The Practice Success Prescription: Team-Based Veterinary Healthcare Delivery by Drs. Leak. Morris Humphries
Thomas E. Catanzaro, DVM, MHA, FACHE, DACHE
The client relations triad, comprising reception, telephone, and discharge staff members, must also have a midday shift, so no one works telephone for more than five hours at a time. Pursuing the recovered pet and recovered client programs, even at fifty percent effectiveness, as described in the VCI® Signature Series® Monograph Client Relations Zone, will easily fund the additional staff needed for these zones and transitions.
The issues impacting most expanding veterinary hospitals often involve new floor plan revisions, which have separated admission from discharge, enlarged or opened up a very large treatment area, and have increased the circulating space and distance. In an expanding hospital staff, without an expanded facility, the increase in traffic, and the traditional front to back "everywhere" doctor habits, causes the staff to waste substantial time waiting and hovering, hoping to be told where to be or what to do, so they do not get "yelled at" by the doctor(s).
The five (or other larger odd number) consultation rooms allow two doctors to work outpatient. Each has two rooms scheduled, using team-based client-centered scheduling and multi-tasking team techniques (mt3). Meanwhile, the center room is the overflow, emergency, and inpatient admission room to help keep things on track.
The new habits are much easier to learn than forgetting/unlearning the old linear habits, which have traditionally made the admitting doctors follow their cases front-to-back, sucking staff behind as they moved. To break the habits, the staff must be totally empowered to be the conscience of the practice expectations. They will be fully supported, when they call a doctor for violation of core values, inconsistent standards of care, or variances from established protocols. For the minimal protocol needs, please see the 2003 AAHA Standards for Hospital Accreditation.
In the team-based client-centered scheduling and multi-tasking team techniques (mt3, outpatient doctors refer cases to inpatient, and inpatient doctors "train to trust" a discharge nurse. Scheduling staff knows which doctor is in which zone, and guides "doctor-specific" clients. Patients do not care who the doctor is that stops pain, or which one protects them from the diseases of the community.
For example, "Doctor A only has afternoon appointments left, Ms. Jones (or, "Doctor A is on inpatient this morning"), so you can drop Killer off early this morning, we can do the needed care as a day patient, then schedule an afternoon discharge appointment with Dr. A."
The most difficult task is the shift from being a doctor-centered practice to becoming a client-centered practice, which schedules the facility, rather than the doctor. Empty consultations rooms serve no clients, care for no patients, nor do they make any money, but are common in doctor-centered practices.
In the new format of team-based client-centered scheduling and multi-tasking team techniques (mt3), when the doctor(s) moves between zones, a new staff zone is entered that is controlled and prioritized by the nursing staff, just like in human healthcare wards. The doctor checks in with the nursing staff before starting to see the patients.
The Key Players
The hospital administrator/manager: This person will vary with the ownership format. In a multi-owner or multi-doctor practice, a board-form of policy and precedent reference must be established (see Veterinary Management in Transition: Preparing for the 21st Century").
The minimum credentials for this administrative person should be a Certified Veterinary Practice Manager (CVPM), as provided by the Veterinary Hospital Managers Association (VHMA; go to www.vhma.org). In the larger veterinary complex situations, this position may, in fact, be an expanded administrative team.
This person serves the board or ownership as the "coordinator of coordinators", and should not be by-passed by any owner or doctor for any practice issue, other than patient-specific case management.
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Explanation of Terminology
In effective governance, the board does not get involved in operations. The board establishes policy and precedence, provides quarterly budget guidance, and focuses on the practice's role in the community. The board works through the manager/administrator in matters of operations and human resource management, and through the medical director in matters involving the standards of care. If board members are also clinicians, they are only clinicians when on the floor, and never assume to be owners or coordinators of operations of medical standards of care.
The Generic Coordinator Expectation
Besides ensuring the zone members have received adequate training to achieve competency, coordinators ensure the resources are available for zone operations, including staff scheduling and quarterly budget review, and are the contact point when there is a change in protocol or operational format.
Coordinators are also link pins for the inviolate core values and standards of care established by the practice leadership. This includes giving respect, setting responsibility expectations for outcomes, and providing adequate recognition of zone members, including maintaining a "safe haven" for zone members from any mental or verbal abuse by others, even doctors. |
The client relations coordinator: This person coordinates the front staff, including receiving and discharging clients/patients, even if done by the OPNTs from the consultation rooms. This person also coordinates telephone/fax/e-mail communications, medical record surveillance for completeness, and client outreach/mailing functions, including reminders, newsletters, health alerts, and news releases. As coordinator, this person ensures the client relations zone members have received adequate training to achieve competency, ensures the resources are available for zone operations, and is the contact point when there is a change in protocol or operational format.
