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May 2015 - Leadership Focus

Focus on Leadership vs Leadership Focus

Thomas E. Catanzaro, DVM, MHA, LFACHE

Dipomate, American College of Healthcare Executives

CEO, Veterinary Consulting International

DrTomCat@aol.com; www.drtomcat.com

Daniel Goleman, author of “The Focused Leader,” explains why leaders need to cultivate a triad of awareness — an inward focus, a focus on others, and an outward focus.

I have written about leadership in many volumes, from the very first book, “Building the Successful Veterinary Practice: Leadership Tools (Volume 1)”, Wiley & Sons Publishing, to multiple monographs in the VIN Bookstore, to a recurring thread in most team-based efforts I have published.  But clients of late have caused me to relook at the leadership from another perspective, as suggested by Daniel Goleman, in “The Focused Leader”.

A primary task of leadership is to direct attention. To do so, leaders must learn to focus their own attention. When we speak about being focused, we commonly mean thinking about one thing while filtering out distractions. But a wealth of recent research in neuroscience shows that we focus in many ways, for different purposes, drawing on different neural pathways—some of which work in concert, while others tend to stand in opposition.

Grouping these modes of attention into three broad buckets—focusing on yourself, focusing on others, and focusing on the wider world—sheds new light on the practice of many essential leadership skills. Focusing inward and focusing constructively on others helps leaders cultivate the primary elements of emotional intelligence. A fuller understanding of how they focus on the wider world can improve their ability to devise strategy, innovate, and manage organizations.

Every leader needs to cultivate this triad of awareness, in abundance and in the proper balance, because a failure to focus inward leaves you rudderless, a failure to focus on others renders you clueless, and a failure to focus outward may leave you blindsided.

THE MANAGEMENT JUNKIE

In my back page efforts in Veterinary Forum, I often talked of those practice owners who were their own worst enemy.  One article I titled the “Management Junkie”, someone who attends a seminar or reads an article and initiates changes out of the blue.  We know that change in adult education requires consistency, the same message 7 times in 21 days just to get buy-in, and then a 90-day application phase without additional changes, unless it is self-generated by the action person (not the boss) to reach the predetermined measurements of success agreed upon at the beginning of the project.  I wrote how Management Junkies could not stay focused or consistent, and derailed the team effort of their practice staff.

The editor had many more readers write in than ever experienced for most articles.  Eight of the eleven stated they felt betrayed, because I wrote about them and their practice, yet I had never been in their practice. I also get this from my FORTNIGHTLY articles, where past clients contact me and ask why I am writing about them; in most cases, I have not, yet they identify with the concept of the article. These are the practice owners who focus on themselves, and not on their team or the broader veterinary community.

The Management Junkie also seldom focuses on the staff member efforts.  They track dollars as if that was the critical yardstick of staff motivation.  I am sorry folks, all healthcare research shows belonging, self-esteem, and personal growth are the usual top motivators, and while money is in the top six, it seldom, if ever, breaks into the top three reasons for job satisfaction. I look at the procedures per 100 transactions for key recognition factors (timely, meaningful and specific).  This requires identification of program managers, training them to a level of being trusted, and then empowering them to excel. Take for instance behavior management – over 90% of new puppy owners want behavior management (it is the second most internet search item after location), yet most practices do not track the Family Fit nurse technician consult. We know most practices stock a wide range of nutritional products, yet many practices do not track the recurring nurse technician nutritional weigh-in and progress consult.  We also know that many clients do not follow our prescription guidelines (this is “client adherence”), yet very few practices assign a nurse technician to follow-up on dispensed meds, nor do they track the follow-up effort.  If you do not measure it, you cannot track it, nor can you recognize staff members who are doing a great job following the written Standards of Care (this is where compliance actually occurs).

The one-dimensional practice leader who starts everything and then changes direction in mid-stream creates a chaos that undermines self-determined progress within the staff members. In most cases, we say they lack empathy!

EMPATHY TRIAD

We talk about empathy most commonly as a single attribute. But a close look at where leaders are focusing when they exhibit it reveals three distinct kinds, each important for leadership effectiveness:

• cognitive empathy—the ability to understand another person’s perspective;

• emotional empathy—the ability to feel what someone else feels;

• empathic concern—the ability to sense what another person needs from you.

Cognitive empathy enables leaders to explain themselves in meaningful ways—a skill essential to getting the best performance from their direct reports. Contrary to what you might expect, exercising cognitive empathy requires leaders to think about feelings rather than to feel them directly.

Emotional empathy is important for effective mentoring, managing clients, and reading group dynamics. It springs from ancient parts of the brain beneath the cortex—the amygdala, the hypothalamus, the hippocampus, and the orbitofrontal cortex—that allow us to feel fast without thinking deeply. They tune us in by arousing in our bodies the emotional states of others: I literally feel your pain. My brain patterns match up with yours when I listen to you tell a gripping story. As Tania Singer, the director of the social neuroscience department at the Max Planck Institute for Human Cognitive and Brain Sciences, in Leipzig, says, “You need to understand your own feelings to understand the feelings of others.” Accessing your capacity for emotional empathy depends on combining two kinds of attention: a deliberate focus on your own echoes of someone else’s feelings and an open awareness of that person’s face, voice, and other external signs of emotion.

Empathic concern, which is closely related to emotional empathy, enables you to sense not just how people feel but what they need from you. It’s what you want in your doctor, your spouse—and your boss. Empathic concern has its roots in the circuitry that compels parents’ attention to their children. Watch where people’s eyes go when someone brings an adorable baby into a room, and you’ll see this mammalian brain center leaping into action. This is the same trait puppies and kittens elicit from our staff members.

In fact, mapping attention to power in a practice organization provides a clear indication of positional hierarchy: The longer it takes Person A to respond to Person B, the more relative power Person A has. Map response times across an entire practice, and you’ll get a remarkably accurate chart of social standing as well as organizational behavior. The practice owner leaves requests/e-mails unanswered for hours; those lower down respond within minutes. This is so predictable that an algorithm for it—called automated social hierarchy detection—has been developed at Columbia University. But the real point is this: Where we see ourselves on the social ladder sets the default for how much attention we pay. This should be a warning to the practice owners, who need to respond to fast-moving competitive situations by tapping the full range of ideas and talents within an organization. Without a deliberate shift in attention, their natural inclination may be to ignore smart ideas from the lower ranks.

OUTWARD FOCUS

Leaders with a strong outward focus are not only good listeners but also good questioners. They are visionaries who can sense the far-flung consequences of local decisions and imagine how the choices they make today will play out in the future. They are open to the surprising ways in which seemingly unrelated data can inform their central interests. Melinda Gates offered up a cogent example when she remarked on 60 Minutes that her husband was the kind of person who would read an entire book about fertilizer. Charlie Rose asked, Why fertilizer? The connection was obvious to Bill Gates, who is constantly looking for technological advances that can save lives on a massive scale. “A few billion people would have to die if we hadn’t come up with fertilizer,” he replied.

This “leadership focus” is challenging. But if great leadership were a paint-by-numbers exercise, great leaders would be more common. Practically every form of focus can be strengthened. What it takes is not talent so much as diligence—a willingness to exercise the attention circuits of the brain just as we exercise our analytic skills and other systems of the body.

The link between attention and excellence remains hidden most of the time. Yet attention is the basis of the most essential of leadership skills—emotional, organizational, and strategic intelligence. And never has it been under greater assault. The constant onslaught of incoming data leads to sloppy shortcuts—triaging our e-mail by reading only the subject lines, skipping many of our voice mails, skimming memos and reports. Not only do our habits of attention make us less effective, but the sheer volume of all those messages leaves us too little time to reflect on what they really mean. This was foreseen more than 40 years ago by the Nobel Prize–winning economist Herbert Simon. Information “consumes the attention of its recipients,” he wrote in 1971. “Hence a wealth of information creates a poverty of attention.”

My goal here is to place attention center stage so that you can direct it where you need it when you need it. Learn to master your attention, and you will be in command of where you, and your practice organization, focus.

April 2015 - TCB

TAKING CARE OF BUSINESS (TCB)

Thomas E. Catanzaro, DVM, MHA, LFACHE

Dipomate, American College of Healthcare Executives

CEO, Veterinary Consulting International

DrTomCat@aol.com; www.drtomcat.com

Taking Care of Business (TCB) was made famous by Elvis Presley.  As I was thinking of what to call this article about “not too smart” ownership practices, it came to mind.

SCENARIO #1 – I was called in because there was very little or no net income at the end of the month.  It was a traditional doctor-centered companion animal practice, waiting for broken animals to come through the front door.  But then as I was looking at the P&L, I noticed $1000 a month going to the local stable as advertising. I asked.  Answer was, “If I advertise for a $1000 a month, my daughter’s horse gets room and board for free”. Then I asked about the three (3) Lexus cars on the books (when the IRS usually allows only 30% of one car). Answer was “mine, wife’s and daughter’s!” Then I asked about the payroll, where the wife and daughter were being paid very well, with little or no presence in the practice. Answer to the syndrome, “an alternative allowance system”. This owner was happily taking the net “pre-tax”, until the day he would be audited. A solution laid in staff empower well care programs, but unless the owner changed behavior, there still would not be any net.

SCENARIO #1a - I was called in because there was very little or no net income at the end of the month. I noticed on the financial reports that the owner’s draw exceeded any production pay (he was not practicing), and in fact, sent the practice into negative numbers every month.  He was living beyond his means, yet blamed his doctors for having low production. His staff and associate turnover rate was a major indicator of the stress level, but he blamed it on everything but himself.

SCENARIO #2 – I was called into the practice because the owner wanted to get out of the converted family farm house and into a new facility, to be built on the property, where the old barn burnt down a few years earlier.  He had to amass the money and get a set of plans drawn. He had seen my text on facility design and thought I could do double duty. He had a draftsman to finalize his drawings, and get an architect to sign off on them for the town fathers.  The draftsman saw the AAHA Text and said he could do the details from my draft plans (by the end of the build, he stated he could now design and built veterinary practices, just with the AAHA text). We set out to develop a comprehensive well care program, utilizing his staff and new mind set for the owner.  His wife was very supportive. At the end of the year-long consult, the new facility was done! I made a final visit, and the owner said he had no more money now than at the beginning of the consult, and did not know how he could fund the new facility.  I had been tracking his numbers and had a strong hunch I knew the problem, so we went to the bookkeeper.  I asked her if the owner took a draw each month.  She said his habit was to come in and ask for the excess cash after bills were paid. When I asked him where the money went, he said he took it home and gave it his wife, never counting it. We investigated the cash flow and his wife said yes, she had invested the money in new $150k home expansion that year. That still did not cover the excess cash I knew the practice programs had driven, and with a little snooping, we found his “trusted” front desk person was taking money and receipts home every evening (yes, he was still on un-numbered paper receipts).  We called the Sheriff and let him handle the details with the DA; the ex-employee confessed to the full amount (more than we had suspected) and made full restitution in the following year.

We built the new facility into the hillside (per his desires, we used open architecture on the main floor so the facility could have another use after his passing). The second floor had the staff lounge and lockers, designed so the second floor had a ground level entrance behind as well as the client entrance on ground level from the front (across the two story, four pillar porch, with a handicap access ramp at one end); ergo, no ADA elevator requirement. Building into the hillside also gave us a major energy savings for wards and the treatment room. By time we were done, his showcase facility was dedicated to his dad and his brothers, wife and kids were in the will to inherit the facility

SCENARIO #3 - This practice had a history of losing doctors and staff in major numbers. Otherwise, it was a normal doctor-centered companion animal practice, waiting for broken animals to come through the front door. Doctors were assigned to duty functions (e.g., surgery) and they did not stray, even if there was no case load; it was interesting to watch them shift from computer station to computer station to keep looking busy.  Staff did the same thing, where it took three certified nurse technicians to change on foot bandage, so they could look busy. The leadership team and I discussed known wellcare programs and staff empowerment; I got “verbal buy-in”. At the first staff meeting, I was the only one there – everyone had an excuse for not attending (4 doctors and 12 staff members). Following day, a second staff meeting, and most attended, although 15 minutes late); attention span was zero! Staff interviews showed “and this too shall pass” attitude, since the owner virtually never kept a promise made to staff. We tried a few things, and the owner would add, subtract or modify the program(s) within 30 days - “and this too shall pass” attitude was reinforced. At the quarterly revisit, we discussed the need for 90 days of consistency to establish new habits, as well as repeating the mission focus details 7 times in the first 21 days (adult education principle). Again, we started new programs, even used Zoetis to add some current audio-visual enhancements, and in 30 days, the owner was changing the emphasis again. This was a leadership disaster!

After six months, the manager finally got the non-practicing owner to look at the new program-based metrics (rather than his traditional dollar centered approach), and proactive vet and staff feedback started; “behavior rewarded is behavior repeated”. As long as we kept the focus on program bookings per 100 transactions, we could track the SOC compliance (internal function), client adherence (external function) and establish meaningful recognition systems for employed veterinarians and staff members. Harmony and pride had started to return, and since most clients perceive staff pride as quality, word of mouth referrals started to increase again.

SCENARIO #4 – It was a small store-front companion animal practice.  It was never a high powered practice.  The previous owner actually did vaccination and spay-neuter surgery, not much more.  It was bought by a veterinarian who had done relief there, and wanted to be close to home.  She had the opportunity to expand it slightly, added an actual surgery suite and better treatment room. She did okay for being in a depressed community, strong in welfare recipients; her manner was caring, and she knew she could not expect too much more from her clients.  Her one-consult room practice rocked along, and the practice plateaued; she spent 18 months trying to move it forward, but to no avail.  She had two part-time nurse technicians, so many a day, she was alone in her practice trying to make ends meet; she was getting frustrated, and even considered leaving the profession.  Then she attended one of my day long seminars, hoping to grasp something to help, although she expected only a “marketing hype” from this consultant. During the seminar, she was a “spring butt”, challenging most of the issues I was raising, but in the end, grasped the “client-centered patient advocacy to extend and enhance the quality and duration of an animal’s life ” message I was sharing as a new practice paradigm. She decided she could really speak for the animal with her clients; she engaged me for consulting services. We slowly developed her staff, and added only one well-care program at a time; in the first year, added a second consult room (which she told me could not be done according to her previous mentors). The first year, we grew the practice by 46% gross, and by the end of the second year, had grown the practice to 100 % larger gross than the 18 months of plateaued year production.  She came out of her shell, and the community and profession recognized her for her efforts.

SCENARIO #5 - My standard expectation with most every practice is shared before we start, "If you do not plan to change, don't invite me in; change will be essential on your part."  The client needs to accept that, before I come in for a year-long consult.

The first 90-day self-training program (monograph, Orientation & Training), and in some cases takes 180+ days, then we go into zone and system training (monograph, Systems & Schedules) to get us to the point of identifying program managers. 

In this case, during the latter part of the first year-long consult, the practice owner  asked me about a practice expansion, and I gave him TWO potential floor plans, taking his 2 consult room facility and drafting a six consult rooms, plus a dental suite, better wards and improved work stations.  He took my drawings to a local architect who quoted $1.5 mil for the project - I paid a site visit and discussed with the architects realistic estimates (front was renovation, about $1000 a square, and new back "new home" construction, again $1000 a square, and center surgery/treatment could be the $3000 a square they had used for the entire plan) . . .  I also straightened out the roof line and added a pitched roof the entire length.  By the time our meeting was over, new estimate was down to $750k. The facility is now a show case facility for team-based healthcare delivery.

They signed up for a second year-long as we worked through team-based healthcare for the new facility.

The practice manager (who had only been a “go-fer” before the consult) went through a major metamorphosis over the two years of the consult. The owner had his challenges breaking free from a doctor-centered mentality.  One memorable epiphany came with an exercise we did in a tent he pitched in the back yard during renovation - I had program managers mind-map their programs then sent them to lunch - while at lunch, I posted them along the walls - upon their return, everyone went to their mind map and at the sound of the bell, move one mind map to the right.  The task, was add ONE THING to the new mind map. The associate doctors were in the rotation.  It was a method of sharing the programs so everyone had a stake in each program.  As we watched, one thing became obvious, the associate doctors ran dry and could not add anything to the most of the program mind maps. The owner finally started to understand why "doctor-centered" was NOT better for his practice.

All of the above demonstrate practice leadership that has a questionable “tenacity of togetherness”, and the following article may shed some light on that subject:

http://www.inc.com/les-mckeown/cultivate-your-challenge-function.html

THE MESSAGE

"We'd be successful if it weren't for the depressed economy."  "Let me tell you, I'd be making it if it weren't for the interest rates I'm paying."  "I'd be on top of the world today if I could just find the right associate."  "You know, I'd really be successful if it weren't for all those new graduates flooding the market."  "We would really be expanding if it weren't for those zoning codes."  This abridged list is attributable to externalists.  They blame some external source, condition, or other people for their failures.  This refusal to accept responsibility for their position in life removes the path to success from their grasp.

The inverse of the externalist is the internalist.  They are performance oriented, accept personal accountability for their successes, failures, and actions.  They know to look into a mirror for the cause of unhappy results.  They do not cry over spilt milk, they just look for another cow to milk.  They take the hand life deals and play it to the very best of their ability.  They are the ones who are not afraid to say, "I don't know," or as Harry Truman's Oval Office sign said, "THE BUCK STOPS HERE."

Essentially, there are only two paths of action in veterinary practice management, or life for that matter: performance and excuses.  Each practice manager must make a decision as to which path he/she will accept as a personal direction of leadership, and apply it equally to his/her practice team.  We may predict and calculate the amount of failure any individual or team will experience by a simple formula:

People fail in direct proportion to their willingness to accept socially acceptable excuses for failure.

The problem with most veterinary practice management assessments are the traditional dictums, "Well, my practice is different - your clients are different - my staff is different."  It ain't so, folks!!  The person who makes this statement is kidding himself/herself and his/her team.  It is only a reason for failure, never success.  This attitude allows failure because the excuse is built into the philosophy of practice that the staff hears every day.

FACTOID: Those that play the “blame game” are only abdicating accountability for resolution.

PHILOSOPHY OF SUCCESS

The philosophy of success lies in the philosophy of management, and the skills of leadership.  We need to define management in terms that allow success to be achieved.  For the purpose of veterinary practice, let me share a personal definition that works for me:

Management is the art of attaining measurable and predetermined goals and objectives with and through the voluntary cooperation, enthusiasm, and effort of other people.

Many texts of the past decade have assessed the skills of management.  Peters and Waterman portrayed the skills of the top companies in their best seller, in Search of Excellence, yet in the following ten years some of those paragons of excellence had actually gone astray.  Times change and skills change, but the art of management continues.  Mike Vance, of Disney fame, said it first: "Mothering is Managing."  It is not the art of winning that is a cornerstone in management, but rather clearly communicating and diligently monitoring tasks and goals, then fairly rewarding the people who achieve them because they have made a commitment to them based on the organizational good and personal interest.

Management is not mothering, but mothering is management.  No mother waits six months to give her kid a performance appraisal for trying to dry the cat in the clothes dryer.  Mothers manage conflict, correct and guide behavior, motivate subordinate and peer social groups, set goals for others, get the dishes washed, diapers changed, garbage taken out, and are still loved.

If you have read my Performance Planning monograph (over 30 monographs are available from VIN Bookstore, www.vin.com, each with its own electronic tool kit), you already know I believe in 90-day performance planning (with self-evaluation for past performance), and the KIS (KEEP IT SIMPLE) forms are provided in the monograph (please keep them to a single sided piece of paper, although the leadership form takes two sides).    

THE K-S-A-A APPROACH

One of the foremost leadership and management courses available today rates all performance by only three factors:  KNOWLEDGE, SKILLS, APTITUDE and ATTITUDE.  This is the KSA-A approach, and the elements are critical.

KNOWLEDGE is the foundation upon which we build.  It allows alternatives to be seen and explored.  Enough knowledge can help overcome the bias and bigotry of the "school of hard knocks."

SKILLS are simply the ability to share knowledge.  The transformation of mental warehousing into action that achieves personal goals and objectives in a timely and effective manner.

APTITUDE is the innate ability to understand the systems and accomplish what is started, to a standard of excellence that be recognized by others as competency

ATTITUDE is the cornerstone upon which leadership and management rely to make knowledge and skills useful to the organization.  The attitude is what builds the team and helps the team select the right path to success.

These are leadership concepts when shared, management concepts when used personally, and rewarding when used routinely.  If we return to our poker hand, we can apply the Knowledge-Skills-Aptitude-Attitude (KSA) concept of management excellence.  Knowledge of the deck and game rules does not provide the skill to play the game.  That skill comes from repetition, mistakes, and disasters.  The need to discover success carries with it the demand to experience failures.  A skillful player adds knowledge with each failure, in cards or in life.  Aptitude is the ability to understand the rules and odds, and make reasonable decisions about the specific procedural process; you cannot ever win at poker unless you learn how to play the hand that is dealt. But the real secret to a successful poker game is the attitude of the player.  A good player bluffs occasionally, but that is only one of many skills brought to the table.  The same rule applies in leadership and management.  The tenacity to keep trying, the knowledge that the cards cannot be blamed, or the skill of reading the body language of others comes as a result of the attitude of self-accountability and personal responsibility for all actions or reactions.

ATTITUDE ADJUSTMENT EXERCISE

Most every problem has an opportunity side, and most every solution can be negative or positive.  On the left are negative situations, and on the right are the opportunities to excel. Your task, is to complete the list.

In veterinary practice, our education gave us the knowledge and the hours we've spent in the consult room, with clients, or in the surgery suite, have given us the skills. Your aptitude is the quest for continual learning and self-improvement. The attitude is what separates the successful practice from the average practice.  In the last example above, the accounts receivable are actually less than one percent, which would be a real reason to celebrate in most practices.  It speaks to excellent client bonding by the staff and practice.  But now look back - What was your first response? 

The attitude of the veterinarians and the hospital manager sets the tone for the implementation of the philosophy of the practice as well as the team's approach to meeting the goals and objectives.  It is this attitude that keeps us in the game, that lets us see where we can make changes, and lets us lead our team to success.

March 2015 EOM - Empowerment of Teams ;  Semester @ Sea 2015

THE PAWN

The pawn seems, to the beginner, to be rather insignificant; its' the weakest and most numerous piece in the game. After all, it is worth only 1 point, the least of any of the other chessmen. However, pawns can be very important as savvy chess players will come to appreciate.  At the beginning of the game each side has 8 pawns. Except on its first move, a pawn may only move one square forward at a time. Pawns can never move backwards. When a pawn makes its very first move it has a choice; it can either move one square or two. If the square immediately in front of the pawn contains another piece then the pawn is unable to move forward. It is blocked. When a pawn reaches the other end of the board it can be changed for any other piece of its own colour, except the King. This is called promotion. Therefore, a pawn can be promoted to a Queen, a Rook, a Bishop or a Knight. Normally a pawn is promoted to a Queen but sometimes there may be a good reason to promote a pawn to another piece instead.

A gambit (from ancient Italian gambetto, meaning "to trip") is a chess opening in which a player, more often White, sacrifices material, usually a pawn, with the hope of achieving a resulting advantageous position. The word "gambit" was originally applied to chess openings in 1561 by Spanish priest Ruy López de Segura, from an Italian expression dare il gambetto (to put a leg forward in order to trip someone). Lopez studied this maneuver, and so the Italian word gained the Spanish form gambito that led to French gambit, which has influenced the English spelling of the word.  In modern chess, the typical response to a moderately sound gambit is to accept the material and give the material back at an advantageous time. For gambits that are less sound, the accepting player is more likely to try to hold on to his extra material. A rule of thumb often found in various primers on chess suggests that a player should get three moves (see tempo) of development for a sacrificed pawn, but it is unclear how useful this general maxim is since the "free moves" part of the compensation is almost never the entirety of what the gambiteer gains.

OKAY - so I am Italian and was raised on chess strategies!

Let's paraphrase the above information into practice terms:

The staff members, to the neophyte manager, seem numerous and insignificant; they are the weakest and least productive element on the practice team.

Savvy chess players equate to well informed leaders who nurture their managers . . .

Staff members hire onto a practice team in support of the veterinarian; an equivalent to single-move pawns.

You never want staff to move backward, and want them to know they can move forward in unique ways . . . this is called empowerment, and requires training for this gambit to work effectively!

The gambetto is the progression to mutual respect and then a specific program manager; they assume the role of leader and team trainer in one specific area of the practice programs (yes, some may look like an upside down rook).

The difference between chess and practice is in chess, a player is NOT allowed a regression and cannot reverse a staff member promotion to program manager.

Why am I spending this time talking about chess?

What I see too often is practice owners and managers moving their "pawns" around like they were cannon fodder. They explain the importance of a wellness program, and then pull the rug out from under the staff members who were listening and believed the empowerment speech - they bought into the new practice vision (concept) of "client-centered patient advocacy to enhance and extend the quality and/or duration of a patient's life"!  Maybe they were committed to outpatient nurse and patient follow-up after a veterinarian's tasking in the consult room, but then were moved back to inpatient and assigned to dental cleaning with NO TIME to follow-up on patient recalls (e.g., drug therapy, nutrition, behavior, etc.).  Maybe they were committed to alignment of workload after morning nursing rounds (e.g., DG1+ before the veterinarian came off outpatient start-up and/or after inpatient veterinarian arrival - hardest first), and then were replaced by a vet who had arbitrary designs on personally taking the better producing cases.  Empowerment is a fragile gambit, and if abused, there is seldom an advantage gained.

In short, some practice owners use staff as insequential pieces on a larger playing board, while others keep the staff motivation and pride forefront in decisions. In some cases, this causes a fracture of a partnership - official or mental - and the manager who ignored the motivation and pride factors, and calls the other leader (who kept these soft factors in the forefront) "charismatic", yet wonders why they find key staff leaving the playing board.

Worst case scenario, the regression leader - one who has stepped up and empowered their team members, then later, reverted to Queen/King based playing strategy (called "doctor centered"), causing practice progress to stagnate, and then after some time and self-assessment, decides the program manager empowerment was really a successful strategy, and reintroduces the program manager concepts . . . and then ignores the empowerment by asking, "Why did you do that?" instead of nurturing the change process (Continuous Quality Improvement - CQI) by asking, "What do we need to do to make that easier/better?" This  "yo-yo" approach to team empowerment compromised by doctor-centered assessments gets a smaller team response each cycle, and then the owner wonders why the results are less each time they attempt to restart the innovation engine. 

Please enjoy the attached article on team empowerment - it is not an easy concept. On the VCI Seminars at Sea 2015, there will be two sessions just to cover some basics, plus proceedings will include the monographs referenced here.  The VCI Seminars at Sea 2015 attachment explains the itinerary, and our cruise director offers an incentive for reserving a cabin this month (March) - he will prepay the traditional tips expected on the ship for you if the $250 cabin deposit is paid this month.

Tom Cat   >*-*<

Thomas E. Catanzaro, DVM, MHA, LFACHE
Diplomate, American College of Healthcare Executives
CEO, Veterinary Consulting International
8 Sean Street
Boondall, QLD 4034
cell: +61 (0)4 1628 5975
Fax: +61 (0)7 3865 2368
Web: www.drtomcat.com
E-mail: DrTomCat@aol.com

STRATEGIC TEAM EMPOWERMENT

Thomas E. Catanzaro, DVM, MHA, LFACHE

Dipomate, American College of Healthcare Executives

CEO, Veterinary Consulting International

DrTomCat@aol.com; www.drtomcat.com

"Empower is an action verb . . . so just do it!"

Let's get radical and talk about profit sharing as a motivator rather than a reward.  The title uses the term "team" instead of "employee" for the average reader's comfort zone, but I prefer to entrench the term "team" or "paraprofessional" when we embark on a participative management program.  Many practices have started to provide their staff a share of the profits on a quarterly or annual basis, or as a retirement plan.  This article will discuss empowerment of the paraprofessional staff, the use of an immediate reward for good work, and putting a fair share of the gross profits in paychecks every month.  Income-based incentives that are repeated become expected by the staff, so if you decide to implement such a plan, call them performance pay, recognition pay, or even management fees.

INCENTIVES

Incentive is a misnomer in healthcare delivery; it is worse than a misnomer in veterinary medical healthcare delivery, it is an insult.  Most staff are not on commission, nor do most veterinary practices pay enough in the first place.  The majority of people join a practice team because they want to belong to a healthcare delivery system that cares for animals.  In our field of endeavor, recognition and a sense of belonging are the two greatest benefits we can give our people . . . but money is still in the top six reasons for performing for almost everyone in health care!

Sharing a portion of the profit by adding it to the paychecks each month makes it much easier for staff members to see it is in their own interest to do a job well and help each other.  Note that I say profit, not just an increase in gross; we cannot spend gross, only net.  This assumes the practice understands profit, has a budget, and believes that programs drive budget (the dream is that a budget will never drive programs in health care).  We use a “Dinner Bell” chart, based on a proactive, program-based, budget, established by the providers BEFORE the reporting period (see CH 4, Building The Successful Veterinary Practice: Programs & Procedures, Volume 2, or the VCI Signature Series monograph, Profit Center Management, with diskette and budget spread sheet, from the VIN Bookstore, www.vin.com).  Client service improves because the staff begins to realize where the cash really comes from.  Clients begin to notice the difference and practice bonding increases.  Staff energy sometimes slows up when things are tight and stressed; if one person slacks up, that is seen as money out of everybody's pocket.  Not much about programs or liquidity should ever be left to chance.

Peer review is far better than paying a manager to look over the staff's shoulders.  When profits are distributed, and the staff understands "income - expenses = profits", new attitudes emerge.  If a technician leaves a gas machine on, there are three people on his/her case:  "What are you doing?  That wasted gas will cost us a bundle of money."  Employee involvement keeps attendance up and costs down.  At most practices, staff are always asking for work relief.  In a monthly profit sharing practice, more staff means more spreading of the profits and the staff worries about that.  Staff members become highly motivated to make sure that there really is a need for a new person and make sure the new team member becomes well trained early so he/she can contribute to the practice profits.

THE STRUCTURE

The basic concept is easy but the decision is hard.  With the pending IRS tax rules, the monthly profit sharing may become a best choice, least tax alternative.  Profits here are defined as the net excess profits AFTER the balance sheet expenses AND income statement expenses are covered.  While the practice accountant can help with the "stubby pencil" review, they seldom understand programs and client service.  It is really the practice philosophy that must be addressed.

Here are some guidelines to get you started:

1. Look at the patient care and client contact operations. What does the State Practice Act allow technicians to do, and are you using them for all the right things?  Can you use technicians for internal referrals?  Topics like nutritional counseling, behavior modification, parasite control and prevention, dental hygiene, and puppy/kitten training are far more profitable when done by technicians and the veterinarian can get on with exam room diagnostics, surgery, or patient care.

2. Be bold with the bucks. The program works when the staff can see it.  Too many profit sharing plans fail because working extra hard only translates into an extra two percent in the paycheck.  By handing out 15-20 percent of the excess profits monthly (remember that budget assumption discussed earlier), a practice leader can really see results.

3. Share power as well as money. The financial rewards only help if the staff participates in designing the standards by which they are judged and if they can monitor performance themselves.  The staff must become accountable for outcome improvements, not just process changes.  Their at-risk concern for the practice's success will keep the standards high.  An example of this would be the call-back and recheck system being a staff responsibility and exceeding an 80 percent appointment log fill (based on available examination rooms, farm trucks, etc.) becoming bonus time.

4. Center on Tomorrow! No one can correct yesterday unless we build toward tomorrow.  The question needs to be, “How can we improve?” versus “Why did you do that?”.  “What can we do to prevent that from happening again?” is a far better leadership question than “Why did we do that?”  Performance planning for the next 90-days needs to replace performance appraisals for the past year (the VCI Signature Series monograph, Performance Planning, with diskette of short and long performance planning forms, from the VIN Bookstore, www.vin.com, provides the details of this leadership and nurturing perspective, as does CH 6, Building The Successful Veterinary Practice: Programs & Procedures, Volume 2, from Wiley & Sons).

5. Don't fret about abuses of the system. The worry is natural but misplaced.  Very few people have entered our profession because they want to ruin a practice.  Staff suggestions are made to help the practice improve, not to irritate the owner or manager.  They need limitations and clear expectations, but they do not require thumb screws and babysitting.  The staff members need nurturing!  If you treat people like adults -- with respect -- they will act worthy of your trust and surpass your expectations.

REVERSE TWIST

Performance appraisals by staff and peers -- that's a reverse twist.  But is it?  If we look at the veterinary practice environment, each member of the team is under constant appraisal by clients, by peers, by everyone from the lowest to the highest paid.  If we recognize this as a fact AND are building a participative management team, then we should initiate appropriate action to get feedback desired.

As a leader, I believe appraisals are essential, but in real time only.  The moment-to-moment training and nurturing opportunities are appraisals.  If someone cannot do a jugular tap, take the time to teach the landmarks and spend a few extra minutes to ensure the team member learns.  That is an appraisal which leads to increased pride and confidence.  To grade the inability to draw blood as "poor" 90 to 360 days later does not solve the problem nor does it enhance the health care delivery. 

During my consulting efforts, I usually advocate performance planning at the beginning of the quarter rather than performance appraisals at the end.  The person sets some personal goals, specifically target actions, they want to accomplish within the next 90-days; this is marked by establishing specific measurements of success which are agreed upon at the beginning.  They are assigned a mentor who will assist them in achieving success.  Their target action is joined with the practice goals, and in most cases posted with them, to ensure the entire team is aware of and supporting the effort.  At the end of the quarter, the person evaluates their own success, and also gets the first chance to redefine the problem and look at a new way to accomplish the target action if it went astray during the quarter.

FEEDBACK

The feedback we need must be balanced -- the good, the bad, and the average.  Average is nice if we are looking for the status quo, but progressive practices seldom are satisfied with what was yesterday.  This is why the mentor is assigned for review and coaching during the quarter, and why the other staff members (doctors, too) are asked to be aware of the target actions of the quarter; their role is feedback and support.  In health care, competency is a single standard of excellence, not a scale from one to ten.  Either we stopped the bleeding or we didn't, either the X-ray was diagnostic or it wasn't, either we cured the animal or we didn't; partial pregnancy does not exist in the real world.  We train people to a level of competency which deserves our trust . . . train to trust!

We all make mistakes, especially if we try something new.  That is the way we gain experience and experience is what reduces mistakes.  Too many practices, especially when pursuing internal promotion/marketing ideas, reward risk-avoidance rather than risk-taking team members.  Anyone who is afraid to make mistakes will usually not grow and learn.  Often these individuals are the ones who resist change for it is seen as different and thereby a potential error if tried. 

Feedback tells us if we are playing it too safe and stifling the team.  It tells us if we are moving to fast and leaving the others behind in a cloud of confusion.  The appraisal process helps each of us calibrate our actions to the expectations of those around us.  It allows us to step back and determine if "they" see what we think "we" see.  It goes back to the old adage, "The whole world seems to be chasing the wrong things, except you and me; and sometimes, I'm not too sure about you."

METHODOLOGY

In the traditional, after-the-fact, appraisal mentality, the reverse twist would let each person complete the "standard" practice appraisal on each member of the staff.  The completed appraisal could be private or public depending on practice comfort zones.  The private responses could simply be to put the completed appraisals in labeled envelopes, probably near the time sheets.  The public appraisal requires thick skin, a sense of humor, and a true commitment to team building.  It is based on the fact that there are no false perceptions, only conflicting observations; it is also based on the assumption there is an effective team leader who keeps discussions positive and in perspective.

In the prospective performance planning process (beginning of the quarter planning), the staff members are expected to help and provide feedback during the process; there is no 20-20 hindsight situation like the traditional appraisal process.  The team works toward success during the quarter, rather than only talking the game.  They must walk the talk during the quarter, or they have no right to talk at the end.  In fact, the old style of grading (1 to 10, outstanding-excellent-good-fair-average-poor, A-B-C-D-F, etc.) cannot be maintained with performance planning.  Competency is success; yes we did or no we didn't.  A partial pregnancy does not exist, nor does partial excellence in health care; either we are competent or we are not.  Competency is excellence and success is achieving the target actions; there is no compromise.  With performance planning, a "ten" employee does not exist, since every person works on continual improvement (target actions) and the leadership is helping them get better on a continual planning process for improved performance of the practice.

Staff meetings can be the sharing time for the boss's positive evaluations, but the better use of staff time is to use meetings to solve problems.  Mini-meetings are often better for the larger practice's staff's problem-solving effort.  Let all the receptionists get together and address their concerns.  Comparisons between peers then reinforces the logic of the challenge evaluation process and gets team commitment toward success.

