Of forests and trees

It's a cliche' for a reason: You can't see the forest for the trees. It is especially apt in running a hospital, with the small complication that the trees are on fire. How much of your day is spent putting out fires? Dealing with staff issues, reworking schedules, having another talk with the associate, calling this or that rep because you're out of something that never got ordered, or discovering that the autoclave no longer works?

Whether you're the owner or the manager, that's what we spend our days doing. We do all of these things AND stitch together pets, see twenty patients, help answer phones, help with impossible blood draws, corral the freaked out aggressive dog in the back room that someone else let loose, call the plumber, answer the e-mail, call the owner with results... Wow! I'm tired from writing the list!

Whether you manage your hospital as a doctor/owner or you are the manager, you know what your days are like. And during all of those emergencies and interruptions you somehow need to put together two coherent thoughts to think about your hospital's marketing goals, set a budget and get that rolling, and think about where the hospital is going and what the next big purchase will be. You need to coherently plan staff training, plan and implement awareness months, introduce new profit centers, look at pricing and ensure that your hospital is pointed the right way.

How often do you really spend doing the second list? Really? How much of that time is high quality, with no interruptions?

Whether we want to admit it or not we all get bogged down in the daily minutiae of running a hospital. We have three dozen things spinning in our heads, and even when we sit down under our desk for an uninterrupted minute to take a serious look at where our hospital is now and what we are doing to change that, someone tracks us down and points us at another fire.

I don't care how well staffed you are, or how amazing your manager is, everyone gets too close sometimes, too buried in the details to see the bigger picture. That is why you need an outside pair of eyes to help you see what you're missing. In 2011 DVM360 recommended that veterinary practices hire a consultant.

They based their recommendation on research conducted at the University of Cincinnati that if small businesses want to avoid costly mistakes they benefit from consulting with others.

Consultants are often able to give you fresh perspective. They walk into your hospital and see it as your clients do. They can sit down with your numbers or your employees and find out where you need to change things.

A consultant can help you devise a plan to fulfill your goals. They can help you stay on track by checking in on your progress and keeping you accountable. They can also avoid the common pitfalls of doing what you've always done and expecting things to change.

A consultant doesn't need to involve a huge outlay of money or time. They can come in for a day or a week. They can help you with one aspect of your practice or help you turn the whole ship around. They can serve as a monthly reminder to staff that you do believe in education, or they can come in once and give you some small pointers you may not have been able to see, what with all the smoke in your eyes from all those fires you've been putting out.

4 Dogs Veterinary Services has been there, we have helped lead veterinary hospitals towards a better future. Please email us at 4dogsvet@gmail.com

The veterinary pharmacy

Recent years have been hard on the veterinary pharmacy. Online pharmacies, big box pharmacies and now even discount stores have eaten away at our pharmacy business. And it's not just human medications, it's Heartgard, Frontline and Cosequin.

What is the future of the pharmacy in the veterinary hospital? Many hospitals have teamed up with their local distributors and are now offering their own products online, often price-matching other online competitors. Most distributer web portals will even price-match for you. A little profit is better than none is how the thinking goes.

But is it? Most hospitals that offer an online pharmacy do it as a convenience for their web-surfing clients, they do not prescribe from it instead of their in-house pharmacy if they can help it. They may not even announce the existance of their pharmacy unless they receive a fax from 1-800-PetMeds or a client asks them to ship something to them on vacation.

We cling to our pharmacies. We've had them since the dawn of time, and even as others nibble away at their edges we fight tooth and nail to preserve our piece of this pie. But should we?

A reasonable argument could be made for removing our profession from the pharmacy business altogether, or at least to the bare bones.

Pharmacy income as a percentage of revenue, according to an article in Veterinary Practice News in 2012 has remained unchanged, that in spite of everyone crying wolf about the near death of the veterinary pharmacy, we as a profession have seen no loss in revenue from pharmacy sales. According the article, gross pharmacy sales account for between 27-29% of veterinary sales. The article states that our reaction to the pharmacy threat has been to lower prices to remain competitive and sell more units.

What is not addressed in the article is what our desperate clawing to keep our pharmacy alive is doing  to practice profitability and public perception of value. If I sell more items at a smaller per item profit, am I ahead? Am I behind? What happens when clients buy medication from us only to find it elsewhere for a third of the cost?

We are working hard for every penny we can eke out of every visit right now. Think of the tremendous burden placed on us by our pharmacy. We order it, we unpack it, we log it into the system, we check and recheck margins on it, we house it in valuable real estate near the front of the building, and in the case of dog food, that real estate can be vast, we drop some, lose some, buy the wrong something, or the client never picks up what we bought. We then count out tablets, ring up charges, print out labels, and take the risk of handing out a wrong medication. In case that wasn't enough, we over and under order, causing client annoyance on the one hand and expired products on the other.

