Protocols in veterinary practice II

Introduction

The first paper in this series looked at why veterinary practices should have protocols, what constitutes a protocol, and how a practice can develop protocols that are meaningful and beneficial. This paper looks at the nuts and bolts of preparing, implementing and revising protocols, and as ever, things start with the practice team.

Getting the team on board

When planning something new for the practice, the first thing to consider is staff motivation, because incentivizing the team to work with you to reach new goals is essential for success. Not everyone is excited about new developments and changes in their environment, and although there are some personalities who are always on the lookout for challenges, even people who are open to new trends and ideas can refuse to cooperate if they are presented with goals that are communicated in a way that appears to be an order or instruction to be followed.

Plan ahead

To get everyone on board as smoothly as possible, initiate a team meeting with time for discussion, rather than confronting everyone with pre-determined goals and a “to-do” list. The meeting should be planned beforehand, so that the new ideas and goals are introduced positively, and you must ask the team what their ideas and comments are. If done in an engaging way, there will probably be a lot of affirmative reactions, and the nay-sayers will (most likely) be overruled. A key issue in this process is to identify the possible advantages for the team. This is because – quite aside from personality differences – it´s much easier for people to say “yes“ to something new if they can identify what benefits they will get if they sign up for a project. So your first job is to look at the task through the eyes of the team members and ask yourself:

• Which advantages and benefits do my team members get if they follow my ideas?
• Which extra incentives could I offer to help them follow me?

Remember that “the worm must be tasty for the fish, not for the fisherman”. Once this mental exercise is complete, you will have prepared a set of advantages and benefits that can then be used as positive arguments in the team meeting. For example, preventive healthcare may be a topic which inspired you at the last congress you attended, motivating you as to the possibilities of developing better preventive medicine protocols for the practice, so you especially want to focus on puppies and their owners. How can you inspire your team towards accepting your ideas?

Tell a story!

It can be very worthwhile to prepare a motivating presentation for the meeting that uses pictures and examples that create a buzz and draw people in. For example, you might introduce the project by telling a story that involves them on more than one level – ideally on a medical level, because you’re all working in the profession, but also on an emotional level, by focusing on puppy owners and their needs and wishes. To achieve this, you could emphasize following key issues:

• Preventive healthcare is a great opportunity to detect disease at the very early stages.
• Protocols focusing on preventive healthcare secure a high standard of medicine and quality of service.
• Offering new services strengthens the bond with existing clients and helps win new clients.
• A new service can create a unique selling proposition (USP) which will stand out from other veterinary clinics in the area.

To underline these points, you could create a fictional story around a puppy and its owner, where the owner talks about how excited he is with the new services that are available for his new baby at your clinic. Take your team members on a journey to show how happy the puppy owner is with what the clinic is offering, and therefore how beneficial protocols are for the team to help deliver this wonderful service. If you create this kind of engaging message, then you have probably already reached your goal and your team is on board.

At this point you may also want to consider another aspect for securing long-term involvement: the possibility of introducing incentives and bonuses that reward team members who promote your new project and stick to the protocol, and this will be discussed later in this paper.

Team members and responsibilities

It is important to remember that the highest degree of motivation is created when people are involved and engaged in a scheme. If people have space to express their ideas, and are actively involved in building a project, they feel that they are essential to it and that they own it. On the other hand, if people are given orders from above, from a leader who just issues commands, usually without explaining the advantages and/or benefits, this can be highly demotivating and jeopardize a whole project.

People generally have different strengths and weaknesses; that´s one of the traits that define their personalities and makes working together interesting. If you are in a leadership position you should ideally already be aware of the various qualities within your team, because it makes assigning certain tasks to the most suitable person much easier. By handing over projects and duties to capable individuals, you create an atmosphere of motivation rather than one of demotivation (e.g., by imposing excessive demands or unreachable goals). So if the environment for working on a new project is established in a motivating way, the next step is to find people with the appropriate skills necessary for the different tasks within the project. Success becomes more likely if the task assigned to a particular person fits his or her strengths, because then work will be much more fun, and goals will be reached more easily. This doesn´t mean that individuals can´t work on tasks that don´t fit their strengths, and sometimes there will not be the luxury of selecting the right person for the job, especially if there is a limited number of people available. It just means that the stakes are higher, so as a leader you must be more watchful, and the road to success may be longer. It might also be a good idea to check which of your team members is already engaged when it comes to a particular topic – these individuals could be a very valuable asset when it comes to planning new projects.