THE INSTRUMENTS

The hardest question in practice is when we ask the receptionist what the clients are saying -- expect some hard data back.  Do not settle for the "all is fine" comments, but don't knee-jerk because one client did not like your exam table manner.  Let consensus become cause for action.  When a similar question is asked by the doctor of the staff, silence is the sign of disaster...their fear is stifling feedback.  The environment is not conducive for problem solving.  Leadership must be brought to bear, and in a consistent long-term manner!

The performance planning process can use forms (e.g., as with the VCI Signature Series monograph, Performance Planning, with diskette of short and long performance planning forms, which provides the details of this leadership and nurturing perspective, and so does CH 6, Building The Successful Veterinary Practice: Programs & Procedures, Volume 2, from Wiley & Sons), or just clearly defined "key result areas (KRAs)."  The KRAs used during consults, and the above referenced forms, include: client satisfaction, economic health, quality, innovation, productivity, personal growth, and organizational climate.  These KRA areas are the starting point for supervisors, they need one idea in each category each quarter.  The paraprofessional staff only needs to select one or two ideas to target per quarter.  They define what the specific element will be for themselves, and then discuss a rational measurement of success with their mentor.

The last instrument to use is your personal goals and objectives list(s).  Once the peer and staff appraisals or performance plans are completed, take the comments and select three to five positive actions that you want to add to your performance plan during the next quarter to better support the staff efforts.  Write them on 3" X 5" note cards -- one for the car visor, one for the desk, and one for the bathroom mirror.  Look at them frequently and evaluate your actions in achieving those goals and objectives.  Writing them does not make them happen, but not writing them gets far worse results.

Reverse twist or straight from the hip, we all need others to help us see more clearly.  Initiate some form of team feedback or participative management today --- a method that is at the edge of your comfort zone.  Push for a better tomorrow.

EMPOWERMENT of OUTCOME or PROCESS?

At this juncture of changing your practice culture, please be careful.  Each member of any practice team is EMPOWERED at some level of healthcare delivery, and in some practices, it has been centered on “turning the crank”, while in others, it has developed decision makers who allow the doctors to spend more time in medicine and surgery.  A “manager” tends to empower getting the process done, while a “leader” empowers people to achieve the outcome.

Managers get work done through people;

Leaders develop people through work.

The most common veterinary syndrome has been when NO ONE seems willing to take the risk of doctor alienation; everyone just wants be told the process they are supposed to do.  This is often called “other duties as assigned”, and then they just wait to be told what to do.

FACT #1 - Staff members have been taught that they are not independent, and in fact, they feel they are not trusted to think or stretch outside the established process, associates and doctors alike . . . this is why leaders must start with sharing the "WHY" of the vision.

FACT #2 - Staff needs information, and when that information has always been close held, even when establishing fees, they just wait.  Leaders need to get the team to rise to a new level, and revive the thought process, but like a trek up the mountains, it is one step at a time . . . and it is not the steps that stop the progress, it is the grain of sand in the shoe that causes people to quit their trek . . . those small, aggravating, distractions . . . those small fears that are enlarged when they are hit with a lightning bolt from a doctor.

• First concept, most all veterinary practices have good, caring, dedicated people, and they have the power and knowledge within them . . . a leader’s job is to let this power out and put the light of leadership approval upon their efforts.

• Second concept - leaders need to promote autonomy, but there must be limits placed on the teams autonomy . . . limits are like river banks, they are needed to make the river move in the right direction . . . without limits, a river is swamp or puddle. What is the "motive" to do this?

                    M = Mission focus (the client-centered patient advocacy)

                    O = Organizational Systems (transition plan "what")

                    T = Team Roles (transition plan "who" by coordinators)

                     I = Image (self-esteem, pride - regular recognition by the boss)

                    V = Values (inviolate beliefs, standards of care, safety to staff)

                    E = Excellence (competency, CQI, learning organization)

• Third concept - Image only comes when each person sees that their contribution is making a difference . . . empowerment requires the LEADER to teach each person things they can do to become less dependent upon directed process . . . every mistake is an opportunity to increase competency . . . the secret is in the question, not in the answer . . . give them the resources an information, then only ask questions to get them to offer two “yes” options . . . if both are equally good, ask an integration question and tell them to "have at it" . . . each issue helps them become more of a self-directed operational team . . . the freedom to act carries with it an accountability for ensuring the outcomes . . . pride is seen when they exceed expectations, so ensure you start with small wins!

FACT #3 - Leadership changes must have a beginning, and the trek will be at least a year.  When hiking the Rockies, there is an acclimatization at 3 days, 3 weeks, and again at 3 months.  The staff members need a leader’s endorsement early in the process, so they know what course is expected by the leadership, and they need to know who is heading each operational team; three weeks into the process of empowerment, they need individualized recognition and follow-up support, so they know the new issue/system will not be forgotten; and at three months, new programs will be seen as better alternatives, or they will be tweaked to become better.  The role of leadership is called mentoring; it is just a single step at a time, and it is a steady but reasonable pace for each member of the team.  The appendices and leadership skills in Building The Successful Veterinary Practice: Leadership Tools (Volume 1) will all come into play.

FACT #4 - A leader sees the vision of what can be, and must keep it in focus for all others . . . the clarity of self-directed team means a leader cannot go back, the team can only go forward.  An empowered team must become accountable for independent thought from the information a leader provides (outcome and limits), and responsible for implementing their plan of action needed to achieve the desired outcome(s) . . . the trek will be a celebration of small wins, and the true leaders must lead the cheering section.

THE NEXT STEP

The next step in the process is soul searching.  Often it seems that sharing the profits, which are getting slimmer each year, is the worst choice ever offered.  But a practice style assessment is needed before a final decision is made.  Sometimes this requires outside eyes.  We have one client (one partner of three) who was a bear, growled and fussed at everyone, knew the consultation was worthless, but since the consultation, his attitude has steadily improved.  He has learned that he knew the right things, that how they were being used had some inconsistency, but that he was "good"; his partners are happier now, too. 

If the Practice Act and your philosophy of practice will allow a technician to counsel a client (nutrition, dental, behavior, etc.), give vaccinations, or do other items that allow them to extend our services without the high cost of a veterinarian, then  enhance the team by trying expanded services and programs centered on them (not the doctors).  If they participate, then practice profit sharing is appropriate.  If the technician can (or will) only work at the doctor's side like a nurse’s aide in the local hospital, then profit sharing will not motivate the independent efforts that we would hope for in a more flexible situation; alternative methods will need to be found to make the best "bang for the buck" impact on the team.

The veterinary extender can be more than just a well-trained technician.  Think of the receptionist who monitors the reminder system, and insures the practice newsletters get to the right clients at the right time.  If they weren't doing that, who would?  If the answer to that question becomes "the veterinarian", then profit sharing might be in order again.

The bottom line is the philosophy of practice and where the practice goals say the practice is to go in the next few months or years.  If status quo is adequate, then do nothing more, but expect a deterioration of the client base, since other practices will be proactive in their service outreach plan and scope of services.  If you wish to keep up with the Consumer Price Index (CPI) for inflation, you need not be innovative; you need six percent over the CPI to allow for a decent retirement program.  If you wish an 11 percent growth rate (health price index (or CPI, which is often lower) at 5.1 percent plus the minimum six percent), then you can work harder, enjoy life a little less, and not expand the use of veterinary extenders within your practice.

CAUTION - CAUTION

The CPI + retirement dollar needs, and/or  the practice growth in gross, are NOT a staff motivator.  Programs motivate staff.

Covert “income desires” into “patient needs” or “client needs”; only discuss programs with your staff in terms of patient advocacy and programs which benefit health and wellness.

Staff members can understand measure the number of dentals to restore puppy and kitten kisses, or the number of follow-up calls to clients who accessed the practice but resulted in only deferred or symptomatic care for patients, or the laboratory value that was out of line and needs another chemistry profile to ensure recovery has occurred.

Never, ever, forget: the only thing we sell is Peace of Mind for clients - all else they are allowed to buy!

But if you wish to work less, practice more, and progress in services and income, motivating your paraprofessional staff with a piece of the action can be a very interesting alternative to pulling your hair out about high employee turnover, excessive work hours, and low payoff for efforts expended.

SAMPLES OF KRA GOALS AND MEASURES

                                                                                    Measures              

            Goals                                       Type                                        Indicator

Client Satisfaction

 "Gee Whiz" service                              O        New client survey ratings

                                                             O        Total client survey rating

                                                             O        # commendations (letters/calls)

 Responsiveness                                  O        % first reminder compliance

                                                             O        Appointment compliance variance

                                                             O        Lead time for surgery

                                                             P         Council of clients participation

 Defections                                           O        Visits per client per year

                                                             O        % return clients

                                                             O        # clients not responding to reminders

                                                             O        Client turnover rate

 Word of Mouth                                     O        % new clients by referral

                                                             O        % transactions due to new clients

 Client Partnership                                P         # client-submitted ideas

                                                             O        $ value of new client ideas

Economic Health

 Surviving                                             O        Positive cash flow

                                                             0         Expense control within budget

                                                             O        Reduction in operating expenses

                                                             O        Inventory turn-over rate

                                                             O        Average client transaction

                                                             P         % income as accounts receivable         

 Thriving                                               O        Income center growth

                                                             O        Net income

                                                             O        % change in income

                                                             O        Patient advocacy $ value

                                                             P         % clients w/multiple visits per year

 Prospering                                           P         # accessing new service(s)

                                                             O        % net on nutritional products

                                                             O        Increased market share

                                                             P         % clients w/multiple visits per quarter

                                                             O        $ put into profit sharing/retirement fund

Quality

 Pride                                                   O        Market survey ranking

                                                             O        # complaints

                                                             O        # staff-referred clients

                                                             O        4-year AAHA accreditation

 Zero Defects                                        O        # litigation action

                                                             O        # of rework cases

                                                             P         Staff action on problems w/o direction

 Special Interest Areas                          P         # CE hours actually attended

                                                             O        # new medical/surgery programs initiated

                                                             P         # cases referred to colleagues

                                                             O        # cases referred by colleagues

                                                                                     Measures              

            Goals                                       Type                                        Indicator

Innovation

 Wide Participation                                P         # action teams

                                                             P         % staff making suggestions

                                                             P         # staff-submitted new ideas

                                                             P         % staff on action teams

 High Payoff                                         O        $ value of staff new ideas

                                                             O        $ value of doctor new ideas

                                                             P         # suggestions/staff member

 Implementation                        P         % suggestions implemented

                                                             0         New program start vs. continue

Productivity                                        

 Output                                                 O        % inpatient cages occupied

                                                             O        Gross revenue/staff (FTE) member

                                                             O        Net revenue/staff payroll

                                                             O        # transactions/provider

 Resources                                           P         Time in meetings

                                                             P         Appointment fill rate

                                                             O        Staff manhours paid per transaction

                                                             P         $ expended for upgrades

                                                             O        % income as cost of goods sold

 Service Excellence                              P         Wait time/client

                                                             O        Expenses per client

                                                             P         % NQA staff budget spent on client issues

Personal Growth

 Staff                                                    O        % turnover

                                                             P         Absentee rate

                                                             P         $ used for staff celebrations

                                                             P         # active target actions

 Optimizing                                           P         # training hours/staff member

                                                             P         % budget for staff training

                                                             O        # disciplinary actions

                                                             O        % revenues as staff compensation

 Learning                                              P         # staff in-serviced

                                                             P         # new in-service topics

Organizational Climate

 Best place                                           O        # clients by staff referral

                                                             P         % new hires by staff referral

 Values                                                 O        Staff opinion survey rating

                                                             P         # staff accolades for using values

 Fun                                                     O        % staff receiving recognition awards

                                                             P         # social events

                                                             O        % staff participating in social events

Type of Measures:

  O = Outcome Measures. Measures indicating reaching the goal.

  P = Process Measures. Measures indicating progress that contribute to outcome.

March 2015 - The Other 3 Rs

Every month I get someone asking me how to become a consultant.  In most cases, it is someone coming out of a single practice experience.  I ask them about their own advanced training, and it has usually been on-the-job experience. I ask about a CVPM credential from the VHMA, and that usually gets a blank stare. I ask about experiences with other healthcare delivery systems, and the answer is most often, "No, just one practice, but I am very good and do a lot." 

They fail to realize the practice culture that developed them, and allowed them to blossum, was a major long-term effort and effort by the practice owner, management, and leadership. I ask them if they read my first three texts, the Building The Successful Veterinary Practice: . . . series (*now from Wiley & Sons Publishers and found on Amazon.com) - in most cases they have not, although a few state their boss has them on the book shelf. Some have read book #10, Promoting the Human Animal Bond in Veterinary Practice (*now from Wiley & Sons Publisers and found on Amazon.com).

A few had used one or two of my 31 Signature Series monographs (each with it's own electronic Tool Kit) available from the VIN Bookstore (www.VIN.com).  Very few have done any outside reading on the theory of management, leadership, and/or team building.

An interesting observation (side note) - many neophyte speakers and writers are using material that was first published over 20 years ago as their new epiphanies, and think nothing of writing 1500 words for a journal or on-line blog.  I am here to tell you, there is NO 1500 word program that will help most downward spiraling practices. The good news, this is a new generation, and they are hearing the concepts for the first time. I started writing books when I heard consultants sharing their "secrets" from the podium, secrets that were common knowledge for the trained and/or experienced consultant. I wanted to put all the secrets into print in open domain!  Now, 15 texts and 31 monographs later, I know I will never get it all into print, but it is great source material for the new consultants, speakers and writers (very few will give references for their "great ideas").

I am amazed that people think they can be good consultants when they have not had the experience of diversity and disasters seen in our profession.  Even after being in over 2000 practices, I still learn something from very practice I visit, usually from the staff, and often from indirect observation and casual conversation.

My recommendation to the "wanna bes" is usually that they try to get a job with a vendor and get into as many practices as possible, and learn from each.  In some cases, there may have been an AAHA Field Consultant opening available, which does the accreditation review for members.

I am not surprised they do not understand how uncommon it is to find a great leader in a veterinary practice - with an experience of one, they have no comparison. As experienced consultants often joke - it is uncommon it is to find a practice leadership with common sense. As an example - try this simple 10 point review:

SCORING YOUR PRACTICE LEADERSHIP

Score you boss on a scale of 1-10, with 10 being the most positive score, for each of the 10 points below:

Does your boss:

1) Behave authentically by consistently living up to promises made

2) Provide an environment that makes you comfortable to have your say

3) Take you out of your comfort zone, empowering you with opportunities to challenge yourself and grow

4) Exhibit good grace when something goes wrong as a consequence of a mistake you or a colleague have made

5) Behave in a way that continues to build your respect and desire to work for them

6) Build an expectation in you to maintain a healthy work-life balance

7) Exhibit empathy at the very times you really need it

8) Have a level of self-awareness that enables them to understand the impact they have on others, including you

9) Contribute to the on-going development of your self-confidence

10) Stay equally balanced when providing you with positive and negative feedback

After tallying your scores, it is time to reflect on what that score means to you now, and for the future. Remember, nobody is perfect, so in my opinion, a score of 70+ should give you a sense that you can learn and grow from your boss’s style and behaviour.

This is how you can start to assess the practice culture. It is very intriguing when you start to ask these neophytes about their practice experiences. I have attached an article about the OTHER 3Rs, another assessment of practice culture and maybe, just maybe, some ideas on how to become a better leader and mentor for your veterinary healthcare delivery team.

And remember, I do have a great new suitcase and will travel anywhere to assist a practice in finding their way out of the fog (consulting options & details at www.drtomcat.com).

Tom Cat >*-*<

Thomas E. Catanzaro, DVM, MHA, LFACHE
Diplomate, American College of Healthcare Executives
CEO, Veterinary Consulting International
8 Sean Street
Boondall, QLD 4034
cell: +61 (0)4 1628 5975
Fax: +61 (0)7 3865 2368
Web: www.drtomcat.com
E-mail: DrTomCat@aol.com

The Other 3Rs

The Other 3 Rs - otherwise known as the “R" Factors

Thomas E. Catanzaro, DVM, MHA, LFACHE

Dipomate, American College of Healthcare Executives

CEO, Veterinary Consulting International

DrTomCat@aol.com; www.drtomcat.com

Woe to the man whose heart has not learned while young to hope, to love -- and to put his trust in life.   Joseph Conrad

This appears as a very unusual quote for a veterinary practice management person to use.  I introduced the “3Rs”, which morphed into the 4Rs, as a discharge review, that is - no patient leaves without being at least two of the 4 Rs! [4Rs = remind, recall, revisit, resolved]. This is NOT about those 4 Rs.  This is about a nurturing practice culture. Our veterinary profession is based on caring.  Whether it be a veterinarian, a nurse technician, a client relations specialist, or even an animal caretaker, people enter our professional sphere because they care about animals and want to participate in giving care to them.  I know of very few people who have entered our profession for the financial rewards, although some do shift their focus after time.  So why the quote?

AMERICAN HEALTHCARE

The average American, Australian, Kiwi, Brit, Canadian, etc., enters their profession by free choice, unlike many foreign countries where the family heritage or pressure determines most careers.  So when the healthcare industry surveyed their workers, they asked about why they were still there and what needed to be present for them to stay within the healthcare field they have chosen.  The answers were varied, but the top six were repetitive themes (but not always in the same order): recognition, belonging, responsibility, money, respect, and the feeling of making a contribution.  It was interesting to note that while compensation was always in the top six, it never made it to number one in any survey group, but each of the others did.

When they looked at foreign countries, belonging was usually the primary reason for employment within healthcare, while in America, the words that started with "R" were the most common responses as the key reason.  That survey is the reason for the title of this article and the above quote is the challenge I provide to each employer (practice owner, manager, administrator, or veterinarian).  There is one special text, Managing from the Heart, by Bracey, Rosenblum, Sanford, and Trueblood, ISBN 0-440-50472-4, published by Dell in paperback, that summarizes the concept most effectively:

          Hear and understand me.

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

          Acknowledge the greatness within me.

          Remember to look for my loving intentions.

          Tell me the truth with compassion.

As a practice consultant, I am most often called in when the practice liquidity is disappearing, or when the staff is quitting so fast the practice cannot keep the doors open without stressing out the doctor.  I start each consult by watching the interactions for a day, then I review 100 medical records the first evening.  This allows me to ask the "right questions" during one-on-one interviews on day two to determine "why" things are as they are.  The answers usually lie within the team, but as a consultant, I need to summarize and fit them into working models which the practice owner and doctors will accept.  This is the other reason for this article.  It is based on past consulting jobs for a significantly complex and large practices, where the common thread was distrust: for the staff upward and management downward.  They usually had been in this cycle for a dozen years, had tried many ideas, but consistently reinforced the perception of distrust.  They wanted a solution from me in the first week!

THE "R" FACTORS IN VETERINARY HEALTHCARE

This is the millennium for the uncommon leader to emerge within our profession.  The animal population is growing by a half-percent per year but the practitioner population is growing by six percent per year.  The old ways are waning, the marketplace is diluted by multiple new practices, and the staff wants more than a pat on the head (or a kick in the butt).  The current veterinary periodicals have displayed many concerns loosely addressing the "R" factors: respect, responsibility, and recognition.  The stories told by the young veterinarians, and those I hear from the practice staffs, all sound similar when assessed for "R" factors.  So let's review what can be done to enhance these traits.

Respect for the individual, for the client, for the patient, for the practice values, it does not matter.  This is a core value of healthcare delivery.  The respect for life.  In the case of P-R-I-D-E, a set of core values that are easy to remember, it falls as the second letter.  But please remember, core values are not weighted, they are equal: Patient - Respect - Innovation - Dedication - Excellence.  The old adage, "Respect is earned," is very important for new associates to understand, but for the staff members entering our individual practices at a poverty wage, it should be a given.  Each person who joins a practice is hired for their strengths.  Each carries with them the most important resource (another "R" word) for success, their mind.  The respect for their opinion, the respect for them as individuals, and their respect for the values of the practice should be cornerstones of communication.

Recognition is something which most veterinarians didn't experience in school.  They were graded and ranked, they were expected to be at the beck and call of interns, residents, clinicians, and professors.  For their first two years of clinical imprinting they were treated as cannon fodder, to be used up and discarded.  It is the rare student who finds a mentor with enough influence to override the pressures of the clinical school years.  This is the "technique" they carry into their first practice, which is either mediated by the new employer or enforced.  Since most seasoned veterinarians expect a new graduate to be clinically competent, the pressure is on.  Few realize that students seldom get to treat many primary care patients.  In today's marketplace, primary care is "skimmed" by the private practices which have proliferated around the university town and only secondary and tertiary care are referred to the teaching hospital.  The caring practice leader recognizes this, and recognizes that EVERY new team member deserves 90-plus days of training, whether they are a professional or paraprofessional.  Behavior rewarded is behavior repeated (two new "R" words).  All parents practice this and children soon learn this.  Recognition, specific and directed, concise and meaningful, up close and personal, will reinforce appropriate behavior.  It will also make the individual feel good.  Recognition may be words, a food reward, titles, a targeted complement, business cards, and sometimes even money.  When money is used as a thank you, don't decrease its effect by trying to take credit for it as a "bonus."  Staff earns every penny they get.  Performance or productivity recognition pay is what they get.  Regularly give every staff member the recognition they deserve (usually verbal and specific), when they deserve it, and the team will flourish and prosper.  So will the practice.

Responsibility is the third "R" and usually follows the first two.  Respect is an initial given and recognition is a training technique, but responsibility is an achievement and should be celebrated.  Responsibility should be more than being given the duty of doing a specific set of tasks without supervision.  True responsibility is becoming accountable for a specific set of outcomes, with the "HOW" and "WHO" being left to the team member(s) AFTER the “boss” has clearly stated the WHY and WHAT. The check and balance comes with the jointly decided “WHEN”, which includes milestones and outcome success measures BEFORE embarking on any new project, program or procedure.  This method of assigning outcomes means the "boss" must trust the staff, must believe they will embrace the practice values in the pursuit of excellence, AND they must be allowed to stumble.  Some will fail, others will make mistakes, and some will shun the assignment of accountability.  Not all team members want to be accountable, many just want to support the team and belong.  The role of support is an important responsibility, and this must be regularly conveyed by the practice leadership.

THE RIGHT LEADER FOR THE FUTURE

This was a therapeutic article, it was targeted toward practices my firm and I have supported.  A micro-spectrum of the profession.  This is also a landmark article since the internal mission statement for Catanzaro & Associates, now Veterinary Consulting International, team members has been: "Creating Leaders In The Business Of Veterinary Healthcare Delivery."  In our first decade of consulting, our brochure and stationary tag-line was "A Covenant With Quality" and I believe these two concepts go hand-in-hand. With the new millennium Y2K panic, we revised our operational thesis to “Take M-2-D Next Level” (Take them to the next level).

Leadership goes beyond management.  The progressive veterinary manager learned to build job descriptions and procedure manuals during the last millennium, which was a good start.  As media writers, we forgot to tell them the rest of the story.  They now need to be leaders.  We tell practices to consider the job description as the minimum competencies required to do the job, and the practice commits to training each new staff member to that level of excellence: competency = excellence in our consulting perspective.  The expectations are the same for healthcare delivery and should be attained in the first 90 days of introductory employment.  If after 90 days the individual has learned the competencies and fits the team, they are then hired onto the team.  Shortfalls in either area may be cause for release (dehiring) during the introductory 90-day period.  After the 90-day period, two new expectations are added to every person's "job" description: 1) solve/prevent the problem and 2) make continual quality improvements (CQI).  If each team member is not empowered to unilaterally solve problems and make improvements, the status quo strangles the practice progress.

It is the uncommon leader who can repeatedly help each person stretch slightly beyond their comfort zone and help them be winners.  It is the uncommon leader who tailors the job to the individual, rather than the reverse.  It is the uncommon leader who nurtures responsibility with recognition, rewards, and respect.  It is the uncommon leader who will survive and flourish in these recessionary times that follow the GFC (global financial crisis).

February 2015 -   Mid-Month

HAPPY VALENTINE'S DAY!

On my consults, we always initiate a procedure tracking effort; we issue the practice an Excel Spread Sheet System for Procedures as well as Key Fiscal Data and a detailed monthly budget with income centers aligned to expense centers keyed to the previous Fiscal Year.  Most veterinary management computer systems do not automatically list procedures.  History tells me that most practices have to realign or add to their categories to get out meaningful procedure data for EOM assessment. Interestingly, these reports stem from a written Standards of Care (SOC) for well-care issues (70% of the front door swing rate for most practices), and most practices have not taken the time to develop this dynamic SOC document. 

ERGO: IF YOU CANNOT MEASURE IT, YOU CANNOT MANAGE IT

New programs need new metrics, else reversion is likely. If you are interested in reading more, there are Signature Series monographs in the VIN Bookstore, one titled Models & Methods that Drive Breakthrough Performance and another titled HORIZONTALLY INTEGRATED VETERINARY WELLNESS MODEL (expanding beyond traditional curative and preventive medicine paradigms), both come with electronic tool kits to make practice adaptation easier.

Some Numbers Do Not Lie - 95, 85, 72, 58, 52, 45

95% of puppy owners want behavior management assistance; in a recent review of web site hits, #1 search was location and #2 was behavior management.  The AAHA text by Linda White, First Steps with Puppies and Kitten: A Practice-Team Approach to Behavior, is a training must!

Serious periodontal disease affects about 85% of dogs, while 72% of cats suffer from tooth resorptions, a type of cavity that often isn't discovered until extraction is the only available treatment.

American Veterinary Dental Society reports more than 80% of dogs and 70% of cats develop signs of dental disease by the age of three.  They also recommend the oral surgery fee should be similar to a toe amputation or surgical removal of a 2-cm mast cell tumor.

Under anesthesia, 60% of the plaque and tartar reside deeply under the gum line.

Half of the practices now have dental imaging equipment, but less than 20% are routinely taking radiographs; 42% of cats and 27% of dogs have oral pathology that can only be diagnosed by dental radiography.

Over 52%of canine patients and 58% of feline patients are considered obese; 45% of pet owners of obese pets do not consider their pets overweight.

Researcher at U of FL found that owners of 1086 non-wellness plan patients spent $868.10 over the research period, while owners of the wellness plan patients spent an average of $1399.20 during the same period; that $531.10 annual increase in income over non-wellness plan patients was based on reduced barriers to access.

On some recent consults, I have seen that 95% behavior management effort reflect only 4 cases a month when tracked, the 85% dental rate expectation reported at below 4%, the over 50% obese cases NOT getting veterinary nurse technician internal referral for tracking, and the nursing staff totally under-utilized for dental radiography.  In some cases, the practices have priced themselves and their DR dental X-ray out of use, since the "vendor recommended fee" actually doubled entry level dental fees.  Look at your community dentist who uses dental hygienists (that is what your clients have learned to expect for cleaning), and talk about dental cleaning (DG1+) and deep dental cleaning (DG2+), rather than scale and polish, periodontal disease, or gingivitis - they are alien terms to 56% of your clients. 

Does you front desk team inquire about bad breath at check-in (response is I made a note for the nurse to check that), and does the outpatient nurse flip a lip, check for brown teeth, state that is the bacteria you are smelling, and state "I have made a note for the doctor to talk to you about that".

Do all pets with other than a 5 on the 9 point Body Condition Score (Purina has nice charts, and the new Hill's picture set has more than 9 categories) get referred to a nutritional advisor (vet nurse) who brings them back monthly for weigh-ins?  How do you track those return visits (you probably have to add specific nurse consults for dental follow-up, nutrition, behavior and similar programs (new metrics).  Tracking specific procedure counts per 100 patient transactions gives you a starting point for pursuing a 10% improvement each month.

CAUTION:

Three critical training factors are existing above, but are not to be taken for granted.

1) Key staff must be trained to a level of confidence that they can deliver consistently with clients

2) They must be trusted to carry their own caseload when cases are internally referred

3) Veterinarians must be ready to refer and to trust the nursing staff

The attached article provides some insights to charting your practice progress within some of the critical issues of veterinary healthcare delivery.

Tom Cat >*-*<

P.S.  DAY FOR AMAZEMENT - A HUMBLING HONOR

FINGERPRINTS WAS JUST PUBLISHED

To think someone thought I have left fingerprints on this profession - wow!

http://veterinarybusiness.dvm360.com/fingerprints-dr-tom-catanzaro

February 2015 -   Managing Strategic Change 

In the grand scheme of things, Strategic Assessments and Strategic Responses, are very difficult for the average practice. Yes, some call it strategic planning, but that has proven to be a misnomer in healthcare. Our clients never get to read the Strategic Plan, the Internet makes the life cycle of "great new ideas" a very short period of time, and most veterinary practices do not have the diversity and experience to foretell the future of technology, community demographics, or the economic marketplace.

Don't get me wrong dear friends, strategic assessment is essential for making the progress needed in today's competitive environment; it must feed timely strategic response! I often hear practice owners saying they want to be innovative and creative, but then they ask me for 20 practices already doing "it". 

Worse, practices try to save money on strategic planning so they do not get a veterinary futurist to mentor their process; they try to do it all themselves. Think about this DIY syndrome . . . the practice is exactly where all those internal resources have brought it!  The practice has the clients it has attracted and retained.  It has the staff members it has hired and retained. It has the programs and procedures the management (maybe leadership) has wanted and developed. Just because you take these same people off-site into a retreat site, that does not cause a different mind-set. 

In fact, most practices are very poor at facilitating their own brainstorming sessions (e.g., who is Tony Buzon and how does he facilitate brainstorming?). The promises made and forgotten in the past taint the mind-set of the players. Many veterinarians and practice managers make the mistake of offering value judgements during the brainstorming phase of the assessment process; they cull ideas and suggestions as they are offered and actually kill interactive discussion (again, Tony Buzon offers great brainstorming techniques and processes). I used Tony Buzon techniques to close every chapter in my text, Building The Successful Veterinary Practice: Innovation & Creativity (Volume 3), Wiley & Sons publishing, which I wrote almost 20 years ago.  I also have a VCI Signture Series monograph, Strategic Assessment & Strategic Response, with an electronic tool kit, available in the VIN Bookstore.

For the record, my text Veterinary Medicine & Practice, 25 Years in the Future, and the Economic Steps to Get There, Wiley & Sons Publishing, has a few non-veterinary "trends" inside the front and back cover, and the first eleven years forecasted have been pretty accurate. So there are references available if you want to try your own DIY brainstorming and Strategic Assessment process. As a veterinary consultant, I am also available to hire on as a facilitator.

So as we get ready for Super Bowl Sunday (Monday here in Australia), I am attaching an overview article on MANAGING STRATEGIC CHANGE, just in case one of the teams show as unready as the Broncos were last year; you have something to ready as you eat that Pizza and snack on the nachos (with or without the three bean chip dip). I have found all beef hot dogs finally (most all "hot dogs" in Australia are 75% pork, patterned after the UK snags), and soft hot dog buns, so I can even make Chicago Dogs as I watch the game Monday (I have fresh Lombardo Italian peppers to make special Chicago Dogs). 

Have a great February!

Tom Cat >*-*<

Attachment:  Managing Strategic Change

MANAGING STRATEGIC CHANGE:

Moving Others from Awareness to Action

Thomas E. Catanzaro, DVM, MHA, LFACHE

Dipomate, American College of Healthcare Executives

CEO, Veterinary Consulting International

DrTomCat@aol.com; www.drtomcat.com

“The new millennium is bringing turbulent times, and the first task of management is to make sure of the institution’s capacity for survival, to make sure of its structural strength and soundness, of its capacity to survive a blow, to adapt to sudden change, and to avail itself of new opportunities”. Peter Drucker, management guru

Strategic change in managed in different ways depending on the practice culture and the practice leadership; these are influenced by variations in organizational capabilities, behavior, values and traditions.

SOME BASIC TOOLS

Many people jump into Strategic Planning with single tool: a SWOT four-quadrant concept. First thing to know is that a Strategic Plan has a very limited life span, for three reasons: 1) any arbitrary assessment by management of the client relations aspects are very difficult to predict, 2) most players do not do their homework before entering the planning session, and 3) in most all cases, they ignore the need for a profession savvy futurist for discussion topics and prediction assessments.

Key elements include an understanding of PEST and SWOT tools, as well as who is selected as the veterinary savvy consultant to mentor the strategic assessment process. PEST analysis (Political, Economical, Social, Technological) can be useful before SWOT analysis because PEST helps to identify SWOT factors. PEST and SWOT are two different perspectives but can contain common factors. SWOT stands for strengths, weaknesses (internal to the organization), opportunities, threats (external to the organization).

• POLITICAL - criteria examples include: ecological/environmental, current legislation, future legislation, international legislation, regulatory bodies and Processes, government policies, government term and change, trading policies, funding, grants and initiatives, home market pressure groups, international pressure groups and wars and conflicts

• ECONOMICAL criteria examples include: home economy, economy trends, overseas economies, general taxation, taxation specific to product/services, seasonality issues, market/trade cycles, specific industry factors, market routes trends, distribution trends, customer/end-user drivers, interest/ exchange rates, international trade and, monetary issues

• SOCIAL criteria examples include: lifestyle trends, demographics, consumer attitudes and opinions, media views, law changes affecting, social factors, brand, technology image, consumer buying patterns, fashion and role models, major events and influences, buying access and trends, ethnic/religious factors, advertising and publicity ethical issues

• TECHNOLOGICAL criteria examples include: competing technology development, research funding, patents, associated/dependent technologies, replacement technology/solutions, maturity of technology, manufacturing maturity and capacity, information and communications, consumer buying, mechanisms/technology, licencing, technology legislation, innovation potential, technology access, intellectual property issues, global communications The above elements are usually ignored by the neophyte planners, making their final SWOT assessments less than strategically meaningful. Beyond that shortfall: 

• What does the organization know about effective change (e.g., transition management)?
• Has some event happened that has caused the need for a strategic assessment, and is that event significant enough to cause commitment to the transition process?
• What has been the practice’s methodology for reaction to events and issues that spurs the practice team to deal with them effectively (waiting for the owner’s decision is NOT beneficial to the strategic assessment process)?
• How does the practice management usually build momentum and garner psychological commitments to achieve transition actions necessary for change or to develop new strategies?
• Have past initiatives used brainstorming (e.g., mind mapping) techniques to get team buy-in as it relates to the practice’s formal planning process?

BASIC PROCESS ELEMENTS

There are three basic process elements that interact in defining and managing strategic change:

1. The cognitive processes of the participants on which an understanding of the organizational environment and perception of the signals for change are based. For a practice that has been ignoring their own core values, vision, and/or mission statement, the cognitive processes of the participants is most often “me centered” rather than “we centered”, and thus makes the strategic assessment participants suspect at best.
2. The social and organizational processes by which these perceptions are channeled and commitments developed within the practice. In a practice where the Standards of Care (SOC) are ignored, or downplayed, the perceptions again are “me centered” rather than “we centered”, and thus as above, makes the strategic assessment participants suspect at best.
3. The political processes by which consensus has been formed in the past, and the power to influence purpose and resources, has a significant effect on the strategic assessment process. A top-down decision tree, delegation of process rather than outcome, and lack of effective “training to a level of trust” during duty hours, automatically derails any team-based strategic planning process.

