Vetlearning

2. The impact of consultation skills on performance Dr Paul R. Manning, MA, VetMB, MSc(VetGP), DProf, MRCVS. Vet Learning

3. Outline of this presentation Identifying success. Define success; ie: what you think you should always do to achieve it in a consultation. 2. Problems and potentials. Discover why you don’t always do it, and perhaps sometimes when and why you do. 3. Models and analysis. Discover ways of monitoring outcome and process. 4. The impact. Discover what effect or impact consultation skills have by monitoring. 5. Improvement. Discover ways of improving those skills which have an impact.

4. 1. Sunday Times business 24.1.10. page 8:The man from the Pru Chief Exec Tidjane Thiam said: ‘I don’t need to change our strategy, I just need to do what we always said we would do… We always said Asia, Asia, Asia,… ..That increased our profits from 1 year to the next by 25%.... I’m allergic to being a role model. I am too aware of my own faults. You should be your own role model. Don’t look to others – be your own master.’

5. Identifying performance and consultation skills : are they related? What is the potential impact? ££,less complaints, more healthcare delivery How can the impact be identified? What can be done to improve the impact? Why is the impact important?

6. What can you measure? Outputs and processes : easy or more difficult?.

7. ‘What is going on here?’ This is a classical qualitative analysis question. (Silverman, D. 2004). Vets tend to hate numbers because they either feel threatened by them, or feel that they do not adequately represent the complexities of the consultation. Asking questions about ‘why, what do they do, and how do they do a consultation’ can stimulate a very detailed and constructive discussion and outcome.

8. A successful consultation Factors which can have a positive impact: Business Planning : Have you got a business plan? Do your healthcare team know the plan? Does your business plan involve what happens in the consulting room? How do you monitor KPI’s against your plan? Do your KPI’s include processes and outcomes involving the consultation?

9. Is your practice client focussed?

10. Where are you looking and what are you looking at?

11. Opportunities Many types of consultation (not just many species) Many different models can be applied and analysed;eg: Calgary-Cambridge, Approaches to the opportunities include: Seminars ‘defining successful outcome’ Observing consultations/audiotapes and analysis Monthly team meetings to raise awareness of opportunities (taken and missed)

12. 2. Consultations in modern veterinary practice: what are the problems and potentials? Observations of consultations. Identifying problems and working through processes to create opportunities.

13. Potentials Increased ATV’s (25% increase, some vets 100% increase : (Manning, 2006) Better work sharing between vets Increased turnover Increased profit from better use of time Increased profit from better use of opportunities and compliance Greater job satisfaction, self-motivation, renewal of enthusiasm. Reduction of client complaints. Practices can become more profitable with greater choice on how to use increased resources.

14. Problems include: Most vets know that consultation skills are important in practice, but until now there have been few (if any) opportunities to develop them. SPVS Masters questionnaire to 9000 vets produced 903 responses :only 1 or 2 disagreed with the statements ‘consultation skills are important to the GP vet and are important for the effective delivery of good clinical service Many vets think consulting skills are just for new grads because ‘experience’ is a good teacher. Most vets (SPVS Masters survey 2002) will choose to learn clinical subjects and give low priority to consulting skills.

15. Is communication our clients’ problem or our problem? Svarstad in a PhD thesis in the USA 1974 was one of the first to challenge the previous paradigm that ‘the problems doctors have are all with their patients’, and change the hypothesis to ‘maybe the problem lies with ourselves, us doctors?’ MSc research (Manning 2003)found vets ranked clinical skills above communication skills in the price of the consultation : clients had the opposite view.

16. Is non-compliance the problem of the clinician or the client/patient? Vet versus client perceptions: Vaccinations : price, homoeopathy, side effects, efficacy, duration of immunity…. Dental surgeries : anaesthetic risk, benefits when cat/dog has not yet stopped eating, heart disease risk…. Arthritis : ‘he’s just getting old’, I really think he could have a better quality of life..

17. Problems in performance Some vets are better than others in performance and rechecks Some vets are popular for the wrong reasons;eg: they don’t charge properly, or they allow clients to get their way over rechecks. Vets vary in their enthusiasm for different consultations. This + knowledge affects uptake of clinical services. Complaints to RCVS/VDS are 80% on communication, consultations. Awareness of clinical disease presence can be low or biased in some clinicians (Schering Plough have a sophisticated data analysis system which identifies best and worst performing practices by product. Other companies can also help improve compliance.)

