1. pets

HOW TO HELP MORE PETS
Table of Contents
OUR CLIENT'S VISIT TO BANFIELD
The Importance of Thoroughness
The Importance of Demonstrating How Much We Care
Value as a Perception
Adding the Perception of Value
The Case Summary
Wrapping Up the Exam
THE BANFIELD APPOINTMENT BOOK
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The purpose of the Appointment Book is:
Appointment Book Features
Scheduling During the Noon Hour
Scheduling Appointments during Wellness/Vaccine Hours
Why do we have vaccine hours?
TIME FOR SURGERY
THE RIGHT TOOLS
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HOW TO HELP YOUR DOCTORS CARE FOR MORE PETS
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Think
HOW TO PUT IT ALL TOGETHER!
THE CLIENT VISIT
A - Client Services Coordinator Duties
1. Welcome
New Clients
2. Check-in
3. Presenting Complaint
Emergencies
4. Introduce Optimum Wellness Plans
5. Show a Video
B-Nurse
1. Get History and Perform Exam
2. Educate
3. Discuss Optimum Wellness Plans
4. Show a Video
Outpatient
Inpatient
C-Doctor
1. Perform Exam
What to Include with Every Exam
The Case Summary
D-Nurse
1. Complete Client Exam
2. Show How To Administer Medication
E - Client Services Coordinator: Check-Out
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Anticipate
Help Them Get Away
Keep Them Organized
Provide The Right Environment
WHAT TO DO IF THE BUS UNLOADS AT YOUR HOSPITAL
Congratulate yourself!
DON'T PANIC!
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INPATIENTS
Drop-offs: Boarders and Medical
A - Client Services Coordinator
B-Nurses
C - Nurses'Aides
Kennel Labels
D - Nurses'Aide
HOSPITALIZED PETS/PETS ON TREATMENT BOARD
A-Nurses'Aides
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Hi
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B - Morning Nurse
C - Surgical Care
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DISCHARGING PETS
Overview
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Duties and Procedures
A-Doctor
B - Nurses'Aide
C - Client Services Coordinator
D-Nurse
E - Client Services Coordinator
PICKED-UPPET
A - Client Services Coordinator
B-Nurse
C-Doctor
D - Client Services Coordinator
To Follow:
SOAPET - Charting Procedures
Treatment List
Circle Sheet
Patient & Client Information
Patient Admittance Information
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Introduction
OUR CLIENT'S VISIT TO BANFIELD
The Importance of Thoroughness
Thoroughness is the single most important determinant of satisfaction with medical care (and
therefore likeliness to return and refer their friends).
To illustrate, suppose you have a bad stomach ache that has been slowly getting worse for 4
days, so you decide to go to the doctor.
Clinic A
You had called ahead, so when you arrive a little early, the receptionist, who was very nice,
already knows your name, asks you if you would like a soft drink, escorts you to a nice chair
to sit in and gives you a selection of a dozen new magazines to read. The clinic is beautiful,
clearly the doctors here are successful. The floors are marble with wool rugs; oak is
everywhere. The plants are beautiful, healthy, alive. The receptionist works you in early, and
a nurse who is also very professional takes you to an exam room. She stays with you and
tells you everything about the practice until the doctor arrives. The doctor is very nice and
friendly, asks you a couple of questions and prescribes some medicine for your stomach
ache. The receptionist handles all the billing to your insurance company.
Clinic B
You called ahead, but when you arrived, you find they have evidently forgotten to write It
down, because you have no appointment. The receptionist isn't rude, but seems a little
down. She tells you to "have a seat and I'll see if I can work you in", nodding to a chair
across the room. After 45 minutes, a nurse comes and leads you into a room, tosses you a
gown and says "Put this on; I'll be right back". After another 30 minutes sitting on the table
(no chairs) in an exam gown that doesn't close in the back, the nurse comes in again. She
asks you questions about all sorts of medical symptoms you have never even heard of, takes
your blood pressure and makes you go down the hall (yes, in the same gown) to provide a
urine sample. 20 minutes later, the doctor comes in. The doctor has you lie on the table,
palpates your abdomen (and just about everything else!) and then has a panel done (another
30 minute wait), after which she gives you a prescription (for the same pills as Doctor A).
Once dressed and on your way out, the receptionist tells you that you'll have to pay today
because they don't bill insurance companies; you'll have to deal with the insurance people
yourself.
Somehow, you recover from your stomach ache, and the office calls, too!
A year later, you get sick again. Which practice will you probably go back to? If you are like
most people, thoroughness will be the most important factor in your decision.
Our goal at Banfield is to combine the best ofA& Bi
By the end of every visit, we want all of our clients to be certain that:
•
We give the most thorough medical care ever given to their pet
•
We all care very much about their pet and their family; we're friendly, considerate and
empathize with them and their pet
•
They have just received a very high value at a very reasonable fee
•
They will bring their pet back for all its care
Introduction
•
They know to call us or stop in with any questions
•
They will convince their friends to bring their pets to us.
The Importance of Demonstrating How Much We Care
It is so true that clients need to know how much you care before they'll care how much you
know!1
We demonstrate how much we care by
•
our actions,
•
our voice,
•
making eye contact,
•
listening to our clients,
•
shaking their hands,
•
talking to and
•
showing affection to their pets.
We can also...
.
Go around the exam table to "the client's side" to explain things, draw pictures, make
contact: the table can either be a barrier or a tool - so make it a tool!
.
Invite kids to listen to their pets' heart sounds through your stethoscope
•
Give kids a toy from the treasure chest (see Treasure Chest in SmartHelp).
•
Discuss things with kids - "Is Buffy eating her food OK?" and "Do you give her water
when she's thirsty?"
•
Warn the pet when something will hurt - "This injection is going to sting for a little bit but
I'm going to rub it for you" (Guess who also isn't surprised if there is a little yelp!)
.
If there's enough time, sit on the bench in the lobby and talk with a client - or better yet,
get a new one in the store!)
•
Act relaxed in the exam room by resting a hand on the exam table or squatting down,
face-to-face to talk to a client who's seated - it quickly puts everyone at ease.
Value as a Perception
...in the mind of a pet's family; it may or may not have a high correlation with reality! Having
our clients receive the best overall value in any service we provide is one of the core values of
our practice. When we consider the long-term health of the pets we care for, we find that value
(rather, our client's perception of what they received) is at least as important as what really
happened. If the client doesn't have a high perception of the value of our services, the pet is
less likely to get needed medical care - in the end, the pet loses.
