Change is the law of life; those who look only to the past or present are certain to miss the future. - John F. Kennedy

In 2002, Iowa State University Press (now Blackwell Press) published the text Veterinary Medicine & Practice -- 25 Years in the Future -- And the Economic Steps to Get There. What has happened since then has caused many of our projections to be rescinded. Artificial Intelligence (AI) research has already given way to Artificial Life research, due to breakthroughs in nanotechnology. If we could grasp the finite level of evolution that occurs every moment of every day, simply because of a response to another living plant, insect, animal and/or environmental pressure, then we would understand that whole populations of organisms are rising and falling, shifting, changing, mutating, and that is nature's law. Sure, we know about endangered species, and the balance of nature, but do we really accept that evolution is a mandate every instant for every organism?

For example, anyone who is passionate about the industrial policy of clear-cutting forests, and is willing to argue that it is more damaging than the ecological policy of fire suppression, ignores the facts from Yellowstone's fire in 1988. Concurrently, the person ignores the fact that both policies have been carried out with utter conviction, and both have altered the virgin forest irrevocably. Both provide ample evidence of the obstinate egotism that is a hallmark of human interaction with the environment. The basic fact is that the biosphere responds unpredictably to our actions, which is not an argument for inaction. It is only a strong argument for caution, and for adopting a tentative attitude toward all we believe and all we do.

We always think we know what we are doing, and we seldom seem to acknowledge that we have been wrong in the past, or might be wrong in the future. We "write off" earlier errors, as the result of bad thinking by less able minds, and then embark confidently on fresh errors of our own.

The National Commission of Veterinary Economic Indicators (NCVEI) was the child of the 1999 "KPMG Mega Study" sponsored by money from our parent veterinary associations (AVMA, AAHA, and AAVMC), and concurrently, the National Board Examination Committee for Veterinary Medicine (NBECVM) started to undermine the established state and AVMA programs with the Registry of Approved Continuing Education (RACE) and the Program for the Assessment of Veterinary Education Equivalence (PAVE^TM), which only causes their own fiscal condition to improve at the sake of the profession.

The Mega Study showed clearly what clients wanted in their healthcare provider: knowledgeable, caring, and informative veterinary practices. Price was the number nine issue. The executive board found six major areas to highlight, and on which to cast blame, but established the NCVEI to deal with numbers, the easiest of the issues to address. The entire report forgot to mention the role of the AVMA, AAHA, and AAVMC in getting us to where we are today. Continuing education is to be designed to prevent this profession from stagnating, yet, in management and leadership, some states do not even recognize the need.

As a consulting firm, Catanzaro & Associates, Inc., sincerely believes that old ways will not allow the new generations to enjoy this profession, and to be forewarned is to forearmed. The "Economic Steps to Get There" starts with the premise of saving, and saving from every paycheck. If you start at the day of graduation, and ten percent of every paycheck is invested outside the monthly cash flow demands, you will never notice the lost income. However, you will see the escalating savings in the investment portfolio. It does not matter if it is a simple IRA or a ROTH IRA, real estate, or limited edition art. Invest in something that will grow in value. The compounded invested dollar is a great security blanket as you age. If the practice offers a pension fund or retirement account, use it to the maximum. Say thank you to the boss often. Almost no one can sell one's practice and have a funded retirement anymore.

But This Text Ain't About Money First

The future veterinary healthcare delivery model needs to be built on competent veterinary extenders, a team-based veterinary healthcare delivery model, which allows the veterinarian to direct patient care for many cases at one time. The money will follow the team-based healthcare delivery, as long as it does not cause the decisions about the quality of care deserved by the patients. Staff is not motivated by the dollar sign, they are motivated by being patient advocates, and being supported by their doctor(s). This may also be called applying those inviolate core values to the mission focus. It requires a standard of care that is consistent between all providers. There cannot be inconsistent core values or variable standards of care in a team-based veterinary healthcare delivery model. The staff and clients will not tolerate this level of inconsistent behavior from their healthcare providers in the coming years.

