Vetcetera Ten ways to determine QUALITY in veterinary care

In response to the question I field most frequently (though seldom worded so succinctly), I’ll offer you a post that attempts a concise response to the issue of quality in veterinary care...and how you know you’re getting it.

It’s like the tired old quip on porn: No one quite knows how to define it...but you always know it when you see it. So goes quality in veterinary care. Hard to define...but usually recognizable as such when you get it. No, not always (nor is porn, frankly) but some constants do hold.

Here’s my version of how to know if you’re getting it from your veterinarian and/or veterinary hospital:

#1 Continuity of care

Do you get to see the same veterinarian if you choose to? If not, is it obvious that your pet’s records are so meticulously maintained that everyone’s always on the same page?

#2 Staff retention

Do you see a different set of staff members every single time you walk in your hospital’s doors? That can’t bode well for other aspects of the business––most notably, your pet’s care.

#3 Reliance on specialists

Though I’ve heard it said that a veterinarian who refers to specialists is one that is not confident of her abilities, modern veterinary medicine would not agree...nor do our courts. Clients have the right to receive all their options when it comes to caring for their pets’ more complex conditions.

#4 A culture of [human] compassion

It’s the hardest thing to quantify. And the one thing otherwise stellar hospitals often lack. In fact, it’s the best places (technically-speaking) that can’t always muster the compassion you deserve––particularly with respect to financial options.

#5 Access to a 24-hour care facility

Ideally, this would be contained in-house. Being offered the choice to have your sick pet spend the night in a nearby 24-hour facility is second best. The key is this: When your pet requires round-the-clock vigilance you’re offered a solution that bests a night in a dark hospital with no one to watch over her.

#6 Cleanliness

You know it when you smell it.

#7 Certified veterinary technicians

These employees are expensive and not all hospitals can afford them. Some areas have too few to go around even if veterinarians were willing and able to pay for this [typically] more highly educated kind of staff member. But when they’re there, you know you’re getting better quality than what most of us can currently offer you. (Look for name tags that say “CVT,” “LVT” or “CAHT.”)

#8 Computerized medical records

Goes to continuity of care and speaks to a hospital’s willingness to keep track of every detail.

#9 Digitized imaging

This refers to X-rays and/or ultrasound images that can easily be sent away for a second opinion. Even if digital images aren’t available, many vet hospitals make it work by referring images for second opinion through the mail or by trekking them over to the radiologist themselves. The idea is that there’s a willingness to share, explore alternatives and seek better care where possible.

#10 Pet friendly concessions

Not all hospitals think hard about what your pets need to be comfortable. Places where pheromone sprays soothe your cats, no-slip surfaces assuage your dog's fears and technicians offer a gentle touch... These can be hard to find. And when you do, you'll know it right away.

***

But as always, there’s a caveat involved in the interpretation of these signs of quality: Sometimes you’re just not willing to pay for all the bells and whistles quality brings (or you couldn’t afford it even if you were). No matter. You still deserve to know what these look like so you can make an informed choice of veterinarians.

But frankly, some of these signs of quality don’t cost very much. Nor should they raise your prices. Excellent clinicians and great hospitals can be found at every level. Still, it is true that finding value is hard––regardless of what you’re willing to pay. Here’s hoping this list helps you find it.

PS: Feel free to add to my list. Most of you have far more experience consuming veterinary services than I do. So speak up!

PPS: Thanks to Terrierman, Patrick Burns for the beautiful foxhound pups pic at the top. All ten are just gorgeous!

November 16th, 2009

Add Comment32 Comments

(Look for name tags that say “CVT,” “LVT” or “CAHT.”)

or RAHT (Registered Animal Health Technician)

Meghan RAHT November 16th, 2009 05:02:17 PM

#5 is difficult is a rural area such as ours. So if a patient is critical, the vet spends the night, usually on a cot next to the animal's cage. And that is only if we can't send them to a large vet hospital in a city an hour's drive away (some clients just can't afford it, but want to try to do something). He's also been known to take patient's home too.

#7 has been difficult in rural areas as well. People with these credentials don't want to live in a rural area or small town very often. We finally hired our first one 6 months ago, and now she's pregnant and not sure she will return after maternity leave! I'm taking a distance learning program for vet tech - nearest program is 1 1/2 hour drive from my home, and I have to work, so distance learning works for me.

#9 is extremely expensive! We're talking $50,000 to $100,000 for a basic, digital x-ray system. Not within reach of a small rural practice. We are saving for it, though!