THE JOURNEY

In essence, strategic thinking involves the kind of clear, objective, hard-headed, logical thinking that most practice owners find inordinately difficult, mainly because of a lack of diversity and experience outside their own paradigms and lives. The road to implementation is NOT that easy. Consider a simple family road trip cross country; you get out the road maps (you need to ensure they are the most current), you look at the options (usually the family members have different, lodging, food, sight-seeing, etc.), you take the family car to the garage for a tune-up (they tell you the front tires need replacing). Trip preparation includes arguments, hurt feelings, and a significant outlay of hard cash. Then it comes to packing the car, including which bags need to be available to which family members on which evenings; departure time is seldom as planned, and tempers get short! The same is true for strategic assessment and strategic response; there are key pitfalls you must watch out for and avoid at all costs:

• Pitfall One (You cannot drive the car without a driver) – no plan, and no planning process, can work unless the concepts have complete commitment from the top. Nothing kills the incentive and participation as much as the staff members sensing the gal is not taken seriously by the boss. The history of “lip service” is a major challenge, and intimidation or indifference by the practice owner kills the practice-wide commitment.
• Pitfall Two (You cannot start until everyone is in the car) – bottom-up planning helps avoid this pitfall, but many practices only take the senior staff on a strategic planning retreat, by-passing the very people needed for practice success of any new program/concept. If the staff avoids accountability and/or responsibility because of ill-conceived timelines or measurements of success, the program(s) are never going to work!
• Pitfall Three (The plan is an end in itself, and the driver adlibs in route). Too many practice believe that having a Strategic Plan is enough (common with professional associations); it has a slick cover, it is bound well, and it fits on the shelf (or in the desk drawer) to be pointed at on some future date. A strategic plan without an action plan is merely a collective wish list, full of pious hopes and temporary resolves.
• Pitfall Four (The road without milestones) – any action plan must have milestones that can be celebrated as progress is recognized (check points are measured and achieved). Grabbing a strategic initiative starts a never-ending process; it become team-wide strategic thinking.
• Pitfall Five (You allow assumptions to become facts) – in reality, planning involves a great number of assumptions; it assumes issues about the marketplace, it assumes certain technology will become available, it assumes costs will stay on a predicted curve, yet is requires everyone to understand assumptions are not really facts! All assumptions must continuously be tested and retested, and when an assumption appears wrong, then the plan must be amended (plan A and plan B, and maybe C D or E, should be in place before the trip even starts). On that family road trip, you make assumptions about road construction, lodging, food availability, and if the boulders fall onto the road, you will assume the kids will not kill each other in the back seat. Checking assumptions keeps your efforts flexible, and ensuring you update your data base frequently may even help by-pass the road blocks looming ahead.
• Pitfall Six (You cannot drive in five different directions at once; you cannot even drive a two different directions simultaneously) – even with the best planning, sometimes an individual will divert into a different direction, or they will be purchasing outside the budget, or another practice reaches a similar community service goal before you do. Herding cats is not easy, but required.
• Pitfall Seven (Confusing hopes with objectives) – survival or profitability are NOT objectives, they are hopes or aspirations. An objective is observable, measureable and chosen correctly. Growing by 10% is not a team objective (it has no substance), while increasing dental grade 1+ prophys by 10% is a measureable objective. Increasing new clients by 10% is an objective, if it is measured. Hiring a nurse technician with specific skills (verified before hiring) is an objective, if those skills are used for a strategic response action plan.
• Pitfall Eight (In Australia or the USA, you cannot make it from the east coast to west coast in one day driving, and you cannot drive to London at all) – there is a real danger in forcing your team towards unrealistic goals. Over-expectations or overpromising will ruin any plan, and demoralize the people without whom the plan is just a lot of empty processes. Any good plan will have goals or objectives requiring people to stretch outside their traditional comfort zone; it makes them try harder and act smarter than they did last year.
• Pitfall Nine (When you give out the rewards, make sure you know what the rewards are for). Nothing tells people in a practice what’s expected of them more surely and more quickly than a targeted reward system (they can be lollipops, wall plaques, movie tickets, or even money). Your practice must have rewards for people achieving their new strategic goals, but there is a trap here. If the rewards are for only short-term goals (e.g., driving 500 miles), there must be also rewards for long-term thinking and long-term goals. After all, driving 500 miles a day in a circle gets you nowhere closer to an expected outcome. A long term strategic Action Plan must consist of a series of short-term objectives toward a long-term success point. Only long-term thinking, planning, and action will ensure survival – as the automobile industry in the USA and Australia has just discovered after a great deal of pain.
• Pitfall Ten (You must talk with your navigator and other members of the family) - Communication is critical, up, down, and side-ways. Communication helps keep track of how the perceptions of progress are seen, how things are going, and transmission of information. Information gathering is not only essential is developing the strategic response, and construction of the Action Plan, but also in the implementation of the plan. Planning, checking, explaining, revising, checking up, and communicating back to everyone, are all part of the information systems needed for team success.
• Pitfall Eleven (On a family trip, you cannot drive the car all by yourself; everyone must learn how to drive) – The ultimate point of strategic planning is to make everyone a strategic thinker and strategic manager. Keeping strategic planning as a isolated senior staff function will ultimately lead to the disappearance of strategic assessment and strategic response as an important prat of the practice life and staff member growth.

There will be those team members who get anxious about any change transition process, some may get angry about the continuous feedback system requirements, and others who just want to get out there and put the rubber onto the road and try to move forward. While I understand these emotions, it is the last group that is right - they will move the practice forward as they move their programs forward.

A MATRIX OF CULTURAL TYPOLOGY

No successful organization will be one type only; they will blend all four types.

PREPARING THE PRACTICE FOR CHANGE

 Building support for change requires “internal selling”, discussed at length in the VCI Signature Series monograph, Leadership Action Planner, available from the VIN Bookstore. There is also a VCI Signature Series monograph, Strategic Assessment & Strategic Response, available from the VIN Bookstore. The VCI Signature Series monograph, Models and Methods, available from the VIN Bookstore, shares some insights on “why” new programs require new metrics. A practice that is unwilling to 

modify their metrics is a practice that is usually destined for regression after the Strategic Planning retreat.

The first item is to get a team understanding of:

A² = G²

If you Always do what you have Always done,

you are going to Get what you always Got.

In most cases, the “unselling of the old” and “selling of the new” are two separate leadership campaigns, yet most veterinary practices do not spend the time needed in doing either. However, these two tasks are interdependent and inseparable. The process must ensure the team members are convinced that the times have changed, the status quo will not ensure the future, and the transition process for change is needed. In practices where innovation has been encouraged, where outcome goals were Zone accountabilities, and change efforts have been rewarded, strategic assessment and response become easier.

In practices with a strong sense of mission, vision, and/or purpose, where inspired leadership motivated others to pursue the long-term goals of the zones and/or practice, formal planning mechanisms have been viewed as less important in the implementation of the transition to change. If you read the characteristics of entrepreneurs, most of them have no plan(s). When you put a plan on a piece of paper team members feel they cannot change it or adjust it, so you have lost the ability to have a strategic response to a dynamic strategic assessment.

On consults, I try to convince practice owners that they owe the staff members the WHAT and WHY of new ideas/programs (basis of the written SOC). They then need to empower the zone teams to develop the WHO and HOW (which takes a bit longer than a doctor-centered edict). After the Zone teams have the WHO & HOW figured out (e.g., protocols), the zone coordinators and leadership come together to jointly discuss the WHEN, which includes milestones and success measures. Training time precedes any implementation effort.

PACING THE CHANGE

On my year-long consult planning, I do a month-by-month step-by-baby-step process checklist, and ask the practice leadership to pace themselves, and keep me posted on their progress. I provide augmented set of metrics, and integrated spread sheets tailored to their practice, with the request to submit the documents with updated data monthly for my review and feedback. Even with these custom-built tools, there are practices that will not alter their metrics, so they do not complete the spread sheets, and feedback becomes minimized . . . change is minimized concurrently.

• Identification of “hot buttons” (key interests) of various staff members, and the strategic empowerment through directed training toward outcome goals, underlies many new program initiatives.
• Knowing when to act and when to delay is essential in managing the transition process for change initiatives.
• Change-makers must often wait for a propitious moment and prepare to take quick action when the time is ripe.
• Deciding whether to make an immediate attack or move more slowly is usually more a matter of management style than planning policy.

CRITICAL ELEMENTS OF MANAGING STRATEGIC RESPONSES

Great leaders move others to action through the force of their personalities, their style of management, the in-house educational process, and the use of Task Forces to flesh out ideas and build coalitions for their support. That said, there are some critical elements for managing strategic assessments and strategic responses:

• A committed, dynamic, creative top management group which is able to communicate its vision and goals to others.
• Established system of task force delegation and ad hoc group empowerment to move ideas into action and/or gain broader consensus.
• A practice climate that is ready for change, or at least is capable of responding to external and internal stimuli.
• History of team commitment through participation and involvement.
• Maintains a system that is ready to reward innovation, excellence and encourages people to take risks, while NOT penalizing them for honest failure.
• Recognizing when a more participative style is necessary and willing to sacrifice management prerogatives and control to further the team approach.

The half dozen elements above need to be “in effect” before a strategic assessment group session is formulated. The team members must believe their contributions are appreciated, promises will be kept/honored, and that they have been empowered with CQI (continuous quality improvement) within their sphere of influence. If you cannot see yourself committing to the above six elements in daily operation, then please do not commit to a team-based strategic assessment and strategic response effort.

January 2015 (mid-month) - Leading Your Team & Charisma in Leadership

The New Year- time for making those resolutions that will too often be forgotten by February.  A survey of 1000 Australians found 69 per cent of us intend to make at least one New Year's resolution. And while less than a quarter of us will stick to achieving our goals, there is a secret to succeeding. A year-long study at the University of Hertfordshire in the UK found the key to keeping your resolutions varies according to your gender. For men, setting specific realistic goals, such as "lose five kilograms by April", rather than just "lose weight", is best. 

Women should share their resolutions for the coming year with others, as, according to study leader Professor Richard Wiseman, "women benefit from the social support provided by friends and family". "If you halve your goal you'll be more likely to achieve it," dietitian Kate DiPrima says. "Instead of saying you'll exercise every day, make a commitment for three times a week. This way you'll have a sense of achievement rather than failure."

"The greatest danger in times of turbulence

is not the turbulence; it is to act with yesterday’s logic."

Peter Drucker, Management Guru

In a veterinary practice setting, it means looking at your written Standards of Care (SOC) and comparing them to the historical KPIs (e.g., key procedures per 100 transaction).  It also means a time to assess the SOC document for long needed upgrades to the WHY and WHAT of that document.  The WHO and HOW are protocols that belong to the staff, driven by the clear and concise written SOC document.  WHEN is the time after the nursing staff has done the WHO and HOW protocols to meet with the key providers and establish time lines, success measures, and training commitment needs.

PLEASE - keep it real.  Stating, "We will make 15% more money!" has nothing the staff can grab onto and work on to achieve.  If you state, "We will book 10% more DG1+ dentistries each month, compared to same month last year.",  that is something everyone can work toward.  The RECOVERED PET and RECOVERED CLIENT PROGRAMS (10% more each month than the same month in the previous year) are also great goals for the front desk team.

So saying that about resolutions and resistance, I drafted the attached article to talk about change, transition, and the paradigms that prevent both. I hope it is helpful for the new year - and maybe, just maybe, a few of you will decide you need a savvy veterinary guide.  My consulting programs are listed at www.drtomcat.com - also, unlike the newbies who "say" they are consultants, my philosophy is well established in the 15+ books I have published (most are available from Amazon.com, except the two new ones that are in the VIN Library for FREE download), and the 30+ monographs in the VIN Bookstore.

I wish you the very best in the new year, and hope your change transitions are exciting, fruitful and filled with wonderment.

Tom Cat >*-*<

January 15, 2015

LEADING YOUR TEAM

Thomas E. Catanzaro, DVM, MHA, LFACHE

Dipomate, American College of Healthcare Executives

CEO, Veterinary Consulting International

DrTomCat@aol.com; www.drtomcat.com

Graphic built by VHMA

"The objective of leadership is to accomplish the mission in the minimum time and with the maximum balance of individual needs."

Dr. T. E. Catanzaro

Profit-based performance standards require effective leadership to make them work as positive motivators.  The ultimate objective of leadership in any organization will always be the successful accomplishment of the goals and objectives of that organization.  In veterinary practice, Veterinary Consulting International has defined the ultimate veterinary hospital management objective as follows:

TO ENSURE QUALITY HEALTHCARE DELIVERY FOR EVERY PATIENT PRESENTED WITH AN ACCEPTABLE RATE OF FISCAL VALUE AND ADEQUATE QUALITY OF LIFE FOR THE PRACTICE AND ITS STAFF WHILE ESTABLISHING A CLEARLY DEFINED AND CLIENT-PERCEIVED VETERINARY SERVICES MARKET NICHE IN THE COMMUNITY.

In striving to achieve this goal, the leader must accept full personal responsibility for all his/her decisions and must continually assess the situational environment in which the practice operates.  Continuous quality improvement (CQI) requires that every member of the staff is accountable for the daily activities and pride in the tasks performed; the client perceives the outcome of that effort as quality care.  Using profit-based performance standards is one method to recognize the staff's contribution to the hospital's CQI program.

STYLES OF LEADERSHIP

Too often leaders focus their efforts on short-range goals at the unnecessary expense of their subordinates (the team is subordinate to the leader, but do not need to be made to feel that way).  In the long run this can be detrimental to both the staff and the practice.  Effective leadership is accomplishing the mission with a minimum expenditure of personal time and effort and an appropriate balance between practice, staff, and individual needs and goals. 

Leadership ability becomes increasingly important as the practice team expands.  When the practice becomes a multi-practitioner healthcare delivery system, leadership becomes a prerequisite for team building and success.  While there are many styles of leadership, shades of grey in the spectrum of good approaches that vary with the situation, most all can be classed as either directive or nondirective leadership methods.  The directive leader tells the staff exactly what to do and lets them know who is the boss.  Group members have the secure feeling of knowing exactly what is expected of them.  Nondirective leaders seek the opinions of team members, consult with them in planning and decision making, and sometimes, on non-health care issues, even put ideas to a democratic vote.

 MATCH THE CONTEXT

Neither approach is appropriate at all times.  In general, directive styles will be more appropriate in lifesaving situations and with starter-level employees, and a more participative style in practice management situations and with professional and paraprofessional associates.

Summarizing research, models, and theories developed by a variety of social scientists, Claremont McKenna College professor Dr. Chemers gives this advice:  "If your subordinates do not have the knowledge necessary to perform the task, or if their attitude is such that they lack commitment to the goal at hand, a directive approach is warranted."  The most common example of this situation is the chemotherapeutic regimen for a patient where the drug, dose, and duration and administration is dictated by the veterinarian.

Of course, even the best veterinarian doesn't always have a clear picture of what the most desirable course of treatment should be.  You may need a colleague's perspective or the staff's ability to provide subjective information on the case or client; here, participation is called for.  When a veterinarian is nondirective, it is more likely that the team members' intellectual abilities, years of practical experience, or technical capabilities will contribute to the task.  This is especially true for challenges in practice management that deal with client bonding or improving productivity.

The participative style has some important bonuses.  It makes team members feel autonomous -- a proven motivator for many personality types -- and it gives them the opportunity to develop their skills.  In deciding between the two schools of leadership, also consider the bottom line -- "Can subordinates be expected to energetically implement a management decision if they didn't participate in making it?" 

 A COMPATIBLE FIT

If one style or the other feels uncomfortable to you, don't be surprised.  Many theories assume that any person can be equally adept at any behavior; this just isn't the way it is.  A considerable body of research shows that leaders have personal styles that they are more comfortable with and that they habitually use.

If you are the type who is very concerned about relationships, about harmony, and about acceptance by the staff, you will lean toward the participative styles.  They place greater emphasis on morale.  If it is very important that people like you, there will be difficulty with the directive styles of leadership.  On the other hand, if there is a high need for order and a very strong desire to accomplish a task efficiently as possible, you will find frequently that the directive approach is favored.

Knowing which end of the spectrum is preferred by your colleagues or the practice owner can help you work with them more successfully.  If you are the associate and the practice owner is highly directive, you can depersonalize and defuse most situations instead of taking his personality as a personal affront.  More importantly, if two veterinarians are both directive in style, there will be conflict about whose directions are best.  Both want an orderly practice environment -- but based on their own order.  If both veterinarians are participative in nature, they may want to avoid conflict so much that they don't control problems and, therefore, waste a lot of time.

People need to understand their own inclinations, the partner's style, and if employed, the leadership style of their boss.  If attention is paid, situations can be recognized before they reach an impasse.

Regardless of styles, the secret is to communicate effectively.  This means that information is given AND received in each exchange.  Brains and ambition are hard to recognize and reward if they are muffled by lackluster or annoying verbal traits.  It doesn't matter how brilliant or sincere an individual is; if the message doesn't come across verbally, it will be lost.

 THE FILTERS

Information is processed at various levels of understanding.  Based on the mind-set of the listener, it flows through the experiences of the past and distortion is added.  Every person has these filters, so additions and deletions are made based on interpretation.  Some of the more common filters seen in practice leadership situations include:

 * What the leader believes he/she "heard", either verbally or in writing.  Clarification is seldom discussed.

 * What the leader believes the staff should know, for their own good or for "protection" of the practice.

 * What the leader believes the staff wants to hear, regardless of the practice needs or environmental situation.

 * What the leader thinks should be "toned down" or "built up" for the benefit of the receiver.  Facts are mediated

 * What the leader's values and attitudes do to the information; the bias of prejudice and personal ethics.

 * What stress or stresses the leader is operating under, at home or in the practice.

 * What importance the leader attaches to the information, the validity of perceptions other than their own.

 * What the leader feels at the moment that the information is being received or when passing the information to others.

When we consider the filters that information must pass through at each level, it is understandable that distortion, dilution, or total loss of understanding occurs.  Do not misunderstand these comments.  After all, it is the leader's job to overtly filter messages in order to clarify them or add to them as required.  The leader, however, should not allow personal feelings and stresses to filter communications inappropriately or covertly.

The downward flow of information has the practices' seal of approval behind it; a kind of gravity flow exists.  On the other hand, feedback is critical to ensure communication has occurred; remember, both the giving AND getting of information is essential for effective team communications.  The average veterinary healthcare delivery team also has filters installed in the communication process.  Many of the "staff filters" are more severe and cutting than those applied to downward communication, making meaningful feedback more difficult.  Some common filters that staff members apply to upward communications are:

 * The notion that any opinion in opposition to the bosses' idea is "negative thinking" and therefore bad.

 * The notion that practice teams always gripe, and you should only worry when they don't.

 * The belief that the information is unimportant and that the originator does not have the big picture in mind.

 * The belief that the veterinarian(s) are not interested in the paraprofessional perception.

 * The belief that you will get into trouble for passing along this type of observation or information.

 * The belief that the information will reflect adversely on you, your ability, or the staff effort.

 * The belief that the practice manager/ownership only want to be told the good things and not the bad things.

Do not think that all filters are bad.  Some filters serve a useful purpose.  You should try to solve problems, or when addressing a problem, offer at least two alternative solutions.  You need to take the appropriate action, try the best alternatives, and pass on the significant information.  Whining is not constructive communication.  The acid test is to ask yourself whether you would need or like to have the information if you were in the leadership position.  Only pass the information on if the answer is yes. 

 THE BRIDGE

Some guidelines for communicating more effectively with either style of leadership are:

 * Keep it short, simple, and direct.

 * Word your questions so that they will elicit a "yes" response; the position is then associated with the positive.

 * Suit your message to the audience.

 * Use words like "let's" to automatically associate yourself with the team.

 * Use a story or anecdote as a window.  Construct a vivid scenario of "what if" or "when" to make the team imagine the events already occurring.

 * Using words like "right" or "truth" puts your position on the positive side of a debate.

 * Know when not to speak.  A dramatic pause after a particularly important point will stress your sincerity.  It also allows you to evaluate the reception.  If negotiating, present your case then leave in silence.

Improving your own communication skills to meet the needs required to cope with varying leadership styles is only smart business.  Select those things you can effect, and do your best to be all you can be with those things you can influence.  Do not spend great amounts of time fretting over things that you cannot influence.  It makes for a far better practice environment. 

MAKING IT COME ALIVE

This is the time of practice change . . . ambulatory medicine lone-doctor practice paradigms have been modified by expansive multi-doctor facilities, linear scheduling has given way to multi-tasking, doctor-centered decisions have yielded to client-centered planning, curative medicine training has become secondary to wellness services for companion animals, and the list goes on and on.  The mission focus is no longer centered on just doing a great veterinary job on medicine and surgery, and with the new Pet Wellness Programs being promoted in many venues, savvy leadership must restate the mission focus to excite the hearts of staff and clients alike, something to the effect:

Client-centered patient advocacy to enhance and extend

the quality and duration of the companion animal’s life.

Through an awareness of the filters and barriers in the practice communication systems, a leader can decide which communication system can be used, how to reduce the effects of the filters, and where to look should breakdowns occur.  Good communication does not just happen -- it must be developed and maintained be each and every team leader.

An important facet of any leader's responsibility for developing and maintaining effective communications is that of daily coaching and counseling.  The veterinary healthcare team wants to be better; they want to give the best to the clients and patients.  Communication is the most significant means of influencing a team member's behavior, their image of self-worth, and their participation in the practice's goals and objectives.

--------------

Charisma in Leadership
Thomas E. Catanzaro, DVM, MHA, LFACHE
Diplomate, American College of Healthcare Executives
CEO, Veterinary Consulting International
DrTomCat@aol.com ; www.drtomcat.com 

CHARISMA DEFINITIONS, as a noun:
1. Theology . a divinely conferred gift or power.
2. a spiritual power or personal quality that gives an individual influence or authority over large numbers of people.
3. the special virtue of an office, function, position, etc., that confers or is thought to confer on the person holding it an unusual ability for leadership, worthiness of veneration, or the like.

As you walk into the bookstore, and wander down the business text aisles, please note the number of texts on leadership and management. This is proof-positive that there is no one set answer for the best outcomes. The first text I published, Building The Successful Veterinary Practice: Leadership Tools (Volume 1) Blackwell/Wiley Publishing, was caused by my consulting team taking me to task because the first book I drafted, Building The Successful Veterinary Practice: Programs & Procedures (which became Volume 2) referred to leadership and teams, but did not give the basics. Volume 1 has 14 leadership skills which can be taught, but the assimilation into daily life is much more difficult than just reading the text.

Most students of team-building have long acknowledged that many aspects of leadership remain a mystery. I believe that both TRUST and RESPECT are critical organizational behavior elements of leadership, and another such attribute is the concept of “charisma.” Charisma has been described as a quality that enables leaders to influence others, to attract followers, and achieve remarkable outcomes beyond that of any individual.
According to the late Peter Drucker, leadership was all about delivering results. While the nature of these results may vary from one organization to the next, all organizations exist to bring about some form of desired result. As a leader, you have been charged with the challenge of delivering those results that truly matter within your organization, whether it be a veterinary practice, a family, or a volunteer organization. And be certain of this, it is not just any result, but something that others consider extraordinary — something that pushes and passes the boundaries of normality. Drucker’s incisive insight into the nature of leadership was quite empowering to American leadership for many decades. As a leader, you have many demands on your time. If you are clear about the results you want to achieve, you can focus your efforts and limited time on those activities that contribute the most to delivering results. Yet, while Drucker’s view provided a focus, it failed to differentiate between a star individual and a great leader. To be effective at work, both staff and their leaders need to be focused on achieving the best results that they can. The best player on a team does not always make the best captain or coach. Why? Because leaders are concerned with delivering results through the IMPACT they have on the attitudes and actions of others. Any success as a “leader” is all about the impact made on those that have been led. Understanding that leadership is all about the impact you have on others is central to enhancing your own leadership effectiveness. The central question becomes, “How can I have more of an impact on others?”
There was an interesting book published in 2009, Unlocking the Mystery of Inspiring Leadership, by Zenger, Folkman, and Edinger, that started as follows:
Mysteries Block Progress
About five percent of the population will develop a stom¬ach ulcer at some time in their life. For many years, it was assumed that the cause of stomach ulcers was excess acid in the stomach that came from stress, diet and general lifestyle. The wall of the stomach became inflamed and sometimes this was so severe that the stomach would be perforated, in which case it often became a bleeding ulcer. Physicians recommended that patients eat bland diets and avoid stress because excessive stress and the production of stomach acid were known to go together. Some foods were thought to either be more acidic or to cause the stomach to produce more stomach acid.
Then in 1982 two Australian scientists discovered that the bacterium “Helicobacter pylori” was the cause of more than 90% of stomach ulcers. Discovering that the basic cause of ulcers was something totally different than had been assumed led, of course, to radically different treatment. Without that discovery we can only assume that physicians would still be prescribing bland diets and stress avoidance for ulcer patients
A Leadership Mystery
Let us now switch to a totally different arena, the study of leadership. Despite all the research that has taken place about the nature of leadership, practitioners and scholars have long acknowledged that many aspects of leadership remain a mystery. What’s more, we have described these mysteries in terms that readily concede that it they are something that we simply do not understand. We would like to address one such mystery.
Often, leaders have been identified as possessing some remarkable quality that sets them apart from others. This quality enables them to have a powerful influence on others. It causes people to be attracted to them. It enables them to achieve remarkable outcomes. We have labeled this quality “charisma,” coming from the Greek word mean¬ing “gift.” It was thought that this quality was a gift that was bestowed upon some and not others. No one knew where it came from. Unlike other leadership skills such as giving compelling oral presentations or delegating, no one attempted to teach charisma.
But having given this quality a label allowed observers to say things like, “Well, the reason she has been so effective in her role is that she’s charismatic.” Others hearing this would nod their agreement and concur. Everyone pre¬tended that they understood what was meant. In truth, no one had the faintest idea what ”charisma” was, other than that there was a special quality this person possessed.
For those involved in leadership development the ques¬tions were even more profound. Not only is there a ques¬tion of understanding it and being able to define it; but more importantly, can it be learned or acquired? Can it be measured? What kind of impact does it really have? Is there one way that charismatic or inspiring leaders behave or does charisma have several “flavors?” What the authors discovered after assessing 14,500 leaders confirmed, “expertise, inspiration, and motivation” were the key factors from followers for defining leadership competency. Inversely, when assessing leadership competency, followers (managers, peers, and those who report to them) poor leaders got the lowest scores in these same areas.

Like most researchers, these three authors loved to make lists of the feedback they received, and defined three major areas which set inspiring and charismatic leaders apart:

AREA ONE – ATTRIBUTES (broad and general qualities)
1. Role Model – excellent examples of WHAT they want others to do
2. Change Champion – constantly challenging the organization to change
3. Initiative – a driving force to make things happen for the better (status quo goals were considered NOT INSPIRING).

AREA TWO – BEHAVIORS (six discrete, actionable behaviors used by inspiring leaders)
• Stretch Goals
• Clear Vision and Direction
• Effective Communication
• Developing People
• Teamwork
• Innovation

AREA THREE - EMOTION (the contagious nature of the positive mental attitude)
? Evoking a similar and positive emotional response in others
? Leaders position acts as an accelerant to any emotional contagion that occurs, altering the organizational behavior into an energy flow (inversely, negative emotions of any type shut down the organizational culture’s energy flow).

BACK TO THE VET TRENCH

The data from multiple authors indicates that inspiring leaders utilize a variety of ways to connect with those about them (Hershey & Blanchard called it Situational Leadership, which I thought was a great term, so included it in my 14 leadership skills). The good leaders don’t do just one thing. Indeed, it is the combination of several approaches that lifts people to a higher level: Great leaders use five or more, and usually vary the approach with the people involved, project goals, and organizational culture level (for more information, see the VCI Signature Series monograph, Human Resources & Organizational Behavior, available from the VIN Bookstore, www.vin.com)

In the 500 page (18 appendices), March 2008, VIN Press text, The Practice Success Prescription: Team-based Veterinary Healthcare Delivery, which is now available for FREE DOWNLOAD from the VIN Library (www.vin.com), I shared both a SYNERGY MODEL, and LEADERSHIP PRACTICE IMPACT MODEL . . . Training To Trust is the first step in the SYNERGY MODEL, and Building Mutual Respect is the second step. As far as the perception of clients – they really don’t care how much you know until they know how much you care! The other favorite quote I use on consults is paraphrased from Lord Baden Powell:

What you do speaks so loudly, they can’t hear what you have said.

Every veterinarian must learn to be an effective leader, especially when pursuing client-centered patient advocacy in well care. Every specialist must learn to be an effective leader, especially when developing satisfied referring veterinarians as well as satisfied clients. Every practice owner must learn to be an effective leader, especially when pursuing the team-based healthcare delivery model, and when leveraging a veterinarian’s time is important. In fact, every member of a practice healthcare team must learn to be an effective leader, for the sake of peers and clients, as well as the promotion of health for our patients.

Becoming an inspiring leader is not limited to one set of core values or leadership action-based taskings. Rather, inspiring leaders draw on a number of attributes and behaviors, all powered by their preferred emotional method. The choice is NOT whether you want to be an inspiring leader or not; it is a function of perceptions of the practice team and clients. My suggestion is that the 14 leadership skills I have published in many venues be combined with one of the behaviors or attributes listed above and infuse it into daily behavior with positive emotion toward the practice team and clients. Experience shows definitively that by doing so, a practice owner or manager will become perceived as a more in¬spirational leader and, in turn, have a more productive and profitable practice.

-----------------------

January 2015

The New Year- time for making those resolutions that will too often be forgotten by February.  A survey of 1000 Australians found 69 per cent of us intend to make at least one New Year's resolution. And while less than a quarter of us will stick to achieving our goals, there is a secret to succeeding. A year-long study at the University of Hertfordshire in the UK found the key to keeping your resolutions varies according to your gender. For men, setting specific realistic goals, such as "lose five kilograms by April", rather than just "lose weight", is best. 

Women should share their resolutions for the coming year with others, as, according to study leader Professor Richard Wiseman, "women benefit from the social support provided by friends and family". "If you halve your goal you'll be more likely to achieve it," dietitian Kate DiPrima says. "Instead of saying you'll exercise every day, make a commitment for three times a week. This way you'll have a sense of achievement rather than failure."

"The greatest danger in times of turbulence

is not the turbulence; it is to act with yesterday’s logic."

Peter Drucker, Management Guru

In a veterinary practice setting, it means looking at your written Standards of Care (SOC) and comparing them to the historical KPIs (e.g., key procedures per 100 transaction).  It also means a time to assess the SOC document for long needed upgrades to the WHY and WHAT of that document.  The WHO and HOW are protocols that belong to the staff, driven by the clear and concise written SOC document.  WHEN is the time after the nursing staff has done the WHO and HOW protocols to meet with the key providers and establish time lines, success measures, and training commitment needs.

PLEASE - keep it real.  Stating, "We will make 15% more money!" has nothing the staff can grab onto and work on to achieve.  If you state, "We will book 10% more DG1+ dentistries each month, compared to same month last year.",  that is something everyone can work toward.  The RECOVERED PET and RECOVERED CLIENT PROGRAMS (10% more each month than the same month in the previous year) are also great goals for the front desk team.

So saying that about resolutions and resistance, I drafted the attached article to talk about change, transition, and the paradigms that prevent both. I hope it is helpful for the new year - and maybe, just maybe, a few of you will decide you need a savvy veterinary guide.  My consulting programs are listed at www.drtomcat.com - also, unlike the newbies who "say" they are consultants, my philosophy is well established in the 15+ books I have published (most are available from Amazon.com, except the two new ones that are in the VIN Library for FREE download), and the 30+ monographs in the VIN Bookstore.

I wish you the very best in the new year, and hope your change transitions are exciting, fruitful and filled with wonderment.

Tom Cat >*-*<

Thomas E. Catanzaro, DVM, MHA, LFACHE
Diplomate, American College of Healthcare Executives
CEO, Veterinary Consulting International
8 Sean Street
Boondall, QLD 4034
cell: +61 (0)4 1628 5975
Fax: +61 (0)7 3865 2368
Web: www.drtomcat.com
E-mail: DrTomCat@aol.com

January 2015 - It Is Not Change

Attachment:  II IS NOT CHANGE

IT ISN’T CHANGE THAT DOES YOU IN – IT IS THE TRANSITIONS!

Thomas E. Catanzaro, DVM, MHA, LFACHE

Dipomate, American College of Healthcare Executives

CEO, Veterinary Consulting International

DrTomCat@aol.com; www.drtomcat.com

Faced with the choice between changing one’s mind/behavior

 and proving that there is no need to change,

almost everyone gets busy on the proof.

John Kenneth Galbraith

It is not the changes that do you in, it’s the transitions.  Change is not the same as transition. Change is situational: the new program, the new role, the new team, the new policy. Transition is the psychological process people go through to come to terms with the new situation.  Change is external, transition is internal. The 3 P barrier (pride, process, paradigms) exists in most all veterinary practices.

Unless transition occurs, change will not take hold and flourish. That is what causes great ideas to fall flat.  We have all heard the story, “The more things change, the more they stay the same.” Translating this syndrome into real practice-centered terms, “there can be any number of initiatives for change, but unless there are transitions, nothing will be different when the dust clears.”

Several of the important differences between change and transition are overlooked when people think of transition as simply gradual or unfinished change. When we talk about change, most people naturally focus on the expected outcome that the change will produce. If you are moving from California to New York City, the change may be seen as crossing the country (with multiple routes and key milestones), and probably learning your way around the Big Apple. The same is true for a veterinary practice changing to a team-based healthcare delivery format rather than a doctor-centered format, or maybe just establishing an electronic communication system for internal coordination between practice zones. In each case, the new arrangements must be understood if we are to be ready for the change.

Transition is different. The starting point for transition is not the outcome but rather, the ending that you will have to make to leave the old situation behind. Situational change hinges on the new thing, but psychological transition depends on letting go of the old reality and the old identity you had before the change took place. Nothing so undermines organizational change as the failure to think through who will have to let go of what when the change occurs. Transition starts with an ending!

To accept that transition starts with an ending is paradoxical at best! Test this fact with your own experience. Think of a big change in your life: your first veterinary practice position, or the birth of your first child, or a move to a new house. Good changes, all of them, but as transitions, each one started with an ending.

With your first veterinary practice, you had to let go of the student peer group and the safety of a bell curve assessment. You entered an arena where competency was required, and competency was excellence – mediocre (average) does not cut it in practice.  With a new baby, you had to let go of a regular sleep, extra money, time alone with your spouse, and the spontaneity of going somewhere when the two you felt like it. Here too, your sense of competence may have been challenged when you found yourself unable to get the baby to eat or sleep, or even just stop crying. With a home move, a whole network of relationships ended. Even if you wanted to “keep in touch” it was never the same again. You used to know where to go for what: stores, the doctor, the dentist, the plumber, the neighbor who would house sit for you when you traveled. You have to let go of that feeling of “being at home” for a while.

Even in these “good” changes, there are transitions that begin with having to let go of something. There are endings.  There are losses. The failure to identify and be ready for the endings and losses that change produces is the largest single problem that veterinary practices encounter in change management. This is the reason in consulting that we require NEW METRICS for new programs; if you do not change the measurements for success, you will most often revert to the old system that produces the old metrics.

I find practices that refuse to adopt the new spread sheets we provide, many of which are procedure specific, while the “old systems” used monetary metrics, which do not support a clear standards of care KPI per 100 transactions. We have a monthly budget projection, with paired income to expense center categories, but that often requires a realignment of the Chart of Accounts, which many practices resist. I have had some clients who would prefer to make excuses rather than accept a shortfall that exists in the old practice systems and concurrently they resist initiation of closure on outdated paradigms or the establishment of new metrics for new processes and outcomes.

Once you accept that transition begins with letting go of something, you have taken the first step in the task of transition management. The second step is understanding what comes after the “letting go”: the neutral zone. This is the no-man’s-land between old reality and the new. It is the limbo between the old sense of identity and the new. It is a time when the old way is gone and the new does not feel comfortable yet. It is for this reason that I modified our year-long consult to have quarterly revisits. In the early years, I made it optional, and those practice that wanted to “save money”, did not fund the quarterly visits; these practices had a high reversion rate. So I made the quarterly visits part of the year-long process, as well as a step-by-baby-step new training program to ensure staff developed into trusted team members, and our new program success rates increased. Sure, some practice owners wanted to short circuit the training process, and when they attempted that, the transition stopped and reversion usually followed.

It is important to understand the “neutral zone” for several reasons:

• If you do not expect it, and understand why it is there, you are likely to try to rush through it, and become discouraged when you cannot do so,
• You may mistakenly conclude that the confusion you feel is a sign that something is wrong with you.
• You may be frightened in the no-man’s-land and try to escape (some staff members take flight when faced with primary accountabilities), lending to higher than usual staff turnover as the programs are initiated.
• To abandon the transition situation is to abort change efforts, both personally and organizationally, and to jeopardize continuous quality improvement (CQI) initiatives throughout the practice team.
• If you escape prematurely from the “neutral zone”, you will not only compromise team member empowerment and change, but also lose a great opportunity.
• Painful through it often is, the neutral zone is the individual’s and practice’s best chance for creativity, individual renewal, and program development. The positive aspect of the neutral zone is realized after it is crossed, after the staff is trained to a level of trust, and after mutual respect becomes an operational reality.

The neutral zone is this both a dangerous and opportune place, and it is the very core of the transition process.  It’s the place and time when the old habits are no longer adaptive to the situation, paradigms are challenged and many are extinguished, and new team-adapted programs begin to take place. It is the winter in which the old crops are plowed under and returned to the soil as decayed matter, while the New Year’s growth begins to stir and take root. It is the night where we disengage from yesterday’s concerns and start preparing for tomorrow’s opportunities.  It is the chaos in which the old form dissolves and the new form emerges.  It is the seedbed of the new beginning that most uncommon leaders seek.

ENDING – NEUTRAL ZONE - NEW BEGINNING

Most people make new beginnings only if they have first made an ending and spent some time in the neutral zone. Yet most practice owners try to start with the new beginning rather than finish with it. They pay virtually no attention to endings. They do not acknowledge the existence of the neutral zone, then wonder why their staff have so much difficulty with change.

I respect your misgivings, but concurrently, I don’t believe they represent real obstacles outside the leaders mind. I am not saying transition management is easy – only that it is essential.  I have used the following change formula to defeat the old paradigm of A² = G² : If you Always do what you have Always done, you are going to Get what you have always Gotten.

