The previous diagram depicted the leadership impact on practice flow and assimilated practice flow. Yet, there have been shortfalls during implementation in some practices. As diagnosticians of human behavior, we sought out research in lateral fields.

In American industry, "boss-driven" projects have about a thirty percent chance of success, while team-driven projects have a seventy percent chance of effective implementation. The human healthcare industry started their research and showed that the tangibles -- clinical competencies, regulatory factors, management techniques, and fiscal success monitoring -- only accounted for thirty-five percent of program success. They looked at the intangibles, those issues and factors that must be nurtured for team synergy, and found the other sixty-five percent success impacted practice programs. Synergy is the magic ingredient. It links the multiple aspects of human preferences with the business factors of healthcare delivery. It is the essential element in the unique art of leadership, one that establishes and maintains the organizational spirit.

Figure 3.

The model shows that the tangibles rest on the intangibles and the intangibles support the tangible gains. Without the synergy bridge, or organization spirit, the four intangibles and three tangibles become just seven observed factors of a successful organization. Again, the neophytes center on the tangibles. They are easy to measure. Most people who know the words, but do not understand the dynamics, only address the intangibles at the time of crisis. The tangibles are very important. They are the fruit of dedicated people, working hard to be the very best. It is the savvy leader who understands metaphorically that quality fruit can only grow from healthy plants and a nurturing environment. Those fruit represent the intangibles.

Tangibles

These are what bombard practice owners every day. They have substance and measurements. Since the KPMG Mega-Study of 1999, NCVEI has provided yardstick factors, sometimes mislabeled as benchmarks.

 A benchmark would be specific service/system outcome(s) from a statistically significant group (large enough n) of similar type practices, with similar demographic catchment areas, comparing the users' practice to the top fifteen percent of the group. Again, remember, the large enough n, or sample size, is needed for a statistically significant group for comparisons.

 In 2003, AAHA published their significantly important Compliance Study, showing potential incomes lost per doctor, based on good medical standards and accepted patient "needs". The value of lost services was in excess of $630,000 per doctor per year, if one hundred percent client acceptance was achieved.

 Many general practices assumed that by using the AAHA data to institute new programs, it would move them toward the NCVEI published yardstick measurements. Easier said than done.

 The missing tangible was Safety, Bio-ethics, and Ethics, the barrier that caused staff to lose confidence and/or loyalty to the practice programs, because they perceived a violation of safety standards, variable bio-ethical behaviors/decisions, and/or ethical behavior by the managers, doctors, owners, or leaders.

It is easy to say "Safety, Bio-ethics, and Ethics", but it is far more than just Material Data Safety Sheets (MSDS) for Occupational Safety and Health Administration (OSHA) compliance.

 Safety includes under-staffing issues, where skilled holders are not available, proper eye protection for dentistries, ear protection for kennel workers, uniforms and other personal protective equipment (PPE), as well as historical action in maintaining rabies titers, and supporting other preventive programs.

 Bio-ethics is more than a consistent practice position on euthanasia for age and syndromes, ear crops, declaws, and tail docks. It includes prioritizing care based on patient needs instead of income potentials, and/or training for skill competency before tasking someone to assume case accountability, and/or animal husbandry issues for inpatient and outpatients.

 Ethics is walking the talk and doing unto others as you would have them do unto you. It is first, do no harm. It is a series of perceptions by those watching, including: Was it needed? Did it match core values? Is it state of the art medicine/surgery? Or even, Was it the right thing, at the right time, for the right price?

 If you can say "I would like it to be published in the local newspaper," it is probably ethical, while a case that would embarrass you with your family or friends would likely not be. If you perceive it was wrong, then it should not have been done, or even contemplated.

Intangibles

 Trust: Is each person being provided the training they need to be trusted to assume accountability for specific outcomes, and is that training continually updated, during recurring training episodes, to meet the practice evolution?

 Practices need to establish a TRAINING DAY, where you pick one day, any same day per week, and make it happen every week. The AAHA study showed most companion animal practices have about twenty-eight percent non-productive staff time, so taking three hours a week out for training is not restrictive, and increases production during the balance of the week.

 Stop appointments at 11:00 a.m., reserve 11:30 a.m. to 2:30 p.m. for team time/training, and restart appointments at 3:00 p.m. This provides a NO EXCUSE core three hours for team training.