So, 7 out of 10, does that mean we are just an average practice? Not compared to a lot of other rural practices! We have improvements to make, but we are doing pretty well for a rural practice in Michigan in 2009!

Sassy November 16th, 2009 05:22:55 PM

All great points!

I don't know if my vet's practice has digital imaging or not, the last time we needed an x-ray was several years back and they were still using films, but they were able to develop them onsite. (I have no idea how it works, but the vet & I were looking at the films within 10 minutes of them being taken.)

The practice has a lot of techs - I am always in at different times, and they are super flexible with their employees so a lot of them work part time.

I would add one other thing - and it's more of a personality thing I guess - people that understand that your dog or cat is the MOST adorable one on the planet, and doesn't hesitate to tell you (and them) that they are the cutest things ever. :)

Cindy November 16th, 2009 05:38:34 PM

Good Vet/Client communication is a must.

Elizabeth - from Nova Scotia November 16th, 2009 06:00:12 PM

On-site ability to do dental x-rays if the practice does dentals

Cheerfully provides copies of your pets records and test results on request

Abnormal test results always discussed with you

Receptive to challenge including the undoubtedly sigh-inducing: "I was doing some research on the internet and I read that . . . "

Willing to discuss alternate approaches if you have a good reason (such as home prepared diets rather than RX, alternative medicine, etc)

Doesn't push unnecessary treatments (although sometimes it's hard to tell what's unnecessary)

Tells you like it is (esp. in end of life situations) and is willing to stop if the animal will not benefit, even if there is "unrecognized revenue" as a result. In other words, humanity over profits

Has standards that are enforced for supervision of staff and after hours monitoring

Pulse oximeter monitoring and anesthetic options for surgeries

#7 is a problem where I live and I DRIVE AN HOUR for it. That plus 24 hour.

So quality oriented businesses can WIN if the public is educated, hopefully by less painful means than I was.

IMHO, the main reason #7 is a problem (and my area is NOT rural, it is major metro area) is that too many vets are too CHEAP to pay LVT/CVT/RVT staff what they are worth. This is basically the result of a local survey conducted by a vet, so I'm not making this up.

BTW under pressure from veterinary associations, some vet boards are further relaxing rules, allowing unlicensed staff to do MORE procedures, re-defining "supervision" as meaning: available via cell phone on the beach, etc. Reprehensible.

Stefani November 16th, 2009 06:09:07 PM

Thanks Megan. Wish I could say it was a typo. Unfortunately, I've got to call it a "senior moment." ;-)

Dr. Patty Khuly November 16th, 2009 06:17:53 PM

When I take my pet to the doctor, I don't want to get the impression that the vet has something else on his/her mind. Essentially, while in the exam room, I want the full attention of the doctor and I don't want to feel rushed. Not that I want to stand around and chit chat, I just don't want it to seem like the doctor is rushing.

I really enjoy the opportunity to communicate with my veterinarian via email. I especially enjoy email reminders when my pet is due for exams/vaccines, etc. One small caveat to that is when I get emails that have misspellings (especially if it's my pet's name), really, really poor grammar (the whole email is one long sentence that equates to a paragraph of information), etc. It may sound a tad picky, but I want my veterinary clinic to sound like they know what they're doing regardles of the communication medium.

Veterinary Student November 16th, 2009 06:28:48 PM

Another great list of tips helpful to our Tripawds members! We've linked to this post in our veterinary specialist referrals forum. Thank you.

tripawds.com November 16th, 2009 07:27:51 PM

All great info...But for me, #3 and #10 are the most important because reliance on specialists are very vital on the health and security of your pets while pet friendly concessions are really hard to find on vet clinics or hospitals.

Kate November 16th, 2009 09:13:50 PM

This is such a great site: too bad about the ads here or whatever they're supposed to be.

Another very important thing is that the vet listens to you. I stopped going to one practice because of that very thing. I won't even go into it but I suspected what the problem was with my dog.......the vets there blew me off & put my dog through all kinds of testing that was very expensive. All through it, I kept insisting that they at least consider what I had been trying to tell them........NOT! When all was said & done & I had spent all this money doing it THEIR way, we found out that I had been right all along. I spent nearly $400 on something that would've cost me nearly nothing had they listened to me or at least considered it at the beginning.

I'm not a vet & I know little about anything medical but this was pure gut instinct plus knowing my dog's habits that led me to my thoughts on this.

Vets need to learn to listen to the pet parents & at least consider what they are saying. New vet listens to me.