DR CAT’S CHANGE FORMULA:

Change – D² x P² x M² < costs

D² = discomfort => desire to change . . . if you are comfortable in your fur-lined rut, change will not occur until it becomes uncomfortable, which then drives a desire for change.

P² = Participative Process . . . the power of many brains is part of the process, as is buy-in by the entire team, without team buy-in, change will not occur.

M² = Mental Model . . . there has to be a clear methodology, including training to trust, to accept the new concept/model; people do not go into the neutral zone without some form of vision of where they are going.

Less than Costs = physical, mental, fiscal, social, personal, etc.

NOTE: primary factors are divided by multiplication signs, and if any one factor is ZERO, the outcome is NO CHANGE.

CAUTIONS!

• Please do not turn the whole thing over to individual contributors as a group and ask them to come up with a plan to change over to team-based programs. Involvement is fine, but it has to be carefully prepared and framed within realistic constraints; simply to turn over the power to people who don’t want a change (64% of the population) is to invite catastrophe.
• Please refrain from making change into small stages, combining first and second and then adding the third later, the change the managers to coordinators last. This one is tempting because in a process-oriented practice, small changes are easier to assimilate than big ones, yet one change after another is trouble and causes no relief from the original discomfort. It is better to introduce change on one coherent package.
• Please resist the temptation to pull the best people in the practice together as a model team to show everyone else how to do it. We know this is appealing, but it strips the best people out if the zones and hamstrings the zone team’s ability to duplicate the model team’s accomplishments.
• DO NOT SCRAP THE PLAN to find one that is less disruptive. Forget this option immediately – you had good reasons to initiate the change processes – it is your job as a leader to find out how to make it work!
• Do not tell people to stop dragging their feet or they will face disciplinary action. Don’t make threats, they build ill-will faster than they generate positive results – but ensure you have made outcome expectations crystal clear and concise.

So if you do not know how to get started, consider hiring a guide, a veterinary savvy consultant who understands the void of the neutral zone!

November (mid-month) - Debate & Strategic Interactions

October 2014 (EOM) - Zoning Concepts

October 2014 (mid-month) - Patient Advocacy

September (EOM) 2014 - Marty Becker Fear Free

September (mid-month) 2014 - IQ vs EQ Leadership

September 2014 - Program-based Budget Planning

August 2014 - Family = HAB

July (mid-month) 2014 - Beyond Problem Solving

July 2014 - Veterinary Practice Images

June 2014 - Multi-generational Team

May 2014 

April - mid month 2014

March - end of month- 2014
   Attachment:  Interpersonal Skills

March - mid month 2014
   Attachment:  Mentoring Mania

 End of January/Beginning of February 2014
   Attachment:  EQ Evolution

September (mid-month) 2014

IQ vs EQ LEADERSHIP

Thomas E. Catanzaro, DVM, MHA, LFACHE

Diplomate, American College of Healthcare Executives

Veterinary Consulting International

DrTomCat@aol.com; www.drtomcat.com

In his 1996 book, Emotional Intelligence, author Daniel Goleman suggested that EQ (or emotional intelligence quotient) might actually be more important than IQ. Why? Some psychologists believe that standard measures of intelligence (i.e. IQ scores) are too narrow and do not encompass the full range of human intelligence. Instead, they suggest, the ability to understand and express emotions can play an equal if not even more important role in how people fare in life.

What's the Difference Between IQ and EQ?

Let's start by defining the two terms in order to understand what they mean and how they differ. IQ, or intelligence quotient, is a number derived from a standardized intelligence test. On the original IQ tests, scores were calculated by dividing the individual's mental age by his or her chronological age and then multiplying that number by 100. So a child with a mental age of 15 and a chronological age of 10 would have an IQ of 150. Today, scores on most IQ tests are calculated by comparing the test taker's score to the scores of other people in the same age group.

EQ, on the other hand, is a measure of a person's level of emotional intelligence. This refers to a person's ability to perceive, control, evaluate, and express emotions. Researchers such as John Mayer and Peter Salovey as well as writers like Daniel Goleman have helped shine a light on emotional intelligence, making it a hot topic in areas ranging from business management to education.

Since the 1990s, emotional intelligence has made the journey from a semi-obscure concept found in academic journals to a popularly recognized term. Today, you can buy toys that claim to help boost a child's emotional intelligence or enroll your kids in social and emotional learning (SEL) programs designed to teach emotional intelligence skills. In some schools in the United States, social and emotional learning is even a curriculum requirement.

So Which One Is More Important?

The above example gives you some idea, and in many cases, veterinary school logic prevailed (‘A’ students will end up working for the ‘C’ students after graduation since “A” students have very little client rapport capability). From an academic point of view, IQ has been viewed as the primary determinant of success. People with high IQs were assumed to be destined for a life of accomplishment and achievement and researchers debated whether intelligence was the product of genes or the environment (the old nature versus nurture debate). However, some critics began to realize that not only was high intelligence no guarantee for success in life, it was also perhaps too narrow a concept to fully encompass the wide range of human abilities and knowledge.

IQ is still recognized as an important element of success, particularly when it comes to academic achievement. People with high IQs typically to do well in school, often earn more money, and tend to be healthier in general. But today experts recognize it is not the only determinate of life success. Instead, it is part of a complex array of influences that includes emotional intelligence among other things.

The concept of emotional intelligence has had a strong impact in a number of areas, including the business world. Many companies now mandate emotional intelligence training and utilize EQ tests as part of the hiring process. Research has found that individuals with strong leadership potential also tend to be more emotionally intelligent, suggesting that a high EQ is an important quality for business leaders and managers to have.

So you might be wondering, if emotional intelligence is so important, can it be taught or strengthened? According to one meta-analysis that looked at the results of social and emotional learning programs, the answer to that question is an unequivocal yes. The study found that approximately 50 percent of kids enrolled in SEL programs had better achievement scores and almost 40 percent showed improved grade-point-averages. These programs were also linked to lowered suspension rates, increased school attendance, and reduced disciplinary problems.

Observations

• "…a national insurance company found that sales agents who were weak in emotional competencies such as self-confidence, initiative, and empathy sold policies with an average premium of $54,000. Not bad, right? Well, compared to agents who scored high in a majority of emotional competencies, they sold policies worth an average of $114,000."(Cooper, 2013)

• Research carried out by the Carnegie Institute of Technology shows that 85 percent of your financial success is due to skills in “human engineering,” your personality and ability to communicate, negotiate, and lead. Shockingly, only 15 percent is due to technical knowledge. Additionally, Nobel Prize winning Israeli-American psychologist, Daniel Kahneman, found that people would rather do business with a person they like and trust rather than someone they don’t, even if the likeable person is offering a lower quality product or service at a higher price." (Jensen, 2012)

• "IQ alone is not enough; EQ also matters. In fact, psychologists generally agree that among the ingredients for success, IQ counts for roughly 10% (at best 25%); the rest depends on everything else—including EQ." (Bressert, 2007)

So what does it mean in a veterinary practice?

If you refer to the table above, you can see characteristics/traits of a successful leader on BOTH SIDES of the equation. The challenge is we select veterinary students based on IQ, and the years of school work hard at eliminating any EQ traits.  EQ is client relations, EQ is staff empowerment, EQ is charisma!  The journals are filled with IQ data points, as are our Association conferences and webinars. Contemplate this, what is more IQ than a webinar where you cannot read body language? Our downward spiral into IQ nirvana is becoming a slippery slope.

The charismatic veterinary leader makes mistakes and learns from them.  Yet in veterinary schools, we increase the fear in students by 25% based an intimidation culture which has been present your eons. The fear of failure is ingrained in students before graduation, so learning from mistakes is NOT a cultural expectation in this profession.  That makes incremental change scary but required.  It also makes safe harborage for mundane factors like comparing Gross Turnover, the Average Client Transaction or expense percentages, three factors that have an UNKNOWN NET INCOME influence.

What would happen if a practice would compared lost clients to new clients each quarter? Where would the operational focus be shifted? An easier factor would be pharmacy income compared to pharmacy expense each month; yet most Australian practices still look at ‘Cost of Goods Sold’, which disguises line item comparisons such as pharmacy net income. Why would any logical person combine surgical supplies (zero mark-up), with nutritional supplies (30-35% mark-up), with pharmacy resale (~ 2x mark-up), with laboratory (50-100% mark-up), with DR Imaging (almost pure net), and consider it a rational comparison factor?

What would happen if a practice would compared dental cases booked to total patients seen during the month (dental specialists tell us 85% of adult animals have some dental need)? What would happen if a practice would compared nutritional referrals to veterinary nurses to number of patient seen (surveys show us that about 50% of adult animals have some prescription diet need)? All DG2+ mouths deserve dental X-rays, yet there are still veterinary practices without dental X-ray, or is they have one, are using it by exception. POINT – if the DR dental X-ray series is about $55-$60, regardless of number of images taken, and assuming they are taken by staff members, about 30-40% will become Oral Surgery (DG3+ and/or DG4+) . . . the secret is to keep the entry level dental care (DG1+ and DG2+) reasonably priced (i.e., appropriate pricing for staff delivered care).

Sure, our practice management software cannot give us this data easily.  But why not?  The basic business formula is “Income – Expense = Profit”, yet our veterinary software vendors say “sorry, can’t do that”, and we accept it. Why do we accept mediocrity?

Almost every practice owner and manager can give you the average expense % for common categories, but very few know the offsetting income center and/or expected profit margin for that line item. Think about it – Average is the best of the worst, or the worst of the best – it is the number in the middle – it is mediocrity.

This mediocrity continues into staff empowerment. Sure, most of us have seen dentists working with a 10-16 column per dentist appointment log, to allow for hygienist and whitening appointments. We have seen our physicians operating with medical assistants and nurses, with multi-consult rooms per physicians. And this year, the American Animal Hospital Association (AAHA) has declared 2014 to be the year for “team-based healthcare delivery”, yet I published the 500 page text with this title in 2008 and placed it in the VIN Library for free download.

THE PRACTICE SUCCESS PRESCRIPTION:

TEAM-BASED VETERINARY HEALTHCARE DELIVERY

//www.vin.com/Proceedings/Proceedings.plx?CID=TomCat2007&O=Generic 

So, EQ is often right and IQ is often right.  The reality is that the mix is needed. There are volumes now being written about mindfulness and happiness.  These factors appear pro-EQ and contrary to IQ, but in the real world, it is all about team harmony and self-actualization (thank you Abe – Maslow that is).

You would think those with a high IQ would be looking for a savvy veterinary-specific consultant to facilitate their migration from yesterday to tomorrow, but it is the short-term thinking aspect of those with high IQs that often derails that engagement. I just came out of a practice that was floundering and stressed a year ago, yet after a year of consulting, they had harmony, liquidity and a 54% practice growth. Sure, that is an exception, but it is possible (e.g., 11 to 38% is the usual range of growth when the team is committed and the leader is willing to change)!

September 2014

PROGRAM-BASED BUDGET PLANNING

Thomas E. Catanzaro, DVM, MHA, LFACHE

Dipomate, American College of Healthcare Executives

CEO, Veterinary Consulting International

DrTomCat@aol.com; www.drtomcat.com

About the time we can make the ends meet, somebody moves the ends.                                        Herbert Hoover, 31st President

Before we start, please understand, I don't see budgeting as an accountant's exercise.  We publish a VCI Signature Series monograph, Fundamentals of Money Management, which differentiates between tax accounting and managerial accounting (it includes a Chart of Accounts diskette compatible with QuickBooks, by Intuit).  I see program-based budgeting as activity and program planning for the coming year; it is a series of healthcare delivery commitments by the practice doctors and staff.  The cash budget is only a series of clinical programs to which we have historical data on the income or expense impact on any practice.  A good leader promotes income development activities and allows his/her team to increase net by controlling expenses and extending the healthcare delivery programs beyond the professional diagnostician.  Therefore, the annual budget cycle includes, in my mind, the annual marketing plan and the communication/training plan for the team, as well as commitment to higher levels of quality healthcare delivery.

PROGRAMS = NET INCOME

More veterinary practice owners are learning that a focus on the front door is good business; they know when their procedures are down.  A good program-based budget provides the needed measurements for growth; how many procedures are we doing, and what are the relationships to each other (e.g., dentistries to outpatients, fluids to surgeries, etc.).  These measurements are essential to make success happen; it is also called have standards of excellence in the practice’s healthcare delivery habits.  In the 1998 ISUP text, Building The Successful Veterinary Practice: Programs & Procedures (Volume 2), Chapter Four, and Appendices D, E and F,  examples are provided that most any practice can follow to build a monthly cash budget, establish effective Income Statements, and build upon an established Chart of Accounts (the Chart of Accounts in Volume 2 expanded the AAHA system to include more income centers).  Mechanically, the income statements of the practice should reflect the major income categories produced by the practice’s veterinary software at EOM, and those major categories are then used for the top left-hand column of the budget instead of "sales", and the income history of the last three years can be used to determine the average earning power of each month (percent of annual income).  But the chart is not the planning process, and the planning and projections are what is needed to make it happen.

CONTROLLING CASH FLOW

The traditional approach to restrict expenses and inch the prices upward is adequate to maintain average growth to defend against inflation, but it does not promote expansion.  The cost of professional services continually rises as do the fixed and variable costs.  It is one thing to project an increased income for next year; it is far more difficult to cause it!  The secret to obtain those extra degrees of expansion (practice growth) is based on the increasing horizontal (adding services) and vertical (expanding existing services) levels of income available to the practice.  Income production (new or expanded services and products) is the major variable in controlling liquidity, also called "cash flow" by some.

To control (or monitor) income levels, fees must be projected and cash must be received (and bad debt must be minimized).  We will assume the practice has a clear set of values and core competencies, a future-based vision, and a CONSISTENT practice philosophy in place (an accepted core platform of services and products). This is started with a cash budget, with paired income and expense centers where possible, projected by month, for the coming fiscal year (see  the 1998 ISUP text, Building The Successful Veterinary Practice: Programs & Procedures (Volume 2), Chapter 4, Program-based Budgeting):

1. The historical income (percentage of the annual income earned per month) must be established, either by historical records or experience factors.  This will help decide the percentage of cost allocation per specific month for variable and semi-fixed expenses. 
2. Ancillary income sources must be assessed as opportunities to the practice team available (space and equipment, client acceptance, and human resources).  Using historical expenses will be helpful and must be assessed, expanded, and allocated to specific months based on the horizontal and vertical diversification planned for the upcoming year.
3. A flexible model must be established built on zero-based budgeting.  Start with the assumed profit level required to make the practice grow at the desired rate in the upcoming year, then look at the income potentials current and possible.
4. The practice plan (vision of the practitioner) outlines the one-year, three-year, and five-year hospital director's health care delivery plan, marketing plan, business plan, staff utilization plan (names vary by practice).

Controlling the cash flow means knowing what is expected then measuring the accomplishment of that performance level.  The program-based budget must be compared to actual performance on a monthly basis and adjustments need to be made in the remaining monthly targets if the year end goals are to be met; this is often done in dollars, but when variances occur, you must look at procedure counts or you are just fooling yourself.  As I was surfing the net (AOL and NOAH), I watched veterinarians discuss their 1998 increase in gross, the percentage of gross which was due to vaccines or dentistry, and other such “first liar loses” type discussions.  When are we going to learn?

THE FRONT DOOR MUST SWING

The secret is what makes YOUR front door swing, Every practice has a different formula, but there are common components, and they are called programs (as in program-based budgeting).  We realize that a pre-anesthetic laboratory screen is REQUIRED in virtually every case (although the intensity and scope varies), and as stated in a recent Nevada State Board letter, 80 percent of the surgery cases should have fluids running.  (When was the last time you took a fluid therapy refresher for CE?).  We have stressed the grades of dental conditions, and recording of the grades in the medical records, to the point where those doing it have doubled their income.  We even have a Colorado practice who has contacted Dr. Marv Samuelson (VARL) for assistance to develop dermatology as an income center program (e.g., even in Colorado, 15 percent of the dogs coming in the front door have atopy).

But let’s go forward with fundamentals and see what you are taking for granted, especially in surgical cases.  We know in our hearts that pre-anesthetic blood screening is essential . . .  one State Board has publically informed every practitioner in the State that 80 percent of surgery cases should be on fluids . . . we read about pain management, and listen to seminars, yet believe clients can make a knowledgeable decision about pain management with no training - post-surgical pain killers are not optional - everyone knows PAIN IS INHUMANE!  Yet every day, there are practitioners putting animals at risk, and themselves into liability, by practicing wallet medicine instead of quality medicine.

How about radiology?  Fact: most every practice has forgotten that a radiographic baseline of the thorax is good medicine.  A boarder who is coughing does not always have kennel cough. Dogs do have other problems.  For instance, a negative Difil test tells you about circulating microfilaria, not adult heartworms in the thorax.  Current literature shows that some of the coughing cats previously diagnosed as asthmatic are actually heartworm infested, even in non-endemic areas.  ONLY an X-ray can do this effectively.  Consider this: Dr. Bob Smith (radiologist, University of California - Davis) believes that dogs with a negative OR positive heartworm test still deserve a thoracic X-ray series before starting the preventive care or treatment protocol.  Moving on to the abdomen, when was the last time you did an IVP or cystogram?  There are more things than just foreign bodies occurring in the abdomen. Have you ever considered the diagnostic advantage of a Baro-spheres when doing a laparotomies, since leakage is not a by-product of these pellets?   During a short course recently held, it was stated, “Use of the Penn Hip technique to aid in the diagnosis of hip dysplasia and the introduction of Baro-spheres for barium studies have proven diagnostic advantages”, and one of our clients attended and KNEW he could go back to practice and virtually double their income in this area.

Look at the advances in cardiac evaluation.  The handheld ECG which gives a lead-II rhythm strip can be used with every annual life-cycle consultation (yes, I know you call it an annual exam, but which sounds more accurate?).  The handheld ECG is economical enough that if it was used for each “annual”, at a fee of $2.00 additional,  it would be totally paid for in less than six months; then it is a NET-NET program every time it is used!  The use of echocardiology is on the rise; within five years most quality practices will be using it regularly.  This modality is technique-driven and relatively easy to read; the difficulty lies in determining where and how to place the transducer.  As Dr. Larry Tilley states so often, “Telemedicine now allows a practice to be in contact with a specialist - even across the country - within minutes”.

Reflect on the blood pressure diagnostics of your practice.  It cannot be emphasized enough.  Every practice should be using a blood pressure device daily (e.g., Doppler).  We have some practices which ensure that the feline blood pressure monitoring is part of the annual life cycle consultation.  It has been shown that 60-plus percent of the cats in renal failure can have hypertension.  It has also been shown that hypertension can be manifested in such unusual signs as anisocoria.  Dr. Mike Garvey (AMC, NY) has stated that blood pressure measurement is paramount - for more than hypertension . . . up to 30 animals die every day from hypotension for every animal that dies from hypertension.

ECONOMICS 101 ALA DR. TOM CAT

“Tom Cat, we will damage our relationship if we add these unneeded diagnostics.”  You are right, if they are unneeded.  But in every case stated above, there was a medical need.  The fact that you have taken radiology for granted means the overhead is still larger than the income from the program center.  Yes, program center -- not income center, not profit center.  The front door swings because we believe in our health care programs and share that conviction with clients as NEEDS for their animal(s).  If you don’t medically believe it is needed, NEVER do it!

And for those of you who take one film to “save the client money”, remember what every text and radiologist has stated, “If it looks like a duck, sounds like a duck, and walks like a duck, it must be considered a duck . . . and ducks state very clearly, QUACK, QUACK, QUACK!”  If radiology is needed, two views are needed.  To provide half the care is a violation of professional ethics and the Practice Act.  Think of lameness cases where you have said, “If this does not get better, we may need to take radiographs”.  The client brought a suffering animal to you because they wanted “PEACE OF MIND”, and you only offered them “tincture of time”.  And you wonder why they never come back?  Lameness generally requires radiology to determine the appropriate treatment as well as the prognosis, and in client relations, they came to you because you are the diagnostician!

The ability to believe in good medicine is the cornerstone of a successful practice.  The ability to convey this need to clients is the cornerstone of a profitable practice.  The overhead of a veterinary practice is pretty fixed (in well managed practices, less than 50 percent of the gross income is spent on monthly P&L expenses, not counting rent, doctor monies, and ROI benefits (quarterly rate stays below 48%).  So, it is the delivery of services and products within existing staff and facility capabilities which can make the net income difference.

TODAY IS THE FIRST DAY OF THE REST OF YOUR LIFE

We really don’t care what you have already done; that is past.  What we care about is what you are willing to do.  Every year, new continuing education courses mean you have the opportunity to enhance practice programs.  The continuing education experience which does not add one new program per day of CE attended was a wasted expense.  The new program is designed to provide better care, and there is a value associated with that client benefit.  That value, as assessed to clients, should be reflected in your program-based budget for the year.  The cash flow reports from that computer in your office ONLY reflect the “belief level” of the providers in the new program(s) being offered.  The choice is yours, we are here to help, but the belief starts in your gut and ascends to your heart.  When your heart believes in the program, the clients will accept the care as needed and essential.  It is your choice -- lower the net each year, or provide better health care delivery programs. 

JUST DO IT!

THE PRACTICE BUDGET TEAM

The control of the cash flow from programs that match the core values of the practice is a team responsibility and as such, the plan must be a team effort.  The practice budget team should include the practice owners, bookkeeper, office manager, lead technician, lead receptionists, and an outside mentor.  The technician and receptionist should be involved in those areas where they have a first-hand interest and impact but need not be involved in all parts of the team planning.  The outside mentor can be a CPA, consultant, attorney, or psychologist.  To be most effective, they must be detached from the practice's patient healthcare plan.

To be most effective, this entire day of isolated planning sessions is without spouses.  The spouse, as with any client, usually has a hidden agenda and will muddy the team effort, even if just to wait on the sidelines for a meal companion.  It would be appropriate to form focus groups of respected clients to discuss potential healthcare service opportunities before the off-site planning session.  After the budget planning session, this type of client-centered input may be counter-productive to the success of the plan.

The budget planning team needs a playing field (established rules and historical game experience), and that is usually the past financial statements.  The planning team needs to meet at an off-site location about three to six months before the fiscal year begins and use the historical data to develop a strategic plan for the practice's cash flow.  To be most effective, the practice manager becomes the meeting coordinator and handles all the following:

1. Ensures the "silence of the confessional" between the planners and the staff during the planning process.
2. Coordinates the meeting location, room requirements, meals, and other quality of life support functions.
3. Distributes a meeting syllabus (outline and general ideas) three days before the meeting, seeking other new business that must be returned not less than 24 hours pre-meeting.
4. Re-publishes the revised agenda (increased outline detail, with meeting time allocations) the day before the meeting, with the appropriate resources needed to allow participants to come well prepared.
5. Sets the following times in stone (unusual times help ensure team complies to expectations):

a)       For the key team members (owners, practice manager, and CPA or bookkeeper), possibly with a mentor, start at 7:33 a.m. with a very light breakfast (the mind works better on a lightly filled stomach), coffee, tea, and juice.

b)       At 7:57 a.m., start review of the previous financial statements using an overhead projector so all can see and discuss the key elements (view graphs prepared of previous fiscal year, all twelve months, of the income statements and balance sheets).

c)       Have a practice cash budget outline prepared using percentages per month per element of income or expense, as available, for handout after the historical review and before brunch.

d)       With the arrival of the adjunct team members (associate doctors, lead receptionist, and senior technician), provide a light brunch at 10:37 a.m.

e)       With the expanded planning team, start a review at 10:56 a.m. of the projected program-based budget percentages that were developed from historical data on the previous practice team performance and client utilization habits, and brainstorm which programs can be added or expanded in the next fiscal year (don't kill a single idea during this brainstorm, just write them down and tape them to the wall).

f)        At 12:30 p.m., break for lunch on-site, resume at 2:04 p.m. to develop expected income per program area of interest to support cash budget.  This is often where the "reality check" is provided by the nurse technician and client relations receptionist to mediate the "grand ideas" of the key team.  Human resources are only so flexible and expandable, and these two persons must stand up for the quality of life of the staff.  Pros and cons, alternatives, and methods to reach the "grand ideas" need to be the target of the discussion, but it may require adjusting the personnel budget, equipment budget, or even the facility size.

g)       Soda, juice, coffee, and tea break at 3:31 p.m.  Key staff rejoin at 3:47 p.m., but without CPA/bookkeeper, technical assistants, and receptionist (released for remainder of day).

h)       Resume with emphasis on new business areas, marketing potentials, and client acceptance factors.  Extra expenses (e.g., training, space, equipment) to support new income areas need to be explored in detail.  Compromises will now be required based on the input provided by the lead nurse technician and receptionist coordinator.  At least 60 percent of their ideas need to be incorporated to have the budget be perceived by the team as realistic and a useful process.

i)        Supper break at 5:45 p.m. for two hours, time to relax and unwind.  Attempt to stay away from excessive food or drink indulgences, since there is still work to do.

j)        Rejoin at 7:46 p.m. for a "wrap and polish" session of all that has gone before, to expand on core competencies, core values, and practice philosophy applications. Ensure you include a staff impact assessment and communication plan.  This may include an additional training budget.  Also center on those portions which were provided by the technician and receptionist that could not be used, as well as the changes that will be needed to make the annual program a success.

The need for the communication plan is critical for two elements: the paraprofessional staff and the clients.  A draft transition plan, a month-by-month sequence of changes or additions for the next year, would be an appropriate and organized method to communicate the decisions of the budget planning process.  This plan should integrate all the different plans, and ensure that no member of the staff would be tasked with more than three new functions/habit changes per month.

MINIMUM BUDGET DISCUSSION ELEMENTS

The syllabus and the refined agenda discussed above need to contain certain elements, including: equipment, debt retirement, quarterly financial comparisons, cash outflow discussions, receivables, bad debt allowance (less than 1.5 percent), charity at the exam table (less than 3 percent of gross), employee discounts (less than 20 percent without IRS complications), tax laws, space potentials, computerization upgrades, people allocation per area (based on gross, with quarterly targets, such as 8.5 percent technicians, 7 percent receptionists, 2 percent kennel, 3 percent administrator), and finish with a fee schedule that supports the budget for people and equipment upgrades.

Key financial and operational relationships need to be discussed, to determine indicators that management can observe to easily monitor trends on a monthly basis.  Examples would include, but should not be limited to:

• cost of drugs and medical supplies (12 to 15 percent),
• paraprofessional salaries (17 to 21 percent),
• total W-2 compensation, doctors clinical and staff (less than 43%),
• percent of transactions that are new clients (target 10%),
• number of new clients by referral (greater than 60 percent),
• percent gross from vaccinations/dentals/surgery/anesthesia/etc.,
• percent of gross for mailing (greater than 0.6 percent),
• number of transactions (or percent appointment fill) per veterinarian,
• percent "net" given away (adjustments/discounts by veterinarian),
• aging rate of accounts receivable (30-, 60-, or 90-day accounts by dollar amount),
• the rate of follow-up scheduling by doctor
• diagnostic ratio (pharmacy sales : diagnostic sales)

Some ratios, like the "Pharmacy Sales to Diagnostic Sales" by veterinarian, is a very individual ratio, but centers the doctor's attention on what they can do for the quality of care provided by the practice.  Many of these can be graphed for more clarity when evaluating trends.  In the ISUP text, Building The Successful Veterinary Practice: Programs & Procedures (Volume 2), there are eleven graphs and two charts in the Appendix for watching “the tips of the practice iceberg” on a monthly basis - we call it a dozen dots a month, although it is a baker’s dozen (13)!  These are indicators to watch so you know when to look deeper into the operational trends or fiscal management of the practice.

Beware of the easy factors so often published without "the rest of the story", such as average client dollars per transaction (ACT).  The ACT is often counter-productive since it centers attention on the wrong thing.  What is the "computer's definition" of a transaction; is the ACT reported by veterinarian or by hospital; what is the over-the-counter sales impact; what is the income per inpatient visit versus outpatient visit; what are the payroll hours per transaction; what is the return rate per year (client or patient)?  Some consultants demand that the square footage of the practice be used to compute cost centers, but the allocations of circulating space makes potentially profitable areas appear worthless.  Evaluate services within the resources available to the practice and maximize income from each cost center.  The bottom line of fee structuring is simply, if you are within about 10 percent of the community high, variances from national norms are not significant for the clients who seek quality veterinary healthcare services!

The veterinary computer systems of today are designed to give abundant "data".  This most often is minimal "information" for management decision making.  A savvy practice manager must be able to take the information available and process it into knowledge that can be used for the good of the practice.  In any practice, less than 30 factors are needed to reveal the monthly trends.  In the area of laboratory services, expenses should be tracked by in-house versus commercial and income should be tracked by preventative, pre-surgical, and medical support functions.  The examination/office call (better called "doctor's consultation") should be tracked by rechecks, normal, and extended consultations.  In a healthy, mature practice, monthly operational expenses, without the major variables of rent, DVM salaries or return on investment (ROI), would be expected to be between 45 percent to 48 percent of the gross.  The AAHA Chart of Accounts, expanded in the ISUP text, Building The Successful Veterinary Practice: Programs & Procedures (Volume 2),  provides an easy access and comparison to the regionalized database of the profession.  Quicken or QuickBooks (from Intuit) are excellent software systems for expense summaries and accounts payable needed to support the Chart of Accounts.

Comparisons could include: outpatient drugs and medical supplies versus inpatient drugs and medical supplies, vaccination income as a percentage of gross, hospitalization income, X-ray income compared to expenses, over-the-counter sales, nutritional sales of prescription versus other products, boarding fill rate, baths per transaction, or the eleven fiscal charts provided by Catanzaro & Associates, Inc.  Other expected ratios include rent at one percent per month of the fair market value (triple net lease), DVM wages (owner(s), et al) at 18-23 percent, CPA and legal fees at 0.8-2 percent, office supplies at 1.4-2.2 percent, or maintenance costs of 0.5-1.5 percent.  In more progressive practices, healthcare parameters such as ECGs per thoracic X-ray or kidney dysfunction laboratory profiles per six-years-old or older canines examined are monitored since they relate to income potentials.

MANAGERIAL EFFORTS

Using the practice team to keep the budget plan on track will be enhanced when the accurate data is shared in a timely manner, using a format that is user friendly.  Remember, the staff knows how much a practice takes in each day (they close out the computer), they just don't know what the costs are in most cases.   The team which is used to keep the budget on track will provide feedback which will show the benefit of the time taken to make the information readable.  The practice management methodologies required to make the budget plan happen is as simple as driving "A TRUCK", or in easier terms:

                    A = accuracy of data

                    T = timeliness of data availability

                    R = reformatted as information

                    U = user friendly

                    C = control cost of capturing data

                    K = keep on track monthly

The use of a posted "Dinner Bell Chart" (Building The Successful Veterinary Practice: Programs & Procedures (Volume II), Appendix), helps the staff see the monthly income participation.  It is simply a graph with appointment days on the horizontal axis and income on the vertical axis.  The target line (done in highlighter) starts each month at zero and ends at the cash budget projection for that specific month.  The daily gross receipts are posted on the chart at the end of each day, in a cumulative fashion ($1860 on day one, then $1435 on day two, would put the day two dot at $3295).  The gross income dots are connected in dark ink each day.  At the end of the month, if the dark line is above the highlighter line, the owners take the staff to dinner.  While at dinner, the dinner site of the next Dinner Bell Chart celebration is chosen by the staff.  If the cost of the site selected seems excessive, the owner simply adds that to the target before announcing the cash projection figure for the next month.  As an added benefit and team builder, each third Dinner Bell success celebration should include the families or significant others of the staff members.   They make the practice success sacrifices, too.

When the staff centers on offering the services each animal needs (or the practice needs for professional healthcare decisions), the income should take care of itself.  This statement is based on four assumptions:

   1)    that caring practices only "sell" peace of mind -- they give the client two "yes" alternatives which they are "allowed to buy" to meet the needs stated;

   2)    that the veterinary practice environment for horizontal and vertical diversification has been developed;

   3)    that it is well understood by the staff and healthcare providers; and

   4)    the team has been appropriately trained in both competencies required and client communication techniques. 

These four assumptions are easier said than done, but that is the art of management rather than the science of accounting.  The program-based budget is a system based on quality care, client-centered service, and patient advocacy . . . the accountant’s propensity for stating the obvious with an expense-based budget must be left in the past as lessons learned . . . the future is in making the front door swing, more times for your existing clients.

August 2014

FAMILY = PET BOND = PROFIT

Thomas E. Catanzaro, DVM, MHA, LFACHE

Dipomate, American College of Healthcare Executives

CEO, Veterinary Consulting International

DrTomCat@aol.com; www.drtomcat.com

HAB = human animal bond = the interaction of people and animals in our society = profit center of the future.

A majority of veterinarians make their living because of the human-animal bond, yet most veterinary practices do not capitalize upon the potentials available.  The client calls the veterinarian because they have a concern about the well being of their animal and want an expert to assist them during their stressful decision time; they want peace of mind.  The basic premise which needs to be taken when the phone rings is that “the phone shopper” wants a quality-based, caring veterinarian at “an affordable value”.  A phone “emergency case” wants to be told they have done the right thing by calling and should come into the practice.  No client who calls wants to be told to stay home.

The contemporary pet programs such as active pet selection assistance (AVMA^©), pets by prescription and the Pet Partners^© certification program (Delta Society^©), Prescribe Pets Not Pills (VPI Skeeter Foundation^©), and behavior management (AAHA^©) promote the human-animal bond while supporting the healthcare reverence for life and quality of care programs.  Many Veterinary Teaching Hospitals are starting telephone “hot lines” for pet owners to allow the students who volunteer to better understand the stress of animal stewardship grief and stress.  A multi-faceted, interdisciplinary group, sponsored mainly by Hills, named VetOne^©, started publicizing the family-pet-veterinary bond at major veterinary meetings and in our media as we entered the new millennium.  The text, Promoting the Human-Animal Bond in Veterinary Practice, was released in May 2001, and the second edition was published by the VIN Press in 2009 with a new well care chapter; it has 26 appendices of practical application programs.  HAB information abounds, but practice commitments vary.

Definition of BIOETHICS:         applied ethics to real-life, day-to-day problems of ethical decision making in health care delivery.

In the past, veterinary ethics have been forensic (legal) values we used to describe the professional approach to veterinary practice, but bioethics are the values we use personally in practice. Sometimes the veterinarian is the person who makes the bioethical decision, sometimes it is the person answering the phone, and on some occasions, it is the person who observes the suffering inpatient in a cage.  But more often, the decision is laid at the feet of the lay people we come into contact with -- family, clients, public officials, judges, humane societies, and others.  There is seldom any clear bioethical solution.  Rather, there needs to be an awareness of its existence within the veterinary practice environment.

CHOOSING A THERAPY WHEN DOCTORS DISAGREE

This situation presents a wide array of ethical issues.  Whether or not the client should be informed of the nature and prognosis of the illness is certainly pertinent, but is hardly the most significant question in the bioethics at hand.  Attention should be focused upon a cluster of three basic ethical questions raised in this case:

• Who should make the ultimate decision when choices between alternate modes of therapy must be made is an obvious issue that must be faced in a multi-veterinarian practice?
• When we start to evaluate a patient, then continue to make the treatment decisions (often based on economics in lieu of best care), how should the client be involved in selecting the alternatives?
• The third, and perhaps the most fundamental issue, is who makes the decision when each of the alternatives (often conservative medicine versus exploratory surgery) is substantially correct?

The option to be chosen in each of the above three questions is not just a medical decision based on scientific training, but rather, a professional value judgment.  When a healthcare team is being developed, these cases deserve a full staff discussion so the professional logic, subjective feelings, and practice core values become established so others can make similar decisions in the future.

ACTIVE EUTHANASIA

The American Medical Association states that active euthanasia is illegal, but they only deal with one species of animal.  Exactly what are the fundamental measures of animal value and worth which require the veterinary bioethics to be evaluated?

• A pedigree animal with a genetic defect, or maybe just not meeting the specifications of the American Kennel Club.
• Killing an animal because a family is relocating to a home that cannot allow animals, or maybe the travel requirements are too extensive to continue economic support of the family animal(s).
• The medical ethics of letting an animal die due to a disease syndrome versus accelerating the process and minimizing the family cost or anguish.
• A problematic issue in euthanasia is who should bring up the options first. Is it a client concern or a medical concern?

The alternatives in euthanasia are generally not based in veterinary science.  They are based in personal value systems and practice philosophies.  In many of the practices we support, we suggest a “pain” versus “suffering” discussion when the patient is entering the golden years, when there is malignant oncology present, or other debilitating or chronic syndromes.  Be proud that we can treat pain in many ways now; many clients do not know this.  Suffering on the other hand, is often a subjective value observed by the client, including the animal soiling its den (urinating or defecating uncontrollably at home), bumping into walls due to poor eyesight, inability to maneuvering stairs, snapping at the children when startled due to loss of hearing, or similar behavior challenges.  We spend the extra client time ensuring they know that we can “treat pain”, so they need to call whenever it seems to be present, while in a case of “suffering”, the client must tell us when the love of the animal outweighs the loss of the companion, and it is time for euthanasia.

