As Americans, we often rally around symbolism, we believe in the effectiveness of a logo to establish a community identity. Most salute the Stars and Stripes. In California, the “bear” flag flies with pride. What is the “flag” that flies in your veterinary practice? What are the pride factors? Why do many Australians think the USA is “over patriotic?”
The “client-centered” habits that build most practices during those first few years after the doors opened soon shift to a “bottom line” fixation on the Profit & Loss statements. Then the “flag” of caring for clients often changes to caring about the average transaction fee and gross sales (neither of which have a “net income” insight). The staff starts to fret about their “bonus” rather than client satisfaction. The veterinary practice of the new post-GFC era must do more with less (the bull market is soon due for an “adjustment). The margin of profit has dwindled. A business cannot spend the gross, it can only spend net! The reason for the dwindling net varies with the practice from increased community competition, to veterinary price wars, to poor management techniques, to under-utilized veterinary extenders. Regardless of the cause, the best tools available to change trends are the human resources within the practice. Veterinarians work hard to produce the gross, but the paraprofessionals are the ones who can easily increase the practice net.
BUILD A NEW PRACTICE FLAG FOR TOMORROW
Every practice owner can change their “practice flag.” It is more than a slogan like “Sharing the care” or “We care for pet as if it was our own.” It should be based on a systematic approach to quality health care, continuity of care, and use of veterinary extenders. Veterinary extenders are simply those people or things that give the veterinarian more time for patient care, whether they be forms, policies, computer assisted education devices, or veterinary nurse technicians who provide quality patient and client care. Let’s look at a few of the elements that need to be included in a quality practice “F-L-A-G”:
Followers – every team requires players, else you cannot call it a team – they must
be willing to play by the rules established for the game.
Leadership – every team needs someone to make the hard decisions, set the pace,
and provide the feedback on activities.
Attitude – the attitude of concerned excellence must be seen at all levels, from the followers to the leaders, and must be positive to be successful.
Goals – any team needs to know where they are going, the end point where they can be recognized for making a successful score.
Believe it or not, psychologists tell us that 50 percent of the American work force have the personality that prefers predictable, steady, routine work. Another 16.3 percent of the American work force prefer life styles that are very concise and structured, and a work place loaded with policy statements and procedure manuals. This provides the veterinary practice manager a two in three chance to select a process-oriented follower when they hire people to be on their team. By definition, these type followers must have a savvy leader to be effective and comfortable within their work environment.
The follower (USA, Australia, New Zealand, Commonwealth, etc.) needs to know what the expectations are, where the practice is going, or simply, what determines competence; they do not like rapid, unpredictable, operational changes. The basic issue in healthcare delivery must be competency; training, recurring training, and is required for peace of mind. They need to have a clear “flag” to rally behind. The performance range is not excellent, outstanding, good, fair, weak, or poor; competency is excellence in healthcare, and nothing less is adequate. Every text in human healthcare delivery says a single standard of performance is necessary and, within our consulting programs, that is called “competency” [Building the Successful Veterinary Practice: Programs & Procedures (Volume 2), Chapter 6]. If a staff member is below competency, they “need training”. If they are truly incompetent, they need to be dehired (fired for inability to learn)! Above competency, which must already be excellence (considering the forensic nature of healthcare delivery), is a category we call “ready to train others.” This category recognizes the training ability of the best followers to help improve their team members’ performance. There is a monograph in the VIN Bookstore addressing this Performance Planning Process and offers the forms needed for quarterly self-assessments and goals setting.
Members of a veterinary practice staff want to believe they are in a caring profession, they want to be recognized as being the best in healthcare delivery. When staff members know they share the practice philosophy and vision, that they are meeting these needs, they know they follow the practice standards (flag) of the owner or veterinarian. These philosophies are core values of the practice and apply to everyone. When decisions are made by staff members using these core values, only accolades should occur. No one should ever feel the standards or values are inconsistent. These are the “flag” characteristics of a quality practice and are the keys to practice leadership and team building.
Sharing the dream and vision is one method to build a common team effort. Being fair is impossible, since fairness is in the eyes of the beholder. The good leader ensures that staff is treated in an equitable manner. Stars will be treated differently from the rookies just joining the team, client relations specialists are limited to duties different from nurse technicians, and owners have privileges not available to associates. Equitability is most often defined in the work place as predictability, being able to depend on the veterinarian for support of the practice standards, even if it upset a client. If the doctor learns to say, “I’m sorry, it was my fault, we initiated that program to help the majority of our clients; I’m sorry we hadn’t planned for your situation…”, then the staff will feel supported by the leader. As the boss treats the staff, so will the staff treat the clients. The leader’s vision and dream will be supported when the team is led by example (Building the Successful Veterinary Practice: Leadership Tools (Volume 1), Appendix B, 14 leadership tools are outlined; they should all be understood and in use on a daily basis by every practice manager and leader).
