Do you live to work or work to live? Wanna change? J D (Jim) Stowe DVM EffectiVet Practice Coaching [email protected] This session will dispel another myth. We cannot and must not own a practice and not run the practice. Otherwise our lives will be run by the practice. We will just have a job throughout a career that should give us far more than that. Our profession is reacting and following. We have extended hours because retail industries have extended hours. We pay what we can afford not realizing that we cannot afford to continue to pay ourselves and our staff such low wages if we want to sustain our business into the future. How do we change? We must start by taking care of ourselves first. Then we can begin to work ‘on’ not just ‘in’ our business through effective business planning, customer focus and ‘marketing’ that works. The success of veterinary business depends not on client loyalty but client adoration. If people are not significantly impressed with the business they deal with then they are more likely to choose a different one. In a profession where there are too many veterinarians, too many clinics, fewer animals and increasing costs of delivery the sophisticated consumer of today has a large number of choices for veterinary care. They can even ask the Internet a question that they typically could only have asked of a veterinarian. Not all veterinary practices are equipped to handle these changes. The typical practice is veterinarian-centred with a low staff ratio (from 1:1 to 3:1 depending on the area. The typical practice sees one client at a time despite the fact that there may be two or more exam rooms. It is not uncommon for a practice with more than one exam room to use only one room predominantly. Management of the typical practice has been ‘inherited’ by the person on staff who seems to be the most interested in ‘managing’. Despite the title of Office Manager or Practice Manager the manager is typically not empowered to lead, manage or change things. In fact in some practices the manager is assumed but not titled. In a typical practice the veterinarian (especially and increasingly only the owner) works 2,000 to 2,400 hours per year – despite the fact that the average ‘person’ works 1,800 hours per year. In some veterinary practices the efficiencies of time management are poor because veterinarians do a lot of non-veterinary work (at least 3 hours a day) and nurses do a lot of non-nursing work. In some practices there is very little cross-training to improve efficiency. In some practices everyone is poorly paid including close to minimum wage for veterinary assistants, barely above minimum wages for receptionists and perhaps slightly better wages for nurses. And too many practice owners receive a great deal less than they deserve for the number of hours worked. The consequence of this model of practice is a high staff turnover rate. This is especially true of nurses. The average lifespan for a veterinary nurse in the ‘technician’ profession is 5 years. Another consequence is a high rate of burnout of veterinarians (particularly practice owners). Worse today, this model is not very attractive to the young veterinarian coming into this market. Although it is true of all other professions and occupations the predictions are that veterinarians will not stay in the profession as did previous generations. One of the reasons…people work too hard and get paid too little.

Although other professions have similar problems in the operation and management of their businesses in today’s marketplace they have responded to the economy of practice long ago and in a different way than the veterinary profession. The MD sees more people in less time by leveraging several exam rooms in his or her outpatient office and several beds in hospital cases. The Dentist leverages his or her Dental Hygienist who does the cleaning while the Dentist does the Oral Surgery and Corrective work. The Dentist also leverages several rooms for both Hygienists and Dentists – leveraging chairs. The Optometrist leverages support staff to a smaller degree but is able to see more patients as a result in any case. In Australia (1998 figures) there are 2.4 MD’s per 1,000 people compared to 1.1 per thousand in the UK and 7.5 doctors per 1,000 in Canada and 8 doctors per thousand in the US; there are 9.5 nurses per 1,000 people in Australia. People visit their doctor in Australia an average of 6.3 times per year. With 4 nurses per MD the human system is relatively well leveraged so that doctors do primarily doctor things. Unfortunately both in Australia and Canada the systems are far too oriented to crisis medicine and care of the sick instead of preventive care. We can do more than just sustain practice! In fact there are tremendous opportunities for this profession if we simply change to the times. In companion animal practice the pet is considered a member of the family today not just a ‘pet’. This adoration of furry family members has spurred a 20% increase in spending on them – and predicted to continue to increase by another 5%. Research is proving the value of animals to human health and well-being through the power of the human-animal bond. And preventive medicine and advanced animal nutrition is creating an increase in the number of products and procedures we can and should provide for pet owners. Another model being promoted is a slight variation of the current model: a Veterinarian Centred low staff ratio practice. By keeping staff costs low the practice owner can keep more profit. Many of these practices however are owned by veterinarians who graduated in the 60’s and 70’s and their debt is low while their equity is high. This model may look attractive – except to a potential buyer who cannot achieve the same profit because they have to add significant debt to their side of the equation. Some veterinarians have taken a low-cost-high-volume route. This can be a profitable model because there is a market for ‘cheap’ veterinary care. This model keeps costs low by not offering expensive or extended care for pets. This model charges significantly less than neighbouring practices and attracts those clients who see veterinary medicine as a commodity that can be price-shopped. Unfortunately, it is difficult to maintain a high quality of medical care in these practices because the veterinarians are too busy seeing too many people. The model closer to our discussion today is the low-volume-high-cost practice. This concept has been evolving over several years but it was put more patently onto the veterinary landscape when Cheryl Garner, Systems Management Expert and married to Dr Steve Garner, was asked by Dr Garner to look at the delivery system of his practice, Safari Animal Hospital in League City Texas. The result was a complete transformation of the practice from the ‘typical’ model to one that has a staff ratio of 15:1 and a gross billing of over $ 1 million per full time equivalent veterinarian.

