Protocols in veterinary practice (I)

Introduction

Providing a service such as veterinary medicine is much more complex than simply selling a product. In a typical veterinary service delivery, there is human interaction (between the clinician and the pet owner), but also human-animal interaction (between the clinician and the pet) which is often closely observed by the owner. The flow of these interactions impacts the customer experience even more than the actual service specifications: it is not only what we do and how we do it, but also what we say and how we say it. Variations in customer experience, either between different veterinarians in the same practice, or (even worse) with the same veterinarian across a period of time, are a serious problem. Why?

• Because this variability creates confusion for the owner (i.e., “What is a normal consultation in this clinic? Was it right the last time, or is it now? What should I expect next time?”)
• Because it erodes brand image, sending the message that this is not a team-led, well-structured hospital, but rather a group of unconnected individuals under the same roof.
• Because it can create preferences or employee-specific loyalties, rather than loyalty to the hospital (“whenever you go there, always ask for Dr. Lucy: she’s by far the best and takes more time in consultations than the other doctors”).

In addition, protocols enable individuals and organizations to navigate a quicker “learning curve”. This is akin to playing tennis or golf, where you learn certain techniques and repeatedly train using the same movements, rather than trying a different method every time you play. How can you consistently train a team of players if every one of them uses a different technique?

Therefore, we need tools such as protocols to achieve a reasonable consistency in the customer and patient experiences that we deliver.

What is a protocol?

A protocol is a series of rules, actions and behaviors that the practice team should consistently follow in specific situations. The protocol could be medical (e.g., canine vaccination guidelines), client-driven (e.g., puppy consultation protocols), administrative (e.g., how to handle client credit) or relative to internal practice processes (e.g., how to conduct weekly team meetings). In addition, protocols are often like a puzzle, in that they will interact with, and complement, each other (Figure 1).

Some protocols can be simple and straightforward (such a sequence of steps or actions), while others require more elaborate tools, perhaps involving a decision tree or algorithm, where the outcome of one stage dictates what the next one should be. But whatever their nature and complexity, protocols should be written, distributed and signed by all relevant team members (Box 1); if it is not written down, it is not a true protocol. If complex in nature, a visual summary (e.g., a drawing or infographic) placed in a visible and suitable location is highly recommended.

Box 1. Why all protocols should be written down.

What is not a protocol?

If you ask veterinarians who don’t have formal protocols in their practices why this is so, they usually offer one or more classic “reasons”:

• “Protocols can compromise our professional independence by interfering in my clinical freedom.”
• “Each patient/client/situation is different, and it’s better to customize the service accordingly.”
• “Protocols are not efficient because they bureaucratize our work, imposing unnecessary steps and resulting in longer consultations, which reduce our productivity and cost us money.”
• “Protocols only make sense for young, inexperienced veterinarians and nurses. Once you’ve been in the profession for 10 years you know what works and doesn’t work for you, and you don’t need a paper form as a reminder.”
• “Protocols can generate strong conflict among partners in the practice because they may have different – but still legitimate – approaches to the same situation, and trying to enforce a single common approach may start a useless battle about who is right.”

Armed with these reasons, some clinicians will certainly claim that there is a collective culture in their practice and that everyone understands “the way we do things here”. But if you could talk separately to each team member and ask them for a detailed description of the things they do and say – for instance, in a puppy consultation – it would become apparent that there is no such thing as a common protocol. Essentially, if it is not written down in detail, it is not a protocol, and without this, there is no guarantee of a common approach to anything within the practice (Figure 2).

Why should I do it?

Basically, protocols are useful to optimize procedures, and especially frequent procedures, performed by a team. Why “frequent”? Simply because designing, implementing and maintaining a protocol requires resources, which involves a cost: it would probably be too expensive to focus on processes for things that arise only rarely, unless they are critical in nature. Although protocols may help even where team cohesion is not at stake, they are especially useful to assist interactions between professionals and to ensure that where different team members undertake the same process (e.g., several veterinarians doing first puppy consultations, or several nurses responsible for post-surgery recovery), they actually do it in roughly the same way.

More in depth, there are at least three main reasons to invest into protocols: improving processes, ensuring a homogeneous implementation – whoever is in charge – and fostering the transmission of know-how.

Improving process

Process improvement is clearly a major goal when setting protocols. When a team designs a protocol, all involved members must agree on the best sustainable way that addresses the targeted procedure. This may not be the one-off best possible way, but it must be deliverable on repeated occasions (the best sustainable way); it will be to a very high standard, but it will also be the best one that can be implemented on a daily basis. Doing this offers opportunities to identify bottlenecks and to propose improvements via new organization and/or training and/or investment. For instance, the pain management program used for a specific procedure may be enhanced thanks to the introduction of a coherent practice protocol.

Ensure consistency

Standardized implementation is another important goal. Protocols are a means to provide consistency among professionals doing the same thing in the same practice, for example by recommending bloodwork or proposing the same treatment options for every patient with the same condition. This consistency will improve both team efficiency and the client experience.