The simple rule in leading a team is, “Whether you think you can, or whether you think you can’t, you will make it come true.” The positive attitude builds on the strengths for which each individual was originally hired. We don’t hire people for their weaknesses. The positive attitude says team members were hired to solve the problem, not wait to see what the rest of the people are going to do. The positive attitude is patient advocacy, a quality of care issue, speaking for the needs of the pet and letting the clients get involved in the economic decisions whether or not to access that level of care for their pet.
A great practice attitude is remembering that the only team members who stumble and make mistakes are those who are moving and trying something new. This is a characteristic of learning. Those who never make mistakes and never stumble are standing still and playing it safe. This is not a practice growth posture. The “uncommon leader” will see a mistake and identify it as a training shortfall of the practice; traditional managers just try to assign blame for the mistake. When building a team “flag”, catching people doing things right is more important than catching them doing things wrong.
Everyone wants practice growth but there are many who do not realize that direction is needed for an orderly team advancement. While many practices say they have not had the time to define clear, concise, and embraceable objectives, they have concurrently made the time available to train new staff members on a recurring basis. High staff turnover is often symptomatic of a staff who does not identify with the practice standards. With each training cycle required for new employees, the time taken to build the standards (flag) usually gets shorter because of subject familiarity, degradation because of word-of-mouth concept transfers, and staff shortages.
The foundation of “standards” and “goals” during delegation will be the core values; beliefs and attitudes that are inviolate, by anyone, even the boss. Clear core values allow others to make decisions based on those inviolate standards, and they know their protection from “blame” is always basing the decision on the core values of the practice.
Every team must have a goal, whether it be goal posts, a basketball hoop, scoring the points, or making a touchdown. All team sports have expectations that are clearly defined, from what they wear to the size of the playing field, to how they are to treat others while they try to score. The team captain and the coach tell the team what is expected and how they are to work together to make the score. Some teams need more direction than others. Great goals and team building can start at these sport analogies, but they also go beyond these boundaries. A practice team must be in for the long haul, not a four-hour game of youthful endurance. A good leader keeps the goals and objectives clearly defined and in front of the team. The purpose of the goal is well explained to add the power to the motivation. A great leader also puts himself into the team’s shoes and tries to see the challenges from their perspective. The alternatives are selected from reality and the strengths of the team, not dreams and wishful thinking.
PRODUCTIVITY AND QUALITY
The US and Australian economy is volatile and recovering, and only clear leadership can affect the trend. In the early days, small groups worked together to produce a product or deliver a service. They rallied around a tribal banner. Look to the caveman heritage of hunter/gatherer that led to the development of small community groups seen only a few hundred years ago to see the genetic imprint we carry (University of Minnesota research says 50 percent of personality is genetic):
- The fleetest of the group became the scout/chaser.
- The keen eye became the tracker/spotter.
- The most skilled archer or spear-chucker was the hunter.
- The hunters discussed the method to track and attack the prey, our species survival strength was in the coordinated effort of the team.
- Each person was used for their strength and was not elevated to another position on the team just because they had been on the hunt before.
- Those who did not hunt, gathered the resources needed to support the hunters.
- Gatherers developed skills (baker, shoemaker, blacksmith) that could be bartered for other food stuffs.
Then the industrial revolution came and we moved to a system where hundreds were doing the same mechanical thing. Corporate logos replaced tribal banners. We lost the ability to speak within the total group. Each worker became a number on a massive assembly line, each person was protected from individual responsibility for the quality of the finished product. Labor unions were developed around the concept of the workers’ take-home pay and benefits rather than the quality of the finished product. In the same method, education became an assembly line basis. The three Rs taught at home or in the village school for proficiency gave way to the public/private school system, with grades awarded to increase the evaluation capabilities. Why should there be losers and winners in education?
It would be unrealistic to expect a national reversion, but things can be changed to increase personal responsibility at the practice level again. Take the competition out of the life of students and workers by eliminating grades as well as merit pay would devastate the average American. Teach team cooperation and goal achievement can be implemented concurrently with existing programs, and eventually, people will shift their paradigms based on the management 3Rs (Respect, Responsibility, Recognition) being equitably applied on a daily basis. Giving workers the opportunity to do their job right means giving them the charter to make it better each day (CQI). Put solid values and standards into the framework of your practice image (flag) and promote systems that will bring achievement and recognition back into the practice.
The methods and philosophies to use have been tested and promoted by W. Edwards Deming, the driving force behind Japan’s economic growth. In fact, the highest award that the Japanese developed to recognize outstanding quality is called the “Deming Prize for Quality Control.” James Barksdale, Chief Operating Officer of Federal Express, states the only permanent piece of paper on his desk is the Deming management principles. We know from Tom Peters that Federal Express has developed a cutting competitive edge by empowering their people to act for the good of the company WITHOUT prior permission. This is the human resources commitment that underlies the American industrial success stories of all the leading companies of the 1990s; these commitments to human resource excellence will become the mandate in the new millennium for every business.
While the western industry standards declined, W. Edwards Deming was the moving force to establish quality as an industry standard in Japan. I have taken the liberty to slightly modify the original fourteen management principles developed by Deming and come up with key elements for veterinary practices.