Client perception of value is a curious thing. Let's consider the following example.
Introduction
We have many extremely competent doctors and nurses in our practice
who have performed thousands and thousands of physical exams during
their careers. Dr. Wegert (the founder of Banfield) has performed well
over half a million exams over his 45-year career. Like most of our
partners, Dr. Wegert is a very compassionate and caring doctor, who,
because of his vast experience, can perform a pretty complete physical
exam in about 90 seconds, all the while talking to the client about
something else entirely, whether it's house-training or last night's Portland
Trailblazer game!
In one Banfield study, very experienced doctors completed thorough
exams (including listening to the heart with a stethoscope, and using
either the opthalmoscope or otoscope) while talking with the client during
the physical. At checkout, 15% of those clients told us that the doctor had
not touched their pets - only 20% felt their pet had received an adequate
exam. Perception is not reality; it seems clients become overwhelmed in
the exam room: they may only retain about 10% of what we do or say,
which is why you need to repeat important instructions, present things
both verbally and visually, and ask them questions to make sure they
understand whenever we can.
We found that in order for the client to feel they got great value from the visit, they had to know
that a complete physical examination was done. That's why the number of screens and
questions in PetWare® is designed to take an average of 6 minutes on a normal, healthy pet.
This creates a very high perception of value for the client, which is reinforced when we give
them a printed report of the exam. The thoroughness, depth and documentation of the exam
is likely far superior to any exam their pet has ever received in its life.
Adding the Perception of Value
We add the perception of value by doing some, or all, of the following:
•
The exam is designed to take 6 minutes on a normal healthy pet - need to ask every
question and complete every system.
.
.
The exam is performed by a nurse, then confirmed by a doctor
The client watches an educational video that they are told is specifically chosen for
them, based on the needs of their pet
.
The computer screen is turned toward them so they can watch documentation of the
exam during the process
.
Using the vaccine tray to properly convey the value of the high quality vaccines we use
•
Use the percussion hammer to assess at least the patellar reflexes
.
Using the tuning fork to make at least a crude evaluation of hearing on every exam
•
Using the opthalmoscope to quickly assess ocular reflexes
•
Using a stethoscope to assess heart and lung health
•
Using a thermometer to measure the patient's body temperature
Introduction
•
Doing simple tests like tear tests, flouroscene stains, black light exams, and skin
scrapings in the exam room with the client present.
•
Collecting blood samples, stool samples, ear swabs and aspirates in the exam room
when team skill levels permit.
•
Doctors look professional - clean, pressed white lab coat with embroidered name or
name tag, stethoscope around neck, pens in shirt pocket (not lab coat pocket).
Scissors and hemostats in lab coat pocket - nothing else. Dark slacks, light colored
shirt/blouse, polished brown or black shoes, conservative jewelry and accessories.
(See SmartHelp for complete dress code.)
The doctor should always do the following in every exam:
1. Show something - temperature, videotape
2. Give something - injections, handouts, health forms. The Client Services Coordinator will
give client PE form and vaccine warrantee.
3. Compliment client's pet - (for example, hair good, weight good, etc.)
4. Summarize the case clearly and succinctly for the client - boil it down to 30 seconds.
5. Enter appointment and call back dates and tell client when to come back, as specifically as
possible and tell when you have made their next appointment for and why.
The Case Summary
The Doctor should always discuss the case summary with the client which should reiterate
answers to the following questions:
1. What is the problem (diagnosis)?
2. What is the cause (pathogenesis)?
3. What is the outlook (prognosis)?
4. What is the treatment plan?
5. What is the cost? (You should go over the estimate in PetWare® if you have another client
to see, then have the nurse go over the estimate with the client. If a client will be leaving
their pet at the hospital, print a copy of the estimate for them to take home.)
Wrapping Up the Exam
The doctor should end every exam with: "Thanks for trusting your pet to me. Have I answered
all of your questions? Call me if you have any questions, anytime." Give every new client a
business card (see appointment procedures).
Document everything in the medical notes. Update medical history "S" and "O" as appropriate;
"A" and "P", "E" and "T". Initial your comments in notes if not done by PetWare®.
Scheduling
Overview
THE BANFIELD APPOINTMENT BOOK
The purpose of the Appointment Book is:
1.
To help you learn how to manage your hospital patient flow so that:
a)
Pets get the best care
b)
Clients get the best service
c)
Your team is efficient, productive and mentally and financially successful
d)
Help you help the most pets possible
2.
To help reduce the stress that occurs from lack of planning
3.
To teach you the manual system that will be completely automated in PetWare®
Version II (expected in late 1997)
Appointment Book Features
1.
Each book has enough pages for 3 months
(You should have the book you are using and 5 more so that the appointments can be
scheduled 1 year out).
2.
Schedule by exam room (for 4 exam room hospitals)
a)
b)
c)
Regular appointment blocks are 20 minutes with 5 minute graduations. You can
break 20 minute blocks in half or any other part you think is appropriate (i.e.,
suture removals or the third puppy vaccine in a series may take only 5-10
minutes)
Exam Room Blocks alternate by 5 minutes so that all clients aren't at the same
point in their exams at the same time.
You should start your first morning appointment in the exam room about 10
minutes before the doctor arrives so that the patient is ready to be seen as soon
d)
as the doctor arrives.
You should never block out time for lunches (see "Scheduling During the Noon
Hour", page 7).
e)
You should never block out times for surgery until the patient is in the hospital
f)
(see "Time for Surgery", page 8).
You should schedule on exam room for appointments during vaccine / wellness
g)
h)
You should schedule your last appointment 15 minutes before closing,
When all appointments are bunched together,
clinic hours if you have 2 or more doctors and 3 or more exam rooms.
■
the team is more efficient,
■
them in, and
you can partially cover 'no-show' appointments.
