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Veterinarian Technician September 2007 (Vol 28, No 9) Focus: Physical Rehabilitation

Management Matters: "The Challenges of Managing an Emergency Practice"

by Katherine Dobbs, RVT, CVPM, PHR

    Author's Note

    When I began my career in general practice, I only knew that the emergency clinic was open to provide care to patients when our doors were closed. Then, when I worked in a specialty practice, I often had to give clients information about the emergency clinic in case their pet had a relapse or required treatment over a weekend or holiday. I currently manage a practice that includes a specialty service and an emergency service that operates 24 hours a day, 7 days a week. It is in this role that I have gained an entirely new appreciation for the challenges that face emergency practice managers. The issues that evolve from the combination of specialty and emergency practice are different from the issues that emergency-only practices face; this column focuses on the emergency aspect. I am still learning, but here is a sampling of what I've discovered so far.

    The challenges of managing an emergency practice are a result of the seemingly contradictory nature of the business. Although the primary focus of an emergency practice is to assess and stabilize patients, staff members must also be able to simultaneously deal with owners in crisis — all of whom want their pet to receive immediate attention. The staff want to provide care, yet owners must be able to pay for the services in order for the practice to thrive and, in turn, help more pets. At times, it is difficult to provide high-quality care to a critically ill patient and at the same time handle a distraught owner's reaction to unanticipated expenses. Clients often want answers that are not immediately available; they are sometimes ex­pected to pay for services without knowing the exact costs involved in examining and assessing their pet and conducting additional diagnostic tests, which often can be thousands of dollars more than the initial estimate.

    Because of the demands of an emergency practice, such as extended hours, including nights, weekends, and holidays, it is difficult to staff the hospital and allow employees to have a life outside of work. The emotional challenge for each employee in such a traumatic environment is also a challenge for the management team. With all of these challenges to balance, practice managers must remain a constant presence even though they are not physically present during all operating hours. They often are responsible for managing staff they may rarely see. The challenges of managing an emergency practice can be varied and complex, but considering a few basic principles is a good place to start.

    First Things First

    Triage of a patient and assessment of the client's emotional state can begin before the client even comes through the door, if he or she calls ahead. The practice should have a policy regarding which staff member — a receptionist or a technician — will handle calls that require "phone triage." Because the owner may need to give the pet immediate care before or during transport to the hospital, basic medical training is required for whoever handles this type of call. During the telephone call, the client should be asked a short list of questions to assess the patient's status (i.e., Is the patient breathing? Bleeding? Responsive?). A veterinarian should determine how much medical advice to offer over the phone, if any, depending on the pet's status or problem. Because it is important for the client to have confidence in your practice beginning at first contact, communication training should focus on how to inform the client that it is in the pet's best interest to be seen by a veterinarian.

    On arrival, the pet should be quickly triaged by a technician, and the client should be "triaged" by a receptionist or client service specialist. The client should be kept calm, reassured, and informed about the pet's status, anticipated wait time, and expected costs.

    Speaking of Money

    As mentioned, clients must be kept informed about their pet's diagnostic and treatment options and costs throughout the emergency hospitalization. To avoid unnecessary problems, a solid financial policy must be developed and communicated to all staff members. To be effective, the policy should require the following:

    • Immediate client approval for the cost of the initial examination
    • Ongoing client approval for subsequent treatments or diagnostic tests, particulary lifesaving efforts that need to be conducted immediately
    • Written documentation of estimates and the client's signed consent
    • Discussion of payment options for all costs, beginning with treatment initiation
    • Designation of a staff member to deal with clients who are unable to pay for the emergency visit or clients who dispute the estimate or invoice; this person may be the hospital manager, shift supervisor, or middle manager, depending on the shift

    It is never easy to discuss money during a crisis. However, owners should be allowed to take an active role in making decisions that may affect their family's financial well-being. It is important to discuss the costs so the client can decide whether he or she can afford the treatment or whether the pet should be euthanized because the client cannot afford treatment. Because clients can be very emotional, the staff member who is discussing payment options may need to focus the client's attention by saying something such as, "I understand that this is a very difficult time for you and your family; however, we need you to participate in these financial decisions for the care of your pet."

    You Win Some ... You Lose Many

    A big challenge facing managers in emergency practice is the emotional demands that the work places on their staff. Veterinary staff often choose to work in emergency medicine because of their love of and desire to help animals, but they also must endure trauma and tragedy — sometimes losing more animals than they save. One of the most difficult things about being a veterinary professional in this type of practice is the constant emotional roller coaster ride it can be. One minute, a staff member is comforting a client who just lost a beloved companion — a pet that the staff member personally nursed for days in the hospital — and the next minute, this individual is greeting a new client with a smile, although their heart feels like it has just been crushed. To cope with this emotional roller coaster, veterinary professionals tend to put their feelings on hold and become objective about their job. However, clients need to see that staff are empathetic to their situation.