18. Problems in skill deficiencies Responsibility avoidance Follow through failure (rechecks) Time Management failure Planning failure Failure to elicit client concerns Closing the consultation

19. The consultation skills : Research findings Time management is a huge issue for vets and doctors. Consult skills + define success =measurable outcome. Good listening, higher time to interruption leads to best outcome. Vet dominance suppresses client concerns. Chat/too much social exchange can cause poor outcomes; eg: example of giving wrong vaccine, failure to elicit client concern that hip dysplasia might shorten dog’s life and she wanted an xray.

20. Issues that prevent vets from recommending ‘best practice’ Fear of rejection Being bullied/lack of assertiveness Lack of understanding of the real costs Variance in vets’ perceptions of the value of treatments/diagnostics/prescription diets and their enthusiasm for them Time

21. Are the messages clear enough? Strength or weakness of the vet’s recommendation is key: Reflect on what you believe is best practice………… Reflect on how you recommend it… Reflect on how you fail to achieve client concordance…… Monitor the processes which underpin the outcomes in clinical and financial performance.

22. Are your perceptions in tune with those of your clients?

23. Impact of issuing dental cards on numbers of dentals

24. The vaccination consultation Adding value Encouraging health care Exploring healthcare opportunities Bonding clients Neutering discussions Dietary advice Parasite control advice Use of a checklist for the healthcare consultation including the physical examination.

25. 3. Why do we consult? Can we analyse how we consult? ‘A good man cares for his animals’ Proverbs 12, verse 10. (King Solomon approx 4000 years ago).

26. Meetings between Experts Book by Tuckett, 1985. The physician is the ‘expert’ on the medical science, whereas the patient/client is the ‘expert’ on the body or animal from their intimate knowledge and observation.

27. Models There are lots of ways of looking at a consultation and as many different models. Safari model (Steve Garner USA) gives clients 45 minutes in a consultation, but the vet only provides 5 minutes of that time. Diagnosis is not part of every model, some focus on the exchange of information.

28. Models of consultations Stott and Davies (1979) exceptional potential in every primary care consultation : the opportunities could be explored in four key areas : management of the presenting problems; modification of help-seeking behaviours; management of continuing problems; and opportunistic health promotion.

29. Consultation tasks : applying models to the vet consult No one model fits all consultations. Skills are needed to choose the models most appropriate for the situation, and the processes that are likely to have the most impact.

30. Results of analysis of consultations in vet practice : links to performance Analysis can give important detail on which to develop performance; eg: numbers of open questions/numbers of remarks on medical condition (RIAS), perception of vet/client to uncertainty (Mellanby, JSAP Jan 2007). Identifying and developing the consultation skills involved in the processes provide the links to performance. Models help to identify and position the skills.

31. Post consultation interviews Client feedback did not contain the word ‘friendly’ for the 7 minute consultations, but it did in 10, 15, and 45 minute consultations. Mutual understanding was found to be a) good on what the presenting problem was, b) less good on treatment, c) worse on prognosis, d) diverse on the quality and worth of the consultation.

32. Time management linked to models Time does not appear in the models, BUT: Use of open questions (building rapport) Exchange of remarks on medical condition (explanation, planning) Chunk and check (check understanding, closure) ALL link to models, effectiveness of consults, compliance and time management.

33. Quality management with qualitative analysis Monthly training meetings for the vets in which consultation skills are discussed proactively. This needs to be ongoing, not just a one off meeting. Data collection techniques entering the ‘inner sanctum’. Not just relying on outcomes. Analysis :processes need to be proactively involved in contributing to developing consulting skills. Links to KPI’s may be useful but: ‘Open mind’ is essential to notice things that make a difference

34. Roter Interaction Analysis system (RIAS): Coding of audiotapes Socioemotional exchange Task-focussed exchange Global affect ratings Adaptations Contextual elaborations (See handout) Approaching the vets: Some are keen, many are fearful especially in relation to their perception of ‘bosses’ KPI’s’ Preparation with talks and discussions is essential

35. RIAS : the analysis Bias can be introduced by the researcher because of previous experience and or lack of familiarity with an assessment or scoring system : this is important both in analysing the research and presenting findings to vets who will say ‘yes but that was not actually how or why I did that’.

36. RIAS : results of analysis from research in visits to practices Vet dominated consultations are by far the commonest : listening and eliciting concerns are low priority. Time pressure tends to cause more closed questions which can make the overall time management worse and the outcomes worse. I observed 7,10,15 and 45 minute consultations. Often a limited range of consultation skills were used. There are potentially big opportunities through encouraging use of a wider range of consulting skills.

