DVM, MS, DACVIM
Dr. Morrison is director of veterinary science at Banfield Pet Hospital’s headquarters in Vancouver, Wash. Dr. Morrison has 22 years of clinical veterinary experience. She previously served as the residency program advisor and service chief for small animal internal medicine at Iowa State University’s College of Veterinary Medicine. Dr. Morrison is a 1993 alumnus of Purdue University. She completed a Master of Science degree in Veterinary Clinical Sciences in 2004 from Iowa State and achieved board certification in 2002.Read Articles Written by JoAnn Morrison
As veterinary professionals, the health and wellbeing of our patients is at the core of what we do every day. We are fortunate to be in a profession that allows us to leverage medical research and advancements in technology to continuously learn and improve our skills.
Veterinary professionals share the same goal: to practice the highest-quality medicine in a way that has the best possible outcome for the pets in our care. An important part of bringing this to life at Banfield Pet Hospital is through our patient-outcome improvement work. Implementing such a program is something that all practices, no matter their size, have the ability to do.
Measuring Patient Outcomes and Identifying Population Segments
Before starting a patient outcome improvement program, it is important to first consider measurement of patient outcomes, and there is much to be learned on this concept from our counterparts in human health care. One of the foundational principles of a value-based human health care system is known as the measurement of health outcomes that matter.1 It is important to identify and record those outcomes that are important or a priority to all parties involved in the provision of care. Additionally, recognize that these priorities may be different for each group.
When applying this principle in veterinary medicine, the interested parties include the veterinary team providing the care, the patient, and the client (owner). Outcomes that matter to the patient may be determined with input from both the providing team and the owner. Initially, it may be easiest to identify a patient outcome that matters primarily to the providing veterinary team. Examples of these may include outcomes such as “reduced patient mortality” or “improved patient mobility.” Information on obtaining this type of information from clients is presented below.
Next, identify a clearly defined population segment.1 To improve patient outcomes, start small with a well-defined, accurately identified patient population. This allows for more clear and efficient interventions and follow-up analyses. A population segment can be defined as individuals with the same condition or disease, along with risk factors that may influence outcome. Continuing the outcome examples from above, defined population segments could include: “cats undergoing elective anesthesia” or “dogs with degenerative joint disease” (TABLE 1).
Examining and Analyzing Available Data
Once the desired patient outcome and associated populations have been identified, examine and analyze the available informatics and data.1 If considering anesthesia mortality, identify, review, and analyze available literature and evidence-based information on risk factors that lead to increased mortality.2-5 This helps ensure the veterinary teams providing anesthesia understand the associated risks and the interventions that have been shown to improve outcomes. Examples are provided in TABLE 2.
Identifying What Matters to the Client
When starting a veterinary patient outcome improvement program, the outcomes that matter to the health care provider are just 1 of the 3 components that must be considered. The other aspects are determining what matters to the client—and, by extension, to the pet. This information may not ordinarily be collected during a veterinary visit. Outcomes that matter may be objective (for example, “I want my pet to regain her normal appetite”) and will vary depending upon the patient and the clinical situation. However, measures may also be more individualized and subjective (for example, “I want my dog to return to playing tug of war”) and can include quality of life (QoL) factors that may be defined differently by different people.6,7
Collecting this important information isn’t always easy, but it is critical to identify those factors that are priorities to clients to truly impact patient outcomes. Determine what works best for your clients and hospital team. Some information-gathering options include client surveys, follow-up telephone conversations, targeted questionnaires during hospital visits, and the incorporation of a QoL score as part of the pet’s medical record.
Implementing Specified Interventions
Once the outcomes that matter to the veterinarian, patient, and client have been identified and collected, specific interventions that help achieve those outcomes in the target population can be implemented.1 An important point to remember is that the goal and the outcome need to be patient improvement. Consider the example presented in FIGURE 1 on improved mobility in patients with degenerative joint disease. Items that may be readily measured—for example, number of radiographs obtained on patients presenting with lameness, number of anti-inflammatory medications, or prescription diets dispensed to those patients—are called measures of production. A true patient outcome improvement program will have measures such as a larger percentage of patients achieving success in weight loss and improved pet QoL scores from owners.
Plan, Do, Study, Act (PDSA)
At Banfield, we implemented a quality-improvement tool called the Plan, Do, Study, Act (PDSA) cycle (FIGURE 2).8 This tool, from the Institute for Healthcare Improvement, provides a process to:
- Plan a change or intervention
- Do the work
- Study that the work had the intended outcome; and
- Act on what you’ve learned
Instituting a process management tool like this can help hospital teams ensure that the desired patient outcome improvement has been achieved and make changes, if indicated, based on results.
Developing a patient outcome improvement program may be a novel way to approach the provision of care in a veterinary hospital. However, having a focus on not just treatments within a hospital but also including insights on the results of care outside the hospital from client and patient perspectives provides a more holistic view of the entirety of patient outcomes.
1. Value in Healthcare Laying the Foundation for Health System Transformation. World Economic Forum. www3.weforum.org/docs/WEF_Insight_Report_Value_Healthcare_Laying_Foundation.pdf. Accessed May 2019.
2. Matthews NS, Mohn TJ, Yang M, et al. Factors associated with anesthetic-related death in dogs and cats in primary care veterinary hospitals. JAVMA 2017;250(6):655-665.
3. Levy JK, Bard KM, Tucker SJ, et al. Perioperative mortality in cats and dogs undergoing spay or castration at a high-volume clinic. Vet J 2017;224:11-15.
4. Brodbelt DC, Pfeiffer DU, Young LE, Wood JL. Risk factors for anaesthetic-related death in cats: results from the confidential enquiry into perioperative small animal fatalities (CEPSAF). Br J Anaesth 2007;99(5):617-623.
5. Bille C, Auvigne V, Libermann S, et al. Risk of anaesthetic mortality in dogs and cats: an observational cohort study of 3546 cases. Vet Anaesth Analg 2012;39(1):59-68.
6. Mellanby RJ, Herrtage ME, Dobson JM. Owners’ assessments of their dog’s quality of life during palliative chemotherapy for lymphoma. J Small Anim Pract 2003;44(3):100-103.
7. Yeates J, Main D. Assessment of companion animal quality of life in veterinary practice and research. J Small Anim Pract 2009;50(6):274-281.
8. Institute for Healthcare Improvement. ihi.org/resources. Accessed January 2019.