The Practice Success Prescription: Team-Based Veterinary Healthcare Delivery by Drs. Leak. Morris Humphries
Thomas E. Catanzaro, DVM, MHA, FACHE, DACHE
The inability of a practice owner, the practice leadership, or the multi-doctor board members to understand the new millennium, the emerging veterinary demands, or even the new healthcare environment, can be a major factor in losing liquidity for every participant in the system! Now what does this mean? It means, very simply, and let's be very simplistic here, there are two big areas governance must address. They must know the big picture and they must trust others to know the details and submit summaries to the practice's governance on a quarterly basis.
Concurrently, the definition of a good leader is being someone who has a life outside veterinary medicine. What do I mean by that? Most veterinarians, or even boards, who run their own practice, do not look full of joy. As professionals, these veterinarians are spending forty to sixty hours a week working as a doctor, twenty hours a week reading, and fifteen hours a week talking to people, trying to figure out what the heck is going on in the practice, community, or client access rates.
Too often we find a leader is dysfunctional, due to minutia management or "analysis paralysis." Individual practitioners grow their practice by doing everything themselves in the early years, and they know their minutia, all the way down to: How many scoops of the specific food will cause what size fecal piles in a forty-five-pound intact boxer? They are proud of that knowledge. This happens because they don't understand the big picture, or they become frightened if they raise their gaze to try to understand the big picture.
The "big picture" takes a wider vision than any practice-specific system. It takes a different perspective of the community dynamics, or even the other providers of similar services. The medical director must accept the new graduate as delivered. Practice leaders and coordinators must understand the Generation X need for a balanced life, and everyone in the practice should acknowledge the recessionary economy mind-set of the surrounding population. Please read the following alert:
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New Millennium Alert!
Someone must say it, so here it is. The hours you used to work as a new veterinarian were cruel and inappropriate. To expect anyone to duplicate that sixty to eighty-hour week stupidity in this millennium is dumb and inappropriate.
The new graduate really wants a four-day work week, thirty-two to thirty-six hours of scheduled time. The Baylor Plan in human healthcare is three, twelve-hour shifts in a week, usually a three-day period, including the weekend, with credit for the full forty hours. In human healthcare, no one goes home until medical records are charted and controlled substances counted and transferred, so this covers those post-shift hours for catch-up.
When we start to look for a new graduate, the first thing we do is to screen the graduate's previous life. Does the person have life skills and a work ethic established before enrolling in veterinary school? The second thing we look for is attitude. Is that candidate willing to remain a student for another ninety to one hundred twenty days post-graduation and learn primary care and wellness surveillance? These are things the universities seem incapable of establishing, probably because the tenured system of academia does not require either to be successful.
And as a final shot, most one-doctor practices need to be two-doctor practices, need to embrace four-day work weeks for doctors and staff, which includes owners, and most need to charge appropriate fees for services and products. As Phil Seibert, Jr. CVT, a twenty-five-year colleague and friend, has stated so well, "If those practice owners had common sense, we would be out of business as consultants. But at the current rate, we will be in demand for a long, long time!" |
Too often the leadership focuses on the details, not because the details are critical, but because the details occupy their time, to the exclusion of the big picture questions. This is called the "activity level trap". They feel good because they are doing something, but what they are doing isn't what needs to be done. It's not the big-picture-oriented stuff. Consequently, we will find a leadership group that is relatively sophisticated, when it comes to veterinary economics averages, which is defined as the best of the worst or worst of the best, and details of the organization, those specific client profiles that drive decisions, but don't have a very good concept about what is likely to happen in their environment in four or five years. So, they don't have the ability to go out and create the future. Scary, isn't it?
Refocusing the practice leadership on the big picture requires initial structuring, as well as training development, to make them address the tough decisions on the strategic issues. It also requires changing the information they get. This is a very important strategy to overcome the "minutia management" barrier. This should be addressed in the mission focus and leadership/governance job descriptions to reduce the ambiguity in roles and responsibilities. Every owner group or board runs into the issues of who does what, who bares the ultimate responsibilities for which issue, and what is the distinction between what I do and what you do? Therefore, we have a half dozen "tenets of tenacity", when we establish the initial expectations of a board, a group of doctors, or multi-owners.
See the following box.