The Internet is making knowledge too easy to acquire, and it is raising the veterinary IQ of the clients. The skilled veterinary healthcare staff members want harmony in their workplace, and the doctor-centered model only gives them frustration. Being pulled every-which-way-but-loose by doctors is a discourtesy that cannot be continued. We talk about standards of care and core values affecting the mission focus, instead of a mission statement, because it must be applied to every project and program on which the practice embarks. This is from where a continuity of care is derived, and veterinary extenders MUST have that consistency of performance to do their job, as should colleagues and associates.

No matter how skillful the business strategies are, and how well trained the staff may be, if the core values are floating, no one can make the tough decisions except the boss, so the practice stagnates. The inviolate core values allow everyone to pursue continuous quality improvement (CQI) for their own areas of accountability, and have some security in feeling they can make the independent changes required for healthcare delivery improvements in the practice and in the community.

"Average" is defined as: the best of the worst, or the worst of the best. - Dr. Tom Catanzaro

The veterinary profession abounds with quality assurance (QA) and quality control (QC) checks-and-balances. The AAHA Standards for Accreditation requires QC and QA programs. The veterinary profession has ingrained the QA/QC paradigms so greatly that we do not even stop and think about them. But think about them, we must.

QC is spot-checking the process to ensure it is the same, and QA is spot-checking the outcome for sameness. If the process (QC) and outcomes (QA) are the same, from where does growth come? In a strong QA and QC culture, growth only comes from increased rates of front door swing, or increased fees, which presumes that this is a well-managed practice, and cost savings have already been implemented. In this case the age old formula will apply:

A² = G²
If you Always do what you have Always done,
You are going to Get what you have always Got.

In every other small business, A² = G² means that growth is not coming from new programs or changes. In the real world, A² = G² means NO CHANGE, and to expect any change is insanity. In veterinary medicine, expecting change in a QA/QC practice environment seems to be a normal operational expectation, although it has never happened. It is about time we stop this insanity, add CQI to the QA and QC expectations, review the emerging wellness surveillance programs at www.npwm.com, and power up the practice team.

Here's a list of strategic assessments for re-calibrations of the mind:

 It is not strategic planning, it is strategic assessment and response.

 It is not working longer or harder, it is working smarter and leveraging shorter periods of time, with team-based healthcare delivery programs.

 It is not increasing to a higher ACT, it is more visits per year per pet.

 It is not "national averages", it is creating a benchmark against your current performance and making breakthrough performance an expectation.

 It is not process-based check and balance lists for staff, it is outcome expectations jointly set with the staff, and providing the resources and trust to the staff.

 It is not client compliance, it is consistent standards of care being offered by the practice providers.

 It is not cost control, it is income production,

 It is not quality assurance and quality control, it is continuous quality improvement.

 It is not doctor-centered case management, it is client-centered patient advocacy.

 It is not annual retrospective performance appraisals, it is quarterly proactive performance planning for the future.

 It is not hiring and firing, it is training and retention.

 It is not becoming a female profession, it is introducing a new generation of providers.

 It is not a practice sale to a corporate consolidator, it is building a succession plan for the healthcare team in the practice.

 It is not the veterinarian owner doing management, it is the veterinarian doing only diagnostics, prescribing, and surgery, and allowing managers to become operational leaders.

 It is not selling your practice for retirement, it is investing money every month, from graduation on, for your retirement.

Surround yourself with the best people you can find, delegate authority and provide the resources, and do not interfere as long as the policies are being carried out. - Ronald Reagan

Considering the strategic re-calibration of your mind, the new perspectives team, or the business of veterinary medicine, plus the quote from Ronald Reagan, the 40^th President of the United States, you should be getting interested in effective delegation within your own practice. To this point, the following should have been clearly established and discussed with the staff so they now know "why":

 Leadership's long-term practice vision.

 Inviolate core values.

 Operation philosophy of a staff-run hospital.

 Client-centered patient advocacy.

 Consistent standards of care.

 Dependable continuity of care.

Strategies for Effective Delegation

Three operational guidelines to live by:

 Why and What are functions of leadership and must be shared in a clear and concise manner.

 Who and How belong to the person, zone, or team that accepts the outcome accountability.

 When must be jointly negotiated at the beginning of every project, with milestones and time lines.

