While doctors produce gross it is the staff who promotes net! - Dr. Tom Cat

We need to address staff leveraging and practice multi-tasking training techniques (mt³) as an overview to understand why the staff is so critical to effective healthcare delivery in a bond-centered practice (see the VCI® Signature Series Monograph Building a Bond-Centered Practice). You may recognize similarities of information from previous chapters of this text.

Outcomes:

1.  Team members understand how zones, coordinators, practice manager, and practice owner inter-relate to reach goals.

2.  Team members know the three necessary elements for team membership.

3.  Team members understand why one's specific veterinary hospital team benefits from implementing zoned systems and developing team-centered healthcare delivery.

4.  Coordinators take ownership of their zones and start to communicate effectively, upward, lateral, and downward.

5.  Team members understand that the hospital staffing plan begins with scheduling the facility resources, staffing the doctors to meet the clients' needs, nurses scheduled to support clients and doctors in the facility, client relations schedules to increase client access to the facility, OPNT supports client flow in and out of reception area, and animal caretakers are scheduled to support companion animals' needs.

Step One: Each team member understands how zones, coordinators, practice manager/administrator, and practice owner inter-relate to reach goals.

 Zones: The hospital is sectioned by primary focus areas we call "zones", as shown in VCI® Signature Series Monograph Systems & Schedules for Multi-doctor Hospitals.

 Client relations zone is responsible for making the front door swing. They maintain a working relationship with potential clients, as well as existing clients. The zone members have control over the client and pet flow in and out of the facility, which also includes the control of the work flow scheduled for the other zones in the hospital. They are the first contact the healthcare delivery team has with client and pet, and are the last contact to ensure the client knows the expectation for the next contact. Included in this zone are all the space from the front doors to the front consultation rooms, including medical records, cash drawers, resale, reception seats, telephone receptionist, and all environmental factors, such as smell, neatness, sight, sound, cleanliness, etc.

 Outpatient zone is focused on the client's concern(s), as well as the companion animal's needs. This zone is responsible for communicating the pet's needs ([ ]) to the client on a level that the client can understand. Brochures and hand-outs are explained, before they are provided to any client as the "follow-up additional information" as applicable. This zone's team is tasked with making sure the client's initial concerns are addressed first, knowing that any shortfall to satisfy this client need(s) may cause the client to access another healthcare delivery team to get the answer for the pet's welfare. The consultations rooms, pharmacy, and usually the lab area are included in this zone.

 Inpatient zone begins at the back of the pharmacy, sometimes includes the laboratory, and always the treatment area, imaging, and dental and surgical suites. The concerns of this zone are cleanliness, accountability for resources, prioritization of the healthcare plan, medical treatment, surgery, and nursing care for the patient. A central scheduling system is in use, such as a white board, to coordinate multi-tasking, as well as tracking all unaccompanied animals within the facility.

 Animal caretaker zone is any location used to hold animals when they are in the facility. The members in this zone monitor the individual companion animal's needs related to cleanliness, exercise, food, water, and elimination, as well as other support functions, according to the doctor's orders. There is usually a dual function with facility preventive maintenance, since these staff members have a more flexible schedule.

 Coordinators are members of respective zones. They pull the majority of their shifts within their respective zones as a healthcare delivery team member. They act as facilitators for the zone team, ensure the appropriate resources are available as needed, and are the messengers, as well as the representatives, to the coordinator meetings held regularly with the practice manager. Once any compromise is decided on by the governance, it is the coordinator's duty to sell the compromise as excitement!
This is not a supervisory position in the traditional sense. The primary role of the coordinator is to ensure competency, by identifying the training needs within the zone, ensuring that training occurs for individual members in the zone, recycling people into training, when their productivity or competency seems to slip, and scheduling coverage of the hospital zone based on work load demands not individual staff member preferences. Whoever comes into a particular zone to work must understand the core values of the practice, embrace the standards of care, meet the competency requirements, and remain productive for the full shift. The respective coordinator will enable the staff members in the zone to receive the needed mentoring to ensure team fit and team harmony.