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Tenets of Tenacity
1. There are officers within the board, they are internally selected each year, and their job descriptions are supplemental to the board member job description. This is also required in a group of owners, and applies to the medical director role in a group of doctors.
2. Agenda issues are identified on an annual plan, with the tough ones being programmed one per meeting, and they are addressed first at each meeting. These issues are tasked in advance to a specific member(s) of the group, who researches the issue, applies the core values and mission focus, and inserts no less than three key evaluation factors in the pre-published agenda for the entire group to use in preparation for the meeting.
3. A sequential list of motions is maintained, and issues that have come up for vote are not re-introduced for vote within the following six to eleven months.
4. When any form of arbitrary "turf statement" is identified by any group member, the issue will be tabled and tasked to an impartial member task force for agenda evaluation (see #2 above).
5. Confidentiality is a right and compromise an expectation. Caring counts. Cooperation is required for harmony and system enhancement.
6. Leadership loyalty includes respect for all practice individuals, all services and programs, as well as all previous decisions, whether by votes, existing policy, executive team, etc. Failure to show respect can be cause for censure, removal from the decision-making group, or even de-credentialing within the system, if considered detrimental to the image or moral/legal position of the system. |
Given all this background, how does a leader control chaos, when it is all around oneself? Secret of the ages here, folks: if you create more change chaos than what is engulfing the practice or situation, you can control what you created. Never allow the chaos to become a retrospective assessment of failures and blaming. Keep the chaos "future focused". When using the "chaos of change", you are using CQI to look into the future for specific outcomes (Chapter Seven issues again). When they are reached, the chaos is self-mediated by the team, because they have pride in the new accomplishment. At the core of this leadership process is the ability to select a future goal that addresses most of the current issues causing chaos, even if it is to establish an alternative system with new players for a future outcome.
Walk the Talk
To get started with the correct tone, the leadership must identify the core values of any potential affiliation, internal or external, establish the facility-based mission focus, develop a clear vision of the veterinary healthcare delivery direction required for success, and then create the long-range plan. It is a repetitive process of goal setting, assessment, adjustment, and achievement. The leadership is striving for three ideal conditions to evolve:
1. The goals of the affiliated organization, as a whole, are those that the larger community of referring veterinarians will appreciate and reward.
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The goals of the general practice with multi-doctors or owners, as a whole, are those that the potential population of clients will appreciate and access.
2. For each internal or external affiliation, there is a readily visible objective that is consistent with the goals of the organization as a whole, and available within the resources of the entity.
3. The process of assessment and adjustment is carried out in a way that policies and precedents, as well as strategic practice positioning, maximizes achieving those goals and objectives.
No business organization ever achieves the ideal, whether it is industry or healthcare. What is expected is a reduction in the variances. Chapter Seven will discuss this measurement system. To help start this thought process, there are three elements critical in establishing the explicit mission focus for any affiliated group of veterinary healthcare professionals:
1. Community. In most cases, for the specialty practice, this is a community of general practitioners, and in the general practice, it is the surrounding stewards of animals. A general practice that causes animal owners and animals to access a specific level of healthcare will also usually have a higher referral rate to specialty practices. For the leadership of any veterinary entity, the "community" includes geographic, demographic, religious, and financial groups within the catchment area. This is variable, but often it's based on scope of services, technology available, and personal relationships.
2. Service. General veterinary practices must match their access hours for available services to the demand of the clients. For example, a bedroom community often needs evening and weekend hours, while a retirement community needs mid-day hours. A practice that sets its hours on doctors or staff limitations is hurting its own evolution. Clinical specialties can be board-certified experts, but also depend on benefit awareness of the referring veterinarian. Affiliations that center on developing a successful environment for their referring-base practices get to provide more services than those specialists who only focus on promoting their own "expertise". The broader the scope of services offered, and the simplified publication of a menu of services, the greater opportunity for internal referrals.
3. Fiscal accountability. Financial constraints should be explicitly stated. Clean books are a must. The computer system should be "locked" so no one can make a line item change on an invoice. All discounts, no charges, and pro bono work must be charged out at full value, and adjustments made only at the bottom of the invoice. While a single owner may live off depreciation money and co-mingled personal expenses, these habits cannot continue in a multi-owner complex, or a practice that pays on production. The breadth of the mission and vision is determined by the amount of unfunded and under funded work the practice is willing to undertake. It is wise to set the donation/charity amount annually, during the program-based budgeting process, and take over-budget charity/discount expenses from the owner's ROI, or the production pay of the associate.