Hannie November 17th, 2009 07:58:33 AM

All are correct: compassion (all staff), cleanliness, and an educated staff are a must. The often missing link is a veterinarian who is a "people person" and can communicate well with others.

Robert November 17th, 2009 08:34:21 AM

All excellent points that for the most part we agree with, except that you receive better care with a licensed/certified vet tech.

I/we feel that hands on experience in the field can far outweigh the book-smarts you receive in a CVT program, and that some of the best technicians you can work with are those that have simply been doing a fantastic job working and learning as they go.

That said it is absolutely a benefit to combine work experience with a licensing program to further educate your techs, and they will undoubtedly improve on their skills; but don't undersell those that "only" have on the job training on their resume, they've had to learn under pressure, which quite often produces a more well-rounded technician.

Staff of CPH November 17th, 2009 08:45:01 AM

Staff of CPH: I agree...in that that the best tech I ever worked with (by far) was not degreed or licensed/certified. She was my mentor during my first year in practice and I will be forever grateful to her. She had 20 years of experience and she was the among most upstanding people I've ever met, to boot.

That said, pet owners need to know what they're dealing with. Licensing and certification is an excellent way to achieve that. I'll take any accreditation system as long as the standards are reasonable. What I can't abide is when veterinary hospitals call all staff "technicians" even when they're inexperienced. Degrades everyone, IMO.

Dr. Patty Khuly November 17th, 2009 09:23:57 AM

Tripawds:Feel free to add today's entry to your arsenal as well. You'll appreciate it even more, I think.

Dr. Patty Khuly November 17th, 2009 09:28:41 AM

"What I can't abide is when veterinary hospitals call all staff "technicians" even when they're inexperienced."

Absoulutely!!! Thank you, Dr. Khuly.

"Pulse oximeter monitoring and anesthetic options for surgeries"

While the use of pulse oximetry during anesthesia is a step in the right direction, there are monitors that are far more accurate in assessing patient cardiovascular and respiratory parameters during anesthesia. I would also prefer a dedicated, trained assistant monitoring anesthesia without fancy monitors than a surgeon by themselves with a pulse ox.

Options for the surgeon or the owner? I agree that a hospital should have an varied inventory of anesthetic drugs to choose from and a staff that has experience with a variety of protocols so that anesthesia can be tailored to the individual. I don't agree that owners should be offered a "menu" of anesthesia options.

virginian November 17th, 2009 11:00:34 AM

Pulse oximetry is pretty useless, especially when monitoring anaesthesia. Hair, skin pigment, drying of mucous membranes all cause the pulse ox to malfunction. And really, oxygen levels and heartrate are not good early indicators that a pet isn't doing well.

I much prefer a doppler to monitor blood pressure. You can still hear the pulse (as with pulse ox) but also asses pulse quality and systolic BP. A decreasing BP almost always happens before any cardiac arrest. If BP is not monitored, a pet can have a low bp through surgery and come through but with organ damage from poor perfusion. You can also better monitor pain and fluid therapy.

IMO you can add that to the list:

The clinic owns and USES a doppler!

Meghan RAHT November 17th, 2009 12:23:28 PM

Meghan, I love my Parks Doppler but the newer oscillometric blood pressure measuring devices are more accurate than they used to be and there is always the direct method!!

virginian November 17th, 2009 12:55:54 PM

Hoe accurate is you oscillometric on small dogs and cats?

We have a unit and I find it tempermental and sketchy on the smaller patients. And feeling a pulse on a crashing cat is difficult, let alone trying to use my stethescope to hear it. They're going to have to pry that doppler from my cold dead hands ;)

Meghan RAHT November 17th, 2009 01:10:32 PM

I'm loving our new Cardell oscillometric BP. So consistent. No Doppler here. :-( Perhaps I should talk to my bosses. Will read up first...

Thanks!

Dr. Patty Khuly November 17th, 2009 01:53:39 PM

I've heard good things about the Cardell. We have VetSpecs- I love every other thing about it.

Dopplers are ony a few hundred bucks. We've had ours for years, now we have three. That and a dedicated tech monitoring is how we run our basic anaesthetics. Complicated ones get ECG, Capnograph, core temp, and pulse ox too.

Meghan RAHT November 17th, 2009 03:28:02 PM

Well, after what you wrote about retention, Dr. K, I felt good when I went to the website of the place I take my pets now and saw a wall with long lists of people who have been there 5+, 10+, and 15+ years! (Our vet is in the 10+ group).

And many of the long timers are LVTs!