The outpatient coordinator: This person ensures that the OPNTs and outpatient technical assistants have received training to competency in all active outpatient programs, ensures that the resources are available for zone operations, and is the contact point when there is a change in protocol or operational format. Since the OPNT is accountable for keeping the outpatient doctor on schedule, failure of doctors to respect the OPNT or the practice's social contract with clients, such as being seen on time, the outpatient coordinator may have some "corrective guidance" discussions with doctors, and/or the medical director, to resolve schedule or standards of care issues.
This person acts as the coordinator for the outpatient zone and attending staff members, although the coordinator may functionally be in the total hospital duty site rotation.
The inpatient coordinator: This person is often the most technically skilled staff member, but does not have to be, since this role is to ensure the IPNTs and inpatient technical assistants are adequately trained to operate per doctor orders, without supplemental supervision, and is the contact point when there is a change in protocol or operational format. Since the senior IPNT is accountable for keeping the treatment room, surgery, imaging, and dental operations on schedule, as well as keeping the inpatient doctor's schedule, failure of doctors to respect the IPNT or the practice's staffing system, such as arbitrarily pulling staff away from assigned duties, the inpatient coordinator may have some "corrective guidance" discussions with doctors, and/or the medical director, to resolve schedule or standards of care issues.
This person establishes the mt3 operational protocols for all inpatient workload flow, could act as the shift coordinator for the inpatient zone, ensures a system of internal credentialing for attending staff members, ensures all work stations can operate concurrently, and may functionally be in the total hospital duty zones rotation.
The resort manager (animal caretaker zone coordinator): This person coordinates the Pet Resort (boarding operations), which includes occupancy levels, training of the animal caretaker staff, as referenced in Title 9, Code of Federal Regulations (CFR) and ABKA standards, and guest cleanliness and comfort.
Unlike the coordinators and other practice program managers, a resort manager often conducts business separate from the practice, so the resort manager's zone should be functionally separate from the hospital duty zone rotation. In some low-occupancy situations, or when the facility offers only respite care services, due to size of facility, such as in less than forty units, the resort manager, or animal caretaker zone coordinator, may coordinate with the inpatient and outpatient coordinators to provide the animal caretakers for cross-training as technical assistants within the practice's healthcare delivery zones.
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Respite Care Operations
In most veterinary facilities, there is inadequate space, nor appropriate staff, to provide cost-effective boarding operations. Cost-effective is an economy of scale that allows the maximum occupancy during holidays to dwindle to not less than (NLT) one FTE animal caretaker for thirty-three animals in residence. There is usually a sixty percent shortfall of guest occupancy between holiday seasons, so one hundred units is the usual break-point between cost-effective and staff mis-utilization.
When human healthcare facilities assume daily care and monitoring of chronic need patients, it is called respite care. This is a term used in hospice, for home-care patients being returned to the hospital, while the family providers take a break from the recurring patient care responsibilities.
Veterinary facilities with the smaller-sized capabilities fit better into a veterinary-supervised occupancy for chronic-care patients of established clients, such as respite care services. This is usually done as nursing care, and charged accordingly, for patients needing daily medications or monitoring for health conditions. Yes, some exceptions may be made for "boarders" in the traditional sense. |
The training coordinator(s): This may be a separate position, an additional duty for existing zone coordinators, or a part-time position. It may be handled by one or two people, depending on the practice/shift demands. In conjunction with the other coordinators and the practice's technology and/or operational evolution, the training coordinator(s) is accountable for the monthly in-service training schedule, and identifying the subject matter experts to become the trainers. An associate doctor is "usually" assigned as the lesson plan mentor, so the old habits will give way more easily to new doctrine. The most effective practices close the same afternoon every week for training and meetings. For example, Wednesdays from 11:00 a.m. to 3:00 p.m., which allows 11:30 a.m. to 2:30 p.m. to be dedicated, uninterrupted, training time. This provides for staff meeting time, zone meeting time, and training time without excuses about case load demand. In most all cases, effective teaching requires a hands-on application phase, so even if a vendor buys pizza and does the seminar, some staff member must become accountable for getting the "rubber to the road" in daily operations, while ensuring they maintain consistent standards of care with the staff and doctor delivery programs.
