Compliance begins and ends with the veterinary team

July 1, 2003

Thomas E. Catanzaro, DVM, MHA, FACHE, DACHE

Article

Dr. Thomas E. Catanzaro sifts through the misconceptions about compliance issues in practice.

Millions of U.S. pets aren't receiving the best care and treatment available. Compliance is essential to a patient's health and well-being . . . the biggest obstacle to compliance is the veterinarian's own misconceptions about a pet owner's willingness to act.

- Dr. John Albers,

Executive Director, American

Animal Hospital Association

Client compliance . . . wouldn't you know this profession would use a phrase that blames the client, while the very expensive American Animal Hospital Association study specifically identifies the veterinarian as the primary culprit in the delivery of substandard care.

Where does it start?

Most of us entered veterinary medicine because we cared about animals, and almost every staff member entered this profession because they care about animals. Pet owners have become stewards to their companion animals because they care about those animals, and access veterinary care because they want assurance of health as well as personal peace of mind.

Then veterinary school occurs. People who have lost contact, or do not understand anything about private general practice train the future veterinarians. They are specialists or specialists in the making, they want 45-minute appointments and are supported by the state in most cases (the recent Pfizer studies of 35,000 to 37,000 clients, three years in a row, showed 85 to 87 percent of clients want to be in-and-out of the general practice's consultation room in 20 minutes or less).

Most veterinary teaching hospitals have twice the expense as income, yet no one seems to care. A private practice could never operate with this ratio, yet this is the environment where students are "educated" about the business of veterinary medicine. Students are told, "You cannot afford to do this in practice" or "Only specialists can do this, so you must refer these cases." And we wonder why most veterinarians seem to discount as a matter of course? We just consulted with one New York practice doing $1.5 million a year, but they had no cash flow (liquidity); they had discounted $200,000 and not charged for $300,000 of work during the million dollar year. No one can give away one third of their earned dollars and expect to stay in business.

Understanding compliance

Compliance is the doctor and staff having core values and standards of care that are inviolate. Compliance to core values and standards of care means they are inviolate, that all staff and all doctors say the same thing to clients, especially for wellness care and professional needs. Without a consistency between doctors, staff cannot be effective extenders.

Veterinary practices are no different than any other business, except most of us feel it is a calling rather than a job. There must be protocols and common expectations if the staff members are to become veterinary extenders. The staff cannot have trepidation when it comes to stating the wellness standards, pre-surgical protocols, or preventive medicine expectations.

Example questions to ask yourself include:

What animal, what species, what breed, what age, what sex, is it always safe to induce anesthesia without some form of blood screening?

When is it humane to leave an animal in pain?

What percentage of animals need to be on heartworm medication?

Which animals need to be screened for internal parasites, including the protozoa threats, and at what frequency?

Shouldn't clients who come in more often, and keep their pets dental conditions treated, be afforded a lower cost for a grade 1+ dentistry (about 20-30 minute procedure) than a client who has let it progress to a grade 3+ oral surgery (about a 60 minute procedure?

Sequential weights are a diagnostic aid, so shouldn't each have a body condition score (BCS) associated to them so we know what the previous provider stated?

Research shows that pets can live up to two years longer when on highly digestible premium diets, so shouldn't clients be told this? When an animal has a 10 percent weight change, is that significant?

Aren't the inpatient staff members accountable for patient safety and well-being when hospitalized?

The Veterinary Emergency and Critical Care Society states that 80 percent of all surgery patients deserve to be on fluids. What is the rate in your practice?

Are veterinarians allowed to what is not needed by the State/Province Practice Act?

Review the Veterinary Practice Consultants (VPC) Signature Series monograph, Standards of Patient Care in a Bond-Centered Practice, and/or the VPC Human-Animal Bond Scoring Pocket Card (that comes with the monograph, from www.v-p-c.com), and determine what you really want to stand for in your practice and your community.