Transmitting know-how

Passing on knowledge is crucial for at least two scenarios: integration of newcomers into a practice team, and establishment of a new practice branch. In other words, transmitting knowledge is a prerequisite to growth. Introducing new members into a well-organized team is always challenging and risky, for either the new veterinarian/nurse/technician, and/or the existing team. Protocols provide concrete tools to shorten the integration period and to ensure a quicker convergence between colleagues and the incoming team member, and will also reduce the stress levels of your team, especially in the current pandemic/ post-pandemic period (Figure 3). This process may also be an opportunity to improve protocols thanks to feedback from the new team member. Establishing a new branch will be quite different from initiating a new practice from scratch, and the difference lies precisely in the ability to start from the existing know-how – which comes back to protocols.

At the end of the day, protocols are an excellent way to turn the informal knowledge of any practice – which can otherwise take time and effort to uncover and to integrate – into a tangible factor, and are therefore a valuable benefit. Remember that the main asset of a veterinary practice lies in the know-how of its team. Any practitioner will immediately agree with this statement, yet too many practices invest very limited resources in formalizing this know-how in order to make it transmissible; this is what protocols are all about. Designing, implementing and maintaining relevant protocols is probably one of the main ways to increase a practice’s ability to achieve sustainable and profitable growth, grounded in good science and medicine. This will result in a significant increase in the value of a practice.

Defining protocol objectives and outcomes

If we want to use protocols as valuable instruments to improve medical, organizational and service-related issues in our clinics, the immediate questions are: ”Where do I start? What are the first and the subsequent steps? And how do I define goals, objectives and outcomes?”

It´s important to answer these questions beforehand, because having the right goals can be very motivating and inspiring for the whole team. The first step is actually to separate a genuine goal from a dream or a vision by defining it clearly and precisely, otherwise it may never come true. Defining objectives can be both interesting and challenging, but by using a SMART template (Box 2) the task can be much easier, as this tool allows the creation of tangible goals; as well as enabling all the important factors to be quantified, it also allows assessment as to whether a certain project is really attainable or not.

Box 2. The 5-step SMART tool for planning and checking practice goals.

A SMART Example

To help transpose the SMART template into everyday veterinary life, here’s an example. Assume that you would like to ensure every client with a puppy has a comprehensive offering of all the clinic’s existing health services available for young dogs. From your monthly analysis you have realized that this already works quite well, but it is not carried through sufficiently; maybe the process is not structured and clear enough, or the communication is suboptimal. Clearly there is potential for improvement, and you want to work on this issue by starting with a well-planned goal:

1. S – specific formulation. To have a consistent approach to clients with puppies concerning health plans and related services, your goal could be defined as follows; Every client with a puppy must be offered health services at least once, between 8 weeks and 18 months of age, by using a protocol that defines the content and manner of communication.
2. M – measurable quantity. The indicator for this goal is the number of completed and documented interactions with clients that visit the practice with their puppies (this might be assessed via reviewing owner consent, or by using a tick box in the pet’s file in the PMS, for example).
3. A – acceptance. The issue of inconsistent communication and documentation concerning puppy health plans has been discussed by the team, and there is consent to work on this important subject.
4. R – realistic. The agreed goal is feasible with the resources available, e.g., personnel (team) and technical support (software).
5. T – time (deadline). The project starts on (say) March 1^st 2022, and the deadline to review the goal, check its success and plan or apply additional measures is set for June 30^th 2022. 

With the aid of the SMART template, we have now created a meaningful, achievable and verifiable goal that sounds much better than simply saying: “I’ve noticed that we don´t do a good job informing our puppy clients about our preventive services and health plans. That must change, and I would like you to be more diligent.” That´s not a SMART target, it´s a wish that probably won´t come true!

Now it´s in your hands to plan SMART and successful goals. The only thing left to do is to compile concrete actions that help the team to reach what has been agreed – so in this case by creating a protocol for communicating health plans to puppy owners that come to your practice which contains details such as who, how, when and where this communication takes place.

What are the risks of not doing it?

One thing should be made clear; a veterinary practice may succeed without protocols. However, this is not a given, especially if and when a team enlarges, the number of processes increase, the practice offers a number of different services (e.g., general medicine, emergencies, and referrals) and/or owns several branches. In other words, the importance of relevant protocols is commensurate with the practice size and complexity. This means the absence of protocols, already painful for smaller one-site practices, turns into a huge handicap for larger, multi-site practices. Without protocols, there will be several ways of doing a task among staff members. In most cases, the main differences will be observed between veterinarians, and the support staff (nurses, receptionists, technicians) have to cope with this reality and the problems it creates. For instance, it is not uncommon for several surgeons who operate at the same clinic to use different protocols when it comes to the critical matter of general anesthetics.