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Coordinator versus Manager
In the new American Veterinary Practice, there is an elimination of supervisors and grading of performance, as discussed initially in Chapter 1, Building The Successful Veterinary Practice: Programs & Procedures, as well as the VCI® Signature Series monograph Zoned Systems & Schedules. The era of self-directed teams has always existed in healthcare delivery. Professionals are licensed and accountable to a set of quality and performance standards, established by a licensing agency, as well as the expectations of the healthcare facility.
In human healthcare, every doctor is "credentialed" for a scope of services, and delivers healthcare within those peer-reviewed expectations. In veterinary medicine, we have yet to adopt these self-review processes. But if we do not initiate these standards soon, it will become legislated by public demand.
Coordinators have the responsibility for ensuring human resources have the support they need.
Managers ensure programs are consistent and meet practice standards.
We have always trained animals, and taught students. In healthcare, we nurture people, to ensure learning to competency has occurred. This is the application phase of effective teaching.
Managers get work done through people, while leaders develop people through work.
Coordinators work in the trenches with the team, managers point at the trenches and keep people in them.
A "usual" manager excels at quality assurance and quality control, where QA spot-checks outcomes for consistent standards, and QC monitors processes to ensure consistent standards.
The savvy coordinator excels at establishing an environment that supports continuous quality improvement (CQI) at every level of the organization or zone, making next week better than this week, next month better than this month, and next quarter better than this quarter. |
The inventory manager: This person coordinates the inventory flow, accepts inventory team volunteers, and ensures they understand all expectations for stocking, restocking, and computer maintenance of the inventory pricing and tracking systems. Although vendor stocking is becoming a preferred economy of scale service, there must be someone who monitors the vendors, when they have committed to provide this service. Like the coordinators, program managers, such as the inventory manager, should functionally be in the total hospital duty zones rotation, but may be offered one or two four-hour shift(s) to manage their respective programs.
Program managers: Most assign specific staff members to become mentors and oversight specialists in specific healthcare delivery programs, such as nutritional advisors, dental hygiene, behavior management, parasite prevention and control, over-forty health surveillance, surgical nursing, laboratory, imaging, triage nursing, intensive care, etc. The list could be endless.
These are the people who get sent to special continuing education for their specific program(s) and are expected to come back and implement one great idea for each day of funded CE attended. Remember, "implementation" requires the new idea/program stays alive for ninety days, then, and only then, evaluation can be done by the coordinator team and doctors.
The hiring team: This group is task-organized for each hire, but developed initially as the client relations coordinator, inpatient coordinator, and outpatient coordinator, and maybe the animal caretaker coordinator for certain hires. They are accountable for establishing the needed traits/attributes of the candidate (hire for attitude), the job description needed for the training commitment (train to competency and productivity), and then interviewing all applicants and selecting candidate(s) for employment.
The hiring team immediately becomes the candidate's training team for the orientation and training period (see the Signature Series Monograph Staff Orientation and Training for checklists and systems). This training team does not replace the respective team subject matter trainers, they just ensure the candidate knows how to contact the appropriate trainer, or the alternate, if the primary is not available.
As the practice staff accepts accountability for outcomes, the client relations coordinator, inpatient coordinator, and/or outpatient coordinator may select developing staff members to take their places on a specific hiring team. Remember, the hiring team is task-organized each time for a specific-practice need. A diversified hiring team often is all that is needed to prevent a "them-us" environment from developing, and better, never makes the doctor, owner, or hospital manager the focal point for new staff failures.
The safety committee: One person from each zone is identified by the respective coordinators. They meet with the hospital administrator/manager, or the designated representative, at least monthly to address safety and comfort issues, involving MSDS documents, radiation safety, personal protective equipment (PPE), right-to-know Law, ergometric and repetitive motion concerns, zoonotic concerns, lifting and animal handling techniques, OSHA concerns, facility maintenance and safety issues, as a minimum. The Veterinary Safety & Health Digest, from The Veterinary Safety & Health Digest, 1550 Athens Road, Calhoun, TN, 37309-3035, should be their subscription to review and implement with each issue received. The safety team members are accountable for safety, comfort, and maintenance issues within their respective zones, and have a direct link to the facility board via the hospital administrator/manager.
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The "L" Team
In many veterinary hospitals with which we consult, the coordinators evolve into the leadership team ("L Team"), and assume a role in budget surveillance, program management, and client outreach. They conduct the quarterly budget review with the ownership and administrator/manager, review the program delivery successes and shortfalls, and set the zone commitments for the coming quarter.