Face it, pharmacy is a logistical, expensive nightmare, why are we clinging to it it with such desperation?

Think also of client perception. You have a complicated case come in that needs a work up, hospitalization and a bag full of, at this moment unknown, medications.  You can either present a treatment plan with a 'here be dragons' style of pharmacy add-on that looks like a giant what-if to the clients and can easily raise your plan from $700 to $1000 or more. Do they forego treatments or diagnostics because of that giant unknown staring them in the face?

Your other option is to deal with what is in front of you now and let the receptionist deal with the furious client who paid $700 already and cannot believe that she needs an additional $300 in medications! What thieves we all are!

Neither of these represent what is best for our patient or our reputaion.

Imagine instead, that you adress the contingencies of now, the work up, the hospitalization, various injections and hand her her scripts as she walks out of the hospital. Now we're not theives, we're people recommending a medication, and it is certainly no fault of ours if it's breathtakingly expensive. There will be no negotiating medications versus diagnostics.

We cannot compete for price against the large chain stores. Our product is not superior. So why are we bothering to stay in the fight? Who benefits? The client loses money they could've better spent on treatment or diagnostics. Those treatments and diagnostics help us better serve the pet (and her owners) and are far more profitable for us. The hospital loses valuable consumer trust when the client price shops after the fact. It is hard to see how we gain in this scenario.

Think also of the difference between gross and profit. Pharmacy may account for nearly 1/3 of your gross, but I seriously doubt it accounts for 1/3 of your profit. Big numbers are wonderful to look at, but it's the little number at the bottom that matters. Think of how much money you make doing a $20 anal gland expression, or a $20 Schirmer Eye Test, versus selling a $20 bottle of Rimadyl, or heaven forbid, a bag of  Z/D.

Perhaps the smart thing for our profession is to divorce ourselves from our pharmacies as much as we possibly can. We will have to still keep the veterinary only products, and a few things on hand for emergencies. Think of all the space you just got for free. Your pharmacy area could be that cat only room you've been needing, or the grieving room you designed. Maybe it can house an ultrasound or another surgical suite. Whatever you put there, my guess is that it will have a bigger impact on your bottom line than that $30,000 you have sitting on your shelves.
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Would you hire them again?

Do you want your hospital to remain nimble and relevant? Well, staff matters. Staff is the face that greets your customer, the face that sticks the thermometers where the sun don't shine, and the face that helps create client compliance. Your staff handles the pet in the back and ensures a smooth work flow so you don't spend your whole day in a state of hysteria. Lastly they are the glue that holds the culture and vision together. They're the people who remember the birthdays and bake the cakes, remember which clients have kids in soccer matches and which just lost a spouse. People personify your hospital's vision, they embrace it and move it forward. Their actions lets your vision shine through to your clients.

We all know when a hospital begins to fall apart, when people begin to bump up against each other instead of gliding past, when back biting and eye rolling become normal, and you begin asking people to just show up, shut up and do their jobs.

How do we keep this from happening? It doesn't happen all at once. It happens slowly, incrementally. In happens with the addition of one employee, or a sea change in attitude in another. Then before you know it you think you want to fire the whole staff burn the place to the ground and retire to the Bahamas.

Again, how do we stop this from occurring in the first place? Obviously, start off by hiring well, and by well, I am not talking about skills. Most staff skills can be taught quickly to an eager and intellegent pupil. What you want are not skills but attitudes. This is covered in depth here.

But what about afterward? How do you know if it's still working? People change, they slide into bad habits, bad attitudes and mistakes happen. What now?

Well, before you bring out your blow torch, sit down with the names of your entire staff in front of you and ask yourself this very simple question, would you hire them again?

If the answer is No, replace them, if the answer is ambivelance, then speak with them, counsel them, help them better succeed. If the answer is yes, then this is your core team. This is where excellence starts.

I suggest you do this at least every 6 months. I also suggest you make no excuses and give yourself no outs. If you wouldn't hire them again, then you're wasting your time and theirs keeping them on. Let them go. This goes for everyone, staff and doctors alike.

Once your staff knows that you will weed out the slackers and malcontents they will be happier. No one wants to work in a hospital riddled with bad behavior and laziness. These people unfairly punish your best workers who will work extra hard picking up their slack, putting up their broken fences and 'jollying' them along.