ANIMAL ABUSE OR NEGLECT

This issue is sad but raises no difficult questions of principle at all.  If there is a violation of the Animal Welfare Act - Code of Federal Regulations (CFR), Title 9, Chapter 1, Subchapter A, there is neglect; if the act was intentional, it is usually considered abuse.   Presumably in these cases, the individual or the family who has support responsibilities for the animal(s) is deemed inappropriate to the animal's welfare.  But the veterinary practice which makes the decision to elevate the issue to the authorities must face bioethical issues.

• Is neglect due to a lower than expected family knowledge of basic animal care, or is the situation caused by an overt disregard for the animal's welfare?
• Does the practice have the right to decide between referral and in-house counseling? If referring the case would cause a greater trauma to the family unit than individual counseling by the practice staff, is there a decision to be made?
• Will this counseling or referral (or lack of it) cause a loss in income or trust for the practice within the community?
• If the community laws or rules tend to promote certain action, or an uncertain or undesirable disciplinary behavior, should that affect the bioethical issues of this situation?

When a practice promotes behavior management services, starting with house training, the incidence of neglect decreases in the clientele.  Most clients are unaware of proper animal care, since they learned from their parents, who in many cases either came from the farm, or had parents who came from rural America, where farm dogs and barn cats had to fend for themselves.  Like parenting, there are very few prerequisites in our family stewardship system, so if we do not do it in the veterinary practice setting, no one will.  This is a wonderful area for staff bonding with clients, and the brochures and literature from AAHA make a great starting point, along with the appendices of the above mention text,  Promoting the Human-Animal Bond in Veterinary Practice.

THE KEY QUESTIONS

It is often said that issues of bioethics fall into two categories: some concern procedures for decisions, others the substance for decisions.  The distinction, while intuitive, is not easy to sustain.  How do we know which values should be followed unless we know what values should to be sought?

In biomedical ethics, there are usually five basic decision-making agents that require consideration by the veterinary practice:

1. The hospital has arrived at a series of policy judgements over the life at the practice, often based on facilities, equipment, and staff limitations or capabilities.
2. The technician nurses and staff often prefer certain types of cases or admissions, and certain treatment modalities that allow them a comfort zone of operation.
3. The client may wish to be involved in, and not merely informed of, the decisions being made in the case.  The values of the client may or may not match the values of the practice.
4. The patient has certain needs and the animal's welfare must be considered when extending any morbid state (the arguments concerning an animal's "rights" are certainly bioethical issues).
5. The veterinarian not only makes the policies of the hospital, but is also bound to interpret them on a case-by-case basis in light of state-of-the-art veterinary medical knowledge, as well as fiscal management concerns of the practice and client.

There is a traditional adage in medicine, that is, "First, do no harm".  In the previous bioethical issues, some would feel that the solutions were clear and definitive, that ethical issues do not exist.  The areas discussed are illustrative of veterinary medical situations where there is room for reasonable people to disagree.  The reason for this discussion was to make the concept of ethics in biomedical decisions become a reality, to show that bioethics do apply to veterinary practices, and to offer the opinion that bioethics should be an element of the decision making process in quality health care delivery in the veterinary practice.

THE PSYCHOLOGICAL BOND

The American Veterinary Medical Association developed and has available all the documents and aides needed for active pet selection assistance by veterinary practices, including some very well done color brochures.  The AVMA also introduced the Lost Pet Kit over a decade ago, yet many practices have neglected to integrate it into their practice programs; with digital photography, it is easy and takes very little space!  The Delta Society has developed the protocols for Pet Partners and pets by prescription within the community and school environment.  Either of these programs can develop new pet owners, clients who are already bonded to the practice since they selected their pet with the expert assistance of the veterinary professionals of that facility.

Human-animal bond resources are available at almost no cost to the veterinary healthcare facility.  There are multiple human/companion animal bond (H/CAB) programs available from associations and other non-profit organizations, and 26 are listed in the appendices of Promoting the Human-Animal Bond in Veterinary Practice.  The international clearing house for interdisciplinary HAB groups and programs is the Delta Society (800-869-6898).  The American Veterinary Medical Association (708/925-8070) has the pet placement handouts and information as well as hosting the American Association of Human Animal Bond Veterinarians (AAHABV – which has a very small membership fee).

The best companion animal practices realize they "sell" only one thing: peace of mind for the client.  They concurrently are a patient advocate and tell the client what is needed for the best of the pet, either of wellness or professional diagnostic concerns.  The client is allowed to select from the list, they are allowed to "buy" what they think they can afford.  Lesser cost alternatives are not offered UNTIL the client asks for lesser cost alternatives, but the "options" must be kept in perspective of lesser diagnostics, lesser response rates, or lesser probability of desired healthcare effects.  Clients prefer to "buy" and hate being "sold" in most every occurrence, and a smart practice leader trains and rehearses the practice team to "sell" ONLY peace of mind, freedom from fears, or psychological comfort while allowing the client to "buy" products and services to their heart's content.

Dentistry is a common human-animal bond practice program . . . lack of oral hygiene is a cause of breaking the human-animal bond, as in so bad a breath that it would choke a horse.  Restoring “puppy kisses” is the ultimate benefit of a dental prophy, but is seldom mentioned.  When a practice starts to “grade” teeth, magic happens, especially with differential pricing.  Dentistry is becoming a quotable commodity, so pricing is a community positioning action as well as client bonding action. The Holstrom, Frost Eisner dental text makes a clear differentiation between Tartar and Calculus, which I use here:

• Grade 1+ - tartar, with biofilm bacteria causing bad breath, brown molars, white incisors, slight red gums, no gingival detachment, door to door it costs $174, total! It is actually a 20 minute procedure for skilled technician nurses, so three 1+ dentals an hour will cause significant cash flow with minimal overhead . . . and if they are in the USA and have the veterinary pet insurance wellness program, most have dental reimbursements, so the cost is actually less!
• Grade 2+ - tartar plaque and biofilm bacteria causing brown molars, brown incisors, red gums, less than 25% gingival detachment, door to door it costs about $284, total! Smart practices require dental X-rays at this point, at a reasonable price (e.g., $65), since about 40% will convert to oral surgery. It is actually a 30-40 minute procedure for skilled technician nurses, so two 2+ dentals an hour will cause significant cash flow with minimal overhead . . . and if they are in the USA and have the veterinary pet insurance wellness program, most have dental reimbursements, so the cost is actually less!
• Grade 3+ - oral disease causing tartar AND calculus on the teeth, very red gums, 25% to 50% gingival detachment, oral surgery and radiographs of the roots are required - cost of oral surgery is usually $800-plus! X-rays are ESSENTIAL, and surgery and anesthesia are timed to determine the fees. It is actually an hour procedure for a skilled veterinary nurse/technician setting up for the veterinarian’s surgery, so one 3+ dental an hour can usually be done, but a doctor must be available in the treatment room for extraction and surgical demands . . . and if they are in the USA and have the veterinary pet insurance wellness program, most have dental reimbursements, so the cost is actually less! Many also reimburse separately for the oral surgery too!
• Grade 4+ - oral disease all the way down to the bone, over 50% gingival detachment, oral surgery and radiographs of the roots are required - cost of oral surgery is $950-plus! It is actually an hour-plus procedure for skilled technicians, so one 4+ dental an hour can be done, a doctor must be available in the treatment room for extraction and surgical demands, and it is systemic condition requiring follow-up visits . . . and if they are in the USA and have the veterinary pet insurance wellness program, most have dental reimbursements, so the cost is actually less! Many insurance programs also reimburse separately for the oral surgery too!

DISCLAIMER - in some areas of the USA, the above example prices are only 50% of the going rates.  We usually recommend to phone or e-mail clients, where we have not assessed the community, that veterinary practices with a single dental rate peg their prices by using their current fee as the 2+ prophy rate, decrease by 25-33% for the grade 1+ prophy, increase by 50-75% for the 3+ oral surgery fee, and at least double for the 4+ oral surgery.

Behavior management is one form of HAB practice service; it is one of the hottest topics on the continuing education seminar circuit in recent years. A survey of Internet searches shows behavior management is the #2 reason for new clients selecting a practice (location was #1).

The primary problem is proactive behavior management services are a staff function as much as a professional service, and the staff members seldom get to attend the seminars.  Obedience training is not behavior management, it is most often handler and location specific.  HAB behavior management is teaching and rewarding the pet an appropriate family behavior by positive reinforcement.  Allowing the client to "buy" these services is a client privilege most practices do not yet offer.  Behavior management programs are easily initiated for dogs using the Gentle Leader head collar (usually provides “power steering” in less than 8 minutes when you understand that “release of pressure” is the animal’s reward of that device).  The 65-page head collar booklet provides the techniques needed for behavior management, but the "caring" practice offers their nursing staff as “head collar fitters” at sale, and as trainers to help the client if they get stuck ($20 per appointment).  This veterinary practice behavior management effort often leads to Puppy Clubs, Kitten Carrier Classes, Senior Clubs, and other client "social" programs (e.g., Guinea Pig Pig Out) which add to the practice bonding (and concurrently increases the client return rates -- and practice liquidity).  In some cases, the practice supports a Pet Partner Program (Delta Society), and gains from the community good will and human interest media stories.

Behavior management is a potential practice area for staff to excel.  Most are client education programs best done by trained staff members (e.g., house training, feeding, new owner orientation classes, etc.).  In America, over 6 million animals a year lose their home and often their lives because of behavior problems.  It is worse in many other countries.  The veterinary practice team which helps prevent this "disposable pet" syndrome not only keeps clients, but gains positive recognition in the community.  Recognition for helping animals is a marketing benefit to the practice without having to advertise or market routine services or products.

Nutrition is the ultimate human-animal bond for most clients.  Clients like to feed their pet, because it makes the pet seem happy.  We know that premium diets and quality nutrition will extend the active life of most companion animals, but we often forget to tell clients about “smaller stools” or “better smelling cat boxes” when feeding the highly digestible premium foods.  Prescription diets should be treated like any other prescription, and be actively monitored by the paraprofessional staff at 2 to 4 week intervals; these can be “no cost” courtesy visits with the “nursing staff”, since purchase of goods usually accompanies a visit to the practice.

Changing “boarding” to a Pet Resort, or Canine and Kitty Camp, and changing “kennel kid” to animal caretaker, can change the atmosphere of the separation encounter.  Using a Kong Toy for “yappie hour” (if they purchase a Kong Toy at guest check-in, a special feeding using the inside of the Kong Toy will be done at 5 p.m. daily, like a happy hour).  When the pet goes home with the Kong Toy and “yappie hour” habit, when the client comes home from work and is greeted by a leaping bundle of fur, they can provide the Kong filled with food, and get changed into their doggy play clothes while the pet is occupied (P.S., Kong Toys are dishwasher safe, and almost indestructible, while not looking like anything in the home, except maybe the Michelin Man).

THE BOTTOM LINE

As a full time consultant, what I miss most about practice is “puppy breath”.  Like most all veterinarians, our staff joins veterinary medicine because it is a “calling”; we know they do not join for the meager salary and benefits alone.  When we can promote hospital staff as patient advocates, human-animal bond specialists, and “nursing” staff (a term the clients understand very well), we can reinforce the “warm fuzzy” aspects of this rewarding profession in their hearts and minds.

In a recessionary economy, clients stay home more, see their pet more, and will strive to fulfill “needs” while they postpone “wants”.  Since 9-11-01, followed by the GFC (global financial crisis), practices which had been using the word “need” for healthcare have had greater client access; after 9-11, most had the best October and November in their history.  Practices that clung to the nondescript “recommend”, or those that offer multiple options and expect client expertise to make rational decisions, had slower months than ever before; clients do not want to make choices when stressed, they want to be told what is needed by someone they trust. 

Explore every client contact for those moments when the family-pet bond can be promoted.  Listen to the Dr. Marty Becker “fear free” initiative being copied at many levels; brainstorm the concept with your staff to get real excitement going. Use every opportunity to acknowledge the important role the companion animal plays by providing their non-judgmental love in these times of stress and worry.  Allow the practice staff members to select HAB areas of interest, help them develop a working knowledge of the subject material and healthcare delivery options, get them practice business cards with their new title (e.g., pain management advisor, veterinary dental hygienist, behavior counselor, nutritional advisor, etc.), and start to promote their interest and new knowledge as a client benefit.  Celebrate the bond every day in every way!

July (mid-month) 2014

BEYOND PROBLEM SOLVING

Thomas E. Catanzaro, DVM, MHA, LFACHE

Dipomate, American College of Healthcare Executives

CEO, Veterinary Consulting International

DrTomCat@aol.com; www.drtomcat.com

Obstacles - those frightful things we see when we take our eyes off our goals.     

T.E. Catanzaro, DVM, MHA, LFACHE

Some practitioners erroneously believe that solving immediate practice management problems is the best way to change productivity and performance.  A better approach is to cultivate ideas whose application and impact range beyond the task of the moment.  Overcoming inertia and getting things done rely on follow-through and breakthrough skills.

BREAKTHROUGH SKILLS

As a team leader or a team member, you must first learn how to present your ideas in a comprehensive and enlightening manner:

   *      COVER YOUR BASES.  Before you show off your personal planning skills, make sure you are seen as doing a good job with your current responsibilities. If you don't have time to think beyond the immediate concerns on most practice days, delegate the more repetitive day-to-day responsibilities to dependable staff members.

   *      NETWORK.  Before you suggest an idea at a team meeting, try to get a feel for the other team members' interests and concerns.  Know the problems they face and the solutions they have developed and address the issue at hand in terms that include their interests.

   *      SEEK OPPORTUNITIES.  View problems as opportunities to solve challenges.  A strategic thinker sees multiple alternatives in events that others view as crises or failures.  Nurture this attitude within the practice team.

   *      BE POSITIVE.  Make your suggestions in a non-confrontational way.  If your idea impacts others, soften your approach with phrases like "What are your thoughts on . . . ?"  Remember, the staff within most every practice cares, they want to help, and their suggestions most always come with good intentions.  Look for the caring intention BEFORE you evaluate the idea(s).

   *      DON'T LIMIT YOURSELF.  Do not hesitate to make suggestions that are not related to the bottom line.  Clients must believe you care BEFORE they believe in your health care plan.  The value of an idea to a practice is measured in quality of life as well as quality of care.  Practice benefits can and should go beyond the cost-saving or profit-producing ideas.

FOLLOW THROUGH SKILLS

Planning a project can be completely different from its implementation and far more difficult than ever anticipated.  When projects stall, everyone becomes frustrated.  Projects stall for many reasons, but the obstacles which initiate the stalling have some commonality. The first secret to proactively enhance the follow through is to recognize obstacles of your own making:

   *      FANTASIES.  The mind can envision how well a plan will work, and it is far happier than when overseeing the actual implementation hassles.  You need to set the fantasy aside and get your hands dirty.  Edison had a vision of how a light bulb should work but had to build over 1,000 of them to turn his vision into reality.  Are you ready for 999 failures to become famous for your new ideas within the professional or client-based community?

   *      FEAR OF FAILURE.  Fear that results will fall short often cause us to let a project quietly die rather than live with poor results. Remind yourself that concrete results, even those that fall short of expectations, are far better than none at all.

   *      INVISIBLE RUTS.  A common pitfall is mindlessly following old habit patterns. We have learned from what went before, and know what works, but the practice plateau or lifestyle stagnation is caused by "non-change" rather than the pursuit of unique or new experiences.  Ask if those old stale protocols are important and determine "why" if the tendency is to retain them.  If the "why" is simply, "We have always done it this way," then bypass them, as necessary, to get things done.

   *      COMFORTING MYTHOLOGIES.  Don't fall prey to the slogans or comforts of tradition.  Southern California community needs are different than the rest of the USA, suburban needs are different than small town rural America.  Marketing gimmicks must be tailored to the community needs, not to the practice by some article or consultant who has not even been in your practice.  If you believe "everything is fine as long as everybody is busy,” you might overlook the benefits of new projects.

   *      EGOTISM.  Thinking that your own intuition and insights are infallible cuts you off from your colleagues' ideas.  Doctor, paraprofessional, or animal caretaker, it does not matter. Everyone has a mind and each mind has unique ideas to share, if harvested in a caring manner.  Objectively review all suggestions, including your own, and implement the best.

   *      FAILURE TO DELEGATE.  You may be shouldering the whole burden because nobody else is as effective as you are . . . or because you don't want to share the credit when a project is done.  Either way, you place the project at risk.  Your odds of success increase greatly when you take on only the tasks that suit your abilities best and let others take on the rest.  Train each person to a level of trust, then delegate the accountability for the outcome to them (not just the process).  Let them improve the program(s).

   *      INFLEXIBILITY.  When an approach is not working, substitute something more positive.  If your staff does not implement your ideas, ask them for alternatives. Let them develop unilateral plans and put those into action, then evaluate at 90 days for benefits.  Never veto ideas just because they are not yours!  Flexibility often requires taking a step backward, but ends up being more productive.

   *      LOVE THE INTRIGUE.  They are either with you or against you, right?  Put aside petty intrigues and enlist everyone's help.  A "them versus us" practice staff will never be a health care team. Only "we" can cause harmony and success.  If you love intrigue more than progress, or you prefer to take credit and give blame rather than take blame and give credit, go into politics or the spy business.

POWER UP FOR PROBLEM SOLVING

In our daily routine of practice we rely upon habits to get the job done, but when we need a creative or innovative solution, many veterinarians don't know where to start.  There are tools that teach creative problem solving.  They don't give you genius, they simply pull out the genius within you.

For those practices that do not have computers, or their computers are not friendly, the soft-cover texts, A KICK IN THE SEAT OF THE PANTS, or A WHACK ON THE SIDE OF THE HEAD, by Roger von Oech ($10.95 and $12.95 respectively, ISBN 0-06-09024-8 and 0-446-39158-1), provide exercises, stories, tips, and techniques to help you strengthen each of your own creative skills.  The books are sold separately, but sometimes you can find them together with a deck of innovation cards, and the set is called a "WHACK PACK."  These aids can be used to awaken these skills in your staff, since they are the best problem solvers we have. Then all you have to do is capture the great ideas from the flow of innovation.

For those who have an ability to use a computer, friendly or otherwise, some of the more helpful software programs include:

   *      IdeaFisher (approximately $495) contains two parts, the Idea-Bank which cross-references 60,000 words in 700,000 ways, and the Q-Bank which has 3,000 very specific questions designed to help you solve common business problems involving product lines.  Available in IBM PC and Macintosh versions from Fisher Ideas Systems, 714/474-8111.

   *      Namer (approximately $195) can help name products or services; it encompasses all kinds of product categories, but it is really best for naming health care products and high-tech services.  It will combine root words related to those fields and come up with 200-300 possible names.  Available in IBM DOS from Salinon Corp., 214/692-9091.

   *      Idea Generator (approximately $195) combines seven brainstorming techniques to take your answers and reintroduce them as questions that force you to view a problem at a greater depth. Available in IBM DOS from Experience in Software, 415/644-0694.

   *      Mindlink (approximately $499) uses a "mental gym" to warm up your mind with creative exercises, then the program runs you through a disciplined, step-by-step problem-solving activity. It forces you to remove yourself totally from the problem.  Available in Macintosh from Synectics, 802/457-2025.

   *      Inside Information (approximately $119) is a very new desktop accessory that contains 65,000 key words and their definitions and related concepts.  Available in Macintosh and IBM DOS from Microlytics, 716/248-9150.

New software to enhance creativity and innovation comes out every week.  There are many other products coming available to help problem solving, innovation, and creative thinking for the average computer user.  It is a smart idea to stop at the local software store and discuss your needs with a hacker on the staff.  Do not buy the software product until you have booted it up yourself, fed in a current problem or idea, and see what the program can do for you.  Not all programmers have the same logic tree as you, and very few understand health care delivery, much less veterinary medicine. These programs are just a logic tree that can be used by most decision makers who want assistance in innovative and creative thinking.

Problem Solving Process - VCI Veterinary Leadership Pocket Guide

DOING GETS IT DONE

When a project stalls, making a new beginning can provide the spark that lets a project catch fire.  Inactivity leads to inertia, then the consultant must be called in to break the paradigms which formed the inertia.  Picture your practice as a giant boulder resting on level playing field. Time has caused it to settle into a depression.  With all the strength available, the boulder may only be moved an inch or two.  If something isn't immediately added to the depression, the boulder will return to where it was.  On the other hand, if something (e.g., an idea rock) was added to the void created by moving the boulder, it will not be able to return to the "old position" and just sit there.  Each movement of the boulder allows another idea rock to be added to the temporary void. In time, the depression will be filled with new ideas and the boulder will be moved on the level playing field in whatever direction is needed, and with a lot less effort than ever before.

With or without an electronic computer, use your brain's natural logic for a five minute "boulder moving effort" when searching for the breakthrough or follow-through ideas.  If you are stuck, agree with yourself that you will start to work on a task at a particular time and will continue for five minutes.  At the end of the five minutes, determine if you want to continue another five.  Make the same determination again, and so forth.  This enables you to take focused action rather than view the project as behemoth and helps to build immediate response rewards.  If all else fails, stop, relax, and remember the words of Isaac Newton:

"If I have ever made any valuable discoveries, it has been owing more to patient attention than to any other talent."

July 2014

VETERINARY PRACTICE IMAGES

Thomas E. Catanzaro, DVM, MHA, LFACHE

Dipomate, American College of Healthcare Executives

CEO, Veterinary Consulting International

DrTomCat@aol.com; www.drtomcat.com

"He who knows much about others may be learned, but he who knows himself is more intelligent.  He who controls others may be more powerful, but he who has mastered himself is mightier still."            Lao Tsu

1. We talk about a practice image, a professional image, an image of caring. Architects like to call it curb appeal, but in today's market, that is not enough! What are you doing, on a daily basis, to improve the practice image?  In the management literature of the past, a "buzz phrase" emerged: "moments of truth".  It was coined by the CEO of SAS (Mr. Carlzon), and simply means "an opportunity to influence a customer, to create an appropriate image".  In every encounter with every person, at least one moment of truth occurs.  Generally, more than a single moment occurs in each encounter to make an impression.  In each instance, impressions and values are established based on impressions and perceptions.  In a veterinary practice, these moments of truth are often the difference between a client becoming a five-times-per-year friend or a once-in-three-years visitor. 

In a brainstorming session with other consultants, we looked at the average veterinary practice client cycle and counted the moments of truth that any practice could possibly influence.  While all the ideas listed here will not fit every practice, the majority should.  The challenge is to get the staff members to accept the responsibility to improve the image in each area they touch.  They need to have pride in what they do, moment by moment, to affect these moments of truth.  To establish that pride in performance is the challenge of leadership, but that is a different article!  Most of the concepts discussed below are expanded in the new Blackwell/Wiley & Sons Press three volume text series, Building The Successful Veterinary Practice, and the sequel, Veterinary Healthcare Services: Options in Delivery.  Look at these opportunities, and discuss them with your team:

Finding the Practice (you need to ask this question of ALL new clients to compile these answers)

          Social Media

          Yellow page ad

          Referral by friend/client

          Newspaper ad

          Community literature source

          Referral by out-of-state veterinarian

          Outdoor signage

          Ancillary pet supply referral

          Staff community service

          Community activities/Rotary/Scouting/women's clubs/government

The Initial Contact

          Phone for a price quote

          Phone for a service quote

          Phone for an appointment

          New Client Newsletter (mailed post-phone contact)

          Directions to the practice

          Stopping in for a tour

          Meeting a staff member out in the community

          Meeting the veterinarian at a community function

          Actual appointment hours offered

Arriving With the Pet

          Practice identification

          Direction signage for parking and entrance 

          Parking lot appearance/tidiness/potholes/debris/droppings

          Access to the front door

          Entry ease and protection of pet from other patients

          Fear Factor enhancements

          Lighting/security

          Initial waiting room impression (smell, sight, sound)

          Access to the front desk

          Staff appearance

          Decor/odor/noise/cleanliness

Client Relations Specialist (Reception) Staff

          Courtesy/attentiveness

          Friendly/smiles

          Responsiveness/caring

          Pace/professional approach

          Phone techniques

          Gossip level

          Talk about pets/clients by name rather than condition

          Bond-centered Practice Approach

          Waiting time (a maximum of seven minutes)

          Amenities available

          Other clients entering and exiting (satisfaction)

Initial Client/Patient Movement Methods

          Appearance/uniforms/shoes/personal composure

          Personal hygiene/makeup/hair/breath/face hair

          Escort to consultation (examination) room

          Initial interview techniques

          Hands on pet within 30 seconds

          Fear Free aspects

          Nurse (Technician) appearance

          Body language/voice tone

          Staff competency

          Paraprofessional rapport

          Bond-centered Practice Approach

          Wellness examination

          Diplomas on wall (staff and doctors)

          Odor/cleanliness/noise

Veterinarian Initial Impact

          Appearance/personal composure

          Treatment of staff

          Respect for Outpatient Nurse comments

          Self-introduction

          Touching the animal

          Listening technique

          Body language/voice tone/rate of speech

          Terminology

          Explanation of consultation/examination/findings

          Patient advocacy/speaks of pet's needs/ensures client decides

          Bond-centered Practice Approach

          Empathy/concern for client's position (feelings and fiscal)

Consultation (Examination) Room Exit

          Summary of findings

          Staff Training to administer treatments

          Bond-centered Practice Approach

          Explanation of charges

Prequalify each departure with the three Rs (recheck, recall, reminders)

          Escort to discharge

          Protection of animal during transit through hall/reception area

Discharge Actions

          Attentiveness at discharge/waiting time

          Discharge desk clutter/appearance

          Cleanliness/odor/noise

          Presentation of invoice/bill (consistency with estimate)

          Collection of fees (some practices have the nurse do this in consultation                     room)

          Dispensing medication

          Concern for client understanding

          Plan for next contact

          Bond-centered Practice Approach

          Establishing the three Rs compliance expectations (recall, recheck,                               remind)

          Privacy/courtesy/caring

          Literature offered to ensure family understanding

Post-discharge

          Follow-up telephone call by nursing staff

          Quarterly Informational Newsletters

          Sympathy cards/memorials for deceased pets

          Thank you correspondence

          Health Alerts (Volume 3, Building The Successful Veterinary Practice)

          Satisfaction surveys

          Reminders

          Recurring social media

Over one hundred moments of truth were listed above and the ability of the veterinarian to directly alter them accounted for only about ten percent of the total.  The balance are done by staff, and the effectiveness is directly proportional to their level of training competence.  Many practices have not yet discovered the value of team-based training, facilitated by veterinary-specific team-based trainers (e.g., see www.drtomcat.com).  The amount of concern (training and rehearsal) exhibited by most veterinary practices does not equal the importance of these client impression opportunities.

Consider the moments of truth from the client's perspective.  How many times can your staff, facility or practice methods offend their impressions of your practice before they are no longer a client?  Conversely, when staff members feel proud of the practice and the healthcare delivery philosophy, every moment of truth is an opportunity to cement the doctor-client-patient bond. 

In fact, as proven in most every service industry, how the operational managers and supervisors treat the staff will determine how the staff members treat the clients.  When Carlzon asked the SAS headquarters staff what their "mission" was, it took three weeks for the team to decide it was "the movement of people."  They closed the headquarters for about six months and took the client-centered service to the field and impressed every one of the 40,000 employees with their importance in the moments of truth.  In two years, SAS went from a failing airline to one of the top three income producers in Europe; five years later it was failing again because the leadership appeared over-impressed with their initial effort and did not continue the client-centered emphasis on all programs. They forgot to look into the future and make the SAS employees responsible for changes in the future (there was NO continuous quality improvement).  SAS lost money.

American examples do exist, like Marriott, Nordstrom, Worthington Steel, Federal Express, and American Airlines, but they are the exception rather than the rule.   In industry and corporate America it has been called Total Quality Management (TQM).  Authors like Juran, Deming, and Crosby have made their consulting fame by basing their approaches on reintroducing employee-based quality and pride factors to American corporations.  They believe that when the employee puts pride into their daily effort, when they are empowered to make changes for the betterment of the team without first climbing the supervisory ladder for permission, the output will be perceived as quality.  The successful veterinary practice empowers its staff to react and change to meet the client's needs.  The staff member needs to have the freedom to commit resources without additional line item permission and to make the client perceive a caring staff and a quality healthcare facility.  In human healthcare this concept is called Continuous Quality Improvement (CQI). 

Assigning accountability to an employee (empowerment) must be accompanied by the needed authority, and these must be supported by job/task ownership.  The staff member must think of the practice as "our practice/our hospital" at every decision point in the process.  In the consulting business, we find that practice "luck" is usually directly related to the preparation of the staff to grab opportunity as it comes knocking.  Where does your practice approach sit in the scheme of things when it comes to preparing your staff to grab the moment of truth and turn it to the practice's advantage?

During the 1970s and 1980s, the veterinary client-centered trend in the United States inched away from client service in the quest for high-tech and personal specialization.  However, the 1990s rediscovered the importance of service to the client, and client-centered service was rediscovered (and the AVMA even published an outstanding series of workbooks to help their members relearn this critical business facet, but very few used the AVMA texts as team-based training workbooks to establish an enhanced practice culture or solidify the practice philosophy).  The new millennium and the GFC has demanded this facet for success be tailored to multi-generational expectations, including high tech savvy and proactive social media outreach!

The practice that best controls its respective moments of truth will become different from other practices in the mind of their community.  These astute veterinary practices will succeed where others have floundered because practice quality and client impressions are communicated during the moments of truth and have very little bearing on the professional facts.  They will become the leaders in the veterinary marketplace as we emerge from the GFC, using new millennium techniques.

 June 2014

LEADING A MULTIGENERATIONAL PRACTICE TEAM

Thomas E. Catanzaro, DVM, MHA, LFACHE

Dipomate, American College of Healthcare Executives

CEO, Veterinary Consulting International

DrTomCat@aol.com; www.drtomcat.com

You have to get different generations communicating so they can appreciate what each seeks and why, as well as identifying what they hold in common. Only through facilitated dialogue, where individuals feel listened to, can different  generations within the practice team discover common ground.    Tom Catanzaro, DVM, MHA, LHACHE

In very leadership course I have ever staffed, or developed, communication is defined as the "getting and giving of information."  In most veterinary practice settings, the doctor has learned to talk "at" the staff members (that is how they were taught in school) rather than with them, and the ownership ensures the manager delegates processes rather than outcome tasks.  This is now compounded by the generational differences seen within veterinary practice teams, which gives the  organizational behavior and practice culture more stumbling blocks than answers.

Currently, most multi-doctor veterinary practices have a staff comprised of four generations: traditionalists, baby boomers, Gen-X and Gen-Y. The difference in attitude and in value hierarchy among veterinary practice providers of different generations is so great that practice owners and younger staff often fail to even hear what the other is really saying. The older embers members of the staff believe the younger members have no work ethic, while the younger members of the practice team suggest the old timers should "get a life."  But these obstacles can often be removed through facilitated dialogue that builds trust and enhances mutual understanding.

Traditionalist practice owners and Medical Directors were born at the end of World War II, and for them, veterinary medicine was a vocational calling. Their profession and self-identity are one in the same, and in their eyes are analogous to James Herriott, a priest, a rabbi, or other minister of the flock. Traditionalists respect hierarchy; join civic, fraternal, and professional organizations; are seldom computer literate, and would never imagine requesting reimbursement for being on call.

Baby boomer veterinarians learned from the traditionalists, so on the surface, they appear a lot like the guys who taught them their craft, often in ambulatory medicine settings. However, they work with a different set of motivation factors: the acquisition of material wealth is core to their practice approach. That attitude is particularly evident in the latter half of the baby boomer generation. Younger boomers are sometimes labeled the "Jones generation", as in "keeping up with the Jones." For the boomer veterinarian, failing to work generates feelings of guilt.  The younger Baby Boomer veterinarians are loyal, do not fear taking on debt, do not tend to accept statements of authority, are not joiners, and are not likely to sacrifice personal pleasures for the good of the group.

Generation X are significantly different from traditionalists and baby boomers. For Generation X, managing time and balancing life are primary values; being part of a veterinary team is only a small part of the existence and self-identity.  They are equally vested in life or lives outside the practice, and for that reason, prefer known shifts. Gen Xers are transactional and seek immediate stability, looking for what they can get for working the prescribed shift(s). They do not tolerate governance well, have a lack of trust in managers, supervisors/or even practice leadership; they are loyal to principles, not organizations.

THE NEW MILLENNIUM

A unique phenomenon occurred in the American workplace, especially in healthcares settings, as we entered the new millennium. before the new millennium, most leaders and employees shared a common generational attitude - they were most all part of the baby boomer generation.  This congruence of generational attitudes clearly led to a more positive work environment and a more aligned and engaged work force, yet as we entered the new millennium, it all started to unravel.

Although Baby Boomers will continue being the primary practice owners and Gen Y associates, colleagues, and staff coming into their sphere of influence. The trend slowed when the GFC struck, and baby boomer retirements were postponed, but the economic restraints are changing again, in time, the generational shift will occur to Gen-X and Gen-Y values.

When Baby Boomers entered the veterinary workplace, the leadership was dominated by traditionalists who saw duty, loyalty, and sacrifice for the good of the practice as part of the definition of their practice existence. baby boomers saw working hard as a means to personal growth, career development, and an extension of their ambition.  As Baby boomers began to dominate the workplace, it led to tensions, and even the split in expectations of "early baby boomers" from "late baby boomers" . . . the disengagement from the practice workforce was perceived by many traditionalists as disloyalty, and major discord followed.

Generational differences impact communication styles, technology needs professional development processes, workplace expectations, compensation & benefit needs, desired leadership styles, and the effectiveness of reward and recognition systems. Generations tend to agree on achievement and a desire for credible, trustworthy leadership. 

Practice leaders who understood that their management styles needed to change thrived in the new multi-generational environment, while those who continued using approaches and techniques from their own past found their ability to lead and motivate greatly diminished; in fact, many of the older styles have been reclassified as "Bullying", and legal workplace actions are being taken at an ever increasing rate.

Today, progressive practice leadership needs to take specific steps to stop the perception of Bullying and prepare for the changing dynamics of the modern veterinary healthcare team.

STEP ONE - Acknowledge the Need for Personal and Organizational Change.

When managed and led appropriately, a multigenerational practice team can be the springboard for greater collaboration, unique exchange of ideas, and a more productive practice.  While I outlined the generations earlier, the Gen Z is not yet in the veterinary workforce, except for maybe a work-study student, yet they will cause another shift in leadership and organizational behavior change needs.

Just as the days of one-doctor veterinary practices are coming to a close, so is the traditional doctor-centered healthcare delivery systems. Veterinary extenders are needed in today's competitive professional marketplace, which requires different training system than the traditional "see one, do one, teach one" attitude of the baby Boomers and Traditionalists.  Training to level of trust is a slow and often computer based staff development program, requiring practice duty time be adjusted since Gen X and Gen Y seldom take work home.  Assigning small but meaningful application projects to newly trained staff requires time and resources be allocated, as well as the "question being the best answer" in many cases; these efforts require special public recognition, for the effort, the milestones reached, and the success measures met in the process. The next step is program accountability, aligned with the interest area(s) of the developing staff member ; again, time, and resources will be required, as well as mentor support (never bullying).

No single style or approach exists for successfully leading the multigenerational practice team. The leadership must adapt to meet the individual needs of all generations. Leading while preventing intergenerational conflict requires encouraging self-identification within the practice team, and subsequent training opportunities. Acknowledging generational differences enables a greater appreciation for values, characteristics, and experiences that help shape the work ethic, motivation, and ideology of the practice team members. Developing innovative solutions to address the value-based needs of each group makes it possible for practice leaders to improve the organizational practice culture, staff motivation, and personal engagement.

STEP TWO - Develop Specific Strategic Assessments and Responses

To optimize human capital, today's veterinary practice leadership must understand what attracts, engages, and retains distinct generations that comprise the modern practice healthcare delivery team.  Key human capital components that will drive the engagement and motivational culture of the practice team include:

• Meaningful recognition for contributions
• A 'safe haven' work environment (no bullying, no yelling, no throwing things)
• Compensation and benefit programs that are not linked to tenure, rather they are linked to program development and specific skill-based programs.
• Using escalating continuing education benefit rewards for greater practice contributions in program development, will yield greater contributions.
• Performance planning for the future, rather than performance appraisals of the past, supported by skilled and caring mentors, recognize the differing attitudes about motivation (e.g., annual assessment processes will need to be replaced by quarterly planning efforts). HINT: performance appraisal process is a one-on-one coaching/mentoring time, to improve the individual's skill, knowledge and/or confidence.
• Flexible scheduling that challenges the current concepts of traditional shifts and location of work.
• Adaptable technology to address differing communication needs and styles.
• Mentoring programs designed to enhance Gen-X and Gen-Y concepts of self-image, commitment and ambition.
• Creative reward and recognition systems, focused on lifestyle, for individuals and team groups.

