Compliance: A Team Effort

For years, veterinary management experts have been discussing how to get clients to comply with veterinary care recommendations. The statistics have been studied, the numbers crunched, and strategies suggested, yet according to the 2009 American Animal Hospital Association (AAHA) Compliance Study,¹ compliance is nowhere close to the goal of 90% to 100%. The struggle is real.

However, there are practices whose numbers break the benchmarks. How do they get clients to “yes”? What do they do differently than those hospitals that are chronically looking at 30% to 50% compliance? The following are my rules for promoting best compliance.

First Rule: Have Appropriate Staffing

This may seem out of place in a compliance discussion, but the veterinary practice must have qualified team members who understand the reasons behind the medicine and enough staff to allow them time with clients. A team that is chronically short-staffed cannot take the time needed to explain the importance of a service or product. Customer service team members working a busy desk alone will not have the freedom to chat and build important relationships with new or existing clients. Doctors constantly facing a lobby full of impatient clients will hear the clock ticking and rush explanations. Technicians and assistants pulled in too many directions are not able to spend quality time in examination and treatment rooms or on the phone.

Second Rule: Establish Standard Protocols

Fortunately for veterinary hospitals, the American Veterinary Medical Association (AVMA) and AAHA have invested time and expertise to create approved standards of care—canine and feline vaccines and diagnostics, pain control, behavior, end of life care, and more—all of which are good bases for building hospital protocols. The American Association of Equine Practitioners (AAEP) has done the same for horses.²

In multidoctor practices, creating standards of care becomes more challenging because medical opinions often vary. One way to clarify a practice’s protocols is to have all the veterinarians complete an anonymous questionnaire listing what they believe to be the best medicine for common hospital procedures.

For example: A practice has 6 doctors on staff and wants to design a protocol for routine canine ovariohysterectomy. The veterinarians fill out the questionnaire, and all except 2 agree that patients should have presurgical blood analysis, be intubated, be given a preoperative physical, and have their blood pressure, heart rate, and O₂ saturation monitored. One veterinarian believes that placement of an IV catheter should be routine, and the other believes postoperative pain control should always be sent home with the patient. Now the practice can begin to develop the protocol based on common beliefs. Then the practitioners can work to reach a consensus about postoperative pain control and IV catheter placement. The practice owner may have to step in and break the tie. The team can also contact a local specialist or use a tool for protocols (e.g., VetCompanion.com) to discover what veterinary specialists say is best. Either way, the practice formulates a protocol that all agree will be the minimum standard of care.

Standards of care are vital to improving client compliance. Clients engage with many team members. The team will discover that it is impossible to educate clients when multiple answers are available.

Third Rule: Provide Team Training

Hospitals that have high compliance rates train the team to deliver a consistent message. In single-doctor practices, this message is simple—it is what the veterinarian decides is appropriate for the geographic area. If a multidoctor practice has followed Rule 2, it now has a standard of care that the team is trained to follow. Training on a consistent message and standard of care is vital. If pet owners receive contradictory information from different team members, they will first become confused—and then mistrustful.

The most important thing we can gain with clients is trust. Consider the following scenario: A client brings in her kitten for a routine spay. Dr. Old School performs the procedure but does not include preoperative blood analysis, placement of an IV catheter, or postoperative pain control in the surgical treatment plan. The entire procedure costs $145. Later, the same client comes back with another kitten for the same procedure, and Dr. Two Years Out performs the surgery—including preoperative blood analysis, placement of an IV catheter, fluid administration, patient monitoring, and pre- and postoperative pain control. The cost tallies $345. Here comes the problem. The client perceives one of two options: either Dr. Old School omitted something very important and risked the pet’s safety, or Dr. Two Years Out padded the bill and charged for a lot of extras that were not necessary. The result? Loss of trust. When quoting the cost of a feline ovariohysterectomy, the team should never have to first ask, “Which Doctor do you want to see?”

A common excuse concerning the lack of team training is the lack of time to do so. What this really means is that the practice does not have a commitment to training, because we always make time for things we believe are important. Some practices choose to close for 1 to 2 hours over lunch, lock the door, turn on the answering machine, and train their staff. These hospitals have a commitment to routinely training their team. When clients have questions, the team has the answers—and the answers are consistent.

The importance of why can never be stressed enough when training to a standard. When doctors determine what they consider to be best medicine for their practice, it is vital that they explain their basic reasoning to the team. Without this knowledge, the team may recite what they have been told, but they never can relay the reason or be passionate about the benefit to the patient or human family. As a result, clients won’t understand the need for important services, and the patient won’t receive them.

It is common for a practice to stock and display every possible parasite preventive. Not only is this poor inventory control, but it sends an inconsistent message to staff and clients that there is no clear choice. The same principle applies to preoperative blood analysis. A common question on surgical release forms is, “Do you want preoperative blood tests?” Why would we ask this of a client who has no training in veterinary medicine? Why are we not leading them based on our expertise? Many clients are often unable to distinguish whether their new dog is male or female. It seems incongruous to ask someone that uninformed to make a medical decision about presurgical care.

Fourth Rule: Practice with Role Playing and Scripts

Not everyone enjoys role playing, but it is an amazing tool. Anyone who has presented clients with a newly offered service knows that if you do not grab their interest in the first 2 sentences, the answer is commonly “I just want what I always get.” However, if you can quickly pique a glimmer of curiosity, you can typically provide a more elaborate explanation and gain agreement to the service for the patient. Developing a good script helps us create our “catch line.” We can work with fellow team members to find the most engaging and effective wording to use and then practice until our delivery is smooth and confident.