It's not easy, but I assure you. If you wouldn't hire them today, then they shouldn't come in tomorrow. It is as simple as that.

Declining vet visits: is education really the answer?

As a veterinary professional, our greatest overriding concern is always prevention. Prevention is the key to everything. It is the key to a puppy not getting deadly viruses, a middle aged dog staying active and slim, and to an older dog having a mouth full of sparkly teeth, but we cannot do it without the pet owner.

Every one knows that in the face of our industry’s preventive care thrust, preventable disease is on the rise and veterinary visits are on the decline. Part of this is due to financial constraints, and part of this is our previous vaccine-centered veterinary visit, both of which we are working on, but the last part may be pet owner education.

The veterinary profession talks endlessly about client education. It is the Holy Grail that will turn our industry around and make every hospital profitable. I too wholeheartedly believe that education will bring pet owners in more frequently, but belief may not be enough. The facts may be pointing in a different direction. Sure correlation isn’t causation, but there is certainly no harm in looking for the problems within our hospitals (where we can affect change) instead of without – where we cannot. We have, as an industry, been stressing education for ten years, and for ten years, people have been showing up less often – not more often – at many of our hospitals. Why?

Perhaps education is only half the solution, and half of the problem. Maybe we are educating our clients well, and then failing them in the end, during the most important aspect of any veterinary visit: the exam.

Remember the adage that a little knowledge is a bad thing? Well, perhaps all of our efforts with titles like “5 signs your cat is sick” And “How to tell if your dog hurts” have backfired? What if our profession is providing just enough knowledge to make our clients dangerous?

We all know how vital the exam is. The entire profession has talked ourselves blue advocating exams over vaccines. Veterinarians are told to explain their exams, “Look at Fuzzy’s teeth? See the tartar there?” We tell clients that Fluffmeister’s lungs and heart sound okay, take a peek in the ears and maybe glance in the eyes and take a look “under the hood”.

And we are doing everything we can to demystify medicine. We explain heartworm cycles and tick behavior, tooth brushing and how to avoid spoiling pets with treats, and then we say, “See ya next year.”

But maybe we need a bit of mystery. After all, I am a fairly educated person, I can look in my dogs’ ears, I can look at their mouths (I often do, and they are clearly not flossing), and I would certainly know if someone was coughing, limping or acting lethargic.

If we want to emphasize our exams perhaps we need to create a bit of mystery. Use the otoscope, use the opthalmascope, use a bit of jargon, “the sclera is a bit red, Mrs. Hatmuffin, it’s probably allergies, but if anything changes…”  There’s a reason Banfield uses a tonopen during every exam.

Think of what transpired during your own visits to a physician: otoscope, opthalmascope, reflexes, breathing in and out, breath holding, coughing, and that’s for the young and spry. We also inevitably pee in a cup that is delivered to who knows where and is never seen or heard from again (do they even run it?). Visiting the doctor involves a bit of mystery. Maybe your pet’s visit should as well.

We are all trying to create educated pet owners, because we all know that the ones who are all over the internet reposting dog-food recalls are our best clients, but we need to remember that the more educated they are, the more likely they are to demand more of us.

I worked with a doctor whose exam consisted of a TPR (maybe), brief stethescope exam, token abdomen feel and a peek under the tail. He believed people were in a hurry and wanted out of the hospital. Perhaps so, but they were dropping good money to cart their dog or cat into the hospital, the least we could do was honor their time with a thorough exam. Had this veterinarian moved to three-year vaccines he never would have seen his clients again!

We all believe that well-care and exams are the cornerstone of well care, and so we probably need to double down on ensuring that those exams look and feel the part to the client. And, bonus: a more thorough exam might just uncover something – you never know.

Aiming a new hire in the right direction

Training a veterinary team is an endless challenge. I remember spending hours at a hospital dreaming up a tiered training plan for new techs only to have it fail spectacularly. Honestly, veterinary practices rarely have the time to sit down and do one-on-one training with new hires.

Instead we tell new hires to follow our most experienced staff around and pick things up on the fly. This is what happens in almost all practices, in spite of our best efforts to do otherwise.

And for most things, like how to clean a kennel, start a room or monitor surgery, this method works just fine, but what about the intangibles? What about the team's goals? Your new hire isn't going to pick that up on the fly. If you're like most hospitals, you're still wrestling with getting existing staff on board with whatever your core vision is, never mind the new hire.

However, your new hire needs to get on board with that vision and fast, or they'll end up being anything but an asset. Think of a new hire as a member of your vision team. You want them to be a missionary for whatever your vision is. In order to do that you need to stress not only what the vision is, but why it's important.