Show you care

Sure there is a compliance issue with clients; these are the people who learned pet care from their parents, and state, "I will never raise a kid like my parents raised me!" The client education needed to become effective stewards of other family members, called companion animals, must be done by the experts, the staff of the veterinary practice. Very few practices offer a "new client day" for new pet owners, yet the ones who do, and provide the certificates (A $35 value as a courtesy from the Acme Veterinary Clinic, for new owners attending within 14 days of adding a pet to their family) to all breeders, animal shelters and pet stores in the community, get many new clients from this caring gesture.

Compliance means not just good record keeping, it means outstanding record keeping; meeting all the AAHA Standards for Medical Records is the minimum level acceptable for any companion animal practice, and the veterinary software needs to be able to track each recurring element. If the software vendor does not care enough to make their system user-friendly to the practice, there are others who will convert the practice quickly, effectively and for free. Caring means no animal leaves the practice without being at least one of the three Rs (recall, recheck or remind), and many are all three, such as: We need the technician to call you half way through the treatment plan (recall) to see if questions have arisen, we need you to return in two weeks for Spike's sequential urinalysis (recheck), and we are putting you on our mailing list for newsletters and wellness need reminders (remind). Would you prefer the reminders to be e-mail or snail mail?

The veterinary profession has vastly overestimated the compliance rate of prescribed services, according to a recent study by the American Animal Hospital Association. The study also revealed that veterinarians and staff members serve as the biggest obstacle for achieving higher ratios.

What did the AAHA Compliance Study about existing practices and their patient follow-up?

The results were dismal:

Twenty three percent of the pets with grade 2 dental disease or higher had no recommendation for dental prophylaxis (ask yourself why didn't they survey grade 1+ dentals, since no man or woman can ever get a second kiss if they have grade 1+ mouth).

Twenty seven percent of pets with medical conditions needing therapeutic diets did not receive recommendations from the veterinary provider(s).

Fifty three percent of senior pets did not have a recommendation for any form of senior screening.

Thirteen percent of the pets were not in compliance with the veterinarian's recommended vaccine protocols.

Eleven percent of the dogs in heartworm-endemic areas had not received a recommendation on heartworm testing.

Only 10 percent of the clients felt veterinary recommendations were based in a profit motive; only 7 percent said cost was a barrier to access of care.

Seventy eight percent of veterinarians surveyed said they were satisfied with their compliance, and 63 percent of those said they felt their client's compliance was high.

Now ask yourself, why was everything in the AAHA survey addressed as recommendations rather than needed care. Why are the major associations in our profession not changing the nomenclature to ensure clients are not confused about the needs for quality healthcare delivery and protection? Answer: The compliance problem is ours, not the clients. The clarity of needs greatly resolves this entire issue.

All unresolved presentations must be listed on the Master Problem List, and logged into the veterinary software for tracking.

All atypical laboratory screens must be listed on the Master Problem List, and logged into the veterinary software for tracking.

For anything on the Master Problem List, a nurse must be assigned to the case, logged into the veterinary software for tracking, and it must be followed until the condition is resolved.

If there is deferred or symptomatic care provided, it must be logged into the veterinary software for tracking and a nurse must be assigned to the case and it must be followed until the condition is resolved.

Nothing is resolved until the Master Problem List has been annotated as resolved, and the follow-up closed-out in the veterinary software.

We have met the enemy and it is us. The client cannot reasonably decide on the merits of different healthcare delivery issues; that is a graduate veterinarian's responsibility. When the medical records do not match the invoice(s), it is pure fraud from an auditor's standpoint. There cannot ever be "forgotten care" or "forgotten charges" or even falsified information (e.g., 45 minutes anesthesia and 30 minute surgery being invoiced as 30 minutes of surgery and anesthesia). We are required by the respective practice acts to have full and accurate records and disclosure to the animal steward on patient and professional needs. The client has the right to allow the animal access to the needed care or not, but at no time are we, as healthcare professionals, allowed to hide the actual healthcare facts or needs from the client.

Compliance to inviolate Core Values and inviolate Standards of Care is internal to the practice, and not a client issue. Compliance starts from the providers and is reinforced by the staff and providers; when there is a consistency in the expected Standards of Care, the subsequent continuity of care becomes easier as well as more beneficial to patient, client, staff, providers and business.