The Practice Success Prescription: Team-Based Veterinary Healthcare Delivery by Drs. Leak. Morris Humphries
Thomas E. Catanzaro, DVM, MHA, FACHE, DACHE
Millions of U.S. pets are not receiving the best care and treatment available. Compliance is essential to a patient's health and well being...The biggest obstacle to compliance is the veterinarian's own misconceptions about pet owner's willingness to act. - Dr. John Albers, Executive Director AAHA
Compliance. Wouldn't you know this profession would use a word that blames the client, while the very expensive AAHA study specifically identifies the veterinarian as the primary culprit in the delivery of substandard care. Don't get me wrong, the AAHA survey proved what we had been saying and doing for years, as a consulting firm: program-based budgets and program-based commitments.
|
First Things First: The Central Thing about the Central Thing is the Central Thing!
When we do financials, we worry about what has been included in a line item. When we do software bundles for services, we worry about the value of each item in the bundle. Then there is the word "compliance", and its abuse.
Compliance was the name of a AAHA Study released in 2003 that showed the clients, who had not accessed veterinary care for their companion animal(s), did not realize the importance of the needed care.
Needed care, as in our consulting partners' use of a box ([ ]) on the Progress Notes, whenever they say "need" to a client, and of which the client has not been made aware, is not the client's fault. Ergo, what veterinary practices need are compliance cops in every veterinary practice -- not! What practices need are consistent standards of care, which lead to a continuity of care between providers, without confused clients.
What the client needs is a concerned "Pet Parenting Program" of education and caring, delivered by informed and knowledgeable staff. Just do it! |
Standards of Care in the Bond-Centered Practice
In human healthcare, cardiologists know that beta-blockers are always needed post-myocardial infarction. Yet, when surveyed, only sixty-seven percent of the M.I. patients were receiving this regiment, when left to the individual doctors. The hospital was a six sigma facility (see Chapter Nine, "Models and Methods that Drive Breakthrough Performance", for details). The beta-blockers became a nursing mandate, and now one hundred percent of the post-M.I. patients are receiving beta-blockers. This facility also looked at post-surgical preventative antibiotics, and found that not all patients were receiving them within four hours, per protocol, because doctors had not ordered them. Again, using the SIX SIGMA process for minimal defects, post-surgical preventative antibiotics became a nursing mandate. Patient care and welfare were put before the doctor's ego, and it was a mandate from the board.
Early research showed that anxious people, who are asked to watch the fish in an aquarium, had an average of a fifteen-point blood pressure drop. The Mayo Clinic cardiologists are prescribing dogs post-open heart surgery, since research has shown that dog owners have a five times greater chance of being alive a year later. The Psychology Department is prescribing pets about thirty percent of the time. Research in South Africa has shown the human-animal bond elicits a series of neuro-chemical responses in the human body, but this is not the human-animal bond people "feel."
Veterinary practices are no different. There must be protocols and common expectations if the staff are to become veterinary extenders. The "warm feeling" manifested in a bond between companion animals and their stewards can be transferred to a client bonded to a practice. he client wants "peace of mind", when they call a veterinary practice. Your staff wants "peace of mind", when they are telling a client what the practice stands for and what are the practice standards of care. The staff cannot have trepidation, when it comes to stating the wellness standards, pre-surgical protocols, or preventive medicine expectations. Example questions to ask yourself include:
|
Question |
What animal, what species, what breed, what age, what sex, is it always safe to induce anesthesia without some form of blood screening? |
|
Answer |
None! So why has pre-anesthetic laboratory screening been optional? |
|
Question |
When is it humane to leave an animal in pain? |
|
Answer |
Never! So why has pain medication been optional? |
|
Question |
What percentage of animals need to be on heart worm medication? |
|
Answer |
All! So why are less than sixty percent currently protected? |
|
Question |
Which animals need to be screened for internal parasites, including the protozoa threats, and at what frequency? |
|
Answer |
All. Frequency will be based on life cycle characteristics. So why do some practices state the heart worm medication treats for all internal parasites? |
|
Question |
Shouldn't clients who come in more often, and keep their pet's dental conditions treated, be afforded a lower cost for a grade 1+ dentistry, about a twenty to twenty-five-minute staff procedure, than a client who has let it progress to a grade 3+ oral surgery, which is about a sixty-minute procedure? |
|
Answer |
Yes! So why doesn't every animal have a dental grade in the computer? |
|
Question |
Sequential weights are a diagnostic aid, so shouldn't each have a body condition score (BCS) associated to them, so we know what the previous provider stated? |
|
Answer |
Yes! So why are there no fields for BCS in the medical records, and why doesn't the practice track BCS on each animal? |
|
Question |
Research shows that pets can live up to two years longer, when on highly digestible premium diets, so shouldn't clients be told this? When an animal has a ten percent weight change, is that significant? |
|
Answer |
Yes to both questions! What has been stopping you from assigning a nutritional counselor to each adult patient? |
|
Question |
Aren't the inpatient staff members accountable for patient safety and well-being when hospitalized? |
|
Answer |
Yes! Then why are pre-anesthetic risk assessment scores, which are on a scale of one to five per AAHA, so seldom recorded in the medical record at admission and on the white board in treatment to help ensure the animal's safety? |
|
Question |
VECCS states that eighty percent of all surgery patients deserve to be on fluids. Tat is the rate in your practice? |
|
Answer |
Why don't you know? So why have the benefits of intra-operatory fluids been ignored for as long as they have? |
|
Question |
Are veterinarians allowed to do what is not needed by the State/Province Practice Act? |
|
Answer |
No! They are only allowed to do what is needed for that patient at that time! So why do students learn the word "recommend", which puts the client into the position of determining/selecting the animal's needs?
