Wellness, the HAB, and Practice Liquidity

In a general companion animal practice, many equine practices, and exotic animal care programs, client-bonding is a critical component of market differentiation. At the base of that client-centered practice effort lays the human animal bond. The human-companion animal bond has been fostered by the animal stewards, not our profession. It must be respected. While it can be nurtured by a healthcare delivery team, the simple recognition of the animal's importance in the family's life is all that is needed to understand the power of the bond in client acceptance of care and return rates. There are a few key statistics to understand when looking at wellness as a practice initiative:

 Current surveys show that eighty-nine percent of the companion animal households consider their pets "members of the family".

 A third of those households give their pet "child" status.

 About sixty-six percent of the companion animal owners will seek veterinary care more often to extend their pet's life.

 About fifty-four percent of the companion animal owners will seek veterinary care more often to detect disease earlier.

 In most general practices, the top thirty percent of the clients leave about eighty percent of the money. Pet parents are the reason for net income occurring within the potential levels of care.

 About seventy-three percent of the companion animal practice clients are women, and have different communication needs from men, who have established most practice paradigms.

 We kill about six million dogs a year for behavior problems, breaking the HAB, and decreasing the practice patient population.

 An average companion animal veterinary practice makes about seventy percent of the income from outpatient for about thirty to forty percent of its overhead. Inpatient care accounts for thirty percent of the income and sixty-to seventy percent of the overhead.

 The AVMA Mega Study showed a kind, caring and informative healthcare provider was why clients selected their veterinarian, and even in the face of a ten percent fee increase, over eighty percent would not change their veterinarians. Good medicine is good business.

Any wellness initiative is not a gimmick, it is a commitment to client-centered patient advocacy. The primary goal of a wellness initiative is to provide practice healthcare teams the information they need to understand it is more than prevention, more than vaccine protection, and more than intensified diagnostic. The needs of animals change with age, breed, species, sex, and genetic predispositions, as well as environmental, family culture, and surrounding community factors. Each practice must establish wellness as a core mission focus, and implement wellness within its own programs, as a truly rubber-to-the-road, integrated, healthcare delivery program.

In the simplest of terms, "good medicine is good business", if the standards of care are inviolate. There is no reason for the clients not knowing, if there are outpatient nurse technicians (OPNTs), who are usually skilled communicators, and can "talk the walk" for the practice expectations, escorting the patient/client into the room and doing the client education after the doctor has prioritized care, before they depart the consultation room. This is not using more doctor time with each client, it is mobilizing the veterinary extenders on the healthcare delivery team to convey the needs [ ] to the client, before they depart the practice, as well as the expectation for the next contact.

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.

 All unresolved presentations must be listed on the master problem list and logged into the veterinary software for tracking.

 All atypical laboratory screens must be listed on the master problem list and logged into the veterinary software 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, 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 followup closed out in the veterinary software.

 Document medical records with conviction. "We need to do X-rays on this dental arcade!" As an example, for an X-ray notation:[ ], L 174 \f "Symbol"\s 13, and "Okay Doc, do it.", would show in the record as X-ray [x] lat L&R mandible [ ], with the new box to be initialed by the people doing the X-rays.

It is not client compliance! It is standards of care!

Some call it compliance, some call it quality medicine. Some staff calls it nagging, and some doctors say it is telling them how to practice medicine. They are all right! - Thomas E. Catanzaro, DVM, MHA, FACHE

Perceptions are reality, and cannot be ignored. When there are variable standards of care between providers in a single veterinary practice, clients get confused, and staff gets frustrated. That is unacceptable. Consistent standards of care must become a "term of employment". When combined with the inviolate core values of the leadership, and practice vision, they set the course for the practice's future.

Let's start with documentation. Problem-oriented medical records are logical and needed for continuity of care:

 S-O-A-P = Subjective - Objective - Assessment - Plan.

 H-E-A-P = History - Examination - Assessment - Plan.

 S or H = What the client said, in their words, never a "translation".

 O or E = Twelve-system physical exam, with normal or abnormal noted:

 Each abnormal explained immediately below.