 Practice manager/administrator is the implementation liaison between principal(s) and the practice team. This administrator represents the staff to the ownership and the principals to the staff. This person constantly balances the personal needs of the team with the needs of the business.
The ownership establishes policy, precedent, and quarterly budget guidance. Decisions are made only when falls of the gavel, when the doctors and administrator (practice manger) are present. When on the floor, any doctor-owner has only three basic functions: diagnose, prescribe, and do surgery. All administrative questions and issues are referred, without exception, to the coordinators and manager.
For the best understanding of governance and administrative delegation, please review Veterinary Management in Transition: Preparing for the 21st Century, which includes eleven self-assessment tools for the leadership to calibrate their approach to effective utilization of management staff.

 Principals (practice owners) are responsible for communicating to the hospital administrator (practice manager) the desired vision, core values, and outcomes for the practice. Ownership influence exists only during the fall of the gavel of the board meeting, with the administrator/manager in attendance, and deals only with policy, precedence, and quarterly budget guidance. Owners are not usually involved in the implementation process. That is the role of the administrator/managers. Practice direction exists only during falls of the gavel of the governance board, as they develop general policy, precedence, and quarterly budget guidance. When in the hospital zones, the owner assumes a doctor role, which is to diagnose, prescribe, and do surgery. The healthcare delivery team in each zone does all other tasks.

 Programs and process

 Practice owner(s) share(s) a vision, policy, precedence, and quarterly program-based budget guidance. The ownership establishes a clear picture of desired outcomes for the practice manager and medical director, so they may implement appropriate actions to achieve daily, weekly, monthly and quarterly objectives.

 Medical director leads the development, implementation, and continual improvement of the standards of care, as well as developing new and improved veterinary healthcare delivery techniques.

 Practice manager/administrator communicates the outcomes needed to the coordinators and facilitates the planning and implementation process with practice team.

 Owners, medical director, and practice administrator/manager are responsible for stating clear outcome expectations, as well as the measurement of success before the process is started.

 The healthcare delivery team in each zone is responsible for planning and implementing the process needed to reach the desired outcome(s) in a timely manner.

Step Two. Team members know the four necessary elements for effective healthcare delivery team membership.

1.  Team fit means maintaining a positive attitude in the workplace, which allows each person to focus on "how I can help make it work". Team fit also means each person is personally responsible to the team needs, is a team player, and enhances the harmony in all areas which the person works.

2.  Competency is based on a self-directed training program. See the VCI® Signature Series Monograph Orientation &Training for the first ninety days, and the VCI® Signature Series Monograph Zoned Systems & Schedules for development of multi-tasking capabilities in a team-based veterinary healthcare delivery system.

3.  Productivity starts with the team member's commitment to reach a competency level that is "productive" to the practice and can concurrently be trusted to replicate performances, without direct supervision, in a timely and efficacious manner.

4.  Client-centered patient advocacy is the delivery modality of communication with the pet parent, the animal's steward and your client. All healthcare providers understand "First, do no harm", and the veterinary profession is committed to speaking for the animal's best health and welfare.

Step Three. Team members understand why the veterinary facility and healthcare delivery team benefits from implementing the zoned systems. The practice vision gives rise to inviolate core values and consistent standards of care, which enhance the mission focus and continuity of care. This becomes the charter for independent decision making within all zones.

 The zoned systems give structure and order to the healthcare delivery. By defining primary focus areas around the needs of the clients and their pets, a team can identify the skills needed to work in each area.

 Zones establish clear behavior expectations for its own zone members, commensurate with practice core values, ownership policy, and precedence.

 The empowered zone members are held accountable for preventing problems and offering solutions to emerging challenges.

 Each team member will be accountable for enhancing communication, as in the getting and giving of information, within the practice. Coordinators facilitate the resolution of issues within their respective zones. No longer are staff members permitted to dump problems and concerns directly on the manager's/administrator's desk, without alternative solutions.

 Coordinators within their respective zones are expected to facilitate CQI efforts at the staff level. Solutions to zone problems should most always come from within the zone team.