DEMING’S STEPS TO QUALITY MODIFIED FOR VETERINARY PRACTICES
- Create a constancy of purpose (innovation, research, education, and continuous improvement and maintenance) for the improvement of healthcare delivery and client-centered service to become competitive, stay in business, and provide jobs.
- Adopt a new philosophy of total quality management that matches this economic age; reliable quality service reduces costs. Awaken to the professional competitive challenge, learn the practice management responsibilities, and address the internal leadership that can be used to make changes occur.
- Cease dependence on mass inspection (inspect bad quality out); eliminate inspection for mistakes. Start to build new quality in; effectively train with caring and help them to learn to do it right the first time.
- End the practice of awarding business on price tag alone, the mind set contaminates internal operations.
- Putting out fires is not that important in the grand scheme of CQI (continuous quality improvement). Collectively and individually, improve constantly and forever the system of production and services.
- Institute training and retraining by skilled and knowledgeable trainers; it is very difficult to erase improper training.
- Institute leadership; discover the barriers that prevent workers from taking pride in what they do and eliminate the causes. The aim of leadership should be to help the paraprofessional staff to do a better job.
- Drive out fear! Preserving the status quo is safe, secure, and an economic disaster; admit mistakes, allow people to take risks, build on discoveries rather than habits.
- Break down all barriers between front and back staff; management creates the teamwork responsibility system rather than dividing the blame.
- Eliminate slogans, exhortations, and numerical targets for the work force; center on quality of healthcare delivery. If they can’t reach production targets, they will come to ignore them.
- Eliminate the numerical quotas and quantity goals based on other people’s performance within the practice or veterinary industry; they impede quality more than any other single factor. Define the expected quality and promote personal pride, not numbers.
- Remove barriers that rob staff of their right to take pride in their workmanship and performance; people are hired because they are motivated, build on this trait.
- Institute a vigorous program of paraprofessional continuing education (on-site and at central meetings), self-improvement and retraining; the education must fit people into new jobs and responsibilities.
- Take action to accomplish the transformation; put everybody to work to accomplish the practice transition. Use the PDCA cycle: Plan, Do a test/trial, Check results, Act).
Deming states that the above concepts, used together, will result in a continuous quality improvement (CQI), but it takes management courage.
RALLY AROUND THE FLAG
George M. Cohan brought a flutter to the heart as he sang, “It’s a grand old flag . . .” and you can do it for your practice. You must build the emotions of support, which requires sharing personal beliefs and a personal commitment to the staff and their goals. It requires stretching beyond personal comfort zones, and taking off your shoes BEFORE you try walking in their shoes. As a backpacker, I can tell you, it is not the height of the mountain, but rather, the grain of sand in your shoe, that prevents the successful assent. Since the practice leader is the key to success, here are less than half a dozen factors that you need to do. “Taking off your shoes” is not always the easiest thing to do. To make success happen, establish the core values as inviolate standards, and then:
You must understand that the needs of staff members (not their wants) must
be met before they will be dedicated to meeting the demands you have for the practice.
- You must find what excites each person (their “hot buttons”), what they want to achieve, how they want to contribute to the practice.
- You need to tailor your staff utilization plan to the strengths of the team members, allow them to build on their own strengths.
- You must be willing to build on small easy successes before you attempt those big challenges (baby steps for those who like the comfort of the status quo).
- You must be willing to commit resources to build their individual self-image before they will buy into saluting the practice standards and philosophical “flag.”
SETTING THE VISION
The vision for the team is the reason for the rally. We go beyond client-centered when we empower our staff to operate independently. Authors like Deming, Juran, or Crosby have used the phrase TOTAL QUALITY MANAGEMENT (TQM), but in healthcare delivery that becomes a misnomer. It isn’t a management system, it is a provider-driven process. A process of each member on the healthcare delivery team striving for continuous quality improvement (CQI) in the areas they touch.
The concept of Continuous Quality Improvement (CQI) is not unique to veterinary medicine. It has been taking hold in the human healthcare arena for the past decade-plus. It is based on core values, pride in performance and clear expectations by management. When pride is the input desired, then quality becomes the output. If the practice builds the team and promotes the personal accountability (pride) as key elements of performance, then the quality outcome is free.
There are many reasons to build a team “flag” and to pursue continuous quality improvement, but the bottom line is that it rewards our staff. It is a factor to increase net, and the net can be shared with the team, but the recognition and pride in personal performance becomes a stabilizing factor in the work force. With the low wages veterinarians usually pay, and the dedication of the staff who join the team, the ability to reward and recognize makes the difference between turnover and tenure. Look to your practice image, internally and externally, and see if it is something others can rally around.
Both clients and staff want to believe in the quality of care, and want to feel safe about the expectations they carry concerning the practice. Build to that level of consistency and continuous quality improvement and the staff will be proud to represent the practice. When the staff is proud, the clients become proud. When the clients become proud, the market niche will develop within your community.