 Weight with BCS, T-P-R, BP, +/- ton-o-pen, +/- Lead II ECG, etc.

 Dental grade (0-4+), and preemptive pain score.

 CBC, blood chemistries, urinalysis, etc., as needed.

 Imaging, as needed, for surveillance or diagnostics.

 A = Assessment, tentative diagnosis (dx), or what is being treated for (R/O)

 Never "open", even for just empirical treatment of symptoms.

 Extended university-style differentials do not help others.

 Needs to explain the signs noted, and support the plan.

 P = Plan for resolution

 Use a box to denote each need (never "recommend").

 Whenever need is stated, room falls silent for client's response.

 Enter client's response in the respective box.

 * (W = waiver, D = defer, A = appointment, X = do it)

 X-ray [D] 72h = Deferred imaging for seventy-two hours.

 X-ray [X] vd/lat R knee; [ ] = Initials of staff taking X-ray in second box.

Note the following protocol formats that were published in DVM Newsmagazine, July 2003:

The 2003 AAHA Standards for the Accreditation of Veterinary Hospitals revealed a new demand for more protocols; most have been long past due in this profession.

We all realize that clinical protocols are important, yet while we spend many hours writing them, they seldom are kept current. The reasons are many, but the key reason is usually they were not developed by the practice team.

Here are a few guidelines for developing protocols that will be embraced and maintained by the entire practice team.

Strategic Preparation (owners/doctors/governance/medical director)

1.  Leadership Identifies Need. For example, forensic, governance, changing scientific knowledge, poor standards of care, new equipment, new services, new products, new ownership philosophy, etc.

2.  Leadership Does Situational Forecast. For example, what players could be involved, which literature and resources are needed for the project team to succeed in meeting expectations, what resources will be needed, what behavior/habit barriers exist, influence of community trends, current literature, etc.

3.  Leadership Sets WHY Into Time Frame. For example, what time-line restrictions exist, what milestones need to be met and when, what will be the accepted key measurements of success, etc.

Strategic Assessment leadership with teams/task forces/staff)

1.  Solicit volunteer action team. Do It Group = Dig Team. For example, selected protocol team of two to three staff, ensure they understand the WHY of the "need", establish the limits of the project scope, as well as the latitude within the limits, review core values and standards of care as they apply to the protocol in discussion, etc.

2.  Develop a vision of the expected outcome. For example, model of outcome protocol expected, desired benefit to patient, client, staff, or practice, etc.

3.  Establish clear goals and objectives. For example, development time allocated to who reinforces the desires to change, ensure a participative process, jointly agree on measurable results, etc.

4.  Write detailed action plans. For example, C-R-A-M each goal and objective at least two different ways (Plan A and Plan B) to reach outcome, and ensure the plan is Challenging (is the stretch worth the effort?), Realistic (can environment handle this?), Attainable (do key players have resources and ability to do this?), and the outcome Measurable (do we know a success when we see it?).

Strategic Response Management (staff teams/task forces)

1.  Establish an information reporting system. For example, progress and learning must be recognized by leadership, even if they are baby steps. Ensure the right things are being measured. New projects require new measurements. Provide supplemental training as needed. Ensure task force/project team has a "hand-off plan" to the appropriate practice zone(s) for after the protocol is developed, to ensure buy-in, etc.

2.  Integrate the protocol into the patient and client practice flow. For example, each protocol does not stand alone, requires orientation and training of staff, must be tested for ninety days before evaluation or major modification, etc.

3.  Review implementation process. For example, desired task outcomes, desired staff acceptance, desired client service, desired patient benefit, cost-benefit analysis, tweaks as needed to detailed action plans for ninety-day test phase, etc.

4.  Determine recognition/rewards. For example public acknowledgment of task force, people, and outcomes; assessment by clients for feedback recognition; percentage of new savings or excess earnings to task force/implementation team; etc.

(The above has been adapted from Strategic Assessment & Strategic Response, a VCI® Signature Series Monograph (www.drtomcat.com). All Rights Reserved.)