Why don't we clearly state the "need a "need", and then shut up and listen to the client about decisions to access that care? |
Cowboy says, "When the boss wants a long talk, you're in for a long listen."
Consultant says, "When the owner realizes the power of the bond, it will permeate everything."
Review the VCI® Signature Series Monograph Standards of Patient Care in a Bond-Centered Practice and/or the VCI® Human-Animal Bond Scoring Pocket Card, which comes with the monograph, and determine what you really want to stand for in your practice and your community.
So What Is Compliance?
Compliance is the doctor and staff having core values and standards of care that are inviolate. Compliance to core values and standards of care means they are inviolate, that all staff and all doctors say the same thing to clients, especially for wellness care and professional needs. Without consistency between doctors, staff cannot be effective extenders.
The major problem in a multi-doctor practice is the lack of a standard of care. Each doctor is usually allowed to "do their own thing", since they have graduated and are licensed. This is flaky thinking at best. It confuses clients and embarrasses staff.
Now take those answers from the previous section, look inside your own practice, and take it to the next level. A basic sample of standards of care is shown below. Use the following topics as a baseline for minimum issues to address, for the continuity of care, and more effective staff utilization:
Canine vaccines
Puppy programs.
Eligibility for skip-year vaccine programs.
Annual life cycle consultation requirement!
Feline vaccines
Kitten programs.
Eligibility for skip-year vaccine programs.
Annual life cycle consultation requirement.
Genetic/congenital predispositions:
Preferred web site.
Client handouts.
Annual life cycle consultation requirement.
Parasite prevention and control:
Feline programs.
Canine programs.
"Traveling With Your Pet" programs.
Annual life cycle consultation requirement.
Medical records:
Client "concern" starts each entry.
All consultation records will be S-O-A-Ped or H-E-A-Ped.
Assessment(s) must address "client's concern" first.
Tell clients clearly what is needed.
Document all "needs" with a box ([ ]).
Client's response is recorded in the box: W = waiver, D = deferral, A = appointment, X = do it!, + = positive, - = negative.
Anything that is not resolved by the end of the consultation/visit is entered on the master problem list and followed by the nursing staff until resolution.
Continuity of care is not possible unless the medical records are legally sufficient, and legal sufficiency includes the practice computer software summaries matching the medical records and fee schedule line item by line item.
The next contact expectation is listed as one of the three Rs on every visit, and told to the client before departure by every staff member involved in discharge planning: R = recall (we call them), R = recheck (make an appointment), R = remind (mail, e-mail, and/or phone, whichever is their preference).
Patient care:
AAHA Standards are minimum requirement.
Physical exams will list all twelve systems as "normal" or "abnormal".
Sequential weights will have body condition scores (BCS).
Animals with teeth with have dental grades (four levels).
All "needs" that are unresolved, deferred, or handled only with symptomatic care, will become follow-up issues for the attending nursing staff, and will be entered and tracked in the veterinary software, as well as summarized in the medical record, when the client has been contacted.
Hospitalization will be charged by care levels.
Increased pain surveillance at presentation and admission will be documented.
Patient care and hospitalization or treatment surveillance is a nursing function, and not a point for doctors to berate staff or become technical staff.
Doctors are to diagnose, prescribe and do surgery, and ensure peace of mind for the stewards of the animals in our care.
Blood chemistry and urine screening:
Minimum mandatory with anesthesia.
CBC with chemistry.
Includes microscopy with every UA.
Sequential laboratory surveillance
Pain management programs
Pre-emptive scoring.
Inpatient scoring.
Surgical requirements.
Go-home protocols.
Cowboy says, "The hottest fire is made by the wood you chop yourself."
Consultant says, "When they discover the standards of care benefits, they will buy-in!"