STEP THREE - Time Implementation Right!

In life, as in making leadership decisions, timing is everything! Strategic assessment leads to strategic response, which comes from analyzing and reporting on catchment area demographics and trends. New metrics are needed for measuring progress and achievement of new programs; old metrics give rise to regression and frustration.

Most successful practices survey their staff on a regular basis to determine organizational climate, as well as assess the intergenerational issues and healthcare delivery program effectiveness.  These surveys should be designed to take advantage of knowledge, strategies, and tactics related generational differences and SOC compliance perceptions in the practice's team-based healthcare delivery programs, for instance (but not inclusive):

• Referral rate from veterinarian to in-house nutritional counselors for non-5 BSC and other nutritional needs (85% of patients seen would be almost perfect, but 10% more than last month would be a realistic goal)
• Referral rate from veterinarian to in-house behavior counselors for basic behavior management family fit consult (recorded by doctor, and by patients seen).
• Referral rate from veterinarian to QOL counselors for senior pets entering their golden years (recorded by doctor, and by patients seen).
• Referral rate from veterinarian to attending nurse for all prescriptions, to follow-up with client at half way point to ensure adherence and possible questions (recorded by doctor, and by patients seen).
• Referral rate from veterinarian to attending nurse for deferred care, to follow-up with client as patient advocate and for possible questions (recorded by doctor, and by patients seen).
• Referral rate from veterinarian to attending nurse for OA patients with photonic pen potential (recorded by doctor, and by patients seen).
• Nutritional return rate, and cross sell of approved treats (recorded by nurse technician, and by patients on program).
• Parasite prevention and control follow-up based on medications dispensed refill rate expectation (hopefully, by assigned nurse technician).

By recognizing the need to change, by developing plans now that may require months to train staff and implement effectively, and by engaging each person in a distinct generational modality, "where they live", practice leaders can best meet their responsibility to their associates and team members - creating the right environment, enhanced organizational climate, and individual opportunities for self-esteem while delivering high levels of client-centered patient advocacy for clinical, operational, and financial excellence.

May 2014

LEADERSHIP FOCUS INSIGHTS

My first text was BUILDING THE SUCCESSFUL VETERINARY PRACTICE: LEADERSHIP TOOLS (Volume 1), my thesis for my masters at Baylor University was based on tracking leadership evolution in the past 100 years, and I have staffed over 19 weeklong leadership courses (only 1 in veterinary medicine), so it is safe to say I have been a student of leadership for over a quarter century. I cringe at many seminar speakers who seem to promote themselves as experts, with no credentials except the PR to get podium time.

At a recent conference, I was recently asked what I saw as major focus areas for leaders. There are many things a leader needs to balance, and besides for the Balckwell/Wiley text, I have three monographs on the subject in the VIN bookstore, but here are a few key things I believe that they should always keep front of mind.

Create Focus: A leader should strive to paint an inspiring vision. Most people don't want to run from something, but rather they seek to run to something. As individuals, we want to be a part of something greater than ourselves. A leader should paint this inspiring vision, and then articulate the priorities to help people know how to make progress against that vision.

Fall in Love with the Problem, Not the Solution: It’s human nature to love our own ideas. In our associations, it is usually the STRATEGIC PLAN, most often written for 5 years and forgotten/outdated within one year.  That means that we hang on to those ideas for too long.  I promote Strategic Assessment and Strategic Response for practices at the community level (yes, there is a monograph on that subject in the VIN bookstore).  Along the leadership or innovation journey, you must ask: Are we making sufficient progress to believe that our original hypothesis is correct, or do we need to make a change? If you never lose sight of the problem, how you attack the solution can remain more flexible, iterative and ultimately, be more likely to succeed.

Lead With Questions Not Answers: The best leaders don’t need to have all of the answers. They surround themselves with great people, and ask the right questions. When doing a practice consult, I get many of the best "turnaround" ideas from the staff members; I use my 2000+ practice experiences to translate that into proactive programs.  It’s not what you know. It’s the questions you ask that help you become a more effective and inspiring leader.

Build Capability Through Principles & Frameworks: Leaders must unpack “WHY” a decision has been made, and not just the “WHAT” the ultimate decision is. The next step is to ask the staff teams within their own zones to develop the WHO and HOW. This practice makes explicit the principles or criteria that you applied to reaching a conclusion. At this point, the WHEN becomes a joint decision, and includes milestones and success measures (which do not change during the implementation process). These principles can then provide teams with a compass to navigate uncertainty and make their own decisions when you are not available or able to assist, moving beyond your individual ability, and building organizational capability.

Cast a Tall Shadow, Not a Dark Shadow: All leaders cast a shadow. The question is whether yours is blocking the sun, or inspiring others with its silhouette to strive for more. As a leader, we must all walk the talk. Leaders need to role model the behavior they want their organizations to emulate. The two greatest indicators of what we view as important are (1) how we spend our time and (2) the questions we ask. Organizations watch these cues to determine what leaders “really view as important”. So be clear on your say/do ratio, and ensure the shadow you are creating is the one you aspire to project.

All that said, if I had all the answers, there would not be 989 leadership and management texts on the bookstore shelves - they would only stock mine.  Not hardly folks.  Situational leadership and situational management are both an art and science.  To adapt a consulting program to any practice requires flexibility and depth of knowledge most neophyte consultants have not yet attained, but they will under-bid my rates for two main reasons: 1) they want the practice booking, 2) they don't value their own knowledge.

Organizational Behavior (a recent VIN Bookstore monograph) lies under most practice programs, and forms the practice culture.  This cannot be changed by a consultant, only by the practice owner.  My job is to mentor the practice owners, and in turn, the practice staff, to move the practice to the next level.  In all honesty, about once every two years I have had to disengage from a  consult because the owner believed in disposable staff or otherwise was a control-oriented boss who was not willing to change one iota.  In those cases, when I am on-site and discovered these type situation(s), I disengage and only charge direct expenses and NO TIME FEE.

I do have available flexible time for consulting in the next couple months . . . but then I start to travel - in July I head to Japan for a HAB speaking engagement, in August I am on VCI Seminars at Sea (Alaska) with 7 other consultants as faculty (new faculty details and revised seminar agenda is at /site/view/214832_.pml if you would like to participate in this "mountain top" adventure CE experience), then in September I am speaking at he Kentucky VMA Annual meeting, and follow that in October, with speaking at the Wild West Veterinary Conference in Reno, Nevada.  I hope to be booked for some consults in coordination with the last two engagements, if we can coordinate the desired dates.  Also please note, a new post-GFC economical consulting program has been added to the web site this month.

The attached article is actually the proceedings from a conference I did in Australia a couple months ago.  People who have come to my seminars over the years know my proceedings are "additional information" and NOT an outline to follow as I speak - they are designed to stand alone and help the reader gain insights to the topic at hand.  I believe the attached article expands well on the Leadership Focus Insights offered above.

Hope to see you on a consult (including the new economical regional program just added to my website) or at VCI Seminars at Sea (Alaska in August), but regardless, sure hope the attached article helps you see some alternatives for possible use in your practice.

Tom Cat  >*-*<

May 2014 Attachment

PRACTICE TIPS & TRUISMS

Thomas E. Catanzaro, DVM, MHA, LFACHE

Dipomate, American College of Healthcare Executives

CEO, Veterinary Consulting International

DrTomCat@aol.com; www.drtomcat.com

If you want to go fast, you go alone. 

If you want to go far, you go together.

For the record book, ideas I am about to share will be contrary to some of your opinions of what a veterinarian-centered practice should be doing.  Some of the ideas will be contrary to your levels of trust.  Some will walk away saying it can never happen on their watch.  In short, many veterinarians CRINGE at the thought of sharing these ideas; that is called ‘university training’ and has proven to be short sighted in most other healthcare professions.

Think of a “high powered” dental practice, where you are booked to see a dental hygienist every six months.  Next time you do, ask them to let you look at the appointment log.  The dentist may have 3 to 5 chairs scheduled for his restoration work, and depending in the practice, there may be 6 to 12 hygienist chairs, which also now do whitening.  That makes 9 to 17 appointment columns per dentist.  Sure, the hygienist columns only reflect about $180 per hour production potential, while the restoration chairs are producing $300 to $600 per hour for the dentist.  In these ‘high powered’ dental offices, you will notice an administrator coordinating all the business activities.  You should also note the extenders working the restoration chairs with the dentist, skilled at getting X-rays as well as molds of the teeth and arcades.  Now think of your practice with one column per provider and ask yourself why have you been limited by the expensive “practice management business software”, which by the way, cannot even do the basic business formula of ‘Income minus Expense equals Profit”.  And you pay how much for that set of limitations?

So today is may be the time many of you get to move the next level . . .

Take M-2-D Next Level

The ideas may make some of you cringe – you will cross your arms, lean back in your chair, and say “no way!”  That is YOUR CHOICE.  I have been in 2000+ practices, and will be sharing concepts that have worked in Australia, New Zealand, Japan, Canada, USA, UK, and Northern Europe.  The CHOICE of which ideas will be yours and yours alone . . . but a word of caution: Never try to implement more than 3 new ideas at a time (within 1 month), and for best results, restrict them to one per practice zone at a time.

TEN TIPS & TRUISMS

#1. Share the Accountabilities.  In any veterinary practice, there are more requirements than most people realize.  I have watched veterinarians change their own light bulbs, open their own mail, snake their own toilets, and otherwise do jobs that reduce their income production potentials.  Attached is a list of accountabilities, and while you may not be excited about sharing some of these requirements, the simple fact is if you do not, they will all take you off line, and you lose $200-$400 an hour from outpatient and $300 to $700 an hour from inpatient production, if you let yourself get distracted with these accountabilities.  You were trained to do them by the school of hard knocks (they were not academic subjects, nor are they journal worthy articles in most cases), so it is self-evident that you can train others to be proficient in any of them!

#2. Develop Program Managers.  In my world, coordinators are the link pin in zone operations, the ‘coordinate the people’ in a practice zone (client relations, outpatient, inpatient, animal caretakers, etc.).  Program managers are the ones that ‘coordinate things’ like inventory, dental care, behavior, immunizations, nutritional advisor, etc.  Attached is a functional staff volunteer list, with built-in resources, to start the Program Manager programs when you get back to your practice.

#3 – Written Standards of Care (SOC). Whenever a practice extends beyond one vet, a written standards of care is needed, this includes when a practice starts to empower their staff members to represent the practice’s core values, mission focus, and standards of patient care to clients.  The AAHA Compliance Study showed that most practices were losing about $630,000 per vet per year by not being consistent in well care and preventive care practices.  By writing the practice’s commitment to well care and preventive care in a single, easy to read document, everyone will become aware of the commitment required.  The SOC should be the WHAT statements, not protocols and not lengthy WHY explanations – that is for staff meetings when programs are being introduced.  Medical record reviews can then be conducted weekly to ensure compliance by each provider to the SOC elements.  Every SOC NEED (never use the word ‘recommendation’) is followed by a X-A-D-W; X = do it; A = appoint it; D = defer it (needs until when date); or W = waiver, never mention it again.  When doing the quarterly budget review, failure to reach target goals are assessed by individual program and individual provider commitment/compliance to expected SOCs (patient needs) and related booking rates for specific programs.  And by the way, with a written SOC document, even the savvy owner should stop making exceptions for his old mates!

#4. Share thank you notes.  When I was in practice, I had a box of thank you cards, blank inside, with practice specific covers, and scanned the local newspapers for reasons to send a hand-written personal thank you note to someone, whether they were a client or not; any community contribution was enough to get a thank you note!  Many people will tell you they have every thank you note they’ve ever received during their professional career.  Many practice post their thank you notes on a bulletin board or in a scrap book, but inversely, send out very few . . . that is a very interesting dual standard in my mind.  If you ever have mailed a thank you note to a staff member at their home, with a real stamp and hand written envelop, for something they have done for the practice, the team, or yourself, you know the gratitude response first hand; the sad thing is many managers have never seen this gratitude because they have not reached out to say ‘Thank You’ in an unusual but memorable way.  Thank you notes put a tangible and meaningful token of gratitude right in the hands of those who need it the most.  Is there a staff member in your practice who makes a difference and for whom you are grateful?  If so, take a few minutes to write him/her a thank you note, and BE SPECIFIC on the behavior you are accolading. 

#5 – 2xFL – think two visits a year for life.  Most every client knows that one dog year is 5 to 7 people years! Yes, we all realize that it is not that easy, but who cares when the client believes that simple ratio.  Most practices have a predominant female client base, up to 70%, who already know they need to see their OB/GYN every two years at least, and their dental hygienist every 6 months.  What would be  the response if they told their OB/GYN, “See you in seven years doc!” . . . answer, NOT HARDLY LADY!  In most all surveys, clients say they don’t come back because no one made it important enough for them to revisit.  It did not help that we taught clients to come only for vaccines, and charged prices so high that the wallet exsanguinations stopped vacations, movies, and even happy meals for the kids.  Start planning the next visit, even if it is with a veterinary extender who is well versed in well care and FEAR FREE PHILOSOPY of practice.

#6 – Use the 4 Rs on every patient every time. The dentist schedules the next visit (6 months or sooner) before your leave the clinic.  The pediatrician hands the young mom a handful of lab forms and schedules the next baby visit before the discharge is completed. Your physician should be setting up surveillance visits for your blood chemistries.  Your car mechanic puts a tag on your windshield when to come back.  The wife’s hair dresser schedules the next visit before she leaves the salon.  Heck, even the dog groomer schedules the next visit as a matter of discharge planning.  So why do vets NOT practice a similar planning technique?  Answer, we were raised by wolves! Actually, we were raised by ambulatory veterinarians who had to deal with producers who put the pencil to the economics of every vet service, so they used the word recommend, and came only when called . . . until the days of herd health and recurring equine dental floats.  Companion animal and equine clinicians need to ensure every patient is at least 2 of the 4 Rs as part of every discharge action: Revisit (make the appointment), Recall (expected telephone contact time), Remind (e-mail, SMS or snail mail promise), and Resolved (medical record entry on successful close out of cases).

#7.  Hire for Attitude.  This is NOT the seventh thing you need to do, it is the first thing to do when building an improved practice team.  Resumes have become a creative writing art form, they cannot be trusted any more (HINT: always call every reference).  In the text, Building The Successful Veterinary Practice: Innovation & Creativity (Volume 3), Blackwell/Wiley & Sons Publisher, there are interview check lists for most positions, with hints on what key words to listen for when assessing attitudes.  In training, we talk about KSA-A: Knowledge, Skills, Attitude and Aptitude. Given a candidate with the right attitude, training the skills and knowledge becomes easier.  When they seem to come with skills and/or knowledge, but do not have the aptitude or attitude, training is very difficult if not impossible.  For every person departing the practice team, it is an opportunity to seek someone with the attitude and aptitude to fill a void or shortfall on the team – do not look for clones!  In fact, in the VCI Signature Series monograph, Staff Orientation & Training (from the VIN bookstore, www.vin.com), there are self-directed training programs for empowering the staff members who have the right attitude and aptitude.

#8. Train to Trust.  There is no “average” in healthcare skills or knowledge, no adequate, nothing that is the ‘fair’ or ‘good’ category of assessment.  Competency is Excellence, there is no other grading system.  Think of placing an I.V. – what is a “C” average, maybe going through both sides of the vein?  Think of a femoral bleeder, spurting a one meter arc – what is a “C” average for stopping the bleeding, maybe a 10 cm arc (this still leads to a body bag)?  Think of placing an anesthetic misadventure (what surgeons call an animal that stopped breathing while on the table) – what is a “C” average, maybe inflating the apical lobes only (this still leads to a body bag)?  Think about “partial pregnancy” – there is no mid-ground, it is ALL or NOTHING in every case.  In recurring performance evaluation assessments, why “grade” past performance instead of planning for the next 90 days?  “Remember what you did last month – well don’t do that again!” does not build a proactive relationship, as opposed to, “What do you want to change, or learn, in the next 90 days?”  The latter allows you to be a mentor, and share accolades while in route to the next level of exceptional performance.  In fact, studies have shown annual reviews are worthless, and prospective quarterly performance planning is what works with the current generation of healthcare workers.  In fact, in the VCI Signature Series monograph, Staff Performance Appraisals and Planning (from the VIN bookstore, www.vin.com), provides individual forms for each zone in the practice, as well as manager and veterinarian forms and formats, for self-assessment and goal setting for the next 90-days.

#9. Understand the Power of the Human-Animal Bond (HAB).  Interestingly, the ‘Human-Animal Bond’ terminology came into vogue with the Delta Society and Dr. Leo Bustad, back in the early 1980s.  Then by 1990, the American Association of Human-Animal Bond Veterinarians (www.aahabv.org) was formed (only a $35 membership fee).  I am a Charter member of both, as well as a past Board member of VetOne, a veterinarian-industry cooperative of the late 1990s.  HAB spawned the bond-centered practice, which then became the client-centered practice, and is now the Pet-centered FEAR FREE practice.  My most current FEAR FREE contribution is the VCI Signature Series monograph, Building the Bond-Centered Practice (from the VIN bookstore, www.vin.com), updated in 2013. Concurrently, my text, Promoting the Human-Animal Bond in Veterinary Practice is now in the Second Edition (circa 2009), with all 26 appendices (mostly staff plug-n-play type ideas) with the new well care chapter (250 pages); the good news is that it can be obtained for FREE – and you should be able to afford FREE.  The book is posted in the VIN Library (www.vin.com) for FREE DOWNLOAD – it only takes a half ream of A4 paper.

#10. Become a Student of Leadership.  I advocate being a continual student of leadership . . . a good leader must be able to manage, but a good manager may not have the slightest idea about leadership.  I once had a CFO approach me and wanted to blame another Director for an operational shortfall, yet I would not participate in the “blame game”.  She returned the next day as offered to take 20% of the blame, if I would support her effort in passing 80% of the blame to another Director, again I asked about ‘future think’ and would not play the “blame game”.  On the third day, the CFO offered to take 60% of the blame if we could shift 40% to another Director; I again told her that if she wanted to work on future prevention, alternative solutions, or even reorganizations, I would participate, but I would not enter into the “blame game”.  She never understood; she was “bean counter” to her core!  In the 2000+ practices I have visited, I have learned something beneficial in every one, usually from a staff member.  My first text was, Building The Successful Veterinary Practice: Leadership Tools (Volume 1), three of my Signature Series monographs specifically address various leadership aspects within a veterinary practice, I have written three separate leadership courses in three different countries, and in the 19 weeklong leadership courses that I have staffed or led, I have learned something about the inter-relationships of the leadership skills, and the inherent understanding of participants about the human nature leadership.  In my text, The Practice Success Prescription: Team-based Veterinary Healthcare Delivery, available for FREE download from the VIN Library (www.vin.com), it comes together as an essential element for a cohesive veterinary practice development plan.  In simplest terms, the WHAT and WHY must be shared by the leader as a new concept is shared and before a program can be moved forward.  The WHO and HOW must come from the appropriate staff members working in the zones to be impacted.  The last step before any implementation is determining the WHEN, a joint agreed upon set of milestones and success measurements.  A good leader does not unilaterally change the target in the middle of an implantation effort.  A manager will often take credit and give blame, but a true leader will take the blame and give credit to others. You can manage programs, yet you must lead people.

Listing ten tips and truisms may sound presumptuous, yet that is the topic the AVBA assigned me.  My preference is to enter into the practice fray and assist a practice team and its leadership to assess the organizational behavior, work through the issues at hand, and move the practice to the next level – this is what tailored consulting is all about!  It is not an overnight fix, nor can it be done by adding some gimmicks; most of us have tried that and found the choices wanting, and the apparent solutions unlasting.  Any of the above tips should be tailored into your own practice philosophy, core values, and mission focus; they must become part of the ordinary and not be seen as passing “tests”.

Speaking of  "tests", I have included a self-assessment for PROFESSIONALISM as a leader in your workplace at the end of this article.  Have fun!

VETERINARY LEADER PROFESSIONALISM SELF ASSESSMENT

The following characteristics relate to professionalism in the veterinary workplace. Answer these questions to see if you exhibit a high degree of veterinary professionalism.  Answer yes if you demonstrate these characteristics or behaviors at least 90% of the time.

1. Do you have all the skills required to be successful as a practice leader? If not, are you in the process of learning them?

2. Do you communicate (verbally, visually, and in writing) well with others?

3. Do your managers deem your behavior to be professional? Does your manager and zone coordinators approve of your attire, the hours you keep, the way you conduct yourself in general? Does he or she seem comfortable coming to you with special projects or to discuss problems or ideas?

4. Do you have a high level of integrity? Do you tell the truth at work? Are all clients treated (and charged) the same.  Do you see personal tasks through to completion and avoid cutting corners?

5. Do you practice the Golden Rule? A true professional treats others with respect and expects the same from them. Do you return borrowed items right away and in good order when you’re done using them?

6. Do you live up to your commitments? In any leadership role, you agree to do certain tasks and assist/mentor others. Some tasks you must do routinely, without asking others to take on your responsibilities; others you delegate the outcome accountability and become a  mentor (e.g., not taking them back). A real test of your professionalism comes in your ability to meet all these commitments while upholding the standards of quality and timeliness set for your practice team. Individuals with a high degree of professionalism make promises to themselves and to others about what they will and won’t do. They keep those promises.

7. Do you report to work at the agreed-upon time (or early), ready to work, and with a cooperative and positive attitude? Do you willingly pitch in during times of staffing or other crises? Do you keep the team informed when you will not be available, and return on time ready to work?

8. Do you avoid conducting personal business while at work?

9. Do you take full responsibility for the results of your efforts and actions?

10. Do you have a quarterly performance planning process in place in your practice, and ensure it operates effectively by monitoring target action progress?

11. Do you have a your own quarterly performance plan and continually seek self-improvement and self-awareness by looking for opportunities to enhance your professional growth?

12. Do you take pride and satisfaction in the work you do, both clinically and operationally?

13. Do you actively participate in one or more professional organizations?

14. Do you keep confidential and staff assessment information confidential?

15. Do you avoid "telling" and "berating" of staff (e.g., the bullying method you saw as a student at veterinary school clinical rounds)? Are new programs
"brainstormed" (i.e., no value judgments during the process) openly with the staff members, and programs allowed to mature within zone staff discussions?

16. Is your practice the employment of choice for veterinary staff in the community?

Mid-month April 2014

I am here in Australia and Easter is coming -  big weekend here - so everyone asks "What are you doing for Easter?" Funny thing - no kids so no eggs to be hid.  No family, so no trips to be made.  I am at the age of reminiscing, and my mind goes back to Montana in the 60s, where Easter was spring skiing - shorts and a sleeveless sweat shirt on the sunny slopes of Bridger Bowl.  I had Head 210 GS skis for the snow in the bowls, and 3' shorties for the groomed slopes.  It was an interesting time, since a Canadian fraternity brother from Banff (Calgary) taught me to ski early on, and I was instructing the beginners at Bridger Bowl (the Bridgers are a unique east-west stretch of Rocky mountains, so there was north facing slopes - meaning GREAT POWDER). So why do I regress here?

When teaching skiing, you have to get people to lean forward (which when rushing down a mountain side, seems crazy).  The exception is when skiing deep powder and you have to float your tips, hence my Head 210 GS skis. But I regress on my regression.  Most beginners just will NOT lean forward, it feels awkward and scary.  I have watched even intermediate skiers on the intermediate slopes going downhill without leaning forward - they think they know better than the experts. When you lean forward, you are committing to the slope, and instead of coasting, you are carving your turns on the mountain. The stakes are higher - the decisions you make each second are crucial . .  . you are fully engaged with the sport, the  each at mountain, and with yourself.

Unfortunately, many skiers never learn to lean forward.  Leaning back is easier, simpler, and feels safer.  It feels more natural (especially if your are a Queensland water skier).  Yet, this resistance to leaning forward leads to mediocre skiing.

I wrote the text, The Practice Success Prescription: Team-based Veterinary Healthcare Delivery, VIN Press, circa 2009, and it is in the VIN Library for free download. Yet it requires the practice leader to "lean forward" as they change their practice culture, and most do not.  They download the book and try to 'cherry pick' ideas, rather than committing to the adventure by leaning forward and craving their course into that mountain. 

The last two Fortnightly News notes included articles on interpersonal skills, mentoring and bullying, but to embrace those concepts, practice leadership to commit to changing the practice culture and organizational behavior paradigms (a new Monograph in the VIN Bookstore). That is not unlike leaning forward when skiing, and in most Baby Boomer led practices, the leadership is NOT leaning forward and NOT committing to carving a new course down the mountain. The reasons are many, but it often comes down to the mentor selected for the practice leadership and practice culture redesign - most Baby Boomer led practices do NOT invest in a qualified veterinary savvy consultant, and if they do, many still revert, even after seeing their staff get excited and fired-up with the new accountabilities of team-based veterinary healthcare delivery.

Leaning forward is scary!  Change is scary!  Altering the interpersonal skills, mentoring and organizational behavior paradigms is NOT easy if you have never done it before. I am always amazed at the veterinary leaders who use bullying styles instead building better relationships (e.g., Crucial Conversations and Crucial Confrontations, by Patterson, et.al.). The authors of Crucial Conversations didn’t set out to write a book on communication; rather, they began by researching the behaviors of top performers. They found that most of the time, top influencers were indistinguishable from their peers. But as soon as the stakes grew high, emotions ran strong, and opinions differed, top performers were significantly more effective. What the authors observed during this study and captured in this runaway bestseller is a distinct and learnable set of skills that produce immediate results.

The attached article take sit up a notch. Centers of Excellence is a foray into larger general 

companion practices (multi-doctor) as well as emergency and specialty practices, and discusses how to work and play well with others. Sure sounds like "leaning forward" as you start carving a course down that mountain; and I am available for helping the transition occur in your practice.

Please note - I have added a new, economical, regional practice assistance program to my Australian consulting options, which could be exported with some coordination, titled:

TIME TO SMILE AGAIN (/vci-programs.pml)

Have a Happy Easter, and please remember, rabbits are NOT allowed in Queensland - signs are posted at the NSW border for rabbits that can read. But there is a QLD movement to recruit Bilbies (rabbit bandicoot).  :>)

Tom Cat >*-*<

Thomas E. Catanzaro, DVM, MHA, LFACHE
Diplomate, American College of Healthcare Executives
CEO, Veterinary Consulting International
8 Sean Street
Boondall, QLD 4034
cell: +61 (0)4 1628 5975
Fax: +61 (0)7 3865 2368
Web: www.drtomcat.com
E-mail: DrTomCat@aol.com

P.S. VCI Seminars at Sea (Alaska cruise in August, with a faculty of 8 Internationally-savvy speakers) would be a great opportunity to start that "lean forward" transition for yourself. Details are posted at /site/view/214832_.pml. 

As an alert, the following was just sent by our cruise coordinator, Randy Norris, to a recent inquiry (randy.norris@frosch.com):

We have limited availability on the cruise, but I do have a few balcony staterooms available.  Total cost per person, including all port charges, government taxes, transfers to/from the ship and gratuities…$2,223.53.  This quote does not include airfare.  We also are offering an optional pre-cruise tour of Denali and a post-cruise tour of the Canadian Rockies. If you are considering something else, please let me know. 

PLEASE - Book now and avoid being squeezed out of this great CE adventure! 

Mid-month April Attachment:

CENTERS OF EXCELLENCE
Thomas E. Catanzaro, DVM, MHA, LFACHE
Dipomate, American College of Healthcare Executives
CEO, Veterinary Consulting International
DrTomCat@aol.com; www.drtomcat.com

People are like stained glass windows; they sparkle and shine when the sun is out, but when darkness sets in, their true beauty is revealed only if there is light within.        Elizabeth Kubler-Ross

Why in the world would a consultant who wants to talk about “centers of excellence” start with a quote from the leading author in Death, Dying and Grief?  The answer is basically an observation of what has been happening to our profession.  The Veterinary Teaching Hospitals (VTH) used to be our “centers of excellence,” yet all the recent studies show new graduates are not prepared for the real world of practice.  They have amassed a significant debt, and have not learned to influence decisions by clients for the welfare of the pet.  Most all of the new graduates, interns and residents seem to understand the esoteric logic of academia, but have not learned how to work and play well with others; most would have a hard time getting a “D” in sandbox play.  This is also seen in many of the specialists leaving academia, since they were the “trainers” of the interns, residents, and new graduates.

THE TRUTH OF THE DEMOGRAPHICS

A true center of excellence is more than large facilities, good doctors, and expensive equipment.  We cannot expect people raised in academia to understand the business and client relations required in private practice.  Just about four decades ago, before the expansion of the clinical-based board specializations, many land grant, college-based Veterinary Teaching Hospital (VTH) professors had come out of private practice and into the teaching hospitals; now they go from graduation, to internship, to residency, to academic appointment, to tenured professor, so personal clinical productivity is no longer an expectation.  Concurrently, while the Veterinary Teaching Hospitals have become centers of excellence for tertiary care, some of the privately-owned specialty practices are becoming the centers of excellence for profitable veterinary business models.
 
The one-veterinarian practice is disappearing, and multi-doctor practices are emerging. The challenge is the old one-doctor owner only had to discuss changes with the person in the mirror, but when the leadership base is expanded, the savvy practice owner understands that a change in  operational programs requires a change in organizational behavior.  According to Dr. Glen Richards, the visionary CEO of our corporate consolidator in Australia (as published in the The Australian newspaper earlier this month), "over half the Australian practices are still operating if they were in the 1970s and 1980s." In the USA, we have seen the same challenge; practice owners expand and do not change their personal "discuss it with the mirror" behavior.  So this article is discussing what larger specialty practices have learned, and what successful multi-veterinarian practices have emulated.

A true center of excellence requires the presence of an integrated program of delivering quality health care, including the ability and commitment to measure quality of care on a continual basis and compare it with an external benchmark; high levels of client satisfaction due to better continuity of care; availability of a more comprehensive array of services; ability to handle the full range of complications; and lower cost based on improved efficiency and productivity through the implementation of standards and staff-based facility operations.

While the concept of centers of excellence is not new, it is gaining more attention as veterinary specialists, multi-owner facilities, and multi-doctor practices begin to exhaust their abilities to increase revenues by the “traditional” methods.  One of our consulting partners is a sole-owner surgical practice where the ownership takes home about $1.6 million a year.  We also consult with a seven million dollar grossing partnership (it was less than $3 million when we started working with them) that still refuses to manage all elements of the practice, or even measure productivity by the individual owner, so they must rob Peter to pay Paul, thereby reducing their individual personal take-home income to less than a quarter million apiece.  We have one university VTH where the neurologist was a true work enthusiast, and actually asked how she could help the fiscal condition of the VTH; after assessment, we told her to take one less case a day, since she was losing more than $1000 on every billed case.  These examples are not unusual, since most VTH systems collect a much smaller portion of their costs in fees than private practices (the worse case VTH we have encountered has been $400,000 annual gross collections for more than one million dollars of veterinary healthcare service sales).

THE BOARD’S ROLE

Leadership and performance assessments have become established business tools, but are still rare occurrences in healthcare, veterinary or human!  Many veterinarians avoid feedback on performance, or go through such assessments without a clear idea of the process and how to maximize the feedback they receive.  Many times this has been caused by the sender, who is going through a process they have read about without really understanding the core elements of the philosophy.  For ANY assessment to be successful, it is important to define expectations up front, take an active role in the nurturing and developmental process, and then to build on strengths as the assessment process is shared.

The current management guru thinking is that the most comprehensive assessments give you feedback from different types of people - including your direct team, your peers, lateral service specialists, and the administrative supervisor(s).  Sad to report, for Gen-Y staff, it is often from their peer group from social media, totally uninformed individuals supporting the Gen-Y staff member's perceptions of "fair".  The real assessment should have a broad enough base to allow open feedback, such as - career development, intellectual abilities, management style, team skill development, interpersonal communication styles, emotional profile, and personality/behavior make-up and traits.  In the normal world, this is called “open feedback,” in management it is often called “360 degree assessment,” and in the practice, it is usually called “a pain.”  Regardless of what you call it, after it has been done, you should be able to:

• know that it has been a positive effort, discussing the good aspects that need to be expanded upon; it should not be a negative, fault finding, exercise
• connect daily actions, thoughts, and perceptions to career/work goals
• increase self-knowledge and become more aware of the routine thought processes
• determine how others perceive you, both personally and professionally
• learn to better manage others’ perception of your behavior and actions

 
 If you approach the feedback process with the right attitude and the right information, you too can expect to achieve improvements, The following are a few tips for maximizing the value of the feedback experience:

? Select the right organization for the feedback.  It is important to select the facilitator and individual(s) who will conduct the feedback exercise.  This is not a project for the “do it yourself” practice manager.  The organization should have a history of facilitating the feedback process in veterinary medical situations, they need to respect the social contract associated with healthcare delivery, and they must appreciate the “calling” which most veterinary professionals and paraprofessionals carry with them into this career.  Most important, the facilitator should have a personal style with which the Board is comfortable.
? State what you want and why in the first interview.  Before the Board initiates a facility-wide feedback system, they must decide what they are hoping for and why.  Ask, “What do we want to achieve?  What do the players in the practices want from us?”  The trite answer of wanting to know the strengths and weaknesses does not usually warrant the cost of bringing in an outside facilitator.  There must be more.  If the plan is to identify paraprofessional coordinators and managers to cause the doctors to have more productive time, then state that clearly . . . Have outcomes in mind before starting.
? Understand the different types of feedback that will be received.  There are two types of feedback, destructive (negative comments) and constructive (positive ideas).  Some people call these “strengths” and “weakness” when they do strategic assessments of the business environment, and use the terms “opportunities” and “threats” when they look outside the business entity.  When a Board wants a facilitator to coordinate a 360-degree feedback assessment of key players, personalities and perceptions color the process in many cases.  If the Board has been stingy on recognition, benefits, or even pay raises, managers and practice leaders are seen in a dimmer view.  Sometimes this is reported as someone having weak fiscal skills, when in fact, the Board has never shared budget authority with anyone.  It is important to note, each assessment of the practice entity or the senior administrators/managers is actually a reflection on the Board’s ability to make their key people successful.
? Use the feedback to structure specific outcome plans.  Reports for the sake of reports sets the wrong tone - how the information will be used to “make a better tomorrow” reduces the blame setting and forces people to make commitments for future action.  In some cases, the new directions will be contrary to some of the staff, and they need to be allowed to go on a quest for a better personal environment; this is called “dehiring” in some of our reference texts.  It is not that you hire bad people, it is that the environment/culture of the veterinary entity grows in a direction different from which the individual desires, and that is why they deserve to be set free to seek other opportunities.  A good Board empowers people, while a great Board empowers teams; empowerment is for the new and improved future outcomes, not just doing the processes of the past.
? Follow-up with your colleagues.  Everyone on the Board of a specialty group should be seeking information from the referring practices to assess the reputation of the facility.  If it is a large general practice with extended evening “urgent care” hours, clients need to be contacted personally and the reputation assessed.  Some of the information about the practice will have a tendency to cause “knee jerk” reactions, but resist the urge!  The information from others is how we learn of the perceptions, and perceptions are REALITY for the people who hold those feelings.  Following up with peers, direct reports, and coordinators within the practice can also help develop strategies to improve relationships and plan the practice’s self-development.
? Respond appropriately to negative or positive comments.  Whatever the Board learns during the feedback effort, ensure you keep a balanced assessment - the goods most often outweigh the negatives by many fold, but many Boards only hear the negative.  Feedback, negative or positive, is not a cause for interference with operations, unless it is a Board policy or precedent that has caused a challenge to operations.  Share the feedback in a positive perspective, even if it was negative, and allow the staff to develop the action plan for resolution of the negative or continuation of the positive.  Remember, behavior rewarded is behavior repeated, and positive feedback is a morale booster, especially from a Board.
 
 If the Board appropriately defines core values and expectations, apply them to the mission focus when making policy and precedent decisions, positive feedback should reinforce the core values and expectations.  Concurrently, the Board must  ensure an adequate program-based budget is developed for the staff to operate the facility and programs (see the Wiley text, Chapter 4, Building the Successful Veterinary Practice: Programs & Procedures (Volume 2), for details on program-based budgeting).  A well-conducted leadership assessment can be an integral part of the team’s development, and it must be seen as a long-term investment in the practice’s development and growth.
 