■
you can take in surgeries and dentals the same day they are done and work
Scheduling
Overview
Assume you have 30 clients scheduled for the day. You should have them in 4 blocks, such as:
#2
Exam Room 4
Exam Room 3
Exam Room 2
Exam Room 1
9:10
#3
9:15
#4
11:15
#9
#1
#5
9:05
#6
11:05
m
11:10
#8
#10
11:25
#11
11:25
#12
2:05
#14
2:10
#15
2:15
#16
2:20
#13
#17
2:25
#18
2:30
#19
2:35
#20
2:45
#21
2:50
#22
2:55
#23
5:00
#24
5:05
5:15
#27
6:45
#30
9:00
9:20
9:35 -11:00 Open for surgery/walk-ins/treatmenls
11:00
11:20
11:45 - 2:00 Open (or surgery/walk-ins/lunch
2:00
3:10 - 5:00 Open for surgery/dentals/walk-ins
#25
5:10
#26
5:30 • 6:35 Open for walk-ins/treatments
6:35
#28
6:40
#29
This schedule gave you 4 open blocks of almost 2 hours each! If you had scheduled
according to the old paradigm - spreading patients out evenly over the whole day, you
couldn't have seen anyone who dropped in, the team would be more stressed
(constant, slow production), and you could not have helped any pet that needed
dentistry or surgery that day.
It takes teamwork to manage your hospital flow this 'new1 way - but the results are really
worth
a)
b)
c)
the effort:
More pets get helped
More fun / less stressful for the team
More production / better bonuses
3)
The cover has the dates included in the book for easy reference.
4)
Each date and day of the week should be written in the upper left corner in the space
provided. You may want to use sticky notes or tabs to make opening to a particular
week easier.
5)
Fill in Doctors available in the spaces provided as soon as they are scheduled so that
you can tell clients who they will be seeing.
6)
Time breakdown of a typical visit is outlined with typical average times for various
presenting complaints. Pet2 will ultimately figure this out for each doctor and schedule
accordingly - these estimated times are for your reference to use as guidelines. As you
can see, the overall average exam room time is 18 minutes - we schedule, 20 which
leaves time for cleaning between patients!
7)
Expected drop-offs (for Wellness Plan Exams, dentals, rechecks) should be scheduled
ahead of time and called the night before as a courtesy reminder (remind when to drop
8)
An abbreviated list of patients in the hospital or boarders in overnight should be
completed so that you can tell the clients what's going on when they call.
off and not to feed).
Scheduling
9)
Overview
There is a space for you to write in your daily and week-to-date statistics. These should
be filled in, graphed (our instructions on graphs) and posted at all times in the treatment
room.
10)
Instructions: Read the instructions daily until you have them memorized. Make sure
every new team member reads the instructions and this daily until they know it better
than you do!
11)
All appointments should also be entered into PetWare®. PetWare® is better at printing
lists of phone calls than you, and when we go to PetWare® and get rid of these books
for all scheduling, you don't want to have to enter everything then!
Scheduling During the Noon Hour
If you schedule horizontally on the schedule (i.e., every 5 minutes) instead of vertically (every
20 minutes), and therefore group the appointments that will come in by appointment, you will
almost always have a natural break someplace between 11 and 2. The doctor can go to lunch
then, knowing you haven't missed an opportunity to help a family.
If you schedule lunch by blocking out an hour, there will almost always be at least one client
that can't make it any other time; their pet will either not get care, or will get it somewhere else.
Doctors care very much about pets (they wouldn't have spent 8 years and $100,000 getting
their education otherwise); most are happy to take their lunch an hour earlier or later in order to
help more pets.
If the doctors have a Chamber of Commerce, Mall Business Managers, or local Veterinary
Association meeting at a specific time, then that time will need to be blocked out. These
appointments are important to building the practice, but there is no other acceptable reason to
block out the schedule for lunches.
Scheduling Appointments during Wellness/Vaccine Hours
Why do we have vaccine hours?
Many pet owners do not understand that a thorough physical exam twice a year is at least as
important as giving vaccines (you won't know if the vaccine will even work until you have
assessed the pet's immune system and general health).These owners do love their pets but
don't yet understand the value of or want to pay for an exam with their vaccinations. Some of
these pets have been getting shots at vaccine lines in mall parking lots or from low quality
operations, or worse yet, not getting their pets any preventive care at all. One thing is for sure
- their pet isn't getting an exam like we give, so it isn't getting the best care possible to
maximize its life.
One of our practice's core values is to reduce barriers to care (the artificial barriers that stop
pet owners from getting their pets the care they need) - one of those barriers for these people
is the exam/office call fee. We make that barrier zero! However, our goals during the free
office call are to:
1.
Provide the pet with the best physical exam it has ever had to uncover any health
problems.
2. Update all Wellness Care (vaccines, deworm, HWT, FeLV/FtLV test)
Scheduling
3.
Overview
Make sure the client understands the pet has received the best exam it has ever
received
4.
Help the client develop a plan for providing all the other care the pet needs but that
they decide not to do today.
5.
Get the client committed to a total wellness care program
6.
If the client understands what they have gotten, they will either enroll in a Wellness
Plan or not mind paying for an exam when needed.
To achieve these goals, our practice provides times that pet owners can bring their pets for
wellness care and not pay an exam. These times should be at least 6 hours per week (include
at least 2 hours on the weekend) and be during times that are generally less busy. It is
critically important to make this visit high value and enjoyable for the client. You have to do
that by setting expectations by telling the client,
"We have special wellness times on Wednesday, Thursday and Saturday from
1-3. During those times, we do not charge exam fees for well pets, even though
every pet still receives a complete and thorough exam. This service is very
popular and since we don't have appointments for well pets during these times,
waits can range from 1 minute to 60. We also have Optimum Wellness Plans
where all office calls and exams are free, anytime."
If you have more than one doctor and have four exam rooms, you should schedule
appointments in one exam room for other pets that will pay exam fees (such as pets with
medical problems). These pets will be seen at their appointment times. If all exam rooms are
full (or you only have 2) and a sick pet needs to be examined during vaccine hours, make sure
the treatment area is presentable, and take them there for their exam, explaining, "All our
exam rooms are occupied but the doctor wants to see Buffy right away, so if you don't mind,
we'll take you both to the treatment room for her exam." Clients should not be left alone in the
treatment area. Never send clients with sick pets that need care away - even if they
arrive during vaccine hours! You can see the pet in the treatment room, hospitalize it,
or move it to the front of the line - sending it away is unacceptable.
TIME FOR SURGERY
Obviously, when doctors are in surgery, they can't be hopping from exam room to exam room.
On the other hand, for each time you block out surgery time and the client never shows up
(30% reschedule at the last minute), you automatically lower production by 10% that day!
When you schedule horizontally, you will have times that you can put surgeries into. When the
patient is admitted, that is the time to schedule the surgery (if you need to at all). Then only
block out that time that the actual surgery will take, plus 10 minutes for the doctor's scrub. The
doctor need not be present in the treatment area for surgical preparation and recovery.