Standards of Care: Sample Funding of Practice Programs

The Standard

Every outpatient presentation will have a full twelve-system physical exam documented, with normal or abnormal marked for each system, including the TPR, BP, Lead II ECG, and urine screening ERD. This will also include a dental grade (0, 1+, 2+, 3+, or 4+), a weight with body condition score (BCS, nine-point system, from Purina Chart), and a preemptive pain score (1-10, per the VCI® HAB Scoring Pocket Guide).

Experience Factor

Starting at two years of age, an annual early renal damage (ERD) screening test is expected until the over-four period. (See the Pfizer senior's brochure chart.) About thirty to forty percent will be positive, as most of the younger animals will be due to grade 1+ dentistry needs, deserving early renal diet. Both Waltham and Hills state that shifting early to a quality renal diet can virtually double the life span of the animal, while Purina states that any shift to a premium diet at middle age will add twenty-two months to the quality of the patient's life.

About five percent of the positive ERDs will be high positive, requiring immediate CBC and blood chemistry as a precursor to intensified diagnostics. At thirty days' post-dental prophy and diet, a subsequent ERD will usually reflect negative, and the provider should celebrate with the client. About five percent will continue to be positive, requiring sequential CBC and blood chemistry as a precursor to intensified diagnostics.

Client narrative to phone shopper on office call

"Our semi-annual doctor's consultation includes both a screening ECG and a blood pressure assessment, now possible with new consultation room instruments. These are included in the basic cost of $38. As you call around town, please ask about these two critical diagnostic tests, so you will be comparing like services. The web site for national wellness standards is www.npwm.com, if you are interested. May I send you a brochure explaining the vaccination needs of you pet?"

Client narrative to client making appointment for semi-annual life cycle consultation

"Our semi-annual doctor's consultation includes both a screening ECG and a blood pressure assessment, now possible with new consultation room instruments. These are included in the basic cost of $38. We also need a urine sample just as your physician does. We can draw it or you can bring us a sample in a margarine bowl. Are there any other questions?"

Basic Math: ERD is purchased from Heska at $8.50, though micro-albumin should be a lower cost from Kacey, and resold at $17. Initially, in four hundred transactions, about half will be semi-annual consultations, so that is about $1700 more net a month just from the initial ERD. Positives are thirty to forty percent, most needing a grade 1+ or 2+ prophy, at $94 and $154 respectively, so at $100, that drives an additional $8000 from prophys and an additional $80 ERDs post-dental, which is about $680 net income. The renal diets will cause about an additional $1000 net, using VetCentric home delivery. This simple urine screening program, therefore, drives over $11,000 per month per FTE veterinarian.

One sample (dentistry) of practice outcomes, when doctors support the practice's standards of care:

Grade all teeth. Tell clients:

 "Brown teeth equals bad breath, red equals pain."

 "We need to do a dentistry."

 "Is this the level of care you want for Spike today?"

 "Do you want us to admit Spike today for that dental clean-up, or do you want to make an appointment for later this week?"

Fact. American College of Veterinary Dentists state that eight-five percent of all animals presented have some form of dental care need. This is also stated on Virbac's CET Dental Brochure for clients.

Fact. Linear scheduling gets a doctor about four hundred to four hundred fifty transactions a month, fifty percent more with multi-tasking programs.
Math. Four hundred to four hundred fifty times eighty percent equals three hundred forty to three hundred eighty-two patients with dental needs.

Fact. Given a "yes-no" choice to needed care, about half the clients will select "yes". Given two "yes" options, such as do it now or schedule it later, over seventy-five percent will select "yes".
Math. Three hundred forty to three hundred eighty-two times fifty percent equals one hundred seventy to one hundred ninety-one patients with dental "yes"

Fact. There are about twenty dental prophy days in most months.
Math. One hundred seventy to one hundred ninety-one patients over twenty days equals eight to ten dentals a day.

Fact. Teeth grading techniques have been standardized by the veterinary profession, and grades relate to time required to do the prophy, which relate to cost, and veterinary software tracking capabilities

 Grade 0: This denotes a clean and unremarkable dental arcade, no gum indications of detachment or inflammation, and a reason to schedule the animal in for a subsequent courtesy check-up with the attending nurse in about four to six months.

