We awaken in others the same attitude of mind we hold toward them. - Dr. Tom Cat

I have written much about CQI. It was introduced as basic leadership skills in 1997 in the text Building The Successful Veterinary Practice: Leadership Tools. CQI was introduced with ten "pillars", the foundation of the future. While the concept has been "borrowed" and tweaked by some other veterinary consultants, the original ten pillars were listed as:

1.  Trust in values.

2.  Commitment.

3.  Accountability.

4.  Recognition.

5.  Training.

6.  Communications.

7.  Reminders.

8.  Expectations.

9.  Evaluations.

10.  Problem solving.

I pointed out that like all foundation pillars, they were not a "pick and choose" set of pillars. One crumbling pillar causes the structure to fall.

After several years and a lot of "field assessment" of practice implementing the Pillars of CQI, in the VCI® Signature Series Monograph Models & Methods That Drive Breakthrough Performance, I modified the ten pillars to twelve pillars in the new model:

1.  Standards of care.

2.  Trust in core values.

3.  Commitment.

4.  Accountability.

5.  Recognition.

6.  Continual training.

7.  Communications.

8.  Behavior reminders.

9.  Expectations.

10.  Evaluations.

11.  Problem solving.

12.  Continuity of care.

These pillars were placed atop the 2003 AAHA Standards for Accreditation, which are not unlike the ISO 9000 Quality Standards for Industry, and were capped with the Malcolm Baldridge Quality Award (refer back to Chapter Nine, Page 463). Then I applied the Six Sigma process, and showed how to measure progress against your own practice trends. The monograph was written for the TOP forty percent of veterinary practices NOT using national averages for self-assessment, as the national average equals striving for mediocrity.

Character and Life Skills Beyond Science and Technology

It is neither the scientific nor the technical which make successful veterinarians, it is their leadership and life skills that are the defining success factors. - Workshop for Veterinary College Administrators, Educators, and Practice Management Consultants National Commission on Veterinary Economic Issues

The beginning chapters of this text dealt with the evolution of management into leadership, with tools and techniques that allow a practice to become team-based, and for clients to perceive a full team in support of them and their pets, instead of just a single doctor.

In the original version of Building The Successful Veterinary Practice: Leadership Tools, when I introduced CQI with ten pillars, I also shared an old adage I have used to measure leadership acceptance of the team approach:

Because I dissent I am not disloyal.
Because I differ I am not disloyal.
Because I care I will challenge assumptions!

My seminar approach is simple. If you can say the above at a staff meeting, and the staff nods their heads in agreement, you are probably there. If you say it and they look dumbstruck, you are not walking your talk.

That said, and calibration now being shared, it is time to look at the numbers relating to success and prosperity.

Implementing Program-Based Planning

How do you get enough time to do all of this "new stuff" needed for program-based planning? Simple. You don't! It must be a team effort.

Every staff member must be involved in the new programs and processes. The leadership establishes clear core values, assigns accountability for reasonable outcomes, then become visionaries and trainers. The following six elements must be accepted as a minimum set of requirements and expectations for program-based budgeting to work:

1.  The practice must have a team that believes. They must believe in the core values of the practice and in the standards of quality healthcare delivery. They must believe in the "why" of the programs, as patient advocates, not as just "new income sources" for the boss.

2.  The leadership must be willing to "train to trust". Each member of the staff must have the in-service training opportunity to gain confidence and competency in the new programs and support procedures. A "trusted" staff member will receive an "outcome" accountability, and the doctor, or manager, will not worry, or even care, about the process. Success measurements will be founded in outcomes and results.

3.  The practice leadership will practice daily the three Rs of building self-worth in all of the staff members: Respect, Responsibility, and Recognition. Respect for all immediately, responsibility concurrent with training to trust, and recognition, since behavior rewarded is behavior repeated.