Developing the Action Person

The average person deserves a clear set of expectations, such as directive description and training, followed by a period of persuasion that they can do the job or task. As they gain confidence, provide coaching to hone their "edge" of excellence. This instills a feeling of respect and self-esteem. After the directive-persuasion-coaching sequence, then delegating the outcome can occur, ergo, personal accountability leads to pride in accomplishment. Ensure the outcome is well defined, and the limits of operational flexibility are identified. Avoid process delegation.

Clarification

If changes in the outcome expectation(s) occur during a delegated process, NEVER unilaterally change the outcome measurement. Rather, act as a consultant to the action person and offer alternatives for consideration. Unless we clearly understand the problem or project, we can never be comfortable with delegating it to someone else. Get all the facts available, and review the demand(s) periodically for the tasking, the expectation, the obligation, the measurement, and the consequence. In some cases, tenured staff members may perceive an infringement on their "turf". Some even try to control the practice flow by controlling knowledge. A caring leader will bridge these barriers with one-on-one coaching, leveling the playing field for the action team(s).

Rebounding

Learn to respond to an idea by saying, "That seems to be a great idea. Why don't you develop that with a staff member team and present it as an implementation plan at the next staff meeting." As a practice owner, accept the fact that almost NO ONE on staff ever wants to hurt your practice. Staff are caring and compassionate people, who are working for lower than expected wages, because they want to nurture animals and/or clients. Encourage staff members to take ownership and developmental responsibilities for practice enhancement ideas.

Pass it Down Effectively

Traditional veterinary practices' concept of delegating has been to simply dump some process on a staff member. Learn to pass accountability down, as if it was important. Giving staff the desired outcome, with a sample if possible. Ensure that a time frame has been jointly agreed on within priorities. The authority to act requires resources be allocated, which include internal leadership support commitments, before the delegated program/project is initiated. When the responsibility for completion rests with a staff member, and the resources required are released in a timely manner, such as time, people, money, etc., it is surprising how effective the team becomes.

Delegate Out-of-House

Passing demands, especially low priority work, to outside contract labor, specialists, or temporary hires, increases internal productivity. A few examples would be the electrician, plumber, a janitorial service for evening clean up, a graphic artist to help develop the brochure, or a typing service for the new client handouts.

Ban "ASAP" or "STAT"

In areas outside of patient healthcare delivery, these mean different things, but usually, "As soon as I can get to it." It leads to frustration. Jointly negotiate the due date, when you delegate. For large projects also negotiate time lines to milestones. As a staff member, never accept a project or task without clearly understanding the expectations of the demander, for the "when" and "what" of the responses.

First Things Last

The common habit of last-in, first-out is often perpetuated by the in-basket. We work it from the top down. Turn it over next time, then work it, from the bottom up. Better yet, sort it by priority:

 A = Vital: A sense of urgency; timely response required; cannot be put off without consequences; must be done.

 B = Important, but not vital: Can delay temporarily, without penalty; do after the "A" priorities.

 C = Necessary to be done eventually, but not time-critical as yet: Do as time allows.

 D = "Never put off until tomorrow that which you could get someone else to do today."

Fully Face the Failures

It is important that the leadership place every failure into perspective. In a failure situation, knowledge was generally increased. People learned a lesson. Therefore, every failure is a learning success. The leader needs to fully face failure, since he/she had the training and resource allocation accountability, and be ready to say, "What can we do better next time to get a different result? What skills do we need to take time to improve? What have we learned that will help us in the future?"

When in Doubt, Manage from the Heart

 Hear and understand me.

 Even if you disagree, please don't make me wrong.

 Acknowledge the greatness within me.

 Remember to look for my caring intentions.

 Tell me the truth with compassion.

Brutal honesty: what a phrase. Truth with compassion: what a feeling. The source text for this concept is an easy read: Managing From The Heart, by Bracey, Rosenblum, Sanford, and Trueblood, and is one of those "breakthrough texts" for some doctors who have always been "me" centered. Some practices have used Who Moved My Cheese? as a breakthrough text for change, and Crucial Conversations is recognized as a breakthrough text for stressful communication challenges. Breakthrough texts also occur at teachable moments. If you are not ready, someone's highly recommended breakthrough text may be so much "mind candy" to you, though not a meaningful discovery. That is called adult learning. It was not your teachable moment!

If you have to prove you are right, you're probably wrong!