 COORDINATE CARE AMONG SPECIALTIES
 
 Centers of excellence apply a multi-disciplinary approach to healthcare delivery.  Under this approach, the zones of the hospitals are operated by the staff, and they ensure the doctors stay on schedule and use the equipment and support staff in the zone in a safe and appropriate manner.  Admitted patients are evaluated by specifically-trained veterinarians, ancillary providers, and if necessary, clinicians from a variety of other specialties.  Many specialty practices employ a social worker to help the clients through the stress-filled times of patient crisis, thereby freeing up the staff for critical and specialized healthcare delivery demands.  In the case of many specialties, the patient needs “urgent care,” and there is a reluctance to refer to the VECCS  specialist on staff.  When a multi-specialist complex uses a team approach to manage crisis cases, the process is usually shortened, and most often, the patient recovers sooner.  The multi disciplinary approach is crucial for treating patients with complex medical problems who need immediate care!

 
 One of the most important keys to success of a center of excellence is grouping the specialties together in a seamless, integrated, and organized fashion, in both patient care and facility utilization.  Currently, some multi-disciplinary, specialty groups are vying for the same patient market, which can be a major stumbling block to true integration.  For example, in vascular services, interventional radiologists compete with cardiologists, who compete with surgeons, which can create an environment of minimized cooperation.  Or in emergency medicine, the ER clinician doing an ultrasound, which is often done by the radiologist or internal medicine clinician during daytime hours, is based on patient need, and not "turf", for the case at hand.  However, if the Board deals with these issues at first occurrence, and forces collaboration of the right specialties to find the best and most cost effective treatment for the patient, the client and the referring clinician have increased confidence in the facility’s ability to handle complex healthcare problems.  For this collaboration to be effective, the specialists involved need to establish uniform clinical protocols so that a busy practitioner does not have to spend time figuring out whether and how to proceed with the best treatment plan.
 
 When practices have the ability to use a center of excellence veterinary healthcare delivery system, they have the potential to influence the practice’s market share, improve client satisfaction, enhance the quality of care, and increase the perception of value within the community.  When a practice complex centers on pacifying specific whims of specific doctors, rather than staying client-centered (clients are referring practices and animal owners), a downward spiral will develop which causes major dysfunction in operations.  So as a savvy veterinary healthcare player, either on the staff or the Board, keep your focus on patient advocacy and client-centered service; talk to the referring veterinarians and exceed their expectations for information and support.  Ensure you know the core values of the veterinary healthcare complex, and the expectations of the Board and hospital administrator, as well as the chief of your specific specialty. 
 
Veterinary practices, their practitioners, and in some cases, the specialty practice staff, strive to be an integral part of a center of excellence, and have the potential to influence an organization’s market share, client satisfaction, quality of healthcare delivery, and perception of value by the community. In a team-based general companion animal practice, the staff members are empowered to represent the practice's SOC expectations; the word NEED replaces "recommendation, and a "healthcare plan" replaces the traditional outdated "estimate" process (i.e., left hand column of value discussions rather than right hand column price justifications/negotiations). 

One emergency practice we deal with has caused the referring practices in the community to increase the use of TKO fluids (to keep open), just because they send virtually every animal back to the referring practice in the morning with I.V. systems flowing.  These emerging progressive and patient-centered type practices, which do not mediate the standards of care based on outdated paradigms, become a benchmark for the professional community as well as client community.  The staff gains pride in the continuity and standards of care, and clients perceive that pride as quality; most clients will  pay for quality as a value, since it provides a peace of mind towards the animal they steward.  Peace of mind, that is all that we "sell" at a center of excellence; all else the client is allowed to buy for their surrogate family member.

End of March 2014

In the last Fortnightly News notes (Ides of March), I attached an article about I.Q. vs E.I. - and that got me thinking, which is usually dangerous for someone.

While most vets have a high I.Q., or at least a very high academic history, E.I. is NOT a given.  When I was doing a seminar for the CSU Veterinary School students, one approached be after the seminar and said, "By what you said, we have to deal with people as veterinarians, I may be in the wrong profession, I am in veterinary medicine so I only have to deal with animals!" I nodded and said she was correct, and no animals carry wallets or credit cards, so she had to deal with people if she went into practice.  Her follow-up was equally interesting, "So, it looks like I have to go into research."  I explained to her about boards, supervisors, and even in academia, colleagues. Her response was as expected, "So what am I supposed to do? I have spent 7 years of University pursuing veterinary medicine and I am about to graduate in a year, and I do not want to deal with people!" My answer was simple, I told her to join Toastmasters, or take a Dale Carnegie course, or maybe get some personal counseling, since people will always be in her future once she leaves the hallowed halls of academia. That got me an unexpected response, "Oh, that's right, I could get an internship and residency and stay within academia!" My response was, "Students are people!" and she responded,"But no one cares if a professor does not relate well with students, and the reciprocal is true, no one cares if students cannot relate well to to the world."

On the 2000+ veterinary practices I have visited, as well as the 19+ week-long leadership courses I have staffed, the major variable is E.I. (Emotional Intelligence).  In fact, in most cases, the core issues lie with the practice owner, Medical Director (often the same person), or practice manager (who has usually been trained by the practice owner, who has not had management or leadership development experiences except at the school of hard knocks).  Practices have the staff members they deserve (they have been hired, trained, and retained) and the clients they deserve (they have been courted, oriented, and retained). Then they invite me in and want me to change everything they have built, without changing themselves.  My consulting engagement letter now says, "If you do not plan to change, do not invite me into your practice."

When we build a veterinary healthcare delivery team (the 500 page book is in the VIN Library for FREE download, www.vin.com), we first train the staff to a level of being trusted, then build a mutual respect by using small 'outcome oriented' tasking, with accolades by the practice leadership for the journey as well as achieving the milestones and approximating the expected success measures. After that, we empower the staff member(s) to develop a program within their interest area, and give them the resources (time, money, Internet sources, etc.) to develop and implement a client-centered, patient advocacy, program plan.  Again, we do this with accolades by the practice leadership for the journey as well as achieving the milestones and approximating the expected success measures. It is only after these sequential steps that true team harmony starts to surface, and that then lends itself to inter-team synergy and an enhanced practice culture, which lends itself to the improvements in productivity and performance. 

What do we usually see when a practice is embarking on this journey without a mentor?

1) Practice owners cherry picking the 500-page reference, and skipping steps, and then wondering why no one is moving forward as desired.

2) Medical Directors or managers tasking process, rather than outcomes, and then wondering why there is no initiative for continuous quality improvement (CQI).

3) Staff members who have been "burnt" before, so they lay back and internally think, "And this too shall pass." With tenured staff, this is often the discussion outside the practice setting.

So the attached article is about mentoring; the good, the bad, and the ugly.  And yes, I am available to sign-on as a practice mentor (consultant, see my web site, shown below, for the current time-based fee details), so the journey does not have to be an exercise of frustration.  If you have never been there, and have never developed a true team-based veterinary healthcare delivery team system, step-by-baby-step, please do not embark on the journey in the dark.  Please, get help (the VCI Seminars at Sea 2014 would be a great synergy time, information below).

I am available on both sides of the Pacific pond. :>)

Tom Cat >*-*<

Thomas E. Catanzaro, DVM, MHA, LFACHE
Diplomate, American College of Healthcare Executives
CEO, Veterinary Consulting International
8 Sean Street
Boondall, QLD 4034
cell: +61 (0)4 1628 5975
Fax: +61 (0)7 3865 2368
Web: www.drtomcat.com
E-mail: DrTomCat@aol.com

ALASKA - Adventure CE - AUGUST 2014

THE BEST FAMILY  & TEAM REWARD TRIP EVER!

End of March Attachment:  Mentoring Mania                                    MENTORING MANIA

 Thomas E. Catanzaro, DVM, MHA, LFACHE

Dipomate, American College of Healthcare Executives

CEO, Veterinary Consulting International

DrTomCat@aol.com; www.drtomcat.com

“The mediocre mentor tells. The good mentor explains. The superior mentor demonstrates. The great mentor inspires.”    Dr. Tom Cat

Students graduate from veterinary school and are told to find a good mentor for their first job.  The academics don't tell them, and the students fail to realize, mentoring is NOT core subject in veterinary school, nor are there progressive continuing education courses specializing in making doctor-centered veterinarians acutely aware of what mentoring is all about in today's professional arena, nor are there course that teach the skills and attitude needed to be a great professional mentor.

THE TWO-WAY STREET

Mentoring is a two-way connection based on trust, honesty, and competencies. Agreed upon expectations and boundaries help manage the balance in the mentor-mentee relationship. My own understanding and experience for mentoring relationships started at the Academy of Health Sciences, in a one-month, full time, faculty development program, and has been honed over many leadership courses, as attendee, faculty, and course director; I have never been involved in a course or consult where I have not learned something new about mentoring and leadership. In short, mentoring relationships ensures that both parties are accountable, responsible, and engaged, and have a few basic "rules" for the process:

1. Only mentor people who take the commitment seriously and are action oriented.

2. Teach mentees how to think, not what to think.

3. Ask a lot of questions.

4. Listen carefully.

5. Keep advice simple.

6. Build on strengths to counter weaknesses.

7. Hold people accountable, e.g., "When will you . . . ?"

8. Set expectations, "What will success look like?" "What happens when you

          succeed?" "What does failure look like?"

9. Stay involved. respect appointments to meet, overlying schedules, and engage in

          Q&A, listening!  Don't just commit the time - commit the energy!

10. Consider the whole person, including home life, hobbies, and outside interests.

          Are any affecting performance or concentration?

11. Hear their caring intentions, don't make them wrong when an idea is shared.

My favorite tool in mentoring is to use literature, and teach mentees how to research, challenge, and think for themselves. When assigning a project, refer to a history, or biography, and prepare yourself for some interesting revelations. Ideally, a mentor should always work on becoming a better mentee, and a mentee should work on becoming a great mentor. Different mentors, however, have different attributes - no one has all the answers.  It is possible that you may be unable to provide the right guidance for any number of reasons. Look into yourself and acknowledge, if that is the case, that the maximum benefit is not there for the mentee. Give him/her permission and time to seek another relationship that may be of assistance.

Sometimes, having two mentors simultaneously can be of benefit to the mentee.  One from inside the practice, and one from outside the practice (maybe from Rotary or elsewhere in the community). First and foremost, the mentee must be comfortable and relaxed with the in-practice mentor; the outside mentor may make the mentee uncomfortable, since they may not respect the paradigms and excuses found inside the practice.  The tension in this arrangement keeps the mentee on their toes and makes them high conscious of personal behaviors, as well as highly focused on the discussion at hand.  It will take an extra effort to address the assignment(s) and ensure the quality of the finished project or final discussion summary.

TELL-TALE SIGNS THAT INDICATE YOU ARE NOT A GOOD MENTOR

When he came out of surgery, no one was standing around; in fact, the entire staff had all disappeared.  I was consulting in a two partner practice in Texas, and noticed that a busy inpatient team vanished when one partner was about to emerge from surgery. I finally found the staff gathered around a picnic table on the back of the property, and asked them about the exodus.  They were honest,  That partner would come out of surgery and reroute/retask everyone without even asking what they were doing. It made for a very fractured work day, not to mention a very poor practice culture. The other partner, who was a great outpatient clinician, when confronted with this syndrome, tried to make excuses, but when I would not accept the excuses, decided they needed to have a crucial confrontation (Patterson's second book after Crucial Conversations); I provided him the text.

Are you a mentor that loves to tell stories about your own successful  cases, or maybe your hobby, or even your pets?  Do your team members make lame excuses to avoid you?  Have you tried empowering your trained and trusted people, just to revert and take back all decision making, returning to the traditional control-freak mode of a doctor-centered practice?  Chances are, if these things are happening, you are the problem, not the solution.  Here are a dozen various tell-tale signs (they all do not have to occur within your style for mentorship to be negated):

People's eyes glaze over, they do not make eye contact, and some even yawn when you are pontificating.

You notice that no one asks questions to clarify what you mean about any item or project.

Colleagues invite others into the conversation with you, then soon disappear.

You talk incessantly about your subject of choice, never asking of an opinion or input.

You spend too much time in communal areas, like hanging out in the break area or around the front desk

Staff members find  a reason to leave when you enter the break area.

You have a list of petty complaints about the practice operations, and never hesitate to air them publicly.

When not in surgery, you spend your day looking for ways to make your days more interesting.

As a manager, you seem to delight in listening to practice gossip.

You know very little about the staff members, but they know a lot about you!

Staff members in the break area put on their ear-buds as soon as you enter the area, or pretend to be talking/texting on their phone.

Staff brainstorming energy reverts to safe program tweaks, and the staff starts to wait for the new ideas to be issued by the owner again.

FEEDBACK LOOPS

When I ask any mentees what matters most when leading a project team, I often hear about connections between people, not the crunching of numbers.  Successful leaders excel in empowering others to assume management/project leadership by asking, "What do you think needs to be done?", not "What do you want to do?" This type question sets the stage for mentee to prioritize milestones and success measures, not his/her own engagement.

Effective mentoring improves productivity; it strengths skills be reinforcing lessons already learned. It helps others recognize their own special gifts and potentials; it builds confidence, and more often than not, it teaches both mentor and mentee new things about organizational behavior (see Signature Series monograph of that title in then VIN Bookstore, www.vin.com). 

If your mentoring efforts are done with an honest commitment to others (sometimes called "servant leadership", a term coined by Bob Greenleaf in 1970, made popular by Blanchard & Hodges in 2003, and expanded by Sipe and Frick with the "7 Pillars" in 2009), you will find mentoring brings personal enrichment, revitalizes your day, and provides an enduring sense of accomplishment as you follow the personal growth of mentees and the practice team.

Ides of March

The Ides of March (the "middle of March") is the 15th day of the Roman month of Martius and is most closely associated with Julius Caesar - it was not a good day for Julius - he got stabbed 23 times by his "trusted" friends on this day in 44 B.C. - most of us know how that feels.

I was just asked this past week to submit an article to a national magazine on comparing practices.  At best, comparisons are odious.  How would you compare an apple to a watermelon, since they are both red? How would you compare a sea slug to a Great White Shark, since they are both live under the surface of salt water?  How would you compare one-doctor veterinary practice, in a one exam room leasehold facility, with two part-time staff, in a depressed catchment area (family income 30% below major community average), with most clients having less than a high school education, to a progressive, six consult room, free standing, three doctor practice in an upscale community with an average "college degree" client base? 

The article for this Fortnightly is discussing Emotional Intelligence (EI) instead of IQ, since the depressed community EI may in fact be higher than that of the upscale community . . . and the practice that underestimates the HAB and EI of their clients will likely plateau and wither away. I have seen it happen, and in one case, the consulting client forbid me to discuss programs when trying to rally support from her tenured staff. Three months later she came back and asked "Which Programs should we start with to get buy-in".  The challenge was deeper than that - she had hired technicians who were all breeders, so they naturally answered all questions on the phone and kept clients from coming into the practice. We had to find programs for each staff member that would require them to bring clients into the practice.

In another recent practice consult, we were converting from a spay-neuter practice to full service, but referral of well-care issues to staff was not occurring. We first issued pocket notebooks to each staff member, with programs across one margin and provider vets along the other, and each week, notebook pages were provided the manager to count the in-house referrals, and veterinarians who had swore to the SOC well-care compliance issues yet had no referrals to staff had the opportunity to meet one-on-one with the medical director/practice owner, to discuss their SOC compliance rates and well-care commitments. This required a confrontation, which most veterinarians try to avoid, so I had the leaders read Crucial Conversation by Patterson, et. al., and made them address the practice health vs "nice guy" paradigms.

When the smoke cleared, it was all EI factors!

Hope you enjoy this edition, and please think about the Alaskan Seminars at Sea 2014 in August, (/site/view/214832_.pml), since these type issues can become your tailored open one-on-one discussion time to help YOUR practice. The optional pre-cruise rail trip to Denali and the optional post-cruise trip to the Canadian Rockies are added benefits for making this a family outing to remember . . . adventures like this make continuing education a memorable time.

Ides of March attachment:  Interpersonal Skills

IMPORTANCE OF INTERPERSONAL SKILLS

Thomas E. Catanzaro, DVM, MHA, LFACHE

Dipomate, American College of Healthcare Executives

CEO, Veterinary Consulting International

DrTomCat@aol.com; www.drtomcat.com

For most people, Emotional Intelligence (EI) is more important than one's learned intelligence (IQ) in attaining success in their lives and careers. EI is the ability to monitor one's own and others' feelings and emotions, to discriminate among them, with an ability to read signals from other people, and use this information to guide one's interpersonal relationships, actions and thinking in an appropriate manner.

Steve Bressert & Kendra Cherry

We have heard it before, but it bears repeating: Studies show at 90 percent of veterinary practice leadership failures are attributable to shortfalls in interpersonal competencies - factors such as leading team-based healthcare programs, developing a positive work environment centered on clear Standards of Care, retaining inspired staff, developing respect and trust, and coping with change. The message is clear - if you are going to excel as a leader in a multi-doctor, team- based, veterinary healthcare delivery system, you must master the "soft skills" of caring leadership.

In veterinary healthcare management, where the basic unit of business is the person (stressed client or caring staff member), these skills are even more important, it is a shame that it was not in the basic curriculum of veterinary school.  If the veterinary healthcare providers on your practice staff are spending time replaying a conflict in their minds, their energy is directed away from patient care and client-centered service.  If you lack the "soft" interpersonal skills to motivate your frontline healthcare delivery staff members, including fully accepting the written well-care Standards of Care (SOC), as well as the optimally using the new information technologies, your practice could be missing revenue opportunities and/or negatively affecting patient outcomes and client perceptions.

Emotional intelligence - however "soft" it may seem - has a direct effect on aspects of the practice as concrete as patient safety, client perceptions of clinical outcomes, staff pride (which client's perceive as quality) and profitability. The following is a closer look at the FIVE CRITICAL interpersonal competencies.

KNOWING YOURSELF

It sounds easy, but in fact, self-knowledge is challenging for most veterinarians; we were all raised in a "no error" academic culture, so blaming and rationalization seem to reign supreme. To truly know ourselves, we must become aware of our blind spots, those situations we don't handle as well as we should for optimal business performance. For some practice owners, this involves failure to listen to the viewpoints of others, for some it involves making tough decisions with appropriate urgency, for others it concerns difficulty motivating their own staff. One tendency I am seeing more often is the GEN-Y leader sharing her thoughts out loud (as if they were on Facebook or a smartphone network with peers), which staff members perceive as a plan in the making, and when the thought/dream disappears, the staff become disillusioned; false starts actually cause reserved acceptance of all new initiatives by staff members.  Most veterinarians, especially in Australia, have a tendency to sweep shortcoming, as well as personal weaknesses, under the rug rather than cause a confrontation. Yet inevitably this backfires, the rug gets too lumpy and people start to trip over the accumulated shortfalls being ignored. When weaknesses are ignored, we are also ignoring how they affect others, whether we are overtly aware of the challenges or not. Self-knowledge enables you to recognize your weaker areas and take corrective action.

MAINTAINING CONTROL

Most veterinarians believe that they maintain control; they were trained in case management where all control must lie with the attending provider.  Yet challenge is that the staff members may not agree with the practice owner's self-definition. The key here is to be aware of when you are losing control. Do you pause and reflect when you are entering that territory that is difficult, or does your voice get louder and your understanding of others diminishes? Is your tendency to overreact or under-react? In a large facility I had developed, we also did the community animal impoundment (and adoption), and one of my credo positions was NEVER will I see inhumanity in my practice culture.  We had a new kennel staff member decide it was easier to power wash the run with the animal still in it rather than change the animal to another run when cleaning (per protocol); when I caught this individual power spraying a run with a dog still in it, I shut the system down and physically escorted him through the clinic and out the front door.  The word went out - do NOT ever be inhumane to an animal in this practice! While the occasional outburst can be attributed to being human, if your personal pattern is seen as more extreme - if you are perceived as becoming overly upset or shutting down - you are undermining your own effectiveness.

MAINTAINING MOTIVATION

Motivation is a combination of optimism and perseverance from inside an individual; again, our professional education has usually based on a "bell-curve" academic logic and fear of failure.  Studies have shown that most people have a biologically based "set point" for optimism; when selected to veterinary school, that optimism is very high, and during the professional years, fear increases by an average of 25%. Some people look at a glass as half full, others think it is half empty; very few accept that the glass is full, and only the ratio of the contents may vary. Reality encompasses all three perspectives, yet the more positive the assessment, the better leverage the leader has.  Optimism cascades own to those you are leading, enabling them to stay motivated and positive; the more positive a team member is, the more motivated and tenacious they will be in reaching for enhanced outcomes. When managers are habitually pessimistic and primarily critical, the followers become less innovative and more risk-adverse.  Perseverance is the second part of the motivation equation.  A leader must demonstrate the ability to stay on course through thick and thin, setting a clear vision of where the practice is headed in the long run.

RECOGNIZING OTHERS' INTERESTS

Good leaders have the ability to take a win-lose situation and craft at best a win-win solution, or at the very least, a tolerable outcome perception for all involved. When seeking a transactional attorney for my consulting team, it was almost impossible to find an attorney who understood WIN-WIN - attorneys are raised in a WIN-LOSE culture - but for partnerships, I needed a win-win mind set on our transactional attorney; I eventually found one and we developed him in veterinary medicine, where he has been recognized a yardstick of excellence, and was eventually elected to the Presidency of the USA Consulting Association, Veterinary Partners. To recognize the interests of others, you must know the needs and perspectives of all the parties involved (perceptions play a large part in the formation of perspectives). Only with this level of insight can a leader create buy-in and get the team members behind the practice agenda.  Rather than attempting to control the process every way, which only alienates the followers, a savvy leader defines the WHAT with clarity and provides the WHY in a logical client-centered patient advocacy manner.  The great leader then gives the team members ample time to develop the WHO and HOW, as it pertains to their practice zone(s) and their perceptions of client-centered patient advocacy.  Then the legendary practice culture allows ample time for leaders and followers to come back together, set the WHEN, including training time, starting point, realistic milestones, and measurements of success. Remember the famous adage, "I must know where my people are going so I can run ahead and lead them to a successful completion."

COMMUNICATING FLEXIBILITY

Flexible communications is the hallmark of great leaders.  When developing the Leadership Training Course for Belize, we introduced the concept of "ARF" in the interpersonal relations leadership skill, and participants really grasped the concept.  You could hear "ARF" coming from campsites throughout the jungle; "ARF" stood for Absolute Rigid Flexibility. Leaders must be able to adjust their communication style according to the needs of the situation.  This involves being aware of the effects of your words, as well as the tone of your voice, on each specific audience you encounter.  For example, managers often misjudge the powerful impact of their words and emotions on their team members, communicating with them in the same way they would with a well informed peer. But new and unsure staff members are less likely to push back, challenge, or even seek clarification from their leaders, which all too often leads to miscommunication and feelings of alienation.  This one-way "communication attempt" is not true communication; communication is the getting and giving of useful information.  Talking "at" someone inevitably increases the relational "static" and slows practice progress, often derailing effective outcome results and smashing any feelings of personal pride.

BUILDING INTERPERSONAL SKILL SETS

Good interpersonal skill sets are built over a lifetime, but there are several steps you can take to start building these skills faster and more effectively:

TALK WITH YOUR TEAM

Teach those around you to give you open, honest feedback about your leadership style. That means NOT disagreeing with their assessment, but rather, saying thank you in a caring manner. Tell them what areas you are working on and enlist their help. You might not always get the whole truth, but just demonstrating that you are trying to improve your emotional intelligence skill set can help your team improve their performance as well.

READ

I like to start practices with Bracey's book on Managing from the Heart, Paterson's text on Crucial Conversations, and a few of my Signature Series monographs from the VIN Bookstore (www.vin.com), but there are a myriad of articles and books on communication skills and emotional intelligence. Many of these references provide strategies for real world situations such as resolving conflict or motivation of the team. The simple act of reading about emotional competencies will increase your awareness of behavioral expectations for becoming a "best practice".

DEVELOP MIND MAP BRAINSTORMING METHODS

Tony Buzon has the easiest texts to understand mind mapping, and my text, Building The Successful Veterinary Practice: Innovation & Creativity (Volume 3), Blackwell/Wiley & Sons Publishing, not only describes the process for veterinary practices, but also ends each chapter with a mind map for the reader's completion. Remember, when brainstorming, there is NEVER an assessment in an idea or input item, and if it sounds "off the wall", it goes into the parking lot in the corner of the mind map so it can be recalled for later(even if it is home phone call to "bring home the milk"). Mind maps are built and expanded upon by the group, and then people get to sleep on the ideas, and readdress the mind map on the following day. Eventually, the mind ma is transferred to a project sheet (format is provided in the Leadership Action Planner monograph, VIN Bookstore).

COMPLETE FEEDBACK EVALUTATIONS

The concept of the 360-dgree feedback has often gone astray since they migrated from positive to negative feedback items. If you desire a 360-degree feedback system, keep it sweet, short, and to the point, addressing the positive attributes of the individual an what could be improved with expansion. There are many on-line sources, but as a caution, do NOT use a negative feedback format; this is the time the primary stakeholders get to build on what is good about someone. Other type assessments include personality and behavior self-surveys; behavior can be a term of employment and effected by the practice culture, but personality cannot be changed from the outside.  Self-assessment surveys can often help alert the caring user to blind spots and opportunities for development.

WORK WITH A SAVVY VETERINARY CONSULTANT/LIFE COACH

External feedback can help you develop perspectives that you might not have addressed previously, and if it is a savvy veterinary consultant, add some team-based training awareness to enhance productivity within the practice operations. A life coach is usually not veterinary savvy, but they are insightful in helping you identify areas where your emotional intelligence skills can have the greatest impact on those around you. While the life coach will help you identify strategies for self-improvement, a veterinary savvy consultant can tailor programs to enhance team strategies to enhance communications and awareness for improved client-centered patient advocacy programs.  Whether you have a life coach or a savvy practice consultant, or both, there needs to be follow-up for plan implementation as well as evaluation of progress.

Ultimately, your success in interpersonal competencies is determined by the experience of your stakeholders, whether than be stressed clients, concerned staff, or caring family members. No matter how effective a communicator you believe yourself to be, if your front line providers, your management team, and as applicable, your board, do not feel the same, you are NOT maximizing your leadership potential.

End of January/ Beginning of February 2014

Sorry about being a bit early with this edition - my relocation next week has Stop Telstra Internet and a Start Telstra Internet with a Telstra service delay expected - I requested services be transferred from my current location to the new location - not a big deal in the USA, but in Australia - different story!  So I requested the STOP to be 31 Jan and the Start to be 28 Jan - but Telstra has not standardized their systems, so the two houses are on different equipment - even handled through different service branches within Telstra - Australians are saying, "yes, so what did you expect?" and Americans are asking why do we tolerate this problem - 8 hours on the phone to get a START without a guaranteed 'no penalty' STOP.  Everything is scripted in Telstra, so no one has to be accountable for the answers - not unlike most software service points.

I have discussed the Tall Poppy Syndrome (TPS) of Australia and New Zealand before, and now, some psychologists are stepping in to define why people are underachievers, or at least, why they do not want to be "stars" in their chosen fields - don't you love it when psychologists try to explain the TPS without stating the obvious.

Unconscious Forbiddance vs Peter Principle - tale of two cultures
What if they suffer from what we call "The Fear of Being Fabulous"? If that’s the case, then it’s not incompetence at issue. Not at all. It’s their unconscious Forbiddance acting up, preventing them from rising through the ranks beyond where they were unconsciously permitted to display their excellence.

Unconscious Allegiance or Loyalty

Suppose a very gifted and intelligent individual grew up in a family, a religion, a culture (e.g., Australia) that preached "modesty," "humility," and danger in standing out (e.g., Aussie TPS). In the young person’s mind, especially before the age of seven when the brain can finally begin to make personal evaluations, these messages are received and stored in the unconscious mind as "The Truth."

But what happens when their manager or boss sees their greater potential and promotes them to a quite visible position where "modesty," "humility," and "not standing out" are impossible? It may look like the "maximum incompetence" version of "The Peter Principle" as that individual starts to decline in professional execution, strategic thinking, timely planning, you name it. But they will not be exhibiting incompetence, rather they will be attempting to get the job done within the bounds of their unconscious allegiance or loyalty to what they learned way early on about the rules of good and expected behavior that are now long standing residents of their unconscious.

Judith Sherven, PhD and her husband Jim Sniechowski, PhD http://JudithandJim.com have developed a penetrating perspective on people’s resistance to success, which they call The Fear of Being Fabulous. http://OvercomingtheFearofBeingFabulous.com

OVERVIEW ARTICLE

http://www.linkedin.com/today/post/article/20140106023810-85384926-a-different-point-of-view-about-the-peter-principle?trk=eml-ced-b-art-Ch-2&ut=12YzsBDNcwG641

So I thought the article I would attach to this Fortnightly Newsnotes would center around Emotional Intelligence (EI), as opposed to IQ (all vets have a respectful IQ, that is why they got accepted to veterinary school); TPS is more of an EI factor.  The article is a bit longer than usual due to the combined concept targets, so please bear with me. 

I also centered many of the examples on multi-vet, emergency, or specialty practices, so I do not directly attack the general practitioner . . . but the principles are the SAME and the learning points are almost identical . . . it is just the multi-vet, emergency, or specialty practices, MUST have effective governance (Boards), and thus are great examples for EI awareness, while single veterinarian practices - a dying breed - do not need it immediately (they just talk to the mirror).

This is one area where a savvy veterinary consultant is almost an necessity - and I hope you will see why as you read the attached article.  I am moving houses this week, from a high set with no A/C to a low set with 4 A/C units - I cannot beat the Brisbane humidity, so I must find an alternative, but the move will be finished before February, so make me a consulting offer (general scope of my consulting time-cost details can be found at www.drtomcat.com) with a couple weeks lead time, more if you are second or third in the queue . . . I have two potential consults in Sydney/NSW area, one for 3-days on-site and another for a year-long (4 days on-site, then 2-days on site a quarter later, and then 2 more days in about 90 days when the self-directed training has been about completed), but without any retainers, they have no guaranteed sequence in my consult commitment planning.

I hope this article helps awaken a few leadership stirrings in your operational practice direction(s), and hopefully, allow you to self-assess the EI of your daily personal interactions/relationships.

Tom Cat >*-*<

Thomas E. Catanzaro, DVM, MHA, LFACHE
Diplomate, American College of Healthcare Executives
CEO, Veterinary Consulting International
67 Chartwell Street
Aspley, QLD 4034
cell: +61 (0)4 1628 5975
Fax: +61 (0)7 3865 2368
Web: www.drtomcat.com
E-mail: DrTomCat@aol.com

P.S.  VCI Seminars at Sea 2014 - AUGUST 2014

Agenda, itinerary, and very special faculty bios at  (/site/view/214832_.pml)

Attachment (Jan/Feb 2014):  EQ Evolution

EVOLUTION OR REVOLUTION vs. WORKING DIFFERENTLY

Thomas E. Catanzaro, DVM, MHA, LFACHE

Dipomate, American College of Healthcare Executives

CEO, Veterinary Consulting International

DrTomCat@aol.com; www.drtomcat.com

The future belongs to those who see possibilities before they become obvious.     John Sculley, CEO, Apple Computer

The days of experience are being replaced by the days of new challenges.  The skills and habits of yesterday cannot answer all the needs of tomorrow.  Emergency practice went from the “fire engine” production practice, to a “rotary” shared by multiple practitioners, so some could sleep a few nights a week.  Then companion animal demands started increasing, and the “rotary” sharing of night call shifted to the smaller critters too.  Then some bright young man decided there was demand for an emergency practice, a practice that opened only in the evenings and on weekends, and the general practice doctors happily referred those night calls to the young man who filled a niche market.  Then came the specialty practitioner, who could not find a home in academia, and was looking for somewhere to practice his/her trade of highly specialized veterinary healthcare delivery . . . and somehow noticed the emergency practice was not being used during the weekdays.  A symbiotic relationship started to form between specialty practices and emergency practices, so facility and equipment overhead could be minimized, as well as 24-hour care becoming available for the specialist’s patients.

Ever wonder why some of the most brilliant and ambitious leaders derail their careers, while those with less obvious "I.Q." skills climb the leadership ladder?  Since 1987, I have been visiting practices and coaching veterinary healthcare leaders in the 'real world settings' they have created for themselves and their practices.  In the early years, I attributed it to lack of exposure to alternatives, since veterinarians seldom stretch outside their own walls - their "knothole" view of the world was usually VERY restricted!  But it was not an I.Q. or experiential factor, it was a shortfall in their innate emotional intelligence (EI).  Most veterinarians scored well in high school and university entrance exams (those are I.Q. elements), but with a shortfall in emotional intelligence, they ended up inadvertently harming their careers as a result of unhealthy behaviors and habits.

Because good leaders, by definition, achieve organizational goals through others, you'd like to assume veterinary practice owners have superior people skills.  However, all too often, this is not the case.

FIRST - in veterinary school, they were taught they were accountable, 24/7, 365, and were trained in case management - seldom was the veterinary healthcare team ever mentioned, much less leadership skills (most academics have tenure, not leadership savvy).

SECOND - when starting a veterinary practice, there is seldom money for staff, so the veterinarian learns to do it all themselves. As they incrementally add staff members, seldom do they consider upward mobility or expanded capabilities of the new staff member; they just look to reduce their own stress and schedule demands.

THIRD - most continuing education venues post-graduation are scientific, with minimal hands-on team-building experiences or interaction exercises, so they do not come away with real experiences reflecting better team development.

Let's give you a chance explore this further - read the following scenarios and then ask yourself, , "What emotion(s) do I feel?":

You were selected to oversee the implementation of expanded practice hours, possibly 24/7, due to your analytical and execution skills.  Your colleagues tell the boss that you spend your time lecturing instead of listening to the team members.  You interrupt others and work from your own agenda, often putting down feedback as "that is wrong".

You are known as the person who always says 'yes' and takes on extra work or completes the tasks of others.  You feel unappreciated and burned out. You wish you could have just one three-day weekend to yourself.

You are in a meeting and the practice manager, or a colleague, takes credit for your program's success.  This seems to happen often, especially with this person.

The medical director is progressive and well meaning, often implementing new programs, but sometimes without adequate training and feedback before implementation. The practice manager downplays the veterinarian's lack of people-skill style to his vet-centered history in the practice.  You are now "in the middle" and in a quandary of how to provide feedback.

There is NO escaping our emotions!  Whether we like what we feel or not, we are emotional creatures, especially in a profession which most of us entered as a "calling" rather than an economic windfall decision.  Daniel Goleman, author of "Working with Emotional Intelligence" and "The Brain and Emotional Intelligence: New Insights" is the leading authority on EI. Goleman's premise is that sensitivity to emotional states (one's own and others) and effective relationship skills (EI) are critical competencies in today's healthcare environments.  But wanting it does not equate to getting it.

The essence of EI is awareness, transparency, and vulnerability.  EI is the ability to cope with setbacks, remain optimistic, elicit charisma (positive attraction) and stay purposeful even when things are not going well.  EI does not mean that you have to be "soft" or "emotional."  EI simply gives you the tools to identify and build on strengths (yours and others), remove barriers, understand limits (yours and others), focus on solutions, and when necessary, call the foul!

FOUR CORE EI SKILLS

ENTER THE EXPANDED-HOURS DRAGON

The new era of veterinary specialty has been prompted by organizations such as VECCS, and the “out of hours” emergency practices have been giving way to 24/7 Urgent Care facilities.  Sharing facilities format have given way to building mega-facilities to house all the specialists and the Urgent Care services.  The only facility problem is that the academic Veterinary Teaching Hospital (VTH) is the wrong model for a private practice, multi-specialty complex.  Teaching hospitals need hallways to move large groups of students, and to divide research fiefdoms for tenured professors.  At construction costs which often exceed $150 a square foot, hallways and circulation space need to be minimized, receiving and treatment support must be centralized between the occupants, and there needs to be a single Board controlling the policy and precedent of the facility.  This has not been taught in our VTH environments.

I consulted with a small, one-doctor, leasehold practice, in a depressed community, which had plateaued for 18 months. Since most clients commuted to work via bus or train, weekdays were slow, yet Saturdays were pure chaos.  We empowered the team, got them to buy-in to the new vision, and trained them as veterinary extenders with in-house training programs as well as outside wet labs.  We then embarked on appropriate pricing dental prophys, DG1+ and DG2+, for the staff to complete while the veterinarian was doing outpatient services and other duties. We built up the liquidity so we could hire a client relations specialist, and then a part-time associate.  Once the part-time associate was integrated into the Standards of Care and practice's operational culture, we moved the operational format to include Tuesday and Thursday evening hours (Wednesday was a big community church night and welfare checks came on Thursday). We increased liquidity so the part-time associate could be full time (yes, it was trial and error finding the right person), with each vet working about a 35-hour week. Saturdays were less chaotic, and Tuesday and Thursday nights became busy outpatient times.