 Grade 1+: White incisors, some brown plaque on the molars, where bacteria live, and no gingival detachment. There is early pain and some bad breath from the bacteria. For a pre-anesthetic risk level 1 patient, can clean them up with a prophy for $94 in about twenty minutes, which includes PA lab; PCV, TP, and BUN. For example, Kacey Vetometer BUN cost is less than $1.50. With a VPI reimbursement of $65, client cost is less than $30.

 Grade 2+: Brown plaque on incisors and on the molars. Gingival pockets are up to twenty-five percent. The red gum pain and bad breath (more bacteria) is more noticeable. With risk level 1 patient, can clean them up with a prophy for $154, which includes PA lab; PCV, TP, BUN, and CBC, plus pain injection, in about thirty to thirty-five minutes. With VPI reimbursement at $65, client cost is less than $90. Late grade 2+ may require X-ray of root deterioration potentials at an extra fee.

 Grade 3+: This starts the "oral surgery" dental conditions, as seen with brown incisors, some tartar build-up, and very red gums, meaning pain and significantly bad breath. Cost is greater than $275+ and includes at least a PA lab, PCV, TP, and six-factor blood chemistry with CBC, pain injection, X-rays of roots are indicated, extractions, and "clean them up" with a prophy. This oral surgery is about sixty minutes effort, requiring doctor attention.

 Grade 4+: The worse of the "oral surgery" dental conditions, with severe tartar build-up down into the bone, significant pain, systemic cascade of infection, and significantly "gag a horse" bad breath. Clean them up with a prophy for more than $400+, which includes at least a PA lab, PCV, TP, fourteen-factor blood chemistry and CBC, X-rays, and pain injection. Additional age or professionally needed laboratory testing will be assessed as extra costs.

These grades should be recorded on the patient data cover sheet during the exit summary by the doctor, and eventually the grade will be used to target mail a health alert, as well as reminders.
Math. Grade 1+ (P.A. risk level 1) equals practice costs equals P.A. lab, one hematocrit tube, broken onto refractometer, plus a Vetometer BUN is equal to or less than $2; add pumice, polish, and fluoride, which equals or is less than $1.50; twenty minutes of isoflurane is less than $2; induction is equal to or less than $5 drugs and supplies; IV TKO, with extension tube to IV Set is equal to or less than $5. Staff time, table, equipment, and facility overhead is SUNK cost, already paid for, and does not reduce overhead costs if not used. Therefore, the total procedure cost is about $15 for Grade 1+ prophy (P.A. risk level 1).

Fact. With everyone grading teeth, three booking profiles will emerge between a group of doctors:

 Heavy same day dentals

 Heavy appointment for dentals

 Heavy deferrals of dentals

These three booking profiles are strictly doctor delivery related:

 Heavy same day dentals: Doctor puts the dog under arm, walks to the back door of consultation room, and states clearly, "We need to do this dentistry and we can get it done today, rather than schedule it later. Is this the level of care you want for Sweet Cakes today?"

 Heavy appointment for dentals: Doctor leaves dog on consultation table and states, "We need to make an appointment to do this dentistry, Mary will schedule it for you." (Mary is the OPNT.)

 Heavy deferrals of dentals: Doctor looks at the client and says, "We need to clean up this mouth, and you should consider scheduling an appointment soon, maybe with the front desk as you leave."

Simplistic Math: If you do not allow the doctors productivity credit for a procedure or product, they will not book/sell many. You have just shot yourself in the foot with a large-bore "dumb" cannon.

Advanced Math: Grade 1+ cost to practice is equal to or less than $15, so for only early detection of dental conditions, at $94 fee, $79 profit per procedure times nine per day equals $711 per day per doctor; two-doctor day equals eighteen per day, which equals $1422 profit, or $7110 net income per week; at fifty weeks a year, that equals $355,500 additional net income for a procedure that only requires the doctor to believe in "puppy breath" and be a pet parent awareness trainer, since the staff does all else.

Fact: Most practices allow this $355,500 additional net income to be missed, since they do not have consistent standards of care, inviolate core values, or even a clear mission focus on wellness and pet parent awareness training.