Most pets should be left for surgery and dentals when the client is in - not brought back on a
different day, making a second trip is VERY INCONVENIENT for the pet owner. Tell the client,
"This dental/surgery needs to be done as soon as possible. I know you didn't
plan on it today, but I also know you are probably very busy. You can either
Scheduling
Overview
bring Buffy back tomorrow or leave her now. If it will help, I can work her into the
schedule today. If for some reason we can't get it done today, I'll give you a call
and let you know, and then we can keep her overnight at no additional charge.
She'll be ready tomorrow, and I know you'll both feel better. This just might be
easier for you."
If walk-ins come in when all the doctors are in surgery, say, "The doctor is in surgery. Let me
check and see how much longer she'll be." Call the doctor on the surgery phone, ask how long
it will be, then tell the client, "The doctor is just about done. Let's get Buffy into the computer
and get the exam going."
If it will be longer than 20 minutes, or the surgery takes longer than expected, tell the client and
offer to kennel their pet while they shop or even let them drop off at no charge - give them a
certificate for half off their next visit.
THE RIGHT TOOLS
This book and the training system that goes along with it are only tools. We are counting on
you to learn how to use it and use it properly. If you have nail to drive and you have a
screwdriver and a hammer, you will get the nail in much quicker with a hammer - but only if
you hold it by the handle and use it properly (either tools can be dangerous if used incorrectly).
Caring
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HOW TO HELP YOUR DOCTORS CARE FOR MORE PETS
Anticipate
You know what the doctor needs next, get everything ready so they don't waste their time
thinking about what it is and asking you or worse yet, getting it themselves and messing up the
cupboards! Examples: Black light, bandage material, muzzle or skin scraping stuff in the exam
room. Or - blood draws, prepping patients for surgery.
Help Them Get Away
Some clients monopolize doctors and it is almost impossible to get away without being rude. If
you call the doctor in the exam room (and have them pick up the phone) you can tell them how
many other rooms/surgeries are waiting for them (or how long they have been in the room) and
it lets the doctor decide if they should stay or tell the client, "I'm very sorry; I'm needed. Let's
see you again on
. My nurse can answer any other questions you have, or please
give me a call" and exit.
Sometimes you may need to call every couple of minutes.
Keep Them Organized
Doctors should diagnose, prescribe, do surgery, build teams, and build client relationships.
Nothing else. Unfortunately, in the heat of the battle, they can regress to "I can do it faster
myself; don't let them get side-tracked reading slides, labeling pills, doing computer entry,
setting catheters.
Provide The Right Environment
We are a team - as such, we need to work together to make Banfield a fun team to be on - it's
more fun for everyone (and you'll get more done!)
.
Communicate: What's going on, what help do you need. Tell clients what's going on
too (they are part of the health care team).
.
Be happy: It's infectious and makes even the worst situations easier to get through, and
pets sense it. If you aren't happy, it rubs off on them and your team. If you're not
happy, the pet won't trust you and you have a higher chance of getting bitten or
scratched.
.
Hustle: It's infectious, too! If clients see you are trying to keep up, they are happier if
they do have to wait because they can see you're trying. You can help more pets if you
hustle and that is its own reward!
WHAT TO DO IF THE BUS UNLOADS AT YOUR HOSPITAL
(15 Clients Arrive at Once)
Congratulate yourself!
Word is getting around that you are the best - no other veterinary hospital has this 'problem'!
Caring
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DON'T PANIC!
Pets feel it, clients feel it, and your team feels it! Pets get tough to care for and are more likely
to bite -so are their owners, and so are your team-mates! (it's that epinephrine release)
Think.
You have at least the following 8 solutions to your situation:
1. Speed the doctors up - call them in the rooms, anticipate, organize them, hustle (they
will follow your lead)
2.
Hospitalize the pet if it is sick. Say:
You've done the right thing to bring Buffy in. I'm not a doctor, but it doesn't take a
doctor to tell she's sick, does it?! I know the doctor will need lab work. Let me call her to
see if it's OK to get that started.
Call the doctor, briefly explain and ask if it is OK to hospitalize and start lab work.
Explain to the client:
The doctor would like us to get Buffy started right now. The lab work will be less than
$100 and the doctor will give you a call in 2 hours - where can you be reached or do you
want to stop back by?
Then get lab work started and put the patient on as a top priority on the doctor to-do
board.
3.
Kennel the pet if it is not sick. Say to the client:
I'm sorry you had to wait (remember: you are NOT sorry the doctor is busy! This
means she is a good doctor that people want to care for their pets). If it would be easier
for you, I can put Buffy in a comfortable kennel to wait and you can go shop and come
back later - we can even keep her overnight at no extra charge if that would be more
convenient for you.
4. Communicate, communicate, communicate! If clients see you are trying hard, and you
let them know what's going on or that there was an unexpected emergency and that you
are willing to bend the rules (kennel their pet for free) to help them out, reasonable
people won't be mad. But you have to keep telling them how long it will be and why
(don't give more information than is necessary - think about what you would want to
know - do unto others....)
5. Anybody that has to wait more than 15 minutes to get into an exam room should get a
certificate for 1/2 off their next office call/exam. Give it to them when they check out and
say:
I'm sorry that you had to wait today. I know your time is valuable so I'd like to give you a
certificate for half off your next visit to show how much I appreciate your patience.
6. Give Clients a Free Exam at another scheduled time during a time you don't expect to
Caring
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I'm sorry you had to wait; it looks like it will be another 30 minutes or so. If it would be
better for you we can kennel your pet (see #3 above) or I'd be happy to schedule a free
appointment and exam at another time when you wouldn't have to wait - how would this
time tomorrow be?
7. Use the Intercom: Let clients know they can shop in the store and you will call them on
the intercom when it is their turn - you can even keep their pet in a kennel if they'd like.
8. Think of Creative Solutions: Don't forget you can use the treatment room for a quick
exam if necessary and appropriate. Giving balloons or little toys from the treasure chest
to kids will often help.
Team
Member
Roles
HOW TO PUT IT ALL TOGETHER!
Client flow is the "who does what" of an office call, from the time the client walks in to the
hospital until they leave the hospital (total should average 32 minutes).
It is critically important for every team member to understand the client flow in order to give our
clients the best service and their pets the best care.