Without protocols, the team’s performance relies mainly on the skills of individual members. Therefore, the first risk of not having protocols comes from the loss of knowledge, possibly linked to changes in the practice team, for example, when someone leaves. The first thought is that this could be critical when the practice loses a clinician – moreover if this person has specific skills. This is obviously true, but it would be dangerous to overlook the possibility that the same risk could exist if the team loses a key nurse or member of the support staff. In some instances, a practice without formalized protocols can even encounter relative knowledge failure following a longer-than-usual period of leave or even the traditional long summer holiday (when informal procedures may be “forgotten”).

Without protocols, a multi-site practice risks an increased risk of divergence. Month after month, different ways of doing things may be implemented at the various sites, and after two or three years of such divergence, it will require huge efforts to get the various branches, or the various teams, to agree to change their habits and to converge again. In the meantime, it will be difficult for those staff members who work at several of the sites to be efficient.

Without protocols, the time taken to adapting a team to new techniques – whether that be small or continuous improvements, or breakthrough innovations – will be longer, less effective and, once again, will pave the way to deeper divergence among team members or branches. For instance, the authors know of situations where the time taken for adoption of the new WSAVA dog and cat vaccination guidelines (published in 2016) varied from a few weeks to several years between the different branches of a practice. Furthermore, six years later, some clinics are still following the old recommendations – and worse, in many cases within the same team, some practitioners have switched to the new guidelines while other colleagues have not.

In summary, protocols are one of the main keys to unlock the door that leads to sustainable and profitable growth. The historical trend from sole practitioners, working with no or limited support staff, toward partnerships and small teams on a single site, and on to multiple site partnerships with larger teams or big hospitals employing several dozen professionals, would be a good approximation of hell without an early implementation of protocols. Make no mistake: the advantage of having protocols is not limited to international companies, it is already necessary for practices with three veterinarians and five support staff, and will be useful even below this threshold.

Two big questions

Before discussing the issue of what a finished protocol should look like, let’s step back for a moment and think about the creation process. One crucial question is – “Should protocols be created by the practice (with the risk of “re-inventing the wheel”?) or can they be adapted or replicated from books, experts or other practices?” The answer may differ depending on what is required – there is a clear difference between a medical and an operational or business protocol (Box 3). For medical protocols it is a good idea not to re-invent the wheel, but rather to adhere to what evidence-based medicine has established as a standard (e.g., official guidelines recommended by the relevant veterinary association). However, it is a different story for business protocols. Each practice is different in terms of culture, in terms of structure, in terms of organization, and in terms of teams. Involving the team in the creation or adaptation of the desired protocols will achieve a greater sense of belonging and commitment, and will probably result in better designed protocols that will work in their practice.

Box 3. Examples of possible protocols for a veterinary practice (from 2). Protocols may fall under more than one category.

The other big question is: how can we ensure that the different team members are aware of and actually follow the different protocols? The following initiatives will improve the implication of your team in adhering to practice protocols:

• Involving them in the creation process.
• Establishing a fixed point whereby the relevant documents can be discussed and reviewed; for instance, dedicate 15 minutes at each weekly departmental meeting to review one of the protocols (Figure 4).
• Creating a training program which requires all veterinarians and nurses to attend a 30-minute weekly training session where all the relevant protocols are explained by an experienced staff member.
• Including knowledge and compliance with protocols as part of the individual appraisal systems in the practice – maybe even by introducing tests, or by random observation.

We will return to these questions in part two of this article.

How to prioritize protocols

Protocols are valuable tools to support the organization in general and to secure high standards and quality of medical and customer services. If you have already undergone a quality management program or certification, you know how important it is to have concise and complete documentation of all the clinic’s processes. The most important issue to understand is that protocols and documentation are not about erasing professional individuality and personal style; it´s about securing the highest possible standards of service in your clinic for every client, and allowing your personal style to be guided by agreed rules and protocols.

When the decision to implement written protocols has been made, and you are ready to take the next step, the question is “Which protocol do I start with, and what is the best option to create it?“ The answer is not always easy, as it depends on your clinic´s portfolio and on the performance of your team. Here are some tips to help you decide and get started:

1. Begin with a protocol for a service or an offer that is already established and works well for your clinic (Figure 5). Choose something that just needs to be updated and fine-tuned, and which won´t cause too much commotion within the team during the process. For example, this could be the annual health check with vaccination – a daily procedure that is offered in most clinics, but often where no standards or protocols exist. This would be a good example to show the team how important protocols are to ensure that clients and their pets always get the same high-quality service, no matter who is in charge and on duty.
2. When the initial protocol is agreed and has been working well after a defined period (e.g., 6 months), and the outcome has been verified (e.g., by reviewing a selection of client files to check the protocol steps are being documented), it´s time for the next step. Now you and your team should choose an established service which lacks a structured and concise approach for how it is promoted to the client; a good example for many clinics could be the protocol for a senior health check for cats aged 7 and older.
3. A subsequent step on the protocol “ladder“ after mastering and revising steps 1 and 2 could be to create a protocol for a more complex service, e.g., a puppy or kitten health plan. The experience, the (hopefully) positive feedback and overall success gained in following the initial steps should then motivate you and the team to develop things further.

Part two of this topic will look at how to motivate the team and successfully implement protocols in veterinary practice.