Complicated "Wake-Up Math: When you start becoming aware of teeth, about twenty-five percent of the procedures should be Grade 1+, twenty-five percent Grade 2+, ten percent will be borderline Grade 2-3+, twenty percent Grade 3+ oral surgery, five percent will be borderline Grade 3-4+, and fifteen percent Grade 4+ oral surgery. In a two-doctor practice, when we error in grading to the low side, this would equate to five Grade 1+ ($470 gross) five Grade 2+ ($770 gross), five Grade 3+ ($1375+ gross), and three Grade 4+ ($1200+ gross) each day, for a total of $3815 a day, or $19,075 more gross income each week. Yes folks, that is $953,750 additional gross income in a fifty- week year, with some additional costs, including doctors' time for the oral surgery procedures.

Fact: If BCS and other nutritional needs are driving nursing advisors to move patients to higher quality diets (premium diets), and if the practice stocks one premium nutrition brand only, the other brands could be home delivered by VetCentric^®. IF... IF... IAMS is identified as the best home delivery product for prescription diets, since virtually all of IAMS' prescription diets are dental friendly, with special "teeth scrubbing" enzymes, and VetCentric^® will deliver it. Then the "50 scripts" program of VetCentric^® will occur each month, qualifying the practice for deeper discounts, which favorably rival PetMedExpress costs to the clients.

Match Factor: This gets the practice monthly dispensing fees from VetCentric^® for no product cost, no stocking fees, no carrying fees, nor any loss/shrinkage worries. It is pure free money for providing a pet parent the convenience of home delivery, and VetCentric^® sends a monthly by-patient report, so your medical records can stay current on each patient receiving prescriptions from the VetCentric^® mail order system.

And your practice has been resisting clear standards of care. Why?

Measuring Success by Average Client Transaction (ACT) Rates

There are many current journals, and many practice consultants, who measure success in practices by quoting the current average client transaction (ACT) or the practice gross. We are one of the few professions or small businesses who operate with only income as a measure. Most everyone else in the world understands that "net income", not gross, is a key measure of success. This means you must know the expense, or at least know income as an operational ratio. We discussed the "diagnostic ratio" for doctors and the "Travel/Circle Sheet three Rs" (recall-recheck-remind) for next-visit planning in Building The Successful Veterinary Practice: Programs & Procedures, so now it appears time to discuss the ACT!

Here is the real question:

 In 2003, the ACT was $94. There was a seven percent medical inflation rate between 2003 and 2004. In 2004, the ACT was $94. Which was a better year for practice income? Please, 2003 or 2004? Choose!

The rest of the story is simply a measure of client visits. In 2003, when the average client transaction was $94, there was one visit per client per year, but in 2004, when the ACT was still $94, there were three visits per year per client! Now which was a better year? Change your mind? Trick question? Okay, try this one:

 In 2003, with four visits per patient per year, the ACT was $93. There was a seven percent medical inflation rate between 2003 and 2004. In 2004, when the ACT was only $89.50, there were still four visits per year per patient . Which was a better year for practice income? Please, 2003 or 2004? Choose!

The rest of the story is simply a description of the operational philosophy. In 2003, there were 1.2 doctor hours and 0.9 staff hours spent per patient visit, but in 2004, when the ACT dropped to $89.50, there were 0.3 doctor hours and 0.5 staff hours per patient visit, but more clients brought in all their pets (recovered pet program). This moved the practice's average from 1.35 patients per household to 1.63 patients per household and made more multi-pet appointments, with an extra ten minutes added to the twenty-minute base appointment for a second or third pet! Now which was a better year? Change your mind? Trick question?

No. These are not trick questions. You saw immediately that the gross dollars of the ACT had very little bearing on the "success" assessment for these practice situations. If you saw the "real answers" that quickly in these scenarios, why have you continued to pursue them on a daily basis? It is return visits and high-density scheduling, as well as multi-tasking, team-based, training techniques used in veterinary healthcare delivery that will make the veterinary practice of the future successful. That is the "success question" you must resolve now.