THE CLIENT VISIT
...starts before they ever walk through the door - approximately 60% of clients call before
coming in, so being courteous on the phone is critical!
•
Always answer the phone by the third ring
.
"Good Morning! Banfield Pet Hospital and Health Center, this is Vicki, how may I help you?"
(Always smile on the phone - people can really tell the difference!)
.
Don't put our client on hold unless you absolutely have to; if you do have to take another
call, say, "I have another call; may I put you on hold for a moment?" Then be sure to check
back with people who are on hold at least every thirty seconds.
A - Client Services Coordinator Duties
1. Welcome
The first impression for every visit is made within the first 7 (yes 7 !!!) seconds! Always make
eye and voice contact immediately when a client walks up to (or even by) the service desk. "A
visit that starts with a smile generally ends the same way - it's your choice!"
.
SMILE and make eye contact, say "Hi" and ask "How may I help you?"
•
After they tell you how you can help, ask "when were you or your pet in last?"
(Clients who were in yesterday on your day off and spent $400 don't appreciate being
asked "Have you ever been in before?" but clients who have never been in before don't
mind "When were you in last?"
•
If they have never been to Banfield before, they will tell you, in which case you can
introduce yourself, introduce your team mates, and offer them information about our
practice.
•
Have the reception screen on "Expected". When the client walks in, this should help
you greet them and their pet by name, if they have an appointment.
•
Treat all clients like welcome quests in your home.
Say, "Hi! My name is 'Rhonda, how may I help you?" in order to establish their reason
for coming in today (called the 'presenting complaint1 in PetWare®).
Once the client tells you their need, ask them, "When were you or your pet in last?"
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New Clients
If this is their first visit to Banfield:
•
Welcome the new client and their pet to the practice and introduce yourself and
everyone in the reception area (yes, even other clients)
•
Ask our new client to complete new client form (help if possible), then enter the
information into PetWare®. Make sure this process goes as quickly, courteously, and
smoothly as possible.
If the pet seems unruly, ask the client if they would like to have their pet rest in the kennel until
they go into the exam room. Point out that this is normal - "Pets are often a little anxious
waiting to see the Doctor and the kennels are more comfortable for them - in fact, that's what
the kennels in the reception area are here for!" If the pet might be contagious, take the client
and their pet into an exam room immediately. If there are no empty exam rooms available, the
pet should be kenneled for the safety of all the pets.
2. Check-in
.
Sit down with the client and get the information you need in order to get them into an
exam room as soon as possible. Always make sure that the client has signed the
authorization to provide care and indicated how they will make payment. Enter the time
the client first entered the hospital in the lower right hand corner of the authorization
form.
.
Give the client a practice brochure and explain our services. Use the brochure to point
out the Doctor credentials, as well as practice features, benefits, and hours. Ask them to
read the brochure and offer to answer any questions they might have.
.
Keep a record of new clients who initially contact the hospital by phone but do not want
to make an appointment. Include name and phone number, whether the pet was sick or
injured, and important points in the conversation. A Doctor or Nurse can rarely
recommend care (beyond first aid) without first seeing the pet. If the client has not come
in by the next day, call them back to check on the pet's condition. This kind of
outstanding service will eventually make that person our client.
•
Have the client weigh their pet while pulling up the patient record in PetWare®.
3. Presenting Complaint
.
Enter correct presenting complaint and weight in PetWare®.
Team
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Check the pet's vaccination history and correctness of all phone numbers and address,
etc. Discuss overdue
vaccinations, T-4's,
etc., with the client.
4. Introduce Optimum
Wellness Plans
Introduce Wellness
Plans and make
appropriate entries in
the PetWare® notes.
•
Emergencies are always first priority. When a client comes in
with a pet that has been hit by a car or is obviously in a life-ordeath situation (or the client thinks it is an emergency situation)
and needs immediate attention, you should:
(1) Get the client and pet into a room within 20 seconds;
(2) Immediately inform the Doctor; and get them into the exam
room.
Place the signed
(3) Access the patient file.
release in the basket
If the client is new, they can fill out the necessary paperwork
and you can do the data entry after the pet is first seen by the
Doctor. However, you should get a signature authorizing the
Doctor to treat the pet as soon as possible on a drop-off form.
If no exam rooms are open, take the pet only directly to the
treatment room. CALL YOUR TEAM MATES FOR HELP!
on the end of service
counter.
•
Emergencies
When someone
comes in with a re-
bandage, drop-off, or
Wellness Plan dropoff appointment, call
the Traffic Controller to have the pet taken to the kennel right away.
It is VERY IMPORTANT that clients get into exam rooms for Doctors to see quickly,
especially in the evenings. Often the pets need intensive treatment that night. It is the
Client Services Coordinator's responsibility to get these people (even new clients) into
rooms within 5 minutes. Paper work and data entry can be completed in the exam
room if necessary.
No one can admit any pet that has had surgery or been treated at another clinic without
the written approval of the Chief of Staff or the Doctor in charge. We generally do not
want to get in the middle of someone else's problem.
Tell every client that calls after 6:00 p.m. when we close. If they are coming in, ask their
names and the phone number where they are, so we can be ready for them. Call if they
are not in by 5 minutes before closing so we know whether we need to wait for them.
As soon as an exam room is empty, the Client Services Coordinator will check to see
that it is clean. Now change the client/patient's status to "In Exam Room #
". Ask
the client, for example, "Mrs. Jones, would you like to bring Ginger into the exam room
to see the Doctor?" Show Mrs. Jones and Ginger into the exam room.
Tell Mrs. Jones that the Doctor's Nurse will be in shortly to talk about Ginger's medical
history and to give her a complete physical exam.
5. Show a Video
Tell Mrs. Jones that the Doctor would like her to watch a short video on {the video tape
subject} because her pet is overdue for
, and then start the video. Put the
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signed release in the holder on the door, then leave the room. When the video is done,
tell the Traffic Controller that 'Mrs. Jones in Exam Room 3 is ready'.
B - Nurse
Introduce yourself. "Hi, Mrs. Jones!, Ginger! I'm the Doctor's Nurse." Touch and greet the
pet. Tell the client that you will be doing a preliminary examination for the Doctor.
1. Get History and Perform Exam
Determine the chief complaint (for example, vaccinations); check vaccination history, perform
an entire exam while touching the pet and talking to the client about what you are finding;
provide education as appropriate and note your discussion topics in the medical notes. Mark
circles yellow for those areas you are unsure of. Discuss fees with the client and offer an
estimate after the Doctor has examined the pet - record in the notes if client wants a printed
estimate.