Drs Robb and Chris Heagle also had a typical practice in Stirling Ontario but they were beginning to do some atypical things. For one, they hired an ad agency to help them with their brand and they hired an interior designer to help them with the impression clients have of their facility. They attended Dr Garner’s seminar in Texas with their staff and they agreed to work with EffectiVet on their practice transformation. The result is that they have had to break many many rules – they have endured a multitude of paradigm shifts to achieve what they have today. At the moment their practice has a staff ratio of 6:1 and is grossing over $ 1 million per full time equivalent veterinarian in a community of only 1,100 people with several competitors within easy driving distance of their practice. In this model the veterinarian must do only veterinary things (diagnose, prescribe and surgery) while a highly trained support team does the rest. This makes the practice team-centred not veterinarian centred. This model is still a work in progress because as we reach a certain point we recognize that there is still more that can be done. Our current position demands that we look at the veterinary fee schedule and work towards a more value-based system than a cost-based one. To achieve it all we must break the rules that govern traditional practice. We must recognize that ‘the business of business is business’ and if we pay attention to the business side of veterinary practice we can improve the bottom line. If we work only ‘in’ the practice we will be ‘run by the practice.’ When we make that paradigm shift and work ‘on’ the practice we suddenly and inexorably begin to transform the practice/business into a more profitable model. There are fundamental principles that must be entrenched for any business to succeed. The question is, ‘what is success?’ To some it means financial comfort, to others, financial excess and yet to many, success is a balance of financial comfort with personal fulfillment. For a veterinary practice to be effective in the context of reasonable financial rewards as well as reasonable personal fulfillment we must have it well planned, well operated and well-managed. To that end, the following concepts describe how to achieve this defined success, the effective veterinary practice. Far too many veterinarians who own their practice work day to day in their job. This is partly because they want it that way because most veterinarians became animal doctors to do just that. The problem is that once we buy or start a business we become (or should become) entrepreneurs. If we are so immersed in just doing our job we get the feeling that the practice cannot survive without us. Veterinary schools prepare us extremely well in medicine but almost completely neglect business skills. Consequently it is difficult for a veterinary business to reach its full potential despite the most sophisticated medical expertise. To break this cycle we must learn to be entrepreneurs who work on the business as well as doctors who work in the practice. We must think systems (entrepreneur) and technical (medical). This means growing beyond the doctor to become a veterinarian-doctorentrepreneur. Will your practice survive without you? Sorry if this disappoints you but yes it can. In fact the more you pay attention to taking care of yourself the more the business will become an effective enterprise. We are our own worst enemies as veterinariandoctors. A successful veterinarian-doctor-entrepreneur can have a reasonable work schedule, less stress, reasonable leisure time, better remuneration and more personal fulfillment. Yes it can be done!

