Concordance and compliance: a practice-wide approach - Veterinary Practice
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InFocus

Concordance and compliance: a practice-wide approach

BRIAN FAULKNER explains how, because compliance is an issue that affects all the components of a successful veterinary practice, it must involve the entire practice team

THE entire veterinary practice team needs to see compliance as an essential component of the practice’s long-term purpose and strategy.

This is because compliance is an issue that affects all the components of successful veterinary practice: patient care, client satisfaction, professional fulfilment as well as sustained commercial success.

Achieving and measuring compliance is an essential component in accomplishing all of these objectives. Contributing to high compliance rates is a significant component of non-veterinary employee job satisfaction.

It is all too tempting to assume that the vets are the “power-players” in veterinary practice and that nonveterinary qualified staff make little difference. In contrast, an AAHA study* showed 75% of compliance impact came from non-vet staff members. That is not to say that the vets hardly made any difference in compliance success. It means that if clients have been primed in relation to a certain compliance issue, a second and preferably a third message makes it more likely that they will comply.

If people hear or see the same message three times, ideally from different sources and in different forms of media, they are much more likely to see it as a consistent pattern and believe it. For example, people remember 20% of what they hear, 40% of what they see, and 70% of what they see and hear.

There is, however, the small matter of the incumbency problem. This occurs when people hold a certain belief that you do not consider to be “true, good and right”. It is often very difficult to change someone’s mind by dislodging the incumbent belief and replacing it with an alternative one, especially if the new belief directly contradicts their incumbent belief.

Changing someone’s mind often requires a combination of individual one-on-one persuasion (usually the vet) as well as a back-drop of reinforcing messages (everyone else in the practice as well as practice marketing materials).

Clinical autonomy

As qualified professionals, vets don’t like to feel that we are being forced into making medical decisions. However, there is a spectrum of autonomy that can operate within veterinary practices that can help achieve compliance without interfering with clinical autonomy.

It is worth considering how clinical autonomy relates to achieving compliance in three main areas: acute sick patients, long-term medical cases and preventive healthcare.

Having practice-wide policies and protocols works well for preventive healthcare (PHC) when everyone knows, agrees and recommends the practice’s stance on each specific PHC issue. With respect to long-term medical cases (LTM), practices often benefit from agreeing a framework with regards to how they monitor, measure and medicate the typical LTM cases common in all first opinion practices.

Finally, vets should be allowed clinical autonomy with respect to how they manage acute medical cases, not least because they need the freedom to be able to establish consensus with the client.

Preventive healthcare

The PREVENT IT mnemonic is a useful way to consider the various preventive healthcare issues. Whilst the canine version is illustrated (below), it is useful to have a separate sheet for dogs, cats and rabbits which represent your practice’s protocols and recommendations. It is important that staff members see these recommendations as best practice as opposed to having to “make a sale”.

It is also important to track success. Practices with higher-than-average compliance track the proportion of their patients that are vaccinated and regularly purchase endo and ectoparasiticdes.

Long-term medical cases

Agree, as a team, as to the ideal ways to monitor, measure and medicate typical LTM cases. Create a chart (similar to the one shown here) that can be handed out to clients as their tracking sheet with respect to each of these items.

Of course, not all patients will require all these medications and monitoring and, even if they do, not all clients will comply with them. However, clients adopt more recommendations when they understand how they relate to a wider strategy.

The acute medical case

How well clients comply with both diagnostic and therapeutic recommendations in relation to acute medical cases is strongly correlated with the veterinary surgeon’s clinical orientation. Clinical orientation describes a vet’s tendency to choose one type of diagnostic-therapeutic intervention strategy over another when presented with a clinical case.

There are two main types of clinical orientation: the reactive-empirical orientation (whereby the vet’s default tendency is to treat the patient based upon a presumptive diagnosis) and the proactive-technical orientation (whereby the vet’s default tendency is to want to try and establish a definitive diagnosis before treatment).

These two orientations can be distinguished by looking at the percentage of a vet’s (or a practice’s) turnover that is made up of imagery and lab tests.

Reactive-empirical cultures tend to have a diagnostic percentage of around 10% whereas proactive-technical cultures tend to be nearer 20%.

It is important to realise, though, that being a proactive-technical culture doesn’t mean that every single case receives a full diagnostic work-up.

Most practices agree that it is entirely legitimate to treat most patients using a presumptive diagnosis; the difference with proactive-technical cultures is that they work up about twice as many cases (say 4 out of 10) than empirical-reactive cultures (say 2 out of 10).

Doubling the amount of diagnostic and therapeutic recommendations during acute medical cases affects all the measures of successful veterinary practice: patient care, client satisfaction, professional fulfilment as well as sustained commercial success.

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