In order for a system to be considered 'normal' and no notes to be entered, the following
criteria must be met:
.
Skin
No alopecia or abnormal scaling/dandruff
No pruritus (itching)
No parasites (fleas, ticks, lice, mites, tapeworm segments)
No tumors/growths or swellings
Clean coat with normal luster
No odor
No dermal defects of any kind
Dewclaws and nails normal length or absent
.
EEN (Ears. Eves. Nose and Lvmph Nodes)
Normal color, consistency and smell
No exudates
No swelling or growths
No parasites
No inflammation
No pruritus (itching)
No sneezing
Normal vision and hearing
.
Oral
No bad breath or trouble chewing
No tartar
No broken, loose or missing teeth
No caries
No inflammatory changes
No swellings, growths, or defects
Normal tonsils and palate
No abnormal color or odors
.
Chest, Heart and Lungs
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No murmurs
Normal lung sounds and respiratory rate (20-35)
No coughing
No upper airway defects
Abdomen
Normal weight/no unexpected weight gain or loss
No vomiting or diarrhea
Normal appetite
Normal abdominal palpation including left and right kidneys, liver, stomach, bladder,
spleen and intestines
No pain during palpation
Normal visual appearance of abdomen
Not pregnant
No known parasites
Skeletal System
No lameness
Normal stifles and patellas
Normal range of motion of all joints
No crepitus in any joints/muscles
No swelling of any joints/muscles
No pain on pressure or manipulation
Foot pad and nails normal
No pain on raising
Anal
Normal appearance
Anal glands normal and empty
No fistulous tracts
No growths or swelling in anal region or tail area
Normal temperature (101.2 -101.8)
No parasites
Normal palpation of testicles
Penis and vulva visually normal
No exudates or inflammations
Other/Nervous Svstem/Behavior
Normal mentation and attitude
No behavioral problems
No seizures
No CNS (central nervous system) signs including head tilt, nystagmus, proprioceptive
deficits, paralysis or paresis
No malaise or lethargy
Afebrile
If any abnormalities are noted in any of the above areas, do the following:
Describe the problem, noting specific location of problem; duration of problem; size,
color, smell, consistency and texture; where appropriate in notes. You do not need to
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type in observations that have been noted in PetWare® screens unless more
information is needed for a full description of the problem.
Do not make diagnoses - only describe findings. Record all information in "General Conditions
Screen", examination on all pets and record appropriately. Determine the TPR (temperature,
pulse (heart rate), and respiration) of all sick pets (otherwise PetWare® will default to 'normal').
2. Educate
Discuss items under "Client Education" checklist in the notes with the client and record brief
answers.
•
Give client appropriate single topic brochures to read.
The Nurse should also check:
.
Vaccination of fecal and heartworm/FeLV due dates; discuss any vaccines or Wellness
tests that are due or overdue with the client.
.
Other data included on the checklist (Hwt/-fecal/T4, etc.); discuss any other preventive
care that is due or overdue.
.
Ask whether the client would like to discuss any of the following areas with the Doctor,
including (but not limited to) flea control, vitamins, and / or diet, and make a notation in
the notes and on the authorization form for areas the Doctor needs to discuss.
Prepare vaccinations in exam room and place on counter in a clean, stainless tray. Explain to
the client that there are over 100 vaccine manufacturers and we use the vaccines that our
Doctors think are the very best. Explain that "because we use only the best vaccines, we stand
behind them 100%." Explain that they will get a warrantee that we will care for the pet if it gets
any disease we have vaccinated against at no charge to them. Also tell the client that the
Doctor will be in a few moments and that you will play a short educational video for them in the
meantime.
3. Discuss Optimum Wellness Plans
Discuss Wellness Plans and enter that you have discussed them by pressing {F9}.
4. Show a Video
•
Start the video when you leave the room to discuss findings with the Doctor. The above
is the "O" (objective) in the "SOAPET"2. Briefly document all of your observations that
are related to the present condition of the pet including any history that was related to
you. All typing in the notes should be done in the exam room with the client.
.
Place authorization form in door box. Make brief notes for Doctor if you will be unable
to discuss findings with the Doctor.
.
Send Doctor into exam room with patient. Make sure that a Doctor is with the client
within three minutes. If this is not possible, check back with clients every two minutes,
so that they know they have not been forgotten. Call Doctors in other exam rooms on
the phone to let them know when a client is waiting.
Team
•
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Assist Doctor as needed.
Outpatient
•
Finish medical record, messages, client call-back, and appointment date and time.
Please authorization form in billing-out box on front counter. Make sure days for
recheck appointments have been entered.
Inpatient
Prepare estimate. Go over prognosis/SX release. Briefly review estimate. Give total.
Ask if there are any questions regarding fees or procedures. Have client read estimate.
Enter estimate approval and amount in notes. Tell the client when to call and give them
a Stay-in-the-Hospital brochure.
Assist with getting lab samples. Label neck band, cage card. Put in kennel. List on
Doctor board. "Make done" services performed. Note that owner approved services.
Initial notes as appropriate.
Handle emergencies
C - Doctor
.
Before entering the exam room, review the case with the Nurse, then write the time
you'll go into the room in lower right hand corner.
1. Perform Exam
.
Enter the exam room, introduce yourself (for example say, "Hi, I'm Doctor Smith" and
shake the client's hand. Use the client's name. Touch and talk to the patient, using its
name. Even though the Nurse has done a physical exam already, repeat a thorough
physical while talking to the client.
.
Review and re-examine all abnormalities noted by the Nurse and make any necessary
notes. Talk to the clients about your findings while you are examining the pet.
.
Auscultate the heart and lungs on every patient and complete an exam. Do medical
procedures; i.e., neuro hammer, otoscopic, ophthalmic exams. Nurse is to have mixed
vaccines in the room to increase the client's awareness of the procedures used for pet
and to increase perceived value to the client.
•
Palpate the abdomen.
•
Palpate testes on male dogs and complete a rectal on dogs over 8 years old at least
annually (statistically, castrated dogs have a higher incidence of prostate cancer than
non-castrated.)
.
Describe findings as you are examining the pet (i.e., nose cold, eyes good, ears clean,
lymph nodes normal, etc.)
The "A" in SOAPET is the Assessment or tentative diagnosis that results in your diagnostic
and therapeutic planning.