 To blame is to abdicate accountability for resolution. No longer can a zone blame someone else for a shortfall. Coordinators will develop inter-zone communications to resolve irritants causing the problem.

 Healthcare delivery team members are either part of the problem or part of the solution.

Step Four. Coordinators take ownership of their zones and start to communicate effectively, upward, lateral, and downward.

 Coordinators work within their zones, so they are leading by example at all times. What a coordinator does speaks so loudly, that no one can hear what is being said!

 Coordinators have a stand-up meeting first thing each morning with the practice administrator/manager. This is a cumulative ten-minute briefing of what the zone is doing today to improve the systems, allowing about two minutes per coordinator.

 After the coordinators' stand-up meeting, coordinators return to their zones and share the "good news" about new changes coming, even if it is in another zone.

 In the early days of a transition plan, the practice manager/administrator has a stand-up meeting with the governance group before lunch. This is a cumulative ten-minute briefing of what the zones are doing today to improve the systems, allowing about two minutes per zone. This is to keep the governance informed, not to get their approval, not to get their ideas, and not to get any negative vibes. This is a just a peace-of-mind debriefing.

 Two-to-three hours on a specific day of the week is set aside for staff meetings and training time. Early in the transition plan, staff meetings may be twice monthly, or every other week, and zone meetings will fill in the two other meeting days. Before ninety days, the individual training days will replace some of the staff meetings. The "first Thursday" all staff meeting has an agenda, with specific elements allocated specific time:

 The ownership starts with five to seven minutes of targeted accolades on progress and changes (behavior rewarded is behavior repeated).

 "GEM (Great Idea) Reports" come next. These are new ideas from web sources brought in by people, who volunteered last month, from sites including:

 www.svbt.org

 www.DeltaSociety.org

 www.drtomcat.com

 www.npwm.com

 www.NCVEI.org

 www.upei.ca/cidd/intro.htm

 www.vspn.org

 TBA

 The staff gets five to ten minutes to discuss the "why" with the principal(s) of any new programs that were put onto the agenda. The practice administrator/manager usually leads this feedback time for the staff, so they are free to share feelings and impressions about new programs/memos since the last staff meeting.

 The practice manager gets seven minutes to review upcoming programs, where volunteers are needed, including the GEM report issues. No volunteers means the practice manager gets to select the initial volunteers.

 The last phase of the meeting is the "problem of the week" or "problem of the month", which crosses zone accountability areas of concern.

 The "problem" may be introduced by the doctor or manager, but it is discussed by the staff. The doctor or manager does not offer ideas. They speak only to put the discussion back on track.

 The end of the staff meeting and the "end of the discussion" occur concurrently. It requires three things: a plan A, a plan B, and a project manager who will be accountable for implementation and reporting back to the next staff meeting(s) on the progress and lessons learned to date.

 After the staff meeting, lunch may be served, but never before or during, and then coordinators, trainers, and DIGs are allowed to have planning time. A DIG is the do-it group, with at least three volunteers, because for every fifteen minutes of planning, and hour is saved at implementation. No volunteers for a DIG means the GEM is tabled until three people come together and want to pursue it. Also one-on-one training may occur for anyone with free time left.

 After the meeting, the doctors may leave the site to discuss standards of care and peer review of medical records, which include one inpatient and one outpatient record from each doctor from the previous week.

 Two-to-three hours on a specific day of the week are always set aside for staff meetings and training time. All scheduled activities are stopped thirty minutes before the "blocked-off" time, and started thirty minutes after the training/meeting quitting time. As the transition plan evolves, staff meetings are integrated with zone meetings and individual training time, an adult education requirement.

 The "first Thursday" remains the all staff meeting, it has an agenda, with specific elements, and it never exceeds one hour. It is followed by DIG time.

 The second Thursday is the one-on-one training day for the individual trainers and people needing assistance. The training coordinator has identified the respective people to do the training, and the practice has credentialed them and their lesson plans as meeting the standards of care of the practice.

