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, Past Executive Director AAHA
“Compliance” . . . wouldn’t you know this profession would use a phrase that blames the client, while the very expensive AAHA study specifically identifies the veterinarian as the primary culprit in the delivery of substandard care.
STARTING WITH THE BOTTOM-LINE
In the cost-benefit analysis, the AAHA Compliance Study reviewed only six routine wellness care programs, and stated: If the average practice (defined as 2.2 FTE doctors NOTE: The methodology which needs to be used was suggested in the new AAHA publication, The Path to High-Quality Care, but there was not a “measurement system” except for access rates, so we direct our better veterinary practices to the new VCI Signature Series monograph, Models & Methods That Drive Breakthrough Performance, for definitive measurement systems (available from VIN Bookstore, www.vin.com). WHERE DOES IT START? Most veterinarians entered veterinary medicine because we cared about animals, and most every staff member entered this profession because they care about animals. Pet owners have become stewards to their companion animals because they care about those animals, and access veterinary care because they want assurance of health as well as personal peace of mind. Then veterinary school occurs. People who have lost contact, or do not understand anything about private general practice, train the future veterinarians. They are specialists or specialists in the making, they want 45 minute appointments and are supported by the state in most cases (the recent Pfizer studies of 35,000 to 37,000 clients, three years in a row, showed 85% to 87% of the clients want to be in-and-out of the general practice’s consultation room in 20 minutes or less). Most veterinary teaching hospitals have TWICE the expense as income, yet no one seems to care. A private practice could never operate with this ratio, yet this is the environment where students are “educated” about the business of veterinary medicine. Students are told, “You cannot afford to do this in practice!” or “Only specialists can do this, so you must refer these cases.” And we wonder why most veterinarians seem to discount as a matter of course? We just consulted with one New York practice doing $1.5 million a year, but they had no cash flow (liquidity); invoice review showed they had discounted $200,000 . . . and not charged for $300,000 of work during the same $1.5 million year. No one can give away one third of their earned dollars and expect to stay in business. The AAHA publication, The Path to High-Quality Care, is a wake-up call. It shows in dollar and cents the impact of a practice which does NOT present the “animal needs” as a client-centered patient advocate on every animal. In the first edition, they still used the word recommendation, which has been shown time-and-again to far less effective than stating the NEED. In the follow-up edition, they showed the word “need” actually double the booking rate. HINT – writing the need in the medical record with box (❑) behind it [or CR-__ in electronic records], and then waiting for the client response (e.g., hwt ❑, or hwt CR-__), helps with the continuity of care. When the client response about the “needed” heartworm test, Section one of the AAHA Standards states you are required to document waivers and deferrals, so the client response (W = waiver (no way doc, do not believe in it); D = defer (let me think about it, maybe later doc); A = appointment (need to wait until payday doc); or X = do it doc!) goes inside the box (e.g., hwt ☒, or in the space behind the CR-D). If it is deferred (D), it needs to be followed by the attending nurse until resolved, so after the box comes the expectation, as stated by the doctor to the client (e.g., hwt [D] 3w = “We can delay this maybe up to three weeks while you consider this, but the mosquitos will be getting bad by the end of the month, so we need to start the protection soon, and need the blood test first to ensure Spike is still free from heartworms before we start the protection medicine; Mary will call you in 7 to 10 days as a reminder.”). Then it is put into the veterinary software computer as one of the four Rs (Resolved, Recall, Recheck, or Remind), and Mary gets the printout on the appropriate morning from the Client Relations Specialist. SO WHAT IS COMPLIANCE THEN? 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 for Risk Level 1 patients, that all staff and all doctors say the same thing to clients, especially for wellness care and professional needs. Without a consistency between doctors, staff cannot be effective extenders. Veterinary practices are NO DIFFERENT than any other business, except most of us feel it is a calling rather than a job. There must be protocols and common expectations if the staff members are to become veterinary extenders. 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: – 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?) – When is it humane to leave an animal in pain? Answer: Never! (So why has pain medication been optional?) – What percentage of animals need to be on heartworm medication? Answer: All! (So why are less than 60 percent currently protected?) – Which animals need to be screened for internal parasites, including the protozoa threats, at what frequency? Answer: ALL that have ANY outside access or reside with other animals in the household! (So why do some practices state the heartworm medication treats for all internal parasites?) – 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 20-30 minute procedure) than a client who has let it progress to a grade 3+ oral surgery (about a 60 minute procedure? Answer: YES! (So why doesn‘t every animal have a dental grade in the computer?) – 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, and why doesn’t the practice track BCS on each animal?). – 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 10 percent weight change, is that significant? Answers: YES to both questions! (What has been stopping you from assigning a nutritional counselor to each adult patient?) – 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 (1-5 per anesthesiologists) so seldom recorded in the medical record at admission and on the white board in treatment to help ensure the animal’s safety?) – VECCS states that 80 