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If the pet is ill and will be hospitalized, the "A" at this point should be your tentative diagnosis.
The rule-out list is listed by PetWare® and will be exhaustive. You should enter enough
tentative diagnosis to address every problem on the problem list - leaving the index number at
"0".
The "P" in SOAPET is the Plan - interventions that facilitate the pet's return to its optimum
state of health. This is largely suggested by the protocol screen in PetWare® and you can add
to it or subtract from it. Saying "Medically Not Necessary" documents that you recommend
against the service in the patient record. Selecting "Client Declines" will document that in the
record and the client will be given a list of these services on the invoice.
The plan includes recommended tests and procedures necessary to rule in or out possible
diagnoses and solve the problems present. The plan, as in previous areas of the SOAPET
system, will be documented by PetWare® (easiest by using the protocol as a starting point) but
any additional thoughts or observations should be recorded in the notes.
Note whether an estimate was given, by writing "estimate" in the notes along with the amount
and it covers up to that point or the entire therapy. This will enable the Client Services
Coordinator/Nurse and Doctors to quickly assess those services that were included in the
estimate.
The "E" in SOAPET is the Evaluation. A determination of how effective the plans were toward
achieving the treatment goals. "E" will be used in the following situations.
.
For recheck examinations, be sure to list "E" in the notes with your observations, client
discussions and next plans ("P").
.
For everyday evaluation of hospitalized patients during treatments
What to Include with Every Exam
1. Show something - temperature, videotape
2. Give something - injections, handouts, health forms. The Client Services Coordinator will
give client PE form and vaccine warrantee.
3. Compliment client's pet - (for example, hair good, weight good, etc.)
4. Summarize the case clearly and succinctly for the client - boil it down to 30 seconds.
5. Enter appointment and call back dates and tell client when to come back, as specifically as
possible and tell when you have made their next appointment for and why.
The Case Summary
The Doctor should always discuss the case summary with the client which should reiterate
answers to the following questions:
1. What is the problem (diagnosis)?
2. What is the cause (pathogenesis)?
3. What is the outlook (prognosis)?
4. What is the treatment plan?
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5. What is the cost? (You should go over the estimate in PetWare® if you have another client
to see, then have the nurse go over the estimate with the client. If a client will be leaving
their pet at the hospital, print a copy of the estimate for them to take home.)
The doctor should end every exam with: "Thanks for trusting your pet to me. Have I answered
all of your questions? Call me if you have any questions, anytime." Give every new client a
business card (see appointment procedures).
Document everything in the medical notes. Update medical history "S" and "O" as appropriate;
"A" and "P", "E" and "T". Initial your comments in notes if not done by PetWare®.
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D - Nurse
1. Complete Client Exam
•
Complete any data entry and client education that is needed.
.
Assist Doctor as appropriate
•
Complete appointment card
.
Place authorization form in bill-out bin.
2. Show How To Administer Medication
E - Client Services Coordinator: Check-Out
.
Check if anything else is needed (like flea prevention, heartworm prevention, vitamins)
•
Give client the invoice to review and explain as needed. Ask them if they have any
questions. Get the Doctor or Nurse to explain anything you are not 200% sure of!
.
Enter payment, complete invoice and answer any further questions.
•
Distribute pamphlets and ask if there are any questions.
.
Let the client know when their pet should be in again, give them an appointment card,
and fill out the date in the appointment book and in PetWare® if this hasn't been done
already.
.
Thank the client for coming and ask them to call if they think of any questions.
•
Enter time out on authorization form in the lower left corner.
•
Place authorization form in the proper place.
.
Note: The Assistant Office Manager will prepare the following graphs:
•
Total time in the hospital
.
Total Doctor time with client.
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INPATIENTS
Drop-off's: Boarders and Medical
The hospital will be open for "drop-ofFs" based on the needs of our clients. The early morning
Client Services Coordinator is responsible for admitting the patients. Any client presenting a
patient requiring immediate care, when a Doctor is not present, should be referred to the
appropriate emergency service or have the client sign the record indicating that they know care
cannot be given until the Doctor arrives. The Doctor must be in attendance at the time of
release of any patient unless another staff member has been authorized specifically in writing
by the Doctor to release the patient. Whenever possible, all client communication regarding a
surgical case, should proceed through the admitting Doctor. Changes in treatment regimes,
medication, go-home dates, etc., should be done with the approval of the admitting Doctor. If
they are not available, another Doctor in charge should make a final determination, but should
leave a message for the admitting Doctor and record it in the patient notes.
A - Client Services Coordinator
•
Greet client.
•
Help sign in and determine the reason for the visit. Enter the time on log-in chart.
•
New clients:
.
Help fill out the "New Client Form".
.
Enter all patient data including the dates of the pet's last vaccinations and what they are
and any medication.
.
Enter presenting complaint and hospitalization screen data in PetWare® so that we will
know if medications, leashes, or carriers are being left, and enter the same information
on the cage card.
.
Complete drop-off sheet or boarding form (See "Boarding") (the form in the file may only
need to be updated) and cage card. Have the client sign the authorization form for care
or the drop-off form with printed release. If time is not a problem for the client with a
drop-off, they should see the Doctor. Tell the client, if a Doctor is not present, when you
expect one, and if the Doctors will not be back that evening, that the pet should be
taken to the appropriate emergency veterinary clinic if it needs immediate attention.
•
Check to be sure the phone number we have can be used to contact the client and that
all vaccinations are current. Make sure to ask the client if they want us to call with an
estimate for any services exceeding $50.
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Make sure to explain the following to all boarders:
•
Ask if there is anything that the Doctor should check. Go over the fees.
.
Does the client want the pet bathed before it goes home?
.
All vaccinations, including kennel cough, will be updated, if they are not current
according to our records or there is written proof of vaccination from another
veterinarian, because we cannot be sure that:
•
•
A good quality vaccine was used.
That it was stored correctly until given
•
That it was given correctly
•
When it was given.
.
We must have an emergency phone number. If there is a medical emergency, we will
treat the pet as if it were our own. Minor problems, such as mild diarrhea, etc., will be
treated as necessary, without trying to contact the family.
.
We will tranquilize the pet if the Doctor deems it necessary for the pet's health, or if the
pet barks uncontrollably.
.
If the pet is found to have fleas, the pet will be bathed to remove them. All pets in our
kennel must be protected.
.