Good organizations are competitive in all three of the above conditions, and continued success requires frequent attention to all three areas. The leadership is also involved in the beginning, during, and at the end of the review process in all three areas. The well-managed, multi-doctor, hospital has a governance system that focuses its attention on the initial steps of identifying the core values, mission, and vision, and setting policy to improve the consistency and efficacy of the over-all operational process.
When extending the mission focus from the leadership's vision to the practice's strategic positioning for the future, the parameters often become broader, more emotional, and even morally based. This generally makes the vision focus farther away than the practice as it is known, and, therefore, becomes more difficult to achieve than the mission focus for the day-to-day healthcare delivery decisions. Both the mission focus and vision are essential perspectives for any team-based healthcare delivery system to embrace. But the terminology often differs. Taken together with the core values of tough decision making, they express not only what the organization is committed to do, here called the mission, but what it intends to do over longer periods of time, here called the vision.
The vision should make clear what the organization hopes to achieve, what constraints it recognizes, and how it will do business. It typically includes:
How the organization should be viewed by both members and outsiders.
The organizational philosophy that guides operational activities
The organization's concept of its strengths and weaknesses.
The care and nurturing of the healthcare delivery team
The evaluation of community opportunities and strengths
The core values, mission focus, and vision become the cornerstones for judging the competing opportunities identified by strategic assessment of the environment. The best planning scenarios are actually several scenarios, developed jointly by the healthcare delivery team, involving technical and professional questions, rather than policy issues. Initial scenarios should be abstract and ambiguous, and made specific only after evaluating the alternatives and potential strategic opportunities. This often includes quantum shifts in service capabilities, or market share, often by additional staffing, affiliations, mergers, or, sometimes, by outright acquisitions or joint ventures.
Strategic opportunities require careful evaluation, since often there are very large-scale resource investments required. Once strategies and priorities are set, the planning effort largely leaves the leadership level and is delegated to the administrator and coordinators at the daily operational level. It is important to empower the staff to accept the mission focus, see the vision, and apply the core values, then celebrate each discovery and increase in knowledge, regardless of success or failure to the arbitrary goal.
In established practices, we routinely see variation between what is written and what is done. The policies, precedents, or even the employee manual, may clarify who bears the ultimate responsibility. But, culturally and historically, the practice people may not have behaved that way. When it comes time for the leadership to exercise the ultimate authority, they meet internal resistance from members within the system who say, "You have never done that. Why start now?"
Inversely, coordinators are trying to implement a new program, and the leadership says," You can't make that decision without checking with us." The leadership quotes the written word and the rebels within the system state, "Yeah, it is in the protocols, but we know you don't care what is expected when it comes to your 'favorite clients', so why do you think you can change now?" Or the worst of all, leadership states, "You've never done this before, so you can't do it now," and the system grinds to a halt.
Please read the following "The Realities of Consulting".
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The Realities of Consulting
This "I don't care what the consultants have said, or what we agreed to when they were on site, you've never done this before, and we've never done it before, so you can't do it now!", is exactly the type practice we detached from in 2003 This was a consulting engagement where the doctor needed a succession plan. He had super staff to take the administrative and operational load off his back, he had a cardiac misadventure five years before, and a body-crushing accident from which he was still recovering. His associate doctor was on maternity leave, forcing him into a six-day practice week. The wife agreed to the plan, when we were on-site, then would not buy into the staff-operated practice after we left. She wanted her husband to practice as he had before the cardiac and before the body-crush accident. She will kill him, with her personal control needs, but since he allows her dysfunction to become a practice cancer, and will not consent to surgery to cut it out, we had to disengage, rather than watch the slow death of the team and practice.
We have seen practices with just two owners taking sixty to one hundred twenty days to make a decision, simply because they have a fear of failure.
We had a seven-owner practice pay for a consult, so they could succession five of the owners into retirement and leave the two newest partners with the six-practice, five-facility complex. Our new staff-based program for the first month drove $44,000 extra dollars, and in the second month produced another $40,000 excess dollars. The second month's new program drove $38,000 extra dollars into the coffer. Two months, and they had a five times return on their consulting fee. Not too shabby. After six months, the five older partners stated it was too much effort to practice quality wellness medicine, and decided to revert to their old ways. The two youngest partners were disappointed, and lost the new facility that was planned, because the other owners forgot why they had the consult.