There are three interdependent levels of work for an enterprise to be effective and successful: a. Entrepreneurship b. Management c. Technical If these 3 elements are not present there can be no fulfilled success. Addressing just the technical-medical side of practice has a high cost – your life goes by as you maintain your job. Worse, the lives of your spouse and children go by as you simply sustain a job. Every decision and conflict at the practice can spill over into personal life because the work can become all consuming. Conflicts at the clinic, with people or money, become home conflicts. “Every business either gives to the family or takes from the family” Michael Gerber, The E-Myth Physician

The lesson of the E-Myth business philosophy is to learn how to develop systems for your business that will make the business operate smoothly, effectively and predictably. Once the business is predictable and profitable the owner(s) of the business will have the luxury of stepping back from the business – it will need them no longer. The luxury, for a veterinary practice owner, will be time to enjoy family and leisure while at the same moment, time to enjoy those aspects of veterinary medicine most valued. Working ‘on’ the business allows the owner to tap into more money but more important, fulfillment of life and career. We must learn to balance the time we spend. Some of our time must be strategic planning in the entrepreneurial mode – ‘on’ the business - while some of the rest of our time is done doing the tactical work which is the management mode working again, ‘on’ the practice and then ‘in’ the business doing the technical work as a veterinarian. If we are out of balance, mostly doing the day to day technical, veterinary care we are being run by the clients, the staff, the cases, the practice because we are always reacting to things that are happening – because we have devoted no time to putting systems into place to address the things that happen. This concept demands several paradigm shifts from the traditional delivery system for veterinary care to an all-encompassing transformation of the veterinary business. This cannot be achieved unless the transformation also encompasses the practice owner(s). Do not attempt to transform a practice-business and not transform yourself. In fact, it can’t be done. The journey you set out upon with these concepts will not only be practice-changing but life-changing. But once you’ve built a veterinary business based on these concepts you will never want to practice as a veterinarian in any other way. Once you’ve transformed your thinking into these views of business, life and medicine you will find far greater fulfillment.

What is an effective veterinary practice? Veterinary practice management consultants today are espousing a new way of delivering veterinary care in the guise of several labels:   

Leveraging support staff High density scheduling Using nurses as ‘extensions’ of the veterinarian

The problem with these labels is they tell only part of the story. The complete novel is far more complex – yet very, very simple. What we must realize that to be a more effective veterinary practice we must develop a much more comprehensive system. To address the needs of animal owners we must invent a better delivery system. That system encompasses absolutely everything we do in a veterinary hospital. Why systems management? a) Because the typical veterinary practice is devoid of a system. People come to work, perform their duties – irrespective sometimes of the duties being performed by their colleagues – and go home. We lose their full value during the day and we lose all of their value when they’ve left the building b) Because attempts to correct the inefficiencies of ‘people’ have failed. We end up with employees who are disengaged from their occupation and business owners who are disenchanted with the talent they thought they hired c) Because when each and every person is fully engaged in an effective system we maximize talent not diminish it. d) Groups outperform individuals in an organization and teams outperform groups. Every person who touches and animal or a client must be an integral part of a team. e) Because the benchmarks we have for veterinary practice are quantified from traditional practice – they no longer apply to a highly effective delivery system. And those benchmarks have been restrictive. Practice owners typically take less pay with each and every investment they make in the practice because traditional benchmarks restrict growth. f) Because people cannot be managed. No attempt should ever be made to try to manage people. Instead a system must be in place so that people know what they do, why they do it and how to do it. We must move to a peopledependent system where people are the ones being ‘managed’ to a systemsdependent business where people become the most important asset. g) Because if we are dependent on people for the business-practice to thrive out business-practice falls off the tracks every time there is a people-problem (maternity leave, vacation, illness, retirement etc.) The system must allow the business-practice to thrive no matter who is working. h) Suddenly everyone will get the opportunity for work-life balance and suddenly everyone will be able to contribute value into the system where they couldn’t before in a people-dependent system. i) Because we need a better system to grow people. As Mark Opperman says, you are only as good as the weakest link in your chain. But a chain that is not linked effectively cannot help the weakest link. And why is someone a weak link? Is it the person or the system? (or lack of a system). Finally the most important reason for us to change our system (invent a system) is for our patients. We are all health care workers in veterinary medicine because we love animals.