Regardless of "leadership" roles, the coordinators should assume the staff scheduling role, as in ensuring resource allocation, within a quarter of being selected, and scheduling staff based on doctor schedules, which were based on client demands and hospital capabilities. This allows the zone coordinators to discuss cross-training and interrelationship support missions on a regular basis, which is practice leadership in action! |
Needed scheduling actions:
Zone the hospital staffing plan:
Outpatient schedules have two columns (rooms) per shift doctor.
Outpatient doctor and OPNT work two consultation rooms.
OPNT escorts all clients/patients from receiving to consultation room.
There is usually a pharmacy/laboratory technical assistant float.
The OPNT and OP doctor never leave the front during the shift.
The OPNT keeps the doctor "on schedule" for the entire shift.
There should be a day drop-off bank of cages close to the front.
Client relations schedules inpatient care regardless of which doctor.
Inpatient doctor and IPNT (RVT) work treatment/surgery.
The IPNT and IP doctor seldom leave the back during the shift.
There is always a treatment/surgery technical assistant float.
Shifts are half day, changing the doctor's role (+/- CVT/RVT/LVT/nurse):
Morning outpatient doctor becomes afternoon inpatient doctor, thereby following any "day admits" that were done, to ensure continuity of care. We have learned to expect about forty percent day admits from the average companion animal practitioner on outpatient, sometimes cresting to fifty percent if they have a favorite diagnostic toy, such as a VetSope, endoscope, ultrasound, ECG, etc.
Morning inpatient doctor becomes afternoon outpatient doctor, thereby being able to discharge the more critical or complex morning drop-offs and surgeries. Discharge nurses should still be doing about seventy percent of the patient discharge appointments.
The late morning doctor is scheduled to start at 11:30, plus or minus thirty minutes, on three-doctor days. Usually this is the 11:00 a.m. to 8:00 p.m. "evening" shift, which starts with spays and neuters from noon-3:00 p.m., allows an hour for phone/food, then evening outpatient from 4:00-8:00 p.m.
Nursing rounds of one hundred percent inpatients are done at 7:30 a.m. and 12:30 p.m., so the senior IPNT and respective inpatient doctor can do rounds at 8:00 a.m. and 1:00 p.m.. The IPNT keeps the assigned inpatient doctor on schedule.
Only the technical assistants (floaters) move between zones, moving patients, and supporting each other's needs.
In some cases, one pharmacy float technical assistant can support two OPNT-doctor teams. Two teams equals four consultation rooms.
In some cases, due to practice workload, the laboratory technician is an independent position. Other times, the laboratory and surgery nurse positions are combined. In some hospitals, imaging is a standalone staff position, especially if the technician has become ultrasound qualified. Yes folks, doctors do NOT do ultrasound procedures except in veterinary medicine. The rest of the world uses well-trained paraprofessionals.
Details of doctor scheduling are discussed in the following multi-tasking team techniques (mt3) scheduling section. The samples need to be adjusted for the midday shift change and the number of outpatient or inpatient teams, but that is internal to the individual practices. Evening hours, as well as extended weekend hours, are a consideration for increasing client access in some communities, after the population is surveyed with an appropriate new client "welcome" form (see VCI® Signature Series Monograph Medical Records for Continuity of Care and Profit).
The doctor schedules need to be done six weeks in advance, so all other staff schedules can be done thirty days in advance by the coordinators. With mt3 in mind, please review the sequence of what happens daily in the inpatient zone:
Morning nursing rounds are done before the doctor's arrival. Cases are prioritized with hardest cases first. Treatments are done without the doctor present by the end of Phase 2 training, as illustrated in the Appendix of the VCI® Signature Series Monograph Zoned Systems & Schedules for Multi-doctor Practices.
At the inpatient doctor's arrival, the nursing report will provide an overview of all inpatient animals on-site, as well as those scheduled to arrive.
The IPNT will highlight animals requiring a doctor's assessment, and the inpatient doctor will ensure they are addressed immediately.
The doctor validates the priority list, and establishes his/her start time. The inpatient doctor will not be late!
At 8:00 a.m., the doctor departs the inpatient area and starts inpatient/surgery admissions from the consultation rooms. Therefore, the inpatient team will ensure:
Updates are entered in the computer.
Overnight patients have an update report called to the owner before 9:00 a.m.
The TTO (talked to owner) patient summary will also be entered in the medical record system before 9:00 a.m. This is a form of prognosis/status report, and, therefore, must be medical record documentation.
At mid-day, another nursing rounds is done between the a.m. and p.m. shifts, to ensure the RTG times are accurate, as well as being ready for the inpatient doctor's debriefing.
On the afternoon/evening inpatient doctor's arrival, the nursing report will provide an overview of all inpatient animals.