Lookee

http://www.alexandriaanimalhospital.com/site/view/166004_AboutOurStaff.pml

Whew.

So:

I used to live block from them, 10 years ago, started taking my pets there. I knew I liked them but I didn't ** understand ** veterinary quality issues. I moved a state away. Ended up taking my cats elsewhere. BAM! Insulin overdose for my Toonces, left alone 13 hours, brain damage and near death.

I WISH I'D NEVER LEFT THESE GUYS.

Which is not to say any vet office is mistake proof, but I know for a FACT that what happened to Toonces would not have happened at this place, because even if someone had made that magnitude of error (unlikely with the place crawling with LVTs with 10+ yrs experience to boot) there are staff there 24 hours and he would have gotten immediate treatment for hypo instead of beign left alone and then found in the morning by YET another person who had NO idea why he was comatose. And apparently gave him more insulin.

How many times do I kick myself for leaving this place? Every day, maybe?

And I spend some time giving them REALLY good reviews and warning people not to walk away from a good thing when they have it. All the time people are complaining about their prices, but I drive an hour for them now and tell the price-complainers my story of what happened when I found a "new" vet just because I move to the next state.

I felt so good today when the vet handed me my cat's xrays on CD ROM as though this was just normal procedure (and it is).

Really, I am seriously thinking of relocating back near them. Maybe I'd rather drive an hour to work and back every day but be closer to a vet I feel good about than be so far away from a place I might need in an emergency, since my pets are a big priority in my life.

Stefani November 17th, 2009 09:38:40 PM

I'm surprised that no one mentioned AAHA (American Animal Hospital Association) Accreditation as a way to determine quality. While the others qualities should be in place at every quality hospital, AAHA Accreditation shows the hospital has really examined every last detail.

We are very proud of our AAHA Accreditation. We worked very hard to achieve this distinction but it only follows the other standards of quality care that we believe in.

Robert November 18th, 2009 12:12:32 PM

Robert: Every time I write about quality issues or standards in veterinary medicine someone calls me out on not mentioning AAHA. It's not that I consciously neglect to mention this accreditation body, more that my area is not very AAHA populated so it's lots less of an issue (out of sight...).

But you're right to be proud of your designation. It is one sign of quality. In fact, whenever someone is moving to a new area where I don't happen to know any of the vets (usually) I tell them to try AAHA hospitals first. But I also caution them not to assume AAHA accreditation is synonymous with the best hospital for their needs. It's a great starting place, though.

Dr. Patty Khuly November 19th, 2009 08:58:33 AM

i agree that AAHA certification is not always a good mark of quality. to me, it just means you were able to get through their checklist/inspection and write a check to AAHA. since i know my hospital's setup and SOP's exceed those set forth in the AAHA manual, i could get 3 or 4 year certification tomorrow ...but i don't really want to pay $1500+ for a plaque on my wall.

@sassy: digital rads are more affordable than you think. doing, 5 studies a week pays for my $60k system (which produces images as good as many $100k systems i've seen). you'll find that you do more studies with the convenience of digital and it's soooo much easier to email images to a radiologist for review.

@virginian & maghan: i was a big fan of my cardell monitor (ecg, nibp, spo2) but grew tired of inconsistent readings with the bp cuffs. i recently bought a doppler (about $975 through my distributor) and my techs LOVE it. i got the vet-bp doppler -it allegedly has a more durable sensor than the parks unit. it helps that 1/2 of my staff worked in an ICU where they practiced using a doppler 1000s of times before ever working for me :) my next monitor will likely be a surgivet ecg/spo2 unit. at some point i may break down and buy a respirator and get an etco2 monitor to go along with it.

Dennis Leon, DVM November 19th, 2009 11:28:05 AM

I agree with Dr. Leon about AAHA accreditation.

The place I took my dearly departed Toonces was an AAHA place. Turned out, little did I know, they had not ONE single solitary licensed vet tech on staff. The head vet left all his patients over a weekend in the care of his son, an unlicensed assistant with no formal training, and other unlicensed assistants, and my cat was given a massive 30 unit overdose.

Then records magically disappeared and all kinds of shenanigans ensued.

AAHA cert or not, they were the WORST vet hospital whose door I ever darkened. And that darned tape AAHA gives their practices played EVERY time I was on hold and I bought that line of bs about quality hook, line, and sinker.

I consider AAHA accred irrelevant.

Stefani November 19th, 2009 11:34:11 PM

I consider AAHA accred irrelevant.

Ouch. Since no one from AAHA reads Dolittler I'll try my best at defense.

