Is client compliance possible in this economy? (Proceedings)


Maintaining consistency in a multiple-doctor practice is a common challenge.

Maintaining consistency in a multiple-doctor practice is a common challenge. But assuming all the doctors are competent, you may wonder why inconsistencies even matter. The reason is this: Differences in medical philosophies can lead to differences in the standard of care - how similarly qualified practitioners manage a patient's care under similar circumstances. These differences lead to confusion among the doctors, staff and clients, and can even result in shortcomings in the patient's healthcare.

Differences in philosophy also create the potential for disagreements that can sour relationships within the practice. The staff may have to learn multiple ways to do the same thing – today I'm paired with Dr. X, so this is the protocol; tomorrow I'm paired with Dr. Y, so I'll do it differently. While this is certainly frustrating for long-term staff, learning multiple processes for the same procedure is particularly challenging for new employees – it's difficult enough to transition to a new job, but doubly (or triply) as difficult to learn several ways to do the same thing.

In addition, mixed messages create confusion for clients – whose recommendation should they follow? Clients may develop doctor preferences based on their perception of the level of care their pet receives, or their perception of the cost of the care in relation to the level of care.

Drs. Brent Cook and Morse Davis of Kingsbrook Veterinary Hospital in Frederick, MD say, "To ensure consistency, the doctors regularly discuss the level of care we provide, how we develop treatment plans and estimates, and how we bill clients. We all respect each other and view this discussion in a positive light– healthy for our patients and clients, and healthy for the practice and doctors."

Use the recommendations that follow to assist in fine-tuning your standard of care and bolster consistency and continuity within your practice.

1. Develop written standards of care. Consistency and continuity of care begin with defining your treatment process for various types of cases. Identify the baseline healthcare components that each type of medical case will receive. For example, what is your preferred heartworm preventive and your standard for heartworm treatment? What components of care do you want all your senior patients to receive? What are your vaccination protocols? What is your standard regarding pain management? Standards set the bar for managing the patient's care. The doctors determine the additional care that is necessary on a patient-by patient basis.

• Create a prioritized list of the standards you want to develop. Delegate responsibility for completing each standard and establish target completion dates for each item. Divide the list into manageable pieces and plan to complete one or two items each week.

• Use the same format when writing your standards to ensure consistency and for ease of use. Dr. Chris Ravary of Temperance Animal Hospital in Temperance, MI uses the following format:

Name of standard _____________________________ (For example, heartworm prevention; vaccination protocol, senior wellness, yeast otitis externa)

Assigned team members ________________________

Target completion date _________________________

Diagnostic workup ____________________________(For example, exam, lab work, imaging, etc.)

Treatment plan _______________________________(For example, medication, diet, hospital care, treatment)

Estimate $___________________________________

Follow-up ___________________________________(For example, medical progress exam, lab work, diet, medications)

Client education ______________________________(For example, presentation in the exam room, tools used in the exam room, take-home handouts)

Staff education_________________________________

2. Involve the entire healthcare team in the process. Create doctor-technician-ward-reception teams to incorporate a perspective from each hospital area, as appropriate. Active participation in developing your hospital standards gets everyone on the same page, and sharing the responsibility makes the project more manageable. Each team submits a draft of their assigned standards for review and discussion during staff meetings, makes necessary revisions after the discussion, and submits the form to management for final approval.

3. Use your standards of care as a teaching tool. Incorporate them into your initial training program for new hires to ease their transition and speed efficiency and productivity. Use your standards to conduct recurring continuing education to maintain continuity and consistency throughout the hospital.

4. Develop a bank of treatment plan estimates based on your standards of care. Written estimates that give expected cost ranges are important client education and communication tools. With a standard treatment plan, you're less likely to overlook patient care items, and you're more likely to capture charges for everything you provide. The doctor then reviews the standard estimate and adds any patient-specific items. Dr. Bob Beede of Intermountain Animal Hospital in Meridian, ID says, "When we give clients more accurate information up front, we're not forced to reduce invoices to match low estimates."

5. Create group codes in your veterinary software to ensure more accurate estimates. This allows the doctor to ask a technician to prepare an estimate that includes specific group fees, which helps ensure you don't overlook charges. The doctor then reviews the estimate and adds patient-specific items. For example, the pre-surgical group could include a comprehensive exam, laboratory test options, and so on. The anesthesia group could include anesthesia, monitoring based on procedure time, and so on.

6. Monitor consistency and continuity of care. Periodically conduct case reviews to determine whether the doctors are demonstrating similar medical philosophies regarding patient care and charging for care.

Select three hospital cases and two outpatient cases per doctor and trade them among doctors. The doctors then answer these questions: Would you have worked up the case any differently? Would you have provided additional recommendations? Was the client billed for all the care provided? If no, why? Discuss the results during your doctor meetings.

• Complete a service analysis (see, Management Tools) to identify how often certain services such as laboratory and diagnostic imaging occur in relation to the number of exams each doctor provides. Are the doctors' ratios similar or significantly different? Some differences can be explained by type of caseload – for example, one doctor may perform no surgeries and therefore do less pre-anesthetic testing. However, assuming all doctors have a similar caseload, the ratios should be similar. Discuss the results during your doctor meetings.

• Pull a random sample of 10 hospitalized cases and 10 outpatient visits completed by each doctor. Divide the cases among your healthcare team and then compare the medical record of services provided to the client's invoice for services billed. Make a copy of the invoice, and at the bottom of it, list the services provided free of charge (either intentionally or unintentionally), along with the usual service fee. Tally the results (see, Management Tools). For example, in 20 outpatient cases you might see missed charges on five (25 percent) with an average missed charge of $10. Discuss the results in your next staff meeting, and try to identify why you're missing charges.

Pulling together on patient care makes for a healthier practice – good for the patient, good for the client, and good for the business.

Case Review Summary: In a Well-Managed Practicesm

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Aaron Smiley, DVM
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