 The "Third Thursday" is now the zone meeting, the coordinator has an agenda, with specific elements, and it usually leads into specific zone training or projects. It is followed by one-on-one time if zone needs have been met.

 The fourth Thursday is the one-on-one training day for the individual trainers and people needing assistance. The training coordinator has identified the respective people to do the training, and the training coordinator has credentialed them and their lesson plans as meeting the standards of care of the practice.

 The "fifth Thursday" becomes the inter-zone invitational staff meeting. It has an agenda, with specific elements, and it never exceeds one hour. It is followed by "task force" DIG time.

 Each Thursday is also the doctors' time for standards of care discussions, and will continue weekly until most all items are addressed, and then will revert to biweekly.

Step Five. Each team member understands that hospital staffing plan begins with scheduling the facility resources to meet community needs/demands, then staffing the doctors to meet the clients' needs, followed by nurses being scheduled to support clients and doctors in facility, and finally the client relations specialists being scheduled to increase client access to the facility. The OPNT team supports client flow in and out of reception area, while the IPNT team supports/treats all unaccompanied animals in the facility, and animal caretakers are scheduled to support companion animals' needs.

 Consultation rooms will be scheduled with a minimum of two rooms per doctor-OPNT team, after training. A pharmacy float/OPNT assistant may be utilized to facilitate scheduling, pill counting, and animal restraint, as well as day admits. In the more comprehensive companion animal practices, we expect about forty percent of outpatients to be admitted per standards of care.

 When the available consultation rooms, not doctors, achieve an eighty percent fill rate, either expanding hours or expanding outpatient facilities will probably be needed.

 The facility resources will be scheduled to meet the needs of the clients first.

 Coordinators will review the demands for clients/and potential clients to have timely access to the facility and healthcare delivery teams, including doctors.

 The doctors' schedules will be developed to maximize facility utilization, while meeting client access needs.

 The doctors' schedule is developed for six weeks into the future, so staff schedules can be forecasted four weeks in advance. Coordinators can approve shift swaps, but WILL not change schedules once posted.

 Inpatient and outpatient nursing coordinators will schedule the needed support to accommodate the inpatient and outpatient doctors' scheduling needs.

 The client relations specialists keep a clear picture of available facility space, anticipated client flow in and out of the hospital, and existing healthcare delivery schedules. For example, surgeries will be scheduled in groups of three minimum, and dentistries will be scheduled in two-hour blocks, if the IPNT team preps and recovers for dental hygiene specialist. Grade 1+ equals twenty minutes, Grade 2+ equals thirty-five minutes, Grade 3+ equals sixty minutes, and Grade 4+ equals seventy-five minutes. All appointments will use ten-minute slots to build appointments, where the last ten minutes in Room 1 overlap the first ten minutes in Room 2. Standard outpatient sick-call equals twenty minutes, add ten minutes for new client, add ten minutes for a second or third pet, add ten minutes for exotic husbandry, and when using the preferred client program, vaccine appointments with OPNT can be ten minutes. Suture removal can be ten minutes, etc.

 Technician assistants and animal caretakers move animals within the facility, after ensuring the animals:

 Smell nice.

 Have all their medications.

 Have any blankets or collars left by client.

 Are the right animal for the right family, showing positive ID of both.

 The animal caretakers are scheduled according to the hospital occupancy, which means thirty-three animals per one FTE animal caretaker. In many cases, this is the entry level for becoming a technical assistant to the IPNT or OPNT zones, which should be supported by a distance learning program.

 Any healthcare delivery team individual who states, "I cannot work that shift", is, in fact, opting for less than full-time work. The healthcare delivery team staff members are not the primary driving factor for the schedule. Facility capabilities and client access demands drive the scheduling process.

 The scheduling of the hospital starts with the above parameters, and a demand-based schedule is developed, usually in half-day blocks. The staffing plan is the responsibility of the respective zone coordinators, who, as a group, are referred to as the "scheduling team", which is usually made up of the zone coordinators, and mentored by the practice manager/administrator.