 The proposed sequence of the month can be aligned in general terms:

 First Thursday: All-staff meeting (11:30-12:30, lunch is after).

 Lunch break.

 Doctors do off-site medical record peer review for standards of care. (See VCI® Signature Series Monograph Standards of Patient Care.)

 Post-lunch: Coordinators do planning for the month.

 Post-lunch: Planning time for Do It Groups (DIGs). (See Appendix A, Building The Successful Veterinary Practice: Innovation & Creativity.)

 Second Thursday: Individual training. (See VCI® Signature Series Monograph Training & Orientation.)

 Third Thursday: Zone meeting and training with CQI emphasis. (See VCI® Signature Series Monograph Zoned Systems & Schedules.)

 Fourth Thursday: Individual training.

 Fifth Thursday: Inter-zone invitational for problem solving.

 Effective Teaching is one of the leadership skills introduced in the text Building The Successful Veterinary Practice: Leadership Tools, while adult education factors are discussed in the VCI® Signature Series Monograph Training & Orientation, which includes a CD Tool Kit and a ninety-day prototype training schedule for new staff members. Adult education factors include:

 Adults learn only when they are ready to assimilate new data, which is called creating a discovery for trainers, or identifying the "teachable moments" and capitalizing on them.

 Most all adults learn best one-on-one, in twenty-minute windows of opportunity, followed by hands-on application to ensure self-confidence is established.

 If learning does not occur, the trainer assumes accountability for the shortfall and develops an alternative training episode for the learner. Teaching-learning is essential to developing healthcare competency. In healthcare delivery, competency is excellence. There are no bell curve grading systems for healthcare skills or healthcare teams.

 Planning is magic in itself. In most studies, every fifteen minutes spent in planning saved an hour at implementation. Veterinary practices seldom take adequate time to plan, then wonder why implementation often allows reversion to the old way. Planning is one of the leadership skills introduced in the text Building The Successful Veterinary Practice: Leadership Tools. "Program Planning", with forms and implementation tools, are discussed in the VCI® Signature Series Monograph Leadership Action Planner, which includes a sequence to establish core values to facilitate team-based healthcare delivery operations.

 In the VCI® Signature Series Monograph Zoned Systems & Schedules, the leadership is tasked with stating at the end of each development phase, in public, "We trust at this skill level." There are five phases to reach a multi-tasking, self-directed, healthcare delivery team. So, the leadership must state, "We trust at this skill level", five separate times over ninety to one hundred twenty days of team development activities, so they will likely believe it by then.

 Respect: After training to trust has been accomplished, staff members must be given areas of accountability: the outcome-based performance standards. Job descriptions are now only elements of the training plans and accomplished by a team-based system that promotes self-directed training and accomplishment. When the training has been completed, and competency is achieved by the learners, outcome accountability is assigned compatible with their zone(s) and duty assignment(s). Competency is, in fact, excellence in healthcare delivery. The savvy leader develops rewards (contingent) and recognitions (subjective). They are utilized to reinforce the leadership's approval and confidence in the person, efforts, and/or outcomes.

 Pride: This is the individual's accepting accountability for outcome(s), and concurrent drive for CQI within the person's sphere of influence, as well as with all clients, vendors, staff, and community contacts. Most interesting is that clients perceive staff pride as quality, and most clients are willing to pay extra for quality. Pet parents want to ensure quality in veterinary care for their own peace of mind. About eighty-nine percent of clients perceive themselves as pet parents, as the pet is given family member status, and a third of those are given child status.

 Harmony and Team Fit: This can only occur after people have been trained to a level of competency that they feel trusted, they have been provided rewards and recognition on a regular basis to reinforce their contributions and healthcare delivery efforts, and they have a pride in performance born of individual accountability for continual program improvement for successful programs within the practice. This goes far in creating a practice culture that self-heals, while showing minimal griping, no derogatory comments, and team members freely helping others to achieve outcomes within practice limitations and time constraints. Morale is high, everyone is happy to come to the practice and spend a productive duty day, and loyalty to the practice image is supported inside and outside the practice setting.

Synergy

 When tangibles are supported and promoted by the intangibles.

 When the team is accountable for CQI, not just the doctors or boss.

 When "magic" in accomplishment is perceived by all.

 When the group becomes a team, the manager becomes a leader, and the doctors become client-centered patient advocates as healthcare providers.