How do we improve veterinary surgery day flow?
Judi Bailey, CVPM, is the hospital administrator at Loving Hands Animal Clinic and Pet Resort in Alpharetta, Georgia, and the founder and president of the Georgia Veterinary Managers Association. She is also the 2016 dvm360/VHMA Practice Manager of the Year.
Ask the dvm360/VHMA Practice Manager of the Year: Our solo practice is growing rapidlyI need advice!
Q. I'm looking for guidance on improving surgery day flow for my team. We're a one-doctor practice that's growing rapidly.
I spent years in two different solo-doctor practices, so I've had to think this through in detail. Here's what the procedure looked like for both team and doctors.
Veterinary technicians and other team members were responsible for:
1. Admitting patients and gathering history, emergency contact information, proper consent forms, estimates and deposits.
2. Taking care of presurgical steps, including blood work (I recommend you do this on a visit prior to surgery day) and pre-meds
3. Preparing the surgery room for the procedure
4. Preparing the patient for the procedure
5. Monitoring anesthesia
6. Watching the patient during recovery
7. Completing discharge instructions and charges
8. Taking care of communication and scheduling, including updates to clients after surgery and during recovery, scheduling the doctor's time for discharge, and alerting clients if the estimate changes before or during surgery.
The veterinarian was responsible for:
1. Calculating or confirming dosages of all drugs
2. Examining pets scheduled for surgery
3. Evaluating lab work (if this wasn't done prior to surgery day)
4. Performing the surgery
5. Personally calling the client after surgery. I know this is a matter of preference, but I recommend you ditch this and assign a veterinary technician to call. In this scenario, the veterinarian sees the client later in a 10-minute exit appointment and goes over discharge instructions. As long as the client talks to the doctor sometime after surgery, I've had success with a technician phone call for routine procedures and an actual face-to-face exit for anything nonroutine or complicated.
Here's how I took those procedures and managed the steps at two different clinics.
Clinic one surgery time overview
> Three-hour block, 11:30am to 2:30pm., four days a week
> A maximum of four surgeries were scheduled for 30, 40 or 50-plus minutes, depending on the kind of procedure
> Thirty minutes was reserved for unexpected complications, necessary phone calls, examining drop-offs and finishing lunches.
> Veterinary team members prepped Pet No. 2 as doctor closed on Pet No. 1, then team members finished prep in surgery after Pet No. 1 was finished
> Team members rotated for lunch time and through prep team, monitor team and recovery team
We blocked 11:30 a.m. to 2:30 p.m. (or any three-hour block in the middle of the day when appointments are the lightest) to handle all surgeries.
The doctor took an early lunch at 11:30 or the first 20 minutes of the surgery slot while the technical team (at least one qualified technician and a lower-level assistant) prepped the first patient. When the doctor was closing on the first pet, the team would prep pet No. 1 outside the surgery room and prepare the surgery suite once pet No. 1 was moved to recovery. They then finished prep on pet No. 2 in the surgery room and monitored it. The DVM scrubbed and moved on to pet No. 2, rotating this way until all surgeries were finished.
During surgery time, the team rotated out for lunch time, the prep team, the monitor team and the recovery team. And even though I say “team” like it was a giant unit, I only had two technicians for the one surgeon. One handled prep, monitored in surgery and started recovery, while the other prepped the next pet and monitored final recovery of the first pet, because they were right next to each other. Both technicians handled paperwork and cleaning after surgeries were done, and they each got a 20-minute lunch break. I know 20 minutes isn't ideal, but at least they got to eat. I didn't always eat when I was assisting in surgery (I'm also an RVT). Now I make my team rotate breaks.
Our doctor's surgery speed determined how many surgeries could be scheduled. We reserved 30 minutes of the three-hour block for unexpected complications, finishing up lunches or phone calls, or the doctor taking time to examine drop-offs that came in before afternoon appointments started back up at 2:30 p.m.
With the above scenario, we scheduled as follows:
> Routine surgeries (ovariohysterectomies/neuters/declaws/Level 1 dentals): 30 minutes
> Nonroutine surgeries (mass removals/Level 2 to 4 dentals): 40 minutes
> Complicated surgeries (only one per surgery schedule or two, if nothing else is scheduled): 50 minutes or more
We would book a maximum of four surgeries, even if all four were “routine,” because we always wanted to guarantee enough time for prep and recovery. We did surgery four days a week because we closed early on Wednesdays.
Clinic two surgery time overview
> Three-hour block scheduled for different days and times twice a week
> Relief/part-time associate saw drop-offs or appointments while primary DVM managed surgeries
> Relief doctor availability and practice software showed the best days and times to do this
> Number of surgeries, surgery times, 30-minute cushion and patient rotation same as Clinic one.
The other clinic used a relief/part-time doctor on surgery days. It was worth $50/hour to have a doctor on hand to see drop-offs or appointments so the staff doctor could start surgeries first thing in the morning to guarantee more recovery time.
I suggest you do a little research (which you can get from your practice management software) ahead of time to determine the busiest surgery and appointment days and the number of types of surgeries you saw. I scheduled only certain days for surgery, based on when relief was available and what my practice software showed would be the best times.
Because I booked relief three months in advance, it was easy to set up my team schedule and my appointment books for client services around what days we did surgery. We used the same format as Clinic one, with different times for different types of surgeries and a maximum number of surgeries. This way a veterinarian could start on procedures as soon as the relief doctor got there and worked until all procedures were done, including breaking for a short lunch for staff.
This clinic closed every day from 1 to 2 p.m. for lunch, catch-up time and staff meetings. Lunchtime is also a convenient time for clients to pick up medications, drop-off for boarding, etc.
The most important thing for a solo practice to be efficient with surgeries is scheduling enough reception and medical staff to handle both prep and client service, so you're good at handling calls or drop-offs that come in while the doctor's in surgery. Other team members outside of surgery need to be able to triage so if a true emergency comes in, they can handle it.
Lastly, I recommend you document in a log the client interaction that happen while the doctor's in surgery. You may find you get enough walk-in and nonsurgery business to justify at least a part-time associate on staff to accommodate all the client needs, including more surgery time.
Judi Bailey, CVPM, is hospital administrator at Loving Hands Animal Clinic and Pet Resort in Alpharetta, Georgia, and founder and president of the Georgia Veterinary Managers Association. She is also the 2016 dvm360/VHMA Practice Manager of the Year.