37. References on RIAS Shaw et al (2004) Use of the Roter interaction analysis system to analyze veterinarian-client-patient communication in companion animal practice. JAVMA 225 (2) 222-229. Roter and Larson (2002) The Roter interaction analysis system (RIAS) : utility and flexibility for analysis of medical interactions. Patient Education and Counselling 46, 243-251.

38. Results of research: reasons to feel optimistic and want to do more Post consultation interviews Clients love their vets,always scored their vets higher than the vets themselves. Vets underscore their consultations, ‘especially when it’s a simple vaccination.’ Vets can fail to give the best treatment by making assumptions about the client, eg : xraying their wallet, or assuming they won’t want the diagnostics or diets without explaining the benefits and giving them the choice. www.vetgp.co.uk (Manning, MSc thesis, 2003)

39. Analysis of likelihood of a vet to recommend Variations in vet opinion affect their likelihood to adhere to an ‘agreed protocol’. Asking a vet in my research when I visited various practices ‘when does she recommend an obesity diet :’I usually do when there is liver disease, diabetes or a heart condition, but for prevention..not usually.’

40. Motivating the client There was clear variation in the skills and enthusiasm of the vets in practices I visited. Range in vets was from ‘absolute top reason for consulting’ to ‘either low priority or not worth mentioning.’

41. Illustration of links between consultation skills and KPI’s, and which research instruments provided the evidence for triangulation (page 167 of DProf thesis, Manning, 2006. MDX University)

42. Table illustrating Nos of remarks exchanged expressed as totals of client and vet remarks added together (page 144 of DProf thesis).

43. 4. The impact.

44. Team ATV’s Receptionists’ ATV’s. May 2004 May 2005 May 06 15.58 20.67 24.05 Nurses’ ATV’s. May 2004 May 2005 May 06 15.40 24.50 26.87 Vets’ ATV’s May 2004 May 2005 May 2006 Jan 2007 48.14 53.55 53.14 65 Price increases 2004-6, none 2006-7.

45. Undercharging/undervaluing consultations :Concessionary fees : training increased awareness and availability of concessionary fees before a 2nd round reduced them.

46. Factors with impact on the consultation : The ‘baggage’. These factors can have a negative impact on the focus of the consultation: Practice economics Employment of staff % animals insured CC and other Government regulations Declining farm animal sector and SA nos Increasing client demands and competition Vets moving jobs £50,000 student debt up to £100,000. Vet fatigue/time of day/day of week

47. Our Unique selling point (USP) ‘According to a recent consensus statement on physician-patient communication (Simpson et al 1991), ‘effective communication between doctor and patient is a central clinical function that cannot be delegated.’ Stewart, M.A. Can Med Assoc J 152, (9), 1423-1433.

48. Can vets address client concerns and preconceptions quickly and within the 10 minute consult?

49. Links between consultation skills and KPI’s Quantitative Gross personal turnover per vet ATV’s Numbers of consults and type;eg: vaccinations, dentals. Volume of prescription diet sales. Numbers and pattern of vet meetings/training in the practice on consultation skills. Qualitative Care components: Listening skills Opportunities taken/missed Enthusiasm of vet Clear, concise explanation. Animal likes the vet. Analysis of post consultation interviews and surveys.

50. References Moreau, P. (2005)’ Practice financial indicators : measure your productivity.’ Eur. J. Comp. Anim. Pract 15 : 211-215. Manning, P.R. (2003) ‘Consultations in Veterinary General Practice.’ MSc thesis. Middlesex University. Manning,P.R. (2004) ‘The semi-structured interview’, Veterinary Review November 57-59. Manning, (2006) ‘Owner communication’. In Cannon, M., & Forster-van Hijfte, M. (Eds). ‘Feline Medicine’ a practical guide for veterinary nurses and technicians, Elsevier. Pp 195-206. Manning, P.R. (2005) ‘Caring in the Consultation’. Veterinary Christian Fellowship newsletter Spring 2005 pages 6-8. Manning, P.R. (2007) ‘The new RCVS Certificate :CertAVP – a change for the whole profession’. Vet Review Jan Pp 27-31.

51. 5. Improving the consultation skillswhich have an impact The reflective practitioner Reflection is a key consultation skill (Adams, 2006)

52. RCVS CertAVP Now …. Contains module in which all candidates have to prove their competence in consultation skills. Delegates here today are likely to have a wide variation in experience from which to share ideas and contribute. www.vetlearning.co.uk

53. What are YOU going to do now? Employee vet Employer vet/practice owner Practice Manager Veterinary Nurse University teacher of undergraduate vet students 5 key action points from the audience?