First, you need to bring up your vision during the hiring process. You bring it up, ideally, in the form of a question, you ask them what their vision is, what they want, what gets them out of bed in the morning. You want to come to an accord. You want to hopefully find a shared passion for your vision. you want your new hire to look excited and relieved that they finally found a place that shares their passion.

If your overriding hospital passion is excellence, then an answer during the interview of a blank stare and shrug is suboptimal to say the least. You need to bring up your vision. You need to stress it. You need to let them know that this is what you believe and what your hospital stands for. If you do not believe they can come on board with this vision, if you get the feeling that your enthusiasm is alone in the room, then this person isn't for you. Remember, you can always find someone with the skills, you need a missionary for the vision too.

Once you bring in your new hire, you need to be reinforcing your vision.  Write, "excellence" on the whiteboard, discuss excellence at the next staff meeting (you're already reinforcing your vision at every staff meeting, right?), remind the new hire politely if she falls short (wrinkled scrubs, etc...). Thank her for sharing your vision when she gets things right.

This is your moment to convert your new hire. You need someone who can internalize your vision and help you move it forward within the hospital. This vision need to resonate with the staff before your clients can begin to see it. For that to happen, you need to hire the right people, and take the time to show them how to walk the walk.

Zero sum game

A zero sum game is a situation where adding more of something to one side means that there is less for the other. You can pay more money towards your retirement, or more money on vacations now, but you cannot do both.

Why am I talking about this? Because your perceptions of the world can intervene with your hospital's goals. You may believe, for instance that the more time your hospital spends becoming cat focused diminishes care for your canine patients.

I once worked with a veterinarian who believed that client service and improving medical standards were oppositional situations. The more we improved medicine, the poorer would be the client experience.

I realized this because every time I brought up the idea that the hospital could improve the medicine it provided the clients, she would mention that the clients liked the hospital now. She had somehow come to believe that there was an inverse relationship between client care and patient care - that you could not sustain high levels of both.

Sadly, after months of trying to improve the hospital's medicine through different means with mixed results, it was only towards the end of my tenure at the hospital that I realized what she meant. All along I had believed that it was one of her many non-sequitors and an effort to change the subject.

Had I been able to drill down to the root of where this belief system was rooted I may have been able to help her business forward and provided better results for her patients.

I mention this because we can all get too close sometimes to hear what the other person is saying. Sometimes listening is harder than it seems. I believed that I was hearing what the practice owner was saying, but I was not, and because I failed to hear it I largely failed to help the patients in her hospital receive the medicine that they deserved.

So the message here is, if you find that you are talking about improving cat care, say, and the other person remarks about how excellent your canine care is, maybe they're saying more about how they perceive the world than they are letting on.

There are many instances where people can believe that unrelated items are mutually exclusive and drilling down to where these biases come from can help your practice move forward. Take the time to examine the things that you believe cannot improve or change because to do so would cause a decline in the quality of another important benchmark. Is what you believe true? How can you test its veracity?

Change is hard, but believing that the change you are making will hurt another aspect of your business will make that change impossible. Whenever you consider a change, look at what fears it inspires, then drill deeper to the core. Find the fallacy and embrace the change, because improvement is never a zero sum game.

Tell 'em where you're going

Does your staff show up, do their jobs and go home? Is that it? Do you try to hand out assignments only to see everyone scatter like roaches? Does your team even know where your hospital is going?

I've asked hospital owners time and again to provide me with their hospital's vision, and it's like I'm asking them to build a spaceship and fly to Mars.

Just because your hospital doesn't have a vision statement, doesn't mean it doesn't know where it's going, but it can mean that.

What are you working toward? Are you just putting in the years until you retire? Are you just dealing with every day as it comes? If the answer to either of these questions is yes, then you have no vision. You have no vision, your hospital will have no vision, and your staff will mimic your attitude.

A hospital that is reaching towards greatness knows that it is reaching towards greatness even if there are no fancy words to tell everyone that. But a hospital that is drifting needs a vision if it wants to go anywhere at all.

Look at your hospital. Look at it from an outside perspective. What is it doing in the community? Why should a client choose you over your neighbors? What motivates your staff to challenge themselves. What gets you out of bed in the morning. Deep down at your core, why are you here dong this thing?

You have to answer these questions honestly if you want your hospital to do more than coast along. You need to hold onto that thing which drives your passions and dedicates you to your job, or your staff will just arrive, muddle through the day, and hold their hands out for a paycheck every two weeks.

Hopefully you want more, you're clients are certainly looking for more, the best members are demanding more or they will leave.