percent of all surgery patients deserve to be on fluids, what 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?) – Are veterinarians allowed to 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” as a “NEED”, and then shut-up and listen to the client about decisions to access that care?) – Review the VCI Signature Series monograph, Standards of Patient Care in a Bond-Centered Practice, from the VIN Bookstore, www.vin.com), and/or the VCI Human-Animal Bond Scoring Pocket Card (free from consults or seminars like VCI Seminars at Sea in recent years), and determine what you really want to stand for in your practice and your community. WE MUST CARE Sure there is a “compliance” issue with clients; these are the people who learned pet care from their parents, and state, “I will never raise a kid like my parents raised me!” Per JCAHO, adherence is applied to clients, while compliance applies to the providers. The client education needed to become effective stewards of other family members, called companion animals, must be done by the experts, the staff of the veterinary practice. Very few practices offer a “new client day” for new pet owners, yet the ones who do, and provide the certificates (“A $35 value as a courtesy from the ACME VETERINARY CLINIC, for new owners attending within 14 days of adding a pet to their family”) to all breeders, pounds, and pet stores in the community, get many new clients from this caring gesture. Compliance means not just good record keeping, it means OUTSTANDING record keeping; meeting all the AAHA Standards for Medical Records is the MINIMUM level acceptable for any companion animal practice, and the veterinary software needs to be able to track each recurring element. HINT – the AAHA standards are an evidence document in court cases as a “standard of the land”, even if the practice is NOT AAHA certified. If the software vendor does not care enough to make their system user-friendly to the practice, there are others who will convert the practice quickly, effectively, and for free. Caring means NO ANIMAL leaves the practice without being at least two of the 4 Rs (resolved, recall, recheck, or remind), and many are three, such as: We need Susie to call you half way through the treatment plan (recall) to see if questions have arisen, we need you to return in two weeks for Spike’s sequential urinalysis (recheck), and we are putting you on our mailing list for newsletters and wellness need reminders (remind). Would you prefer the reminders to be e-mail, text message or snail mail? What did the AAHA study about existing practices and their patient follow-up? The results were dismal: – 23 percent of the pets with grade 2 dental disease or higher had NO recommendation for dental prophylaxis (ask yourself why didn’t they survey grade 1+ dentals, since NO gal or guy can ever get a second kiss if they have a grade 1+ mouth). – 27 percent of pets with medical conditions needing therapeutic diets did not receive recommendations from the veterinary provider(s). – 53 percent of senior pets did not have a recommendation for any form of senior screening. – 13 percent of the pets were not in compliance with the veterinarian’s recommended vaccine protocols. – 11 percent of the dogs in heartworm endemic areas had not received a recommendation on heartworm testing. – Only 10 percent of the clients felt veterinary recommendations were based in a profit motive; only 7 percent said cost was a barrier to access of care. – 78 percent of veterinarians surveyed said they were satisfied with their compliance, and 63 percent of those said they felt their client’s compliance was high. The “lost income” numbers from the programs in the AAHA study are staggering: PROGRAM ANNUALLY PER FTE DVM In the most simplest of terms, “good medicine is good business.” If the standards of care are inviolate, if there are outpatient nurses (OPN is usually a skilled communicator, who can “talk the walk” for the practice expectations) escorting the patient/client into the consult room and doing the client education AFTER the doctor has prioritized care, before they depart the consultation room, then there is NO REASON for clients not knowing. This is NOT using more doctor time with each client, it is mobilizing the veterinary extenders on the healthcare delivery team to convey the NEEDS (❑) to the client before they depart the practice, as well as the expectation for the next contact. HINT – a handout follows the OPN discussion, and is provided for “the family back home” or later review. Now ask yourself, why was EVERYTHING in the AAHA survey addressed as “recommendations” rather than “needs?” Why are the major associations in our profession not CHANGING the nomenclature to ensure clients are not confused about the needs for quality healthcare delivery and protection? Answer – the compliance problem is OURS, not the client’s. The clarity of NEEDS greatly resolves this entire issue. We have met the enemy and it is us. The client cannot reasonably decide on the merits of different healthcare delivery issues; that is a graduate veterinarian’s responsibility. When the medical records do not match the invoice(s), it is pure fraud from an auditor’s standpoint. There cannot ever be “forgotten care” or “forgotten charges,” or even falsified information (e.g., “45 minutes anesthesia” and “30 minute surgery,” being invoiced as “30 minutes of surgery and anesthesia”). We are required by the respective practice acts to have full and accurate records and disclosure to the animal steward on patient and professional “needs.” The client has the RIGHT to allow the animal access to the NEEDED care or not, but at no time are we as healthcare professionals allowed to hide the actual healthcare facts or needs from the client. “Compliance” to inviolate Core Values and inviolate Standards of Care is internal to the practice, and NOT a client issue. Compliance starts from the providers and is reinforced by the staff and providers; when there is a consistency in the expected Standards of Care, the subsequent continuity of care becomes easier as well as more beneficial to patient, client, staff, providers, and business. Compliance means staff stays in contact with clients to ensure their adherence when medication has been dispensed, when there is Deferral (D), or when directed by the attending veterinarian.