To best explain why we need to practice, we need to understand some neuroscience. In the books Brain Rules by John J. Medina and The Power of Habit by Charles Duhigg, we learn that our brain creates neuropathways for the things we commonly do (e.g., bathing, brushing our teeth, preparing our morning coffee). If you have ever driven to work, parked your car, and suddenly realized you have no idea how you got there, you have experienced a neuropathway at work. When we create our script and practice it repeatedly, we are building a new neuropathway that will instantly be available to us when the need arises. This fluency makes us more believable to our listener because we are confident and prepared. The negative issue with these neuropathways is that they never go away. So, when you are trying to make a change in a common protocol, be aware that your brain will continue to pull you toward the old pathway. This is why smokers and dieters relapse. As a team, it is advantageous for members to agree to help each other overcome the old pathway and hold each other accountable for creating the new one.

Fifth Rule: Be a Good Storyteller

Veterinary teams sometimes assume that clients understand more about veterinary care than they typically do. In fact, we can become very judgmental and outraged when clients ignore our advice or delay providing routine preventive care to our patients. According to consultant Thomas E. Catanzaro, DVM, MHA, FACHE, DACHE, veterinarians often assume that pet owners are similar to livestock owners in that they understand basic animal husbandry. Farmers are knowledgeable about how to keep their production animals healthy with vaccination, proper nutrition, and housing. Our clients often become pet owners from a different direction. Perhaps a stray wandered into their home or they walked through a pet shop or a shelter and came home with that cute critter. Therefore, they may have little or no scientifically sound knowledge about proper care.

When pet owners enter the veterinary hospital, the team attempts to educate them, sharing the science and medicine behind the protocols. We often use jargon and terms that are incomprehensible to owners, yet they will feign understanding to avoid appearing uneducated. Instead of overwhelming clients with complex discussions, we should tell them a story. All veterinary teams know powerful stories of how the lack of preventive care resulted in sickness and even death of an animal.

Understanding the reason people purchase reveals the need to be a great storyteller. When people make buying decisions, they like to believe they are being logical, but in reality people buy on emotion.  They are looking for “What’s in it for me?”³ When veterinary teams learn to explain to clients how not giving parasite preventives and vaccines against leptospirosis and Lyme disease puts their family at risk for zoonotic disease and then tell a story of a client who contracted the disease, the client may see the importance of compliance. Use pictures to support your story. One of my favorites is an image of a child with ocular larva migrans. When a client sees the parasitic larva in the child’s eye and understands that the number-one cause of childhood blindness in the world is parasites, such a photo can be a powerful motivator to consistently give monthly parasite preventive.

When telling stories, be sure to use emotion-evoking terms, such as family safety and protecting children. Pets are important members of most families. When we stop talking medically and begin telling stories that induce an emotional response, our clients will be motivated to improve their response to our offerings. Veterinary team members may believe that clients say “No” because of money, but there are other reasons. Some clients fear causing pain, others feel that we don’t care, and others still don’t understand the benefits of our services. We have to be better at showing the benefits.

Rule Six: Remind and Remind Again

In 2009, an AAHA compliance study found that “Practices employing six or more client education/communication approaches achieved significantly higher compliance than those using fewer approaches.”¹ In the age of technology, the wise practice gathers email addresses and cell phone numbers and heavily leverages email and text messages. Still, nothing is more effective than the phone call. Typically, email or text reminders are sent a few weeks before services are due, a second email or text is sent a week after the service is overdue, and then a third message is sent when the service is a month overdue. The third reminder can be the phone call. It is never a bad idea to reach out again with a phone call once a service is 6 months overdue as well. During these calls, we may discover that a pet is deceased or no longer owned by the family or that the family has moved to another area, which is an opportunity to keep the database current.

The language used on reminders is important. A message that says “Your pet is OVERDUE!” just admonishes clients and makes them feel guilty—and people avoid things that make them feel bad. The wording should be, “We miss you, and our doctors are very concerned your pet is unprotected!” This says we care.

It is imperative that patient records be updated for reminder notifications. New patients that present with an illness will miss important future care if reminders are not manually entered. A computer search for “patients without reminders” is a good way to create a list of owners to call. It also helps clean up the practice database so that compliance reports are more accurate in the future.

It is also important to track compliance on remindable services. Most veterinary practice software allows for compliance reporting provided the necessary setup is done. There are also outside services that provide excellent tools for data-mining this information. If you are not tracking compliance percentages, you will be unable to monitor how effective your team is at getting patients back for needed care. Setting goals and targets for the team and then sharing the data to show success or failure is a great way to get everyone focused. When we focus on something, it seems to improve, even if we don’t think we are making a big effort. Being “front of mind” helps in compliance success.

Conclusion

Great compliance takes a great team and a consistent effort to communicate with clients. Share your stories of patient success and failure with each other, gather them like tools in a tool belt, and use them to educate and motivate clients. When you do, you will find compliance will improve and your patients will be happier and healthier. The goal of every general practice should be to never have to treat a preventable disease and instead work to develop a patient base that lives a long life full of the vitality that comes with on-time immunizations and diagnostics, excellent oral care, and proper nutrition.