    Staff members' feelings and emotions can't be changed, but they should be recognized, particularly by practice managers. There are a number of ways to remind your staff of how important they are to the practice and reassure them that you understand the emotional challenges they face.

    • Distribute disposable cameras and encourage staff to take pictures of patients. The photos then can be posted on the employee bulletin board or in the employee newsletter to highlight stories of triumph and tragedy. This is also a good way to memorialize patients and praise the team's valiant efforts.
    • Create a memorial wall or garden where the employees can express their devotion to, and loss of, special patients (using a special plaque, engraved rock, or other reminder of a patient that meant a lot to them).
    • Provide an environment for the staff to express their grief and loss. Informal meetings may be one way for team members to share stories. The practice also can hold official "morbidity/mortality rounds" during which specific cases are discussed or offer an employee assistance program in which staff can receive additional counseling if needed.
    • Provide a grief journal in which employees can collect and express their thoughts and read about the experiences of their coworkers.

    Scheduling Issues

    An emergency practice is often always open, or is open during nights, holidays, and weekends when employees' families may have special plans. However, the practice must be fully staffed, regardless of the day or time. The ideal employee schedule ensures that all shifts are adequately covered and that employees have time to pursue personal interests outside of work. The following suggestions may be helpful:

    • Consider employees' needs and requests as much as possible when composing their core schedule. Veterinary professionals must have time away from the stressors of their job in order to refuel their bodies and recharge their psyches.
    • Develop a standard policy for employees to request a change in their core schedule (e.g., a daytime staff member who now wants to work the evening shift). Are such requests documented and considered first when there is an opening on a particular shift?
    • Compose a standard procedure for requesting time off. How much advance notice is required? Is the employee responsible for finding coverage? How much overtime, if any, is allowed to enable full coverage at all times?
    • Provide cross-training to allow more coverage options (e.g., an assistant and receptionist who are trained in each other's responsibilities).
    • Ensure adequate coverage through­­out the practice to prevent staff from leaving due to burnout. In order to achieve this goal, you may need to hire more part-time or per diem staff or use a relief technician service, if one is available in your area.

    Managing Around the Clock

    Because the emergency practice is always open, the top manager should remain a constant presence, even when not physically present. He or she must conduct routine, mandatory, all-staff meetings to communicate important information. These meetings are difficult to incorporate into the daily life of the practice, but they are important and should be scheduled when most staff members will be able to attend. They should also be held on a day and time when the practice is less busy so that one or two employees can be "on call" if a client or patient needs immediate help during the meeting. These on-call employee assignments should be rotated so that the same person does not continually miss the meetings.

    All-staff meetings should discuss issues and provide information that affects every staff member, regardless of their position in the practice. In between all-staff meetings, centrally located employee bulletin boards can be used to communicate practice-wide information, such as reminders about future meetings, minutes of recent meetings, internal job postings, introductions of new staff members, and time-sensitive information. Memos or postings can also be used to convey information to specific positional groups as needed. All staff members also should have a mailbox or access to email in order to receive important messages.

    It is also essential for the top manager to offer flexible office hours so employees can request a private meeting with the manager. Alternatively, the manager can schedule private indivdual meetings, such as coaching sessions, performance evaluations, or discussion of disciplinary actions or performance concerns.

    A member of middle management — department supervisor, shift leader, or position leader, such as a senior technician or a lead receptionist — should be physically available at all times. For each area and each position, there should always be a "go to" person who is in the position to make decisions in the absence of the hospital manager. The status and responsibilities of middle managers must be well defined and communicated to the entire staff. Even when middle managers do not personally manage other team members, they are responsible for making decisions that affect the operation of their area or activities that occur during their shift. They often are expected to answer questions about protocol or decide when to call in extra staff.

    Conclusion

    There is no doubt that emergency practice is a unique niche in veterinary medicine. Some veterinary professionals thrive in this challenging environment. They know how important they are to pets and clients in crisis and may crave the adrenaline rush of working "on the edge." Emergency practice managers enjoy the opportunity to "rise to the challenge" of putting together the pieces of this paradoxical puzzle in order to provide service that makes a difference, even on nights, weekends, and holidays.

    NEXT: On the Cover: "A Talk with Sandy Hass, RVT"

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