AAHA certification measures hospital compliance with about 900 or so measures of quality. If the a particular standard is updated, hospitals are alerted to the new and current best industry practice. Hospitals are re-accredited very three years and every two years for new members. Personally I am very happy we chose to become accredited. We examined and re-examined every single thing we do. Some standards are common sense others really make you glad that you are following an industry best practice.

Of course, once accredited the hospital must now perform up to that standard. Sometimes we cannot be perfect. Sometimes things go wrong. (AAHA actually has protocols to follow when accidents or other mishaps occur. Learning from errors is part of the path to perfection). In regards to your complaints I think AAHA should have a client complaint process. Perhaps they already do. I encourage you to call.

I would say that individual incidents would not necessarily make AAHA irrelevant. Because of AAHA we try to improve everything we do all the time.

Best regards,

Robert November 23rd, 2009 11:09:38 AM

Please tell me how exactly AAHA is making sure that the vet hospital where my cat was OD'd isnt' still leaving pets alone, unsupervised, with unlicensed vet assistants who are administering drugs, etc.

They're not, that's what.

The place I go to now is AAHA member, and they are **good** as far as I can tell. But it has NOTHING to do with the AAHA cert. It has to do with their practices.

Two places I know of who are also AAHA aren't. In fact, a former employee of an AAHA place where my mom takes her pets told me one of their vets strangled a dog to death. That's on top of the place where my cat was OD'd by someone who had no idea what he was doing.

hmmmm.

Yes, I believe the girl with the strangling story, she had zero motive to tell me that in context, she didn't know ** what ** I do as a hobby, we were talking about a rock band when this came up. And anyway, a vet there diagnosed my mom's dog with kidney failure and handed her a metacam scrip in the same visit, without a word about kidney effects of the drug. Then, when confronted, she refused to acknowledge that she should not have done that, in spite of local referral clinic saying she should not have. If it weren't for me telling my mom not to dare give the drug, I'm sure we wouldn't have had him as long as we did.

AHAA is marketing, flat out. When they start doing UNANNOUNCED inspections and PULLING memberships based on the results, then maybe their cert will be more meaningful. But why would they do that when people pay to be accred? They have incentive not to throw the bums out.

I am a client, not a vet, and I am telling you from the client perspective, I've found it to be poppycock. If you practice quality medicine, word of mouth will make sure people know. If you don't AAHA may bring the ignorant in the door until their pets are killed or injured but then we will tell the world how meaningless and misleading AAHA is.

Stefani November 23rd, 2009 05:49:01 PM

@Stefani I glad to see that you expect AAHA accreditation to mean perfection. That is our hospital's goal too. Unfortunately, we are all too human. We can only do the best we can and improve on everything else.

Robert November 23rd, 2009 08:29:51 PM

It is not expecting "perfection" as you say, to expect that a vet hospital won't leave unlicensed assistants with minimal training in charge of all patients, including drug and treatment administraton with no supervision. That is expecting a BARE MINIMUM of responsible behavior to expect that only qualified people will be left to do such duties. It's not merely an understandable human mistake to do such a thing -- it's a dangerous, careless, substandard practice. Not an "oops, we're only human" mistake but an irresponsible if not outright negligent practice that is BOUND to lead to patient harm, not by accident, but as an inevitable outcome of not giving a damn.

It is also not merely a human mistake to get pissed off and strangle a patient to death.

AAHA inspections might not be able to uncover the latter, but they should be able to uncover the former, dangerous practice. That place had NOT ONE SINGLE SOLITARY LVT at the time. Who did AAHA think they were leaving patients with on weekends, anyway?

Seems like they did not ask.

That tape that ran over and over again telling me that hte hospital adheres to higher quality standards because it's AAHA actually carried some weight with me, reassured me.

Frankly, if I were rich, I'd find others whose pets had been harmed at AAHA hospitals and get together and sue AAHA for fraud and misrepresentation in falsely stating that these hospitals adhere to high quality standards. It can be definitively disproven.

Stefani November 24th, 2009 06:58:21 AM

@Stefani

Most technicians are not licensed. AAHA does ask and like to see as many as possible. And "practice team members demonstrate humae care of animals" is a serious and mandatory AHAA standard. And is also a basic, common sense, and bare minimum standard just to be a decent human not just a veterinary hospital.

Your anger towards AAHA seems misdirected.

Nevertheless, you don't need to be rich to sue an organization. Lawyers love class action lawsuits. Please persue this to find some closure.