Once you have analyzed the strengths and weaknesses of the individuals within your team, and identified who might undertake which task, the next step is to introduce and define the different fields of responsibility, again usually in a team meeting. If it goes well, you’ll find enough individuals willing to take on the various tasks and responsibilities. Key issues to cover could be:

• Introducing and/or creating particular protocols
• Defining or refining responsibilities within certain protocols
• Calling for team members to take oversight for a certain area or protocol

Do keep in mind that large team meetings may not be very effective, because leading such a group is generally much more difficult than leading a small one. Ideally a productive group should have a maximum of 30 people. If you have much larger teams, then it’s a good idea to start by meeting with the leaders from the different clinic departments (e.g., orthopedics, internal medicine, etc.) and then getting them to meet with their teams in turn, to discuss and decide what the actions should be.

One of the most important tasks for the leader is to cross-check choices that are made by the team, and to correct a decision if someone has taken on too much or is not up to the task. This situation may arise for either personal or professional reasons, and if it does occur, discussion on the matter should only be in private between the leader and the individual, to avoid any embarrassment. Here a leader must act in both a supervisory and a protective role, so he or she must have good knowledge of the team members and their abilities, and be willing to trust people and transfer responsibility in a project where required. And if some decisions are later proven wrong, then they can be revised and new solutions found; that’s not a sign of poor management, it just means optimizing a process with a new approach and information as necessary.

Putting the fun into protocol creation

When creating protocols for complex services it is important that the team has previous experience in facing and solving problems, and has received positive feedback in the process. But there is one more factor that should be present when preparing protocols – fun! Why? (Figure 1) Because fun motivates, so to generate the fun-factor you could combine the production of necessary, but tedious, protocols with the creation of others which are more exciting and challenging. So for example you could mix the development of a radiography protocol with a protocol for puppy parties. The goal when systematically interspersing “dry“ and “fun“ topics is to keep your team on track and to gradually build protocols for all the services in your practice.

Protocol nuts and bolts

Designing and implementing protocols is a long-term project that will eventually involve many processes in very different fields of your activity, but as mentioned already, it is strongly recommended to start with a pilot that addresses a limited and very specific subject. The aim is to exemplify the perceivable advantages of protocols in the clinic’s daily life, so a good idea is to choose an easy but useful procedure (e.g., a typical service within preventive medicine), which is probably the best way to provide quick wins to the team at a relatively low cost.

As discussed above, the project should be introduced at a team meeting, where the objective is simply to have a first debate, to propose the idea of a pilot phase, and to submit a short list of possible topics. Assuming the team agrees on a subject, a small volunteer working group can be set up (e.g., two “designers” – usually a clinician and a nurse if a typical preventive medicine service is chosen) and a review team – again a clinician and a nurse). Starting with whatever the clinic’s “best practice” for that procedure is, the designers write a first draft, and the reviewers check it and provide feedback. It’s then possible to refine the protocol as necessary, and after a second consultation with the reviewers, the draft protocol is finalized (Box 1) and ready for wider consultation. This involves checking with the rest of the team: at this point any staff member may offer comments, criticisms, or proposed amendments to the draft protocol. At the next team meeting the final version of the protocol is then presented, and the document either agreed by consensus, tweaked if required, or, if necessary, signed off by the senior management or (for medical protocols), the chief medical officer.

Box 1. An example protocol for a “young adult dog annual health check”.

This official adoption is the starting point of the protocol implementation, but a probationary period (typically 3 to 6 months) is necessary in order to quickly detect any major difficulties and to make any necessary adjustments following feedback from the team. At the end of the probatory period, the working group will issue a second version of the protocol, which then enters the full implementation and maintenance phase.

Monitoring protocol success

Let’s say you are hoping to standardize the way in which your team fills in clinical records when they are examining a patient – and more specifically, you are currently emphasizing the need to always complete a body condition score (BCS) and a dental condition score (DCS) for all patients. How can you monitor to what extent your team is supporting this goal? Various approaches are possible, from basic methods to more sophisticated approaches.