Medication supplies will be reviewed by the Nurse and Doctor, administered, and
refilled, as appropriate. List all medications, special diets, and frequency of
administration, in patient notes. There is no charge for giving the medications.
.
The normal fee will be charged for any of the above services.
.
Pets are released during all Doctors' hours - no other times. Make sure we know the
time and date the pet will be picked up and who will pick it up.
.
We try not to keep toys, leashes, pillows, blankets, etc. If these are left, it is at the
client's risk.
.
Don't admit drop-off spay or neuters on Saturday or Sunday without a Doctor's approval
or rewraps at times that have been previously approved by the Director of Nursing and
the Business Manager. They are never to include weekends, holidays or times after
5:00 p.m. If the client has to have this done during those times, they should be
encouraged to drop off the pet and pick it up later, because we don't have the staff
available to do these types of services during those hours. "Emergencies" are handled
when they need to be.
.
Clients who wish to call in concerning their pet's progress should do so after 10:00 a.m.,
as morning treatments and rounds are not completed until after 10:00. Tell those clients
who call before 10:00 a.m. that the Doctors are still in rounds and that we won't have a
complete report until they are completed, which is usually around 10:00. Could they call
back later this morning for a full report? Tell them information that the morning Nurse
has put on the treatment list.
.
Put pick-up date and time in appointment book for boarders so we can make sure they
are clean and ready.
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.
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Put the authorization form in box in nursing area.
B - Nurses
•
The Nurse makes sure the pet and cage are properly labeled and determines the
urgency of the pet's problem.
.
The Nurse puts the pet on the Doctor's board if it doesn't have to been seen
immediately. If it should be seen immediately, it is the Nurses' responsibility to see that
it is.
C - Nurses' Aides
•
Retrieves pet when notified by Client Services Coordinator.
•
Labels pet, places in kennel, and places cage card on kennel.
•
Pets should be labeled before ever being placed in a kennel (white for boarders, red for
hospitalized or boarders with medication). The pet's label will have: Client's first and
last name, pet's name, and a brief description of the pet.
Kennel Labels
Kennels should be labeled with the following:
.
Client's first and last name
•
pet's name
.
brief description of the pet
•
date the pet is to be released
•
when the bath should be done
.
All this should be completed by the Nurse, if the Nurses' Aide does not know all the
information.
•
Gives SID medications at 7:00 a.m., BID medications at 7:00 a.m. and 5:00 p.m.
D - Nurses' Aide
The Nurses' Aid should check:
•
The board for which pets to medicate
.
The dosages on the bottles to get the medication out.
•
The pet's label for the correct client name and pet name.
.
Then and only then give the medications to the correct pet!!! No medicine is better than
the wrong medicine!
•
If the Nurses' Aide has any questions, it is their responsibility to wait and ask the Doctor
or Nurse.
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HOSPITALIZED PETS/PETS ON TREATMENT BOARD
No client with a pet in the hospital gets charged "boarding" when they are charged for
'hospitalization'. If the medications are so complicated or the pet needs to be "watched" and
examined daily by the Doctor, then the client will be charged for hospitalization.
A - Nurses' Aides
•
Observe patient regularly and note anything that is not normal. Tell the Nurse any
abnormal observations and have them entered on the patient record. Write down on
the cage cards if the patient is eating, drinking, urinating, or defecating and if any
abnormalities you see (such as vomiting, diarrhea, and seizures, and what they looked
like).
•
Clean and feed patients, taking care to follow instructions on cage card.
•
Patients with Parvo and other infectious diseases will be marked "Nurse clean only" on
cage card. Only do as instructed by Nurse or Doctor on these.
.
Do not go into isolation without permission or direction from the Director of Nursing.
B - Morning Nurse
•
Check all patients and boarders visually. Any requiring immediate attention should be
brought to the Doctor immediately.
•
Prepare treatments list according to the form before the Doctor arrives. The Nurse may
administer medications as prescribed, but cannot prescribe treatments or treatment
changes, unless the Chief of Staff has established written "Standing Orders". The
morning nurse can follow established hospital protocol, but cannot institute fluid therapy,
drugs, or other procedures without specific instructions from a Doctor.
•
When doing morning rounds, get patients for the Doctor. Anticipate!!! Don't wait to be
told to get the next patient. Keep the Doctors busy.
•
Assist the Doctor in any way possible.
•
You are responsible for writing up the history or seeing that it is done completely, by the
Doctor, and that the Doctor has personally initialed any notes if you wrote the
treatments. PE and SOAPET should be complete.
.
Complete the record with diagnosis, messages, and proper provider teams.
.
Have Doctor complete Change in Estimate form for any patient that needs services not
on the estimate. The Nurse is responsible for calling the client to notify of changes.
Enter conversations in notes with amounts, staple Change in Estimate form to
Authorization Form.
C - Surgical Care
The life and medical records of any pet you get out of the ward are your responsibility. If you
get the pet out, you must stay with it until it is awake. Make sure the weight on the record is
accurate for the anesthesia!
Team
Member
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•
Enter anesthesia notes in notes screen. The preanesthetic exam must be completed
before the pet is given any drugs. Complete preanesthetic checklist in notes.
.
Preliminary x-ray findings will be entered in the notes.
•
Assist the Doctor in anesthesia and surgery.
.
Type the surgery write-up as directed during the surgery in PetWare® and have Doctor
initial. Write up with any Doctor additions.
•
When the patient reacts to stimuli, is conscious and can keep itself standing, and is
breathing properly, return the patient to the ward.
•
Monitor patient closely until sternal, and then regularly until fully conscious, no matter
what time it is. Do not get the pet out of its cage if you will not be able to see it fully
awake.
DISCHARGING PETS
Overview
No pets are discharged unless fully awake. When a pet is waking up from an anesthetic, it
can hallucinate and bite someone that it would never hurt if it was not under the effect of the
drug. The pet could also injure itself by falling orjumping down stairs or out a window, or could
choke on food or water and be injured.
.
The only exceptions will be those approved, specifically, by the Doctor as a special
circumstance, and C-Sections that are released to breeders that have been in the
business for 10 years and have prior experience with anesthetized pets. The doctor
must give these clients their home phone number and be available for questions - and
call the owners every 2 hours until the pet is back to normal.
.
Call the client when the pet begins to wake up and is in the ward fully recovered.
•
Complete the medical records with personnel, diagnosis, service and message
numbers. Enter recall date and post surgical instructions as directed.