In one central hospital, when we entered as consultants to do the feasibility assessment, the existing ophthalmologist stated very clearly that he did not need any other member of the complex and would not participate in the rental of the common use or shared use areas.  It only took the new board a few months to see the fallacy in that logic; the new replacement ophthalmologist has been cooperating very well ever since.

In a multi-practice owned central emergency hospital, surgical space was utilized by the owners of the outlying practices.  They were supposed to schedule the surgery space use, but a few always wanted “drop-in” privileges, and came in as “owners” and redirected operations to their own benefit.  A few others wanted to handle their own early evening emergencies at their own clinic, and then refer later in the night, yet they wanted a full share payment for emergency use and kept reducing central facility staff so there was more profit.  We were called in by the Executive Committee due to the dysfunctional operations.  We found that while the lack of core values was the key source of the problem, lack of Executive Committee support for the operating standards was what was draining the staff and the liquidity.  The “inmates were ruling the asylum,” and the Executive Committee did not want to address the issues.  We developed a Governance Board structure, core values, clear policy and precedence for operational delegation to the hospital administrator, and a routine follow-up system to ensure the new Board kept their word until they learned the new ways were better.

In one multi-specialty complex, when we were doing the utilization review for a new facility, the radiologist thought he was the center of the world, just like when he was a tenured professor.  He did not understand that radiology was usually a support function for most healthcare delivery in a multi-specialty complex.  He even demanded that every X-ray taken be read by him, and he would bill all the specialists for this service . . . we had the board buy all the radiology equipment and then tell the radiologist what the utilization plan was going to be.

We were conducting a follow-up consulting program a multi-specialty practice, and Dr. DTC, ACVECC, was brought along to provide some emergency and critical care development in the emergency practice staff of the complex.  During the after-hours training, Dr. DTC noted the sound of animals in pain, and offered the surgeon his assistance.  The surgeon deferred assistance.  A few minutes later, the sounds of pain again penetrated his training mode, and he again offered the surgeon assistance in pain management; the surgeon again declined.  This exchange was repeated a few more times, with the same non-responsiveness, and as we departed for the evening, Dr. DTC requested my opinion on how to deal with a specialist who was also the owner, and yet neglected pain management.  I suggested a quiet one-on-one the following morning, between the surgeon and Dr. DTC.  Long story short, after that meeting, it is one of the quietest specialty practices we consult with, and pain is no longer an acceptable option with any patient.  A governance Board system could have addressed this if the standards of care had not been so closely controlled by the owner/surgeon.

In one emergency hospital, established in a store front leasehold, an ophthalmologist wanted to lease the clinical space during the day.  The emergency practice was shareholder-owned, and the share holders saw it as a “profitable offer.”  It took two years to get the flow established so the specialist was clear from the facility before the emergency team started operations.  If there was an informed governance board, these issues would have been established before the first day of occupancy.

One well established multi-disciplinary specialty practice contracted with a veterinary architect to design their new building, and by the time the planning smoke cleared, the specialists had added over 20% circulation space so large hallways could divide their areas . . . they needed an experienced consultant to save them that cost, which now, after a couple years of occupancy, they are scratching their heads at the cost of all that wasted space.  In an effort to “save time,” the board had made the decision to use the expertise of the architect, who gets paid based on the cost of the facility, not based on the effectiveness of the plan.  A second opinion from an established veterinary consultant, with facility management certification (e.g., Board Certification by ACHE), would have saved 20% of the multi-million dollar cost of construction, a great return on investment.

These are all issues where a clear and well-developed governance board could have been used to resolve the issues.  Most shareholder boards of multi-practice facilities or emergency practices, just want a return on their investment.  Some want to milk the cash cow out every month, and there are a few shareholders who want to take hands-full of hamburger out of the cow while it is being milked out by the other share holders.  These examples are not usually the people who want to ensure quality healthcare, or even an appropriate practice/facility culture.  Board members must leave their own shoes at the door, and assume the role of a practice advocate when they enter the board room; the board ONLY exists between falls of the gavel.

SIX TARGETS OF OPPORTUNITY

Our veterinary healthcare system is fundamentally flawed in its design.  It relies on outmoded methods of work, such as linear scheduling of doctors as if they were still driving utes (pick-up trucks) from farm to farm.  The system set up for the staff support has often been a failure, as with doctor-centered practices scheduling based on doctor whims versus facility capabilities and staff becoming veterinary extenders (e.g., seen as ward/service-specific nurses, nurse practitioners or physician assistants in human healthcare).  Practices hire people for their strengths, provide inadequate in-service training, pick on their weaknesses, and then blame them for shortfalls; when anyone ”blames,” they abdicate personal accountability for resolution.  We have already proven that working harder will not improve quality, while concurrently it has proven that it can disrupt over 50 percent of the families.  We can learn to work differently, and it must start by redesigning the systems that we have become so comfortable with over time.

To aid in the transformation of the current systems, we have started to publish the VCI Signature Series monographs for the “do it yourself” veterinarians.  In the case of governance boards (Leadership Action Planner monograph and Chapter 2, Veterinary Management in Transition: Preparing for the 21^st Century, from Iowa State University Press), they must focus and align their environments toward providing healthcare delivery that is:

Safe: as Dr. Bill Kay always said to the incoming AMC residents, “First, do no harm” . . . avoid injuries to patients and staff from care and services intended to help them.  The practice’s Safety Committee must be empowered to be an active sentinel of dangerous conditions.

Effective: providing services based on the best scientific knowledge to all who could benefit, refraining from providing services to those not likely to benefit (avoiding under-use as well as overuse of available equipment).

Client-Centered: providing responsive care that is respectful and responsive to the client’s needs and values, while ensuring that patient welfare guide all clinical decisions and care (give two “yes” options - usually time of access choices - record waivers and deferrals).

Timely: reducing wait time, implementing nurse-centered triage programs, avoiding the perception of harmful delays for both those receiving care and those administering the healthcare delivery.

Efficacious: avoiding waste while providing care that does not vary because of client characteristics (e.g., socioeconomic) or patient threat/attitude (e.g., Chow Chow); ensuring what is needed is recorded in the records, and the client’s response is duly noted in sequence.

Client-centered Patient Advocacy: always speak for what the patent needs, and then fall silent and listen to what the client wants.  Stressed clients do not want options, they want to know what is needed, now!  The traditional good-better-best treatment option logic presented to clients was only economic-based options, not what was best needed for the patient's welfare and quality of life. Stay true to your calling - if you do not speak clearly of what is needed for the pet's quality of life, only the patient will suffer when the client leaves confused.

If all veterinary practice owners, as well as facility boards (e.g., multi-practice complexes, multi-doctor hospitals, multi-owner, shareholders, etc.), could use the above Six Targets of Opportunity as an overreaching blueprint for establishing or reviewing their core values, surely clients would experience greater satisfaction and staff could show more pride (i.e., clients perceive staff pride as a quality factor in most healthcare settings).  The VCI Signature Series monographs, have a series of planning forms/tools to assist in both core value development and project planning (available at the VIN Bookstore, www.vin.com).  Veterinary Consulting International can assist with on-site implementation (expanding the knot-hole); the web site (www.drtomcat.com) shares the various programs and time-based fees.

The 21^st-century veterinary healthcare delivery should be a staff-maintained and monitored system that provides client-centered, patient advocacy, evidence-based, and system-oriented quality care.  All of this can be realized if veterinary healthcare leaders consciously incorporate these aims into the redesign of their Boards and policy/precedent operations.

IT IS IN THE PRACTICE CULTURE

To facilitate the fundamental changes, the environment in which care is delivered  must be considered.  Using the aims above as guidelines, the multi-doctor/practice complex administrators should target the following four areas of the facility environment in their Board feedback reporting system:

The infrastructure that supports the dissemination and application of new clinical knowledge and technologies.  Providing evidence-based care will significantly improve quality . . . to provide such care, the leadership must develop new tools so that referring clinicians can be rapidly made aware of the benefits and adopt the best practices for the patients as standards of care.  In a lateral perspective, alternative care techniques are emerging that assist in chronic care . . . local sources need to be identified early.

The information technology infrastructure is redesigning healthcare delivery and continuity of care.  To reduce errors and improve client confidence, clinical, financial, and administrative transactions must become automated.  Most all of the current veterinary software systems are forensically inadequate, but before the end of the decade, most handwritten clinical data could be eliminated by the next generation of software development.  Significant progress is being made in Progress Note driven linkages, automated inventory systems, and PDA-type input devices, as well as related tools to ensure protection from forensic liability and multiple entry requirements in the software systems.

Payment policies work against practice liquidity.  The traditional habit of cash at discharge reduces the perception of affordable pet care.  Practices must develop linkages with third-party payment systems (e.g., Pet Insurance, Care Credit, etc.); these systems cannot require discounts or membership fees if practice liquidity is to be maintained.  All stakeholders in the veterinary healthcare delivery system must reexamine payment policies to develop methods that provide fair payment for good clinical management of the types of patients being seen.  Financial services must be aligned with the implementation of quality care processes of the best practices and achievement of better/faster patient recovery.

Preparation of the veterinary healthcare workforce must be a concurrent evolution.  Clinical education must be restructured to accommodate the aims of the 21^st-century healthcare system, which includes improved client communication skills, team development, outcome measurements, and individual performance accountability.  Because systems thinking will be a cornerstone of the transformed veterinary healthcare system, the practice staffs will need client-centered skills to transfer skills and knowledge that are perceived as values deserving of appropriate fee schedules and treatment plans.  Management and medicine will become more closely linked, and doctor commitments will drive the elevation of income, thereby reducing the traditional expense percentage management systems.

Redesigning veterinary healthcare operations in multi-veterinarian cultures, using these four Board policy and precedent angles, requires a skilled communicator, hopefully with a high EI quotient. This will allow a better chance for creation of a system that uses the best knowledge which is being focused intensely on the best patient care, and that works across the practice's diverse veterinary healthcare providers and delivery settings.

THE EIGHT STEPS TO MULTI-VET PRACTICE SUCCESS

1.       Ensure the practice veterinarians sets policy and precedence ONLY between the falls of the gavel; trust in the administrative staff for implementation for outcomes.  Hold specific people and groups accountable for improvements in quality or outcomes of care; chart and report on improvements monthly.

2.       Devote as much time to reporting quality issues at professional provider meetings as you do to financial issues.  Focus on the environment and policies needed for selected outcomes that mean most to the patients, clients, and the community.

3.       Base a portion of the top management team’s compensation on achieving quality and outcome objectives, not just on achieving financial goals.

4.       Ensure the stakeholders have a basic understanding of Continuous Quality Improvement (CQI) criteria, and ensure each team member has CQI in their own development plan to assist in the community outreach commitment associated with being a practice leader.

5.       Ensure the operational budget promotes CQI in the continuing education expectations by providing specific opportunities to increase the quality and scope of veterinary healthcare services being offered.

6.       The team members start to play a more active role in researching and securing the needed information to upgrade information systems.

7.       The healthcare team works with external groups in the community and nationally to create a more favorable referral system and professional community environment.

8.       Ensure the entire team has an operational focus on a clear set of core values (ALWAYS inviolate) and mission focus, so if any team member starts to represent themselves instead of the combined practice entity, there are mechanisms for replacement established and the leadership initiates implementation immediately.

Multi-doctor, multi-owner, and/or multi-practice veterinary complex Boards need to center on removing the barriers of “old thinking” and “old paradigms” as they pursue healthcare governance systems that have proven effective.  In the text, Building the Successful Veterinary Practice: Programs & Procedures (Volume 2), Blackwell/Wiley & Sons, chapter 1, describes some of the new paradigms for success in the new millennium:

It was not cost containment - it was increased productivity!

It is not staff recruitment and training - it was staff retention and recognition!

It is not “within the job description” - it is exceeding expectations

It is TRAIN TO A LEVEL OF BEING TRUSTED, not just good or okay.

Don’t respond to the competition - instead meet unmet needs

It was never guest relations - it is client-centered service & patient advocacy

It can never be “recommendation” - it must be “needs”

It is not about assigning blame, it is about giving credit and recognition in a public forum; savvy leaders understand shortfalls are just reflections of their own poor training programs.

It should never be gross income - it must be net remaining in the end!

It is not "me", it is "we", "us", "our"; always together to common outcome targets and duty zone objectives.

When a management group makes quality healthcare delivery the imperative, and invests in developing the practice/facility culture by collaboration with the professional staff, the entire veterinary complex entity starts to become systems-oriented rather than process-oriented.  Practice owners fall short when they are unable to translate modern knowledge into practice, or to apply new technology safely and appropriately concurrent with new third-party payment modalities.  The practice leadership must address the policy and precedent of the healthcare complex (not operations), and monitor the fiscal well-being of the veterinary healthcare entity (not Average Client Transaction); they must hire the right people for top administrative jobs to ensure implementation expertise is available on a daily basis (never do it themselves).  The appropriately skilled veterinary healthcare administrator, with a clear set of practice-developed core values and mission focus in mind, leads the creation of the operational systems that: eliminate rework, eliminate the risk of error, and eliminate uncertain accountabilities.  Concurrently, the administrator must be  constantly striving to heighten client satisfaction, increase professional fulfillment, and foster strong/effective veterinarian-nurse partnerships in patient care.

If you want a hands-on opportunity to assess your EI, I recommend a watching for courses at your local hospital on "mindfulness".  Most  mindfulness courses are designed to assist leaders in becoming purposefully aware of his/her thoughts, feelings, and decisions in the present moment, non-judgmentally.  It serves as a pre-requisite to developing self-awareness and personal wisdom.  Try to stop your immediate responses in a discussion setting by taking a long inhale, and then a slow exhale, before repeating the person's statement/position in common terms.  This should derail any hijacking or refocus efforts common in a vet-centered practice setting.

This is to announce the curtailment of the Quarterly newsletter from Veterinary Consulting International (VCI). As I traveled back to Australia from San Diego, having just received the Leo Bustad Companion Animal Veterinarian of the Year 2012 Award from the American Veterinary Medical Association (AVMA), I thought there had to be a better concept than just sending a bunch of current event sound bytes once a quarter. Also, there sure has to be a better way to solicit interest in consulting services from a displaced yank living in Brisbane (the airfare from Australia to USA is not that much different than coast to coast, so I feel that North America is in still my consulting region).

So a concept has been fulminating around in my mind for awhile, whether to do a blog or not. yet most blogs appear to be social media meanderings, without actual meaningful substance, so I am reluctant to embark on that track.

Then it came to me - what if I share an actual professionally-based article, as I have published in journals around the world, on a regular basis. Not just a repeat article, but new looks at our emerging professional needs, threats, and opportunities. So this month (November 2012) I will send an article as an attachment in lieu of a VCI Newsletter, and I will send another in a fortnight (Australian term for two weeks, or twice a month). It may apply to your practice, and it may not; it may upset your status quo approach to a tightening economy, or it may give you some new ideas. Barring any backlash, it will then continue to be a fortnightly send.

Any feedback would be appreciated, and any discussions of the concept(s) being shared welcomed. Thank you for listening.

Tom Cat> >*-*<

Thomas E. Catanzaro, DVM, MHA, LFACHE
Diplomate, American College of Healthcare Executives
CEO, Veterinary Consulting International
8 Sean Street
Boondall, QLD 4034 AUSTRALIA
Cell: +61 (0)4 1628 5975
Fax: +61 (0)7 3865 1919
web: www.drtomcat.com
e-mail: DrTomCat@aol.com

Mid-NOVEMBER 2012 FORTNIGHTLY ATTACHMENT

TRENDS IN STRATEGIC ASSESSMENT & RESPONSE

Thomas E. Catanzaro, DVM, MHA, LFACHE

CEO, Veterinary Consulting International

67 Chartwell Street, Aspley, QLD  4034, Australia

DrTomCat@aol.com; www.drtomcat.com

"Intellectual growth should commence at birth and cease only at death."

Albert Einstein

There is an elephant in the room . . . so what is the question that is on everybody's mind, but perhaps not asked aloud because we do not feel there is a reliable response.  A question that embodies the uncertainty of our time.  A question that, when sufficiently answered, may put an end to the paralysis felt by many in the veterinary healthcare delivery industry.  Quite simply: What will it take for the veterinary practice owners, particularly those working in a veterinary provider dense community, to finally smile when they arrive home at night?

This question is, of course, a metaphor for the larger challenges facing our industry,  As practice owners wait for a clarity from their Associations or SIGs[T1] , important frontline work is being delayed.  Do practice owners think the answer - the direction we will ultimately need to follow - will come from the group think of Association management or their volunteers?  From consultants?  From within the profession?

When practice owners realize that the answer(s) lie within their own practice walls, they can begin to leverage their capacity for change.  And given the magnitude of change that reform calls for over a relatively short period of time, it is no longer practical to rely on the typically long-range planning process that has become a tradition in veterinary circles (e.g., typical blaming academia or Association leadership).  Indeed, practice owners must plan for many compressed cycles of planning and execution over the next few years (see the planning cycle leadership skill in Building The Successful Veterinary Practice: Leadership Tools (Volume 1), Wiley & Sons Publisher).

Others field give precedence to this shorter-cycle thinking.  In the military, for example, the philosophy regarding strategic planning is that "no plan survives first contact."  Plans that are overly rigid will fail to allow for the course corrections that are necessary in an uncertain and/or fluid environment. "We will stick to our plan" may indeed become the famous last words of otherwise successful practice owners.

Therefore, if veterinary practice owners wish to feel a modicum of control over their practice destiny (recognizing that 'control" is merely an illusion), they must commit to a discipline of planning and execution that allows them to respond quickly to the changing community landscape that surrounds their practice (<span "style="font-family: 'Brush Script MT'; font-size: 12pt;">Signature Series Monograph, Strategic Assessment & Strategic Response, VIN Bookstore (www.vin.com),provides some tools for this new thinking process.  Certainly this advise has been offered before, and frequently ignored, since most veterinarians usually want to see it in operation elsewhere, and in multiple settings, before trying something new.  This gives rise to the caution that it is not just the large practice that acquires the smaller practice, it's the early implementer that acquires the new and enhanced client base.

Given the importance of planning to a practice owner's legacy, it is worthwhile to step back and look at emerging trends is strategic assessment, and what an effective planning model looks like in a strategic response to that contemporary setting.  Practice owners can then assess their capacity to be effective change agents or maybe just plug gaps that stand as an obstacle to their practice's success.

EMERGING TREND 1: UNDERSTANDING THE CHANGE FORMULA

A basic operational premise has been to avoid discomfort in practice.  Yet change will not occur if you are satisfied with a fur lined rut that leads no where.  Another operational premise is if it is NOT broke, do not try to fix it.  Yet many old habits and operational paradigms are actually restrictions to growth and prosperity.  A cornerstone in our profession is for the doctor to be in control at all times, yet empowering the healthcare delivery team enhances the practice culture and leverages the vets time and service capabilities.  And the worry about costs stops the practice from trying anything new without an iron clad guarantee of success.  The formula is therefore:

<span "style="font-family: 'Arial', 'sans-serif'; font-size: 14pt;">C = D x P x M < costs

Where Change = C: D = Discomfort leads to a Desire to change; P = Participative Process for the entire practice team; M = Mental Model of the new format/system; and Costs are less than the metal stress, physical needs, fiscal challenges, social demands, and balance life necessities.

EMERGING TREND 2: LINK STRATEGIES TO PERFORMANCE IMPROVEMENT

We follow the change awareness with one of the most fundamental requirements of effective strategy execution - linking performance improvement (PI) with overall direction of the practice.  As obvious as this may seem, many practices still require all decision be made by the practice owners, and only the processes are delegated, never the accountability for an improved outcome.  Many times this is attempted without Zone Duty Standards, and attempt to include everything in individual job descriptions that end in ". . . other duties as assigned", meaning to most staff, stand in one place an vibrate until I tell you what to do next.  Momentum toward achieving a practice's strategic vision can only be maintained with a pervasive culture of Continuous Quality Improvement (CQI) in all performance within an individuals sphere of influence.  When the CQI efforts regress to tweaking previous changes, it is an indicator that the practice owner is returning to the control-freak format of old.

The most common gap in veterinary practices is the lack of commitment to completing projects on time and tracking results as defined in the original plan; new programs need new metrics, including a timeline for interim successes.  "You are what you measure", and old metrics usually cause reversion to old systems and traditional practice owner controls.

EMERGING TREND 3: RECOGNIZING/RESPECTING NEED FOR PI & CQI

Literature abounds with new and powerful methods in performance improvement (e.g., Six Sigma).  However, the principles of Six Sigma have been in existence for nearly 100 years; the principles and application of statistical assessment of output(s) started in the Agricultural period and moved into the industrial period, exponentially improving yield and performance with minimal additional investment.  But management by statistics (e.g., Six Sigma) has gotten a bad reputation among organizations that do not deploy the methods properly, do not exhibit the patience required when developing the team approach, or those that often use the numbers to beat people into submissive postures.  How does a veterinary practice free itself from statistical suicide?  Step one is 'training to trust', developing every member of the practice in some program area where they have shown an aptitude.  This is slow, step-by-baby-step process of empowerment, to a point that the individual and extend past the areas of training and enhance the program delivery system.

The biggest mistake a practice owner can make at the planning stage is to dismiss the principles of Six Sigma (see the Signature Series monograph, MODELS & METHODS THAT DRIVE BREAKTHROUGH PERFORMANCE, VIN Bookstore, www.vin.com) because, it does not, in itself drive innovation.  On the contrary, Six Sigma can create new metrics that have the capacity to allow innovation to succeed, and all will be necessary ingredients to create a practice recognition system to prevail that will recognize PI and CQI changes.

EMEGING TREND 4: ARRIVAL OF "BLUE OCEAN" THINKING

In 2005, the concept of a "blue ocean" was introduced to industry by authors W. Chan Kim and Renee Mauborgne. Blue Ocean think is provocative because it demand the audience consider a different paradigm: that to create the most profitable presence in the market requires a quantum leap in buyer value while simultaneously achieving a significant reduction in the industry's cost structure.  Innovative business models like Netflix and iTunes come to mind when discussing blue ocean models, but aspects of the model can be found in established industries, such as Southwest Airlines, Cirque du Soleil, IKEA, and others who have used blue ocean thinking.

What does this have to do with veterinary medicine?  To start, please review the text, at //www.vin.com/Proceedings/Proceedings.plx?CID=TomCat2007&O=Generic, titled The Practice Success Prescription: Team-based Veterinary Healthcare Delivery, which is a FREE download from the VIN Library (www.vin.com).  This is NOT what veterinary schools are teaching . . . this is not what Association seminars are scheduling (they like the Board Certified academics) . . . it provides a unique look at the blue ocean of veterinary practice, team-based healthcare for the well pet, which is what is causing about 70% of the average companion animal front door swing.  This also requires a new fee schedule at appropriate pricing levels for staff-delivered well care, not too unlike that done by dental hygienists', which is about 20-25% the time change for dentist-provided restorative dental care. 

A word of caution, our full year consultation service (details at www.drtomcat.com), which starts with a diagnostic 4 days on-site assessment, and is then followed by quarterly on-site visits, augmented with the new procedure-based metrics which we introduce to management, was designed to facilitate the practice transition from traditional sick care vet-center systems to team-based well care programs . . . seldom does a practice transition their mind-set in less time.

SUMMARY

It is obvious that no article, here or elsewhere, will offer a single answer on how to succeed as the most profound changes in client demands are occurring in our communities. There is no legislation that will change these trends.  Fundamentally, practice owners must become leaders within their practice and for their community, and in doing so, create a plan that allows flexibility, while driving the right performance improvement initiatives, and encouraging innovation and willingness to look at the future as being quite different from the past.  It will require practice owners to redefine the fundamentals of planning and execution, and to do this in more compressed cycles.  Inversely, the last practice I personally facilitated needed a floor plan renovation concurrent with staff development and owner recalibration, and 18 months after we started, the staff was ready to come on-line. 

It is that way with elephants you know - it takes a long time to cut it up into 1 inch (2 cm) cubes, a very large pot, and a long slow simmer to provide a palatable stew.  If you expect company, go ahead and cube a rabbit and add it to the stew pot.  But another caution here - not everyone likes finding a bit of hare in their stew (that is a joke - smile).  When practice owners become leaders, and commit to the new PI and CQI premises, they will most certainly be entitled to smile when they arrive home each evening; pride does that to people, especially caring leaders!

AUTHOR'S NOTE:

References provided herein are offered as sources for additional information, and not intended to force procurement of supplemental literature.  Within our consulting programs, all appropriate monographs are provided free of additional charges.

It is an amazing time on both sides of the pond . . .

USA - Republicans offer a 2.2 trillion dollar saving proposal and it is rejected because Democrats want 1.6 trillion in new taxes.

OZ - FRB cuts interest rates to encourage retail spending and lessen the stress on home owners, and the big four banks do not pass it on to homeowners

Queensland - remember the push for solar to save on the electrical bill? Well the new State government wants to tack a tariff on all Solar Households to pay for poles and wires (they say network costs are 50% of the electrical bill) . . . those peole spent thousands of dollars to get away from the over-priced electrical bills, and now they are figuring out ways to levy them anyway.

In the USA it is called a "fiscal cliff" - in veterinary practice it is called reduced client access (reduced discretionary income = reduced pet care for B and C clients)

Business as usual - not hardly . . . so the attached article talks about the new leadership skills needed in these emerging economies. Mid-month VCI Fortnightly will offer an article on leadership in client relations. Hope these one-two leadership insights give you some food for thought . . . we cannot continue the doctor-directed paradigms of practice operations any longer; we need to assess the options, an they have been out there for quite some time; they are field proven as savvy concepts for increased liquidity. :>)

Tom Cat> >*-*<

>

Thomas E. Catanzaro, DVM, MHA, LFACHE
Diplomate, American College of Healthcare Executives
CEO, Veterinary Consulting International
67 Chartwell Street
Aspley, QLD 4034 AUSTRALIA
Cell: +61 (0)4 1628 5975
Fax: +61 (0)7 3865 2368
web: www.drtomcat.com
e-mail: DrTomCat@aol.com

<span "style="font-family: 'Arial', 'sans-serif'; font-size: 14pt;">FISCAL CLIFF LEADERSHIP

Thomas E. Catanzaro, DVM, MHA, LFACHE

Dipomate, American College of Healthcare Executives

CEO, Veterinary Consulting International

DrTomCat@aol.com; www.drtomcat.com

Succeeding under the increasing taxation posture, and the reduced discretionary income culture, requires flexible leaders.

The approaching "fiscal cliff" and other recent Congressional actions, or lack thereof, have placed new stresses on veterinary practices.  The challenges facing practice owners and other veterinary practice management/leadership players are enormous.

These economic changes will test all businesses and families, yet some individuals are more prepared to succeed in the new veterinary healthcare environment than others.  Many of those who will thrive are equipped with certain behavioral competencies – underlying behavior characteristics – that lead to superior practice performance.  So what are the competencies necessary for capitalizing on veterinary healthcare delivery reform to benefit your clients, patients, community, and practice team, and why are they important today?

HOW NIMBLE ARE YOU?

Flexibility and adaptability are especially important in the reshaping veterinary healthcare arena.  The command-and-control leader will encounter special problems in the new environment, as most of the old paradigms will be rewritten.  Successful practices will become more matrixed and complex, whereby accountability and authority will spread throughout the organizational culture rather than resting solely within the practice owner’s traditional comfort zone.  The results will be unfamiliar, ambiguous operating environments. Zone-based positions in particular may experience the impact of operational vagaries, as when the zone leader is responsible for efficacy, growth and profitability of the zone operations but may not be in a position to supervise the operating portion of the zone 24/7, 365.

New job titles, with new duties, may be required weekly; chief transformation drivers will come from the staff member initiatives in Continuous Quality Improvement (CQI). Only flexible and adaptable players need apply, as these kind of zone-based duty standards will replace the traditional job descriptions, and staff leadership positions will require those who are willing to take risks, and practice owners who understand errors are how people who are creating change learn.

While the future may be bright for some, the strategy to get to that future is not always clear.  When we published the text, The Practice Success Prescription: Team-based Veterinary Healthcare Delivery, VIN Press, and made it available for FREE download from the VIN Library, many tried to "cherry pick" ideas and squeeze them into their own control-based paradigms, resulting in chaos.  Chaos can be a great motivator, but a guide through that maze is often needed; those that recruited a veterinary savvy consultant who understood the concepts succeeded, while many of those who opted for the DIY route (do it yourself) floundered and reverted.  Quick, potentially risky strategic changes will be required as the new rules and new future unfolds.  Those who can adapt will be rewarded.

WHAT IS YOUR TOLERANCE FOR RISK? 

As a general rule, veterinary practices are not characterized by a high tolerance of risk.  They tend to operate with caution and are prone to conducting extensive analysis before making business decisions; most want to see an abundance of other practices doing the "new thing" before they are willing to try the ‘innovation’.  The new environment will demand that changes be instituted quickly – without benefit of time to gather all the possible relevant "lessons learned" by others.

Opportunities will come and go at a faster pace than ever before.  S-W-O-T analysis can be used by the leadership team for immediate Strategic Assessment and Strategic Response assessments, but the traditional group-think Strategic Plan is outdated, outmoded, and too slow for the Internet age of change.  Therefore, some mistakes and misjudgments are inevitable (80% of the change actions are based on 20% of the facts).  Practice owners, zone coordinators, and program managers need to be comfortable with risk assumption and potential failure.  This means that inviolate Core Values, a clear practice Vision, and a value-based Mission Focus will become more important than ever before; communication skills will have to be better than ever before.

HOW ADEPT ARE YOU AT COMMUNICATING?

Excellent communication skills have always been essential to achieving success as a leader.  In times of rapid change these skills become more important.  Those who are seeking to communicate a message/observation in the new world of team-based veterinary healthcare delivery should keep in mind the following considerations:

•   Data needs to be converted to information before being shared.
•   Think through the message to its logical end; how it will be delivered and how will it be received.  Most change messages are better shared in person than via an e-mail. Some messages may require the Internet or Postal Service, while others may be SMS or another microblogging approach.  In other words, both the medium and the message are important considerations to tailor to the situation, sender and receiver.
•   Be available, visible, and attentive when communicating with constituents.  Stop multi-tasking: set aside your mouse, put down your smartphone, and listen closely to what people are saying during EVERY interaction. Don’t just make your presence available, make your mind available.
•   Learn to think like a MIND MAP (Tony Buzon has some excellent books on Mind Mapping); non-linear thinking is essential in effective communication.  In the text, Building the Successful Veterinary Practice: Innovation & Creativity (Volume 3), Blackwell/Wiley & Sons Publishing, mind mapping is explained in detail and then every chapter ends with a mind map, yet most readers have not used the format to summarize their thoughts.
•   Learn to persuade rather than merely selling your position (Chapter 5, in the text, Veterinary Healthcare Services: Options in Delivery, Blackwell/Wiley & Sons Publishing, explores the three alignments of persuasive marketing).  Only in rare cases can you tell someone to do something and be rewarded by enthusiastic participation.  Persuading others to your point of view on the basis of tailored information, applied facts, or the potential gains to them, that the idea represents, will be a key to success.

HOW WELL DO YOU MANAGE YOUR TIME?

The new environment will require the practice owner to be effective ina world that is more complicated, that requires more resources than are available, and that will consume even more leadership time than prior to the Global Financial Crisis (GFC) and ‘fiscal cliff’ of tomorrow.  A practice owner will have to exhibit extraordinary time management skills in order to accomplish all that needs to be done and still have a balance personal life.  The ability to run meetings and eliminate unnecessary meetings, for example, will be a significant indicator of whether a practice owner can mange every activity in the time allowed.  The ability to train and empower staff members to be zone coordinators and program managers is another indicator of whether a practice owner can focus on strategic issues rather than just daily operations.

Adopting effective behavioral competencies will be crucial for practice leaders in developing the organizational behavior and nurturing culture needed to succeed in the new world of team-based veterinary healthcare delivery.  Have you developed the behavioral characteristics necessary to survive and thrive?  If you have not yet made that transition, start working on developing them (review the text, Building the Successful Veterinary Practice: Leadership Tools (Volume 1), Blackwell/Wiley & Sons Publishing, for some ideas and techniques), which may require a veterinary savvy consultant since it is an unchartered quest across a scary swamp of pitfalls and quicksand. These leadership competencies will enhance your practice success now and in the long run.

 NEW YEAR (2013) FORTNIGHTLY THOUGHTS

The days are getting shorter now, we have passed the summer solstice in Australia, even though they do not officially set seasons by the solstice - first of the month the season changes, but then in Queensland, there are not that many variances in weather patterns to have seasons . . . except for mossies and rainfall rates.

Last year, the VCI Fortnighly closed with a couple of leadership articles, and this year, we will start with one . . . if you have not gotten the hint by now, let me be blunt . . . given the time and resources, and some level of aptitude, we can train most anyone to be a program manager, but practice teams need uncommon leadership with all the disasters and stresses that are occurring outside the practice walls.

Some practice owners love to say it is a communication issue; it seems to be the "in thing" . . . the second group forming leadership skill is EFFECTIVE COMMUNICATION - the getting and giving of meaningful information. As an FYI, the first group forming leadership skill is knowing and using the resources of the group, and the third group forming leadership skill is understanding the characteristics and needs of the individual and the group.

Howdy good folk - these fortnightly sends have been stressing leadership recently, so this is a rubber-on-the-road application article on ADULT LEARNING. It is a pet peeve of mine about our veterinary education system, since we seldom teach people how to be educators. But since most veterinary schools do not have a faculty development program for their professors, clinicians, residents, or interns, the only thing people seem to understand is case management, which is a "do as I say" approach to creating compliance.

That is another vocabulary shortfall we have embraced as a profession. In human healthcare programs, compliance is a staff function, inside the facility walls, and within healthcare delivery protocols. Adherence is what the client's response is to the directions the provider(s) have given them during the consultation.

The previous vocabulary shortfall is when we refer to an "average" as a 'benchmark' . . . in the real world, a benchmark is the top 10-15% of similar systems with similar demographics, while an average is simply "the best of the worst or the worst of the best". Average is in the middle with 50% of the sample outperforming the other 50%.

Effective Teaching in adult education cannot be a sloppy process with poor planning and unstructured lesson plans. A quality training program has lessons plan outlines for every subject being taught, with performance standards built into the system for the application phase evaluation. What we used to call 'job descriptions' have been used to build the training plan, and success measurements have been converted to duty zone standards and CQI assessments.

Does this sound like a developmental role for the uncommon leader? I should hope so!

But then, when a practice has a hard time getting a handle on these techniques, that is when I get called in to assist the leadership, so it is not all that bad. :>)

Tom Cat>> >*-*<

Thomas E. Catanzaro, DVM, MHA, LFACHE
Diplomate, American College of Healthcare Executives
CEO, Veterinary Consulting International
67 Chartwell Street
Aspley, QLD 4034 AUSTRALIA
Cell: +61 (0)4 1628 5975
Fax: +61 (0)7 3865 2368
web: www.drtomcat.com
e-mail: DrTomCat@aol.com

P.S. I have become the Treasurer, American Association of Human-Animal Bond Veterinarians (www.AAHABV.org - dues are only $35 a year, and you can join on-line at the web site). Since I was selected for the AVMA's Bustad Companion Animal Veterinarian of the Year 2012 last August, a humbling honor, I came up on their radar and was recruited. It has been a fun learning curve, since I have been subtly teaching the Board effective governance as we go along . . . that has been adult education at it's finest, since they have years of experience as 'do little or nothing' group of feel good people (the Board members have traditionally left it all to the President, just as practices like to leave operational direction to the practice owner). Step one has been to assist the President in establishing an operational Committee structure, followed by step two, building an effective Executive Committee formation (there has not been one for years, although the Constitution and Bylaws outlined the systems).

The previous President worked hard and diligently to get the not-for-profit identity established with the IRS, and build a financial support system with the help of sponsors - she did more structural improvement during her tenure than any previous President, so the "Board was happy". That was an interesting measurement of the past we discovered, not unlike keeping the boss happy being a practice measurement of success.

FOR THE AUSSIE'S: Video: What's the Scoop on Poop?

(studies show about 70% of the Australian clients are now procuring parasite treatments OTC from other than their veterinarian, so screening poop has become important - Bayer says about 20% of the pets on quarterly veterinary preventive are still carrying parasites . . . TC)
Have you ever wondered why you have to bring your pet's poop with you when you see your veterinarian? In AVMA's latest Kid Vid, Jonathan asks Dr. Tracy, "Why do I need to bring a stool sample to the vet?" Watch the video.