1. Periodically do a random check of 20-30 consultations delivered by each veterinarian, and review if the BCS and DCS have been reported in the clinical records.
2. Use the practice management system (PMS) to generate a list of all patient records that do not currently include BCS or DCS information, and identify which veterinarian last examined each of these patients.
3. Work with the PMS supplier to ensure that a color warning appears on the clinical exam screen if the patient’s BCS or DCS are missing or have not been updated within the last 12 months. The PMS can also generate a report detailing all patients that have been flagged with this warning, along with the veterinarian/nurse who last saw the patient.

The amount of effort and resources that can be put into measurement and control activities is obviously very diverse. An interesting – and almost philosophical – debate is whether it would not be more efficient to put that same effort in generating awareness and consensus among your team regarding the benefits for the patient by following these protocols. In other words, try to make everyone follow the protocol not because they are afraid of being “caught” and punished if they don’t do it, but rather because they are convinced that it is the right thing to do.

One question sometimes asked is if individual staff members should be offered a financial reward for following protocols, and there are reasons both for and against this type of incentive (Box 2). However, in the experience of the authors, creating an incentive for adhering to protocols is – in most cases – not necessary (Figure 2).

Box 2. Pros and cons of paying incentives for adherence to protocols.

Maintaining and reviewing protocols

Designing and implementing protocols is a key step in building up transmissible knowledge and a fueling sustainable growth of the practice, but in the long run, once the most frequent processes are protocolized, the main efforts should be focused on maintaining existing protocols, although new ones should still be introduced as necessary. The reasons why maintenance is so important are two-fold. Firstly, science may evolve with time, perhaps because current ideas in a given area (e.g., surgical castration, pain management, core vaccinations) can be challenged or replaced by new ones, or because new products or equipment may become available, which need to be adapted to existing protocols.

Secondly, the practice organization will change with time (e.g., more support staff may alter the respective roles of clinicians and nurses, or innovations in communication technology may impact the way appointments or follow-up consultations are made. These evolutions can be internal or external in nature, and require a solid system for protocol review. There are at least two ways to organize this:

1. A systematic review can be undertaken at regular intervals. For instance, every other year each unmodified protocol will be reviewed by a small working group similar to the one that designed the original protocol, but not necessarily the same individuals, in order to answer two questions: is the existing protocol still up-to-date for what is regarded as being best practice for the procedure? And does the existing protocol still fit the present organization of the practice? If the answer is yes to both questions, the working group will simply recommend to the team that the protocol remains unchanged. If the answer is no to at least one of these questions, the working group will propose amendments to improve the protocol. However, in both cases a meeting should be organized to get team feedback prior to making any decision.
2. In-between the systematic reviews, all team members should be encouraged to point out any discrepancy between existing protocols and the actual practice organization or state-of-the-art science. Newcomers are also encouraged to offer feedback, especially if the existing protocols are at odds with what they used to do in their previous employment or at university (Figure 3). Once the feedback is validated, it can lead to a review of the existing protocol following the same process as in (1).

The protocol maintenance method (as well as the initial process of formulating protocols) highlights the growing importance of having a Chief Medical Officer (CMO – also known as Clinical Director) in the team (Figure 4). This is a full-time position in large groups – in fact the largest groups will set up a Medical Committee with several professionals covering the whole spectrum of medical protocols – but it may be a part time job in smaller hospitals or where a group owns a cluster of clinics. Even in smaller practices, it is important to have someone with this responsibility. Of course, the CMO won’t take charge of the whole process of designing, implementing and maintaining every medical protocol – it would be inefficient and counter-productive – but he or she will definitively organize and control these processes.

Finally, let’s see how a “Kitten Consultation Infographic” can do a great job of summarizing a large amount of complex information into a clear and visually appealing item that can be kept in the exam room (Figure 5). This infographic encompasses a large protocol in a single A3 poster which can be laminated to allow the practice team to customize as necessary and used during kitten consultations. It can also be printed out and shared with the pet owner to better explain the clinic’s yearly visit plan, and underline to the owner the services that the practice can offer them.

Conclusion

The impact of protocols on how a practice functions cannot be overstated. When creating and working with protocols you will analyze, revise, and improve all services and interactions in your practice. This process is an invaluable tool to create value for the client and to maximize service and organization of your clinic: everything that doesn´t fit to the new standards can be improved, exchanged, or terminated. That means that the effects of protocols reach much deeper than just giving the clinic’s services a new format. Protocols help a practice and the team to evolve and to give the best service every day, to every client. In addition, protocols support the whole team, because the “way we do things here“ is defined, documented and accessible for everyone to check, however often that may be necessary.