We do not detach from most of these. We help them understand what they are doing to the team. We only detach from an engagement about once every two years. It is usually because someone is treating the staff as expendable. |
Anytime there is ambiguity in role and responsibility, then there is a lack of strategic alignment. This causes an inability to execute strategic responses, and many great opportunities are lost. When a practice has a requirement, but abdicates to the historical or cultural vestige of doing consensus-based decision making for exceptions, the system strategy grinds the progress effort to a halt. The "walk the talk" process must be established concurrently within every hospital zone. Anytime we find two decision systems occurring concurrently, we have a disease that will eat away at the healthcare delivery team. If the leadership can't make a decision, because there are so many historical variances, and they must "touch base" with each entity before they can make a decision, then the leadership is dead. A dead leader must be cremated by being buried at sea aboard a burning ship, then a practice leadership restructuring is required immediately.
Another failure to "walk the talk" occurs with leadership conflict. This is defined as those times when the doctors, the board, task forces, or committees, or even zone coordinators within a healthcare delivery system or systems, are continually fighting with each other. We have all seen this with professional associations and the traditional committee form of reference to who is funded and who is most important.
A veterinary practice can have the worst of both worlds, where they have gridlock and conflict existing simultaneously. Since both of those are inappropriate, there needs to be a way of changing them. So we use some basic principles for system leadership in veterinary medicine affiliations, which, admittedly, are our biases:
Get some form of community involvement in the practice structure, whether it be a Council of Clients, a board member from the local VMA or humane society, or even multiple Councils of Clients to address specific perspectives, which include multi-pet households, seniors, dual-income families, cat-only households, high-paying clients, etc. See the details in Chapter 3 of Building The Successful Veterinary Practice: Innovation & Creativity.
It is not unusual to find a corporate attorney or banker as an advisor to the board of a multi-owner practice system, and some even obtain voting privileges if they are animal owners. If you can have a full mixture, marvelous!
The staff spends a lot of time and energy for the practice with their client bonding and operational concerns. They have a right to examine policy decisions. The position, "This is a community-based system, the leadership acts on the behalf of the community, because that is what a leader is supposed to do, so that we are the responsible stewards of our resources on behalf of the community!" is not unusual. The leadership, through the executive team (coordinators), must ensure the staff understands the "why" of the decisions that are to be implemented.
The multi-doctor practices, and most specialty group hospitals, have a potential for economy of scale savings in personnel management, centralized pharmacy, joint-use wards and runs, central information technology (common computer system), and central medical supply, as well as internal referrals to other specialists or doctors with a special interest. The governance group has the accountability for integration oversight, and any non-participant in the facility risks the event of being de-credentialed if they adversely affect the welfare of the whole.
A skilled leader can make any structural model work, if they select their options based on some conscious, pre-defined, explicit criteria to advance a specific system purpose. As a consulting team, we can make any rational leadership system work, but the problem we have found is that many systems mix and match their decision process criteria so frequently, there is no one system to support. Consistency in mission focus, vision, core values, and standards of care must act as the reinforcement for major decisions. These inviolate concepts are part of the criteria for success.
We believe that any leadership team must be able to make quick decisions, and then task the respective zones the expected outcomes for immediate implementation of "how". If your leadership, or even the coordinators, disagrees with this, or either group selects the operational principle that a consensus-based model of leadership is better, where everyone has authority, it means that no one can make quick operational decisions. Community-based strategic responses are, therefore, not generally possible. These consensus-based groups will usually take one hundred twenty to one hundred eighty days to make a simple decision, and seldom be able to capitalize on a "passing" opportunity.
We like to reserve certain powers with the leadership, and develop the parameters to give them the authority to act decisively. One of the powers we like to reserve for them is what is called the "nuclear button". What does that mean? That means that if they don't get the vision/core value-based quality in the key decision makers, they get to remove them at will. When the leadership has this mechanism, and a member of the leadership team starts to veer away from the core values, vision, or mission focus, they have to have a mechanism to immediately correct the situation. When a leadership group is continually removing members off the decision-making body, or coordinator teams, it is time to "nuke" the system, release everyone, and reconstitute the leadership to refocus the new members on the core business of the practice entity or entities.