4.  Be ready to change every habit and modify every new program to respond to community needs. Strategic response replaces the outdated strategic planning process. Be ready to do unique and unusual things, as if they were usual, and do the usual in a new and unusual way. CQI means every staff member is accountable for unilaterally causing improvement and change on a regular basis for the benefit of the client, the staff, or the practice entity.

5.  Be ready to track more program specifics, based on procedures, as well as dollars. Be ready to upgrade computer knowledge and increase the trend-assessment discussions within the staff. Start getting balanced financial reports. Pair income to expense centers with expenses. Not alphabetized, but rather, in order of importance. Be ready to change accountants if the firm will not support your effort. Be ready to have every member initiate new programs and target actions every quarter. Embrace practice performance planning, rather than performance appraisals of the past.

6.  Accept the fact that this is a new practice process, not a gimmick or a new program. Once started, you can't go back. Once started, you are committed to change the future -- forever. Change will be the norm, and if "it" seems okay, "it" hasn't been assessed well enough for adaptation to the future.

About this time, many practices are saying, "Our veterinary software will not let us do it!", and to that we say, get ready for a shock. Progress note-based veterinary software systems are now available. Sure, Impromed (www.impromed.com) is user-friendly; AVImark (www.avimark.com) provides great bang-for-the-buck tailored veterinary software; DVMax (www.DVMax.com) is the Apple users' preference; Cornerstone is rapidly trying to make their system compatible with the AAHA compliance study and achieve legally sufficient medical records, unalterable after case closure by the attending veterinarian; and IntraVet (www.Intravet.com) achieves high scores on anecdotal user survey ratings in support and service.

Most all surveys conducted by journals and Internet providers ask users to self-rate the systems they are using, which by-passes the comparative or informed aspects of software evaluation. The progress note-based veterinary software systems now available in the USA are:

 RxWorks (www.rxworks.com), with a twenty-plus- year history in 16 countries, and an eighty percent terminal share in Australia, this software is being used at every veterinary teaching hospital in New Zealand, Australia, and recently, the Royal College in the U.K. (300 terminals). RxWorks offers twenty-four-seven telephone support. Headquarters, Henderson, Nevada.

 Alis-Vet (www.informavet.com), was developed in Toronto. Alis-Vet has a fourteen-plus-year history, with only one key development programmer, who works tenaciously to meet the AAHA compliance programs. The company now offers field support in the USA. Headquarters, Toronto, Canada.

 Elinc Via (www.elinc.net) software is two-plus years out of Beta testing, with new players, solid underlying software programs, progressive expansion into many lateral relationships, but not as many linkages as Alis-Vet or RxWorks, due to a shortage of development dollars during start-up. They recently were bought by a radiology firm, so only time will tell about the speed of further development. Headquarters, Plano, TX.

Progress note-driven software systems have been developed to think like a veterinarian, where the unresolved assessment issues (atypical conditions) should cascade to the problem list, including symptomatic or deferred care, which then should be assigned one of the three Rs (recall, recheck, remind) with an attending nurse identification for follow-up, and provide an interactive client contact methodology. In some cases, invoice-driven software is now programmed to tell the practice at the end of the month how many missed opportunities occurred in the past month, while RxWorks actually defaults to action-appointment-defer-waiver choices, so the issue is resolved before the client/patient leaves the facility. Sure is nice to know how many horses got out of the barn during the month, but as an old horseman, I believe it is better to catch them before they leave the barn.

Program-based budgeting is not new. Every new practice leader focuses on the front door swinging and will do whatever it takes to make it swing. It is only mature practices that seem to lose this focus. This simple fact is what makes this concept so valuable. It is why we entered this profession, why we opened the door of our facility, and why we feel so good when things go right. So make them go right. Refocus on the front door, rather than the speed bumps of your life. Seek puppy breath, rather than dragon's breath. Celebrate the little things, have fun again. Make every day worth celebrating, for the staff, the clients, and yourself. Live large!