client/pet scrapbooks, or even the Delta Society Journal can also be made available.
Good medicine also means you are really concerned with the three Rs (Recheck, Reminder, Recall). If a client does not return for the recheck at the prescribed time, your staff members initiate a recall. The "Doctor and I" format has worked very successfully. The technician or client relations specialist (receptionist) automatically initiates the recall as needed. Introducing themselves, the veterinary facility, and then the question, "The Doctor and I were wondering (1) since we didn't see you this week if everything is okay ... or ... (2) whether you had any questions now that you have been home a few days ... or ... (3) if you think Fluffy needs more medication." When the response is other than what a paraprofessional can handle, the technician nurse or client relations specialist (receptionist) can always say, "That's something the doctor would be concerned about. She/he reserves time for client phone calls between 6 and 8 (or 1-3 if your hospital has a slow mid-day). Will you be home at that time?" If you don't have time set aside daily for veterinarian call-backs, establish the time now. You can't afford to be on-call to the telephone, or out-of-touch all day.
Putting it to the Test
It all translates to patient advocacy, speaking for what is needed for the health and welfare of the animal. Good medicine is simply doing what is needed. Accepting that a few of the client will decide to waive or defer the needed care (client-centered service), and overtly validating their decision for the moment, will yield far more net than deciding for clients that they can't afford something. All deferrals are scheduled for return, usually within 72 hours, to start the follow-up process as patient advocates. While a practice's net income is not the primary reason to be a patient advocate, it can be seen as an acceptable reward for good medicine and high professional standards for healthcare delivery.
Reality for the Disbelievers
The AAHA Compliance Study was published in 2003, and showed that the average "high quality" practice, who were proud of their client-centered service, were losing a potential income of over $639,000 per doctor per year in just wellness care.
In 2004, the AVMA started their "direct to client" wellness initiative, "Think two visits a year for life" (www.npwm.com). While they have upgraded the web site and client message content every year, only about 50 percent of the companion animal practices have subscribed for the free training kits; those that have report their client visit rate has moved fro 1.9 (2004) to 3.2 times a year by 2007.
As Veterinary Consulting International, Dr. Tom Cat has introduced these programs and initiatives in Australia, New Zealand, United Kingdom, and other countries with similar results - the Human-Animal Bond is an International reality.
The human-companion animal bond (HCAB) is hard to measure, but we can recognize it when we see it. Patient advocacy is a nice philosophy but it also seems hard to measure. If we can't measure it, we can't manage it. We need to look at an indicator that will work for most practices. We saw the National HCAB movement with clarity following the 9-11 tragedy. The events were so significant, that many veterinary practices had an amazing discovery:
Tragedy at World Trade Center - Americans went into cocoons, malls were empty, restaurants had very few patrons, movies were empty - people were not venturing outside their homes.
As they "hide" in their homes, companion animals provided distractions, and more importantly, non-judgmental love.
Families found comfort in their four footed friends, and the family bond was strengthened
In October (Americans have a short attention span, even in fear), veterinary practices who had been patient advocates, and using the word need, found clients bringing those cherished family members in for the needed care...... they had the best last quarter ever
For veterinary practices who had been waffling, offering clients 'options' and using the word recommend found clients staying away - stressed people do not want to make arbitrary decisions, they want the professionals they trust to tell them what needed to be done....... most of those practices had the worst last quarter ever
Current research shows 89% of American pet owners consider their pet a family member, with a third of those being given child status
Current research shows 89% of United Kingdom pet owners consider their pet a family member, with a third of those being given child status
Current research shows 85% of Australian pet owners consider their pet a family member or 'best mate', with about third of those being given child status
Current research shows 75% of New Zealand pet owners consider their pet a family member or 'best mate', with about third of those being given child status
Build a Patient Advocacy Factor chart. It needs to be on the same monthly horizontal axis as any other monthly fiscal chart (e.g., ten Key Practice Indicator Charts found on the CD Tool Kit of the Signature Series monograph, Profit Center Management), so it may be compared for relationships. The vertical axis is practice specific and is derived by taking the total monthly income and dividing it by an annualized visit factor (e.g., the number of rabies vaccinations given in that same month, the number of ProHeartSR-12 injections, or the number of Life Cycle consultations - ala www.npwm.com - divided by two). With the current extended DOI vaccines, we recommend a proactive Life Cycle consultation program and using that for your calibrated yardstick. The "annual vaccination" or the "annual physical" rate needs to be replaced by the semi-annual doctor's consultation (we call that '2xFL' -as in two times for life), as advocated by the AVMA in their direct-to-client initiative (www.npwm.com). This method of charting gives you a feeling for the annual value of the animal to the practice (something most software programs find it difficult to drive, since invoices are done by client).
This Patient Advocacy Factor concept can be better understood by a practical application. We all know what happens to the average monthly client transaction fee when over-the-counter sales increase. It goes down. Now try this return trade concept using the Patient Advocacy Factor chart. Increases in over-the-counter sales for the good of the pet will cause the graph to go up. If this graph line is tracking on an upward trend, even if your average transaction charge is staying level or dropping, it means clients are coming in more often, possibly for smaller purchases per time, and working more with staff on 'husbandry' issues, and better fitting into the family's discretionary income spending cycle. Usually, the return clients are concurrently increasing their Veterinary I.Q., and therefore start spending far more at the practice per year per pet, so it is a time to be happy!
The pet market is expanding, as is the competition for the Pet Parent discretionary dollars. When the first edition of this text was published (circa 2000), there were 71 million cats and 62 million dogs; now there are over 82 million felines and 72 million canines. Birds have increased from 10 million to 11 million, rabbits have increased 28% to 6 million, and pet turtles (2 million - up 80 percent since 2000) have replaced hamsters (1 million - up 41 percent since 2000) as the fifth most popular pet. As stated in Chapter 1, the USA has moved from 22,000 veterinary practices to over 28,500 companion animal practices in the same period of time. Since only about 50% of the companion animal practices in the USA have subscribed to the free training kits from the AVMA (funded by the FDAH initiative partnership), which support the www.npwm.com initiatives, it seems I need to get more specific:
Which tracking system would motivate your staff to try harder to be a patient advocates?
Which system better monitors the more frequently returning client?
Which wellness programs are best done by staff members?
Which factors are a better indicator of full service?
Since client practice access has shifted from acute care to preventative and wellness healthcare, which programs are a better reflection of good medicine?
Which veterinary healthcare delivery approach recognizes the value of the human-animal bond at the level of the client's perceptions?