The IPNT will highlight animals requiring a doctor's assessment, and the inpatient doctor will ensure they are addressed immediately.
The doctor validates the priority list, and establishes his/her start time. The inpatient doctor will not be late!
Discharge Instructions (DI) are due to the IPNT/discharge nurse at least thirty minutes before the RTG time.
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Inpatient Rounds
The above is an example of staff operational protocol for inpatient rounds, and must be respected by all doctors. Staff must ensure it is kept on schedule. Anything else makes the mt3 system dysfunctional, and the opponents will say, "We told you so!"
Leadership requires commitment, compassion, and consistency. This means the three GRs for leaders must always be reinforced:
Give Respect, Give Responsibility, then Give Recognition. |
The basic key to "system success" is to start to schedule the hospital, rather than the doctors, assign the staff primary patient healthcare duties, led by a shift doctor, and respect the social appointment and care contract given to clients as they access the hospital. These expectations are explained in Chapter 2, Building The Successful Veterinary Practice: Programs & Procedures, and can be applied to the extended-hour discussion so common in companion animal practices (see box below).
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Extended Hours
One size does not fit all! We were supporting a consultant's practice in Florida (yes, we are often the consultants of choice for tuned-in consultants), and they could not fill their evening hour appointments. The owner blamed the staff for not wanting to stay late, so they were shifting clients to earlier appointments. A medical record audit showed that over seventy-five percent of the clients were retired seniors, those people who hate to drive at night.
We have converted a California practice to only a four-day, 7:00 a.m. to 7:00 p.m., work week, M-Tu-Th-Fr, since there are adequate twenty-four-seven emergency practices in the area. And the primary clients, those in the top thirty percent of the income source, were never seen, only their gardeners, chauffeurs, maids, and butlers.
Never extend hours based on "them" or "they", but rather, the feed back from your own Council of Clients. Details are provided in Building the Successful Veterinary Practice: Innovation & Creativity. |
The Operational Zones for the new systems and schedules, as shown in Figure 13 at the beginning of this chapter, would usually include the following areas of staff accountability:
Client relations zone:
Receiving.
Telephone.
Discharge.
Veterinary software operations.
Editing/sending newsletter and health alerts.
Pet parenting programs, including timely reminders.
Client access area maintenance and cleanliness.
Recovered pet and recovered client programs.
Outpatient zone:
Pharmacy-laboratory forward to reception.
Client/patient outpatient movement.
Outpatient client education
Behavior management assistance to clients.
Nutritional counseling of clients for their companion animals.
Parasite prevention and control advisors.
Supervision of pharmacy/lab technical assistant float.
Laboratory operations. In larger practices there may be a lab tech
Client recalls for outpatient follow-up.
Inventory management.
Outpatient zone maintenance and cleanliness
In twenty-four-seven practices a VECCS-certified triage nurse may float between front and back
Title 16, CFR.
Inpatient zone:
Supervision of technical assistant float.
Rounds at 8:00 a.m. and 1:00 p.m.
Treatment room, with ICU/CCU area.
Imaging. In larger practices, there may be an imaging tech.
Surgery. In larger practices, there may be a surgery tech.
Dentistry. In larger practices, there may be a dental hygienist.
Pack prep.
Inpatient white board.
Inpatient zone maintenance and cleanliness.
Isolation cages and patients.
In twenty-four-seven practices, a VECCS-certified triage nurse may float between back and front.
Title 16, CFR.
Animal caretaker zone:
Wards.
Runs.
Cat condos.
Isolation area.
ICU, CCU, and STAT cage systems.
Respite care suites.
Title 9, CFR, and ABKA standards.
Resort (boarding) zone:
Boutique services.
Bathing.
Grooming.
Guest attendants.
Outdoor maintenance and cleanliness.
VIP suite services.
ABKA standards.
Chapter 1, Sub-chapter A, Title 9, CFR.
The Functional Zoning of the hospital allows the respective coordinators to become accountable for the new systems and schedules. They are also accountable for staff competency (training) and productivity (effectiveness within the zone) within their training role.
Each coordinator and staff member must have 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.
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Cross-Training
There are some practices that want everyone cross-trained. That is, they can work in all zones equally effectively. This is a rare and experienced staff member. It is our premise that all staff members need to train in one zone, gain operational competency, and then be allowed to seek training in another zone as appropriate and approved.
It takes about ninety days of development for an individual to become savvy in one zone. To expect any person to concurrently learn all the different zone operations is unrealistic and inhumane. Build on strengths, nurture their development. |