Yet without a system we cannot and do not provide the care for them the way we would like because without a system people make mistakes – that cannot be corrected. In a system, mistakes will still be made – but there will be a system whereby the reason for the mistake is corrected so the same mistake doesn’t happen again. The process involved in building an Effective Veterinary Practice involves moving from a veterinarian-centred model where the veterinarian does everything or where everything passes by the veterinarian before it is done to a team-centred practice where the entire team is on the same page as the veterinarian. Clearly this paradigm shift means that there will be a painful process ahead for any practice that makes the shift. People after all prefer the comfort of the status quo. But we cannot achieve a new delivery system without dramatic change in the way we do things. How do we develop a system? It takes time, effort, commitment and collective passion. An effective system is built on the following building blocks: Vision and Core Values Communication Systems Standards Training Systems Customer Care Systems Patient Care Systems Commitment to Change The objectives for a more effective system: Maximize consult rooms Involve nurses in client education Involve nurses in nursing care – dis-involve veterinarians in nursing care Involve veterinarians in only the following: Dx, Rx, Sx Involve receptionists in solving problems – becoming Client Aids Veterinary assistants become nurse’s aids not just vet assistants

The results: Everyone works to their full potential Everyone becomes a client educator Everyone becomes a problem solver Everyone becomes a pet advocate This is not just high density scheduling but the result is also an increase in capacity. One veterinarian can see more people in a given period of time when there is a tagteam system in place. To the client the process must be completely transparent. What they see is simply extraordinary effort to meet their needs – and exceed their needs – by each and every individual as they move from the first phone call, to the time they first walk in the clinic door, to the impression they have as they are greeted at the counter, to the impression they have in the exam room, to the impression they have of the closure of the experience, to the comfort call and emails they receive after they get home – each and every time they have contact with the practice!

Systems management must increase capacity for fewer veterinarians; increase exposure of more health care professionals to the client so there is an increase in exposure of all of the preventive care we can and should provide; increase the service we provide to each and every animal owner; and increase the level of care we give to each and every patient. We are in a transition phase for veterinary practice. The majority of practices are plodding along without a system – hiding a surplus of veterinarians in an inefficient business model. A few brave practices are developing a systems approach to practice. This is a risk in a sense because as mentioned, the benchmarks we have for veterinary practice are based on the traditional model and the fee schedule we have for a delivery system are based on the traditional model. Yet this system approach is one that veterinarians and their health care teams would never change once they’ve achieved it. Health care workers in a systems-dependent practice are more engaged in the workplace, more fulfilled in their personal goals, more satisfied with the results and better compensated for their efforts (with both an emotional pay cheque and a financial paycheque.) The objective of systems management is to build a business around repeatable and predictable processes. The objective or a systems-dependent delivery system for animal care is for these systems to provide exemplary customer and animal care. How we do this is the subject of a lot of time, effort and commitment to those goals. We can achieve a balance of life and work if we work to live, work on the business and assimilate the business into the following bubble chart. At the core of the business are the Vision and Core Values. Interdependent systems of personal growth, communication, workflow, training and lifelong learning, marketing, health programs and medical protocols and standards of operation make the business and medicine achieve excellence.

The Effective Veterinary Practice

Personal Growth of each member of the Health Care Team Effective internal & external communication systems

Standards of operation practiced by each team member

The Effective Veterinary Practice Core Vision and Values

Comprehensive preventive health care for every animal offered to every client

Marketing and delivering the promise that the system offers

Workflow to maximize exposure of entire team to a comprehensive health plan

Training and lifelong learning about self, others, the business, client and medical care

Connected and integrated through a SYSTEM: Of what is done When it is done and How it is done

References Gerber ME, The E-Myth, why businesses don’t work and what to do about it, Viking Press, The Penguin Group, New York, New York, 1995 Mowatt, J, Becoming a Service Icon in 90 minutes a month, Jeff Mowatt Seminars inc, Dallas, Texas, 2005 Stowe, J D, Becoming an Effective Veterinary Practice, Veredus Inc, Simcoe, Ontario, 2006