Ken Yagi, MS, RVT, VTS (ECC), (SAIM) joins Dr. Andy Roark to talk about how practices actually go through the process of increasing their delegation to and utilization of technicians.
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ABOUT OUR GUEST
Kenichiro Yagi, MS, RVT, VTS (ECC), (SAIM)
During his 20+ years in the field, Ken has dedicated his career to reimagining veterinary nursing. He obtained his VTS certification in emergency and critical care as well as small animal internal medicine and achieved his master’s degree in Veterinary Science. He is currently the Chief Veterinary Nursing Officer for Veterinary Emergency Group, and the Program Director for the RECOVER Initiative. Over the years, he has received the Veterinary Technician of the Year award by NAVTA, the Veterinary Technician of the Year award by the California Veterinary Medical Association, the RVT of the Year award by the California RVT Association, and the AVECCTN Specialty Technician of the Year award. Ken co-edited the Veterinary Technician and Nurse’s Daily Reference Guide for Canine and Feline, and the Manual of Veterinary Transfusion Medicine and Blood Banking, and publishes articles and presents internationally on topics in ECC, transfusion medicine, and the veterinary nursing profession.
Ken works to bring further recognition of the vital role of the veterinary technicians and nurses through work with organizations, being a Past President of National Association of Veterinary Technicians in America, and President of the Veterinary Emergency and Critical Care Society. He is also an advocate for the Open Hospital Concept, encouraging veterinary practices to invite the pet owners to “the back” as a part of the team.
Ken invites everyone to ask “Why?” to understand the “What” and “How” of our field, and to continually pursue new limits as veterinary professionals and individuals.
EPISODE TRANSCRIPT
Dr. Andy Roark:
Welcome everybody to the Cone of Shame Veterinary Podcast. I am your host, Dr. Andy Roark. Guys, I’m here with the one and only Ken Yagi talking about how do you actually start using technicians more aggressively, holistically a assertively, than you have in the past?
How do we actually delegate stuff to technicians so that doctors get on board and the change actually gets made in the practice? That’s what I want to dig into. So Ken and I always talk high level stuff. We’re not doing that today. I really… What do you say in the practice? What are the steps that you have to take to try to change the way that a practice functions and really starts to utilize those technicians to take things off a doctor’s plates? And how do you get the doctors to allow the technicians to do that?
That’s what Ken and I get into today. It is a super fun episode, guys. I hope you’ll enjoy it. Let’s get into this episode.
Kelsey Beth Carpenter:
(Singing) This is your show. We’re glad you’re here. We want to help you in your veterinary career. Welcome to the Cone of Shame with Dr. Andy Roark.
Dr. Andy Roark:
Welcome to the podcast, Ken Yagi. Thanks for being here.
Ken Yagi:
Thanks for having me.
Dr. Andy Roark:
Oh, always. I love having you on the show. You’ve been on a number of times.
For those who do not know you, you’re an RVT and a veterinary technician specialist in emergency critical care and small animal internal medicine. You have been the President of NAVTA, the North American Vet Tech Association, and you are currently the Chief Nursing Officer at VEG.
I didn’t miss anything, did I? I know I miss a lot. First of all, your bio just rolls on. It’s like the Iliad, but I think those are at least some of the points.
Ken Yagi:
Yep, sounds good.
Dr. Andy Roark:
Anything I should add that I woefully left out?
Ken Yagi:
The NAVTA is the National Association of Veterinary Technicians in America, no longer North American.
Dr. Andy Roark:
What did I say? The North American Vet Tech Association? I just make stuff up sometimes. Yeah.
Ken Yagi:
Yeah.
Dr. Andy Roark:
I’m sorry. Hey. Yeah, we pride ourself on factual accuracy here on the Cone of Shame and I’m glad that you caught that.
All right, enough of that. Let’s talk brass tacks here, Ken Yagi. You and I, when I usually have you on, we talk at a high level about where technicians are going and how technicians interface with medicine overall. And we future-cast a lot and things like that.
And that stuff is always fun and I do really like it, but I am about as pragmatic as they come when I get into how do I actually get things done. I like to get things done. And I look at a lot of practices and I think I see a lot of my colleagues who are like, “Yes, I want to use my technicians more.”
And I see a lot of techs who are like “Hey, buddy. Put us in, coach. We’re ready.”
But we’ve got these established systems and workflows and ways that we’ve done things in practice. And breaking out of the old way of doing things is hard. And a lot of people say, “I want to do this, Andy, but it’s scary.”
The idea of giving up control and saying, I’ve been doing catheter placement forever and I know that I’m really good at it. And so the idea of letting people who are not as good as me do it, is terrifying and it doesn’t make any sense. And I go, “Well, you have to give people repetitions and a chance to use their skills. It’s not fair to not let anyone do stuff and then dunk on them because you do it better than they do it.”
I go, “Well, that’s dumb.”
But still, this stepping back part is really, really hard. And so what I wanted to talk with you about today is how do we actually make a change in a practice that hasn’t been leveraging their technicians? So yeah, I want to get into the weeds and pick your brain about things that you’ve seen, where practices have actually made changes. And people who have been established techs have not come out and gone into a new practice, but they’ve gone into an established practice and over time they have grown in that practice and that practice has evolved.
Because medicine changes, guys. And I really think that if you’re practicing medicine the way you were five, 10 years ago, then you haven’t grown and it’s time to grow. So I want to help people grow today.
So Ken, when I lay that out at first, how does that sound?
Ken Yagi:
That sounds great, so let’s get right into that.
Dr. Andy Roark:
All right, so let’s go to work. So where do we start here?
I’ve got my practice and I’m like, I don’t know, am I lever… I think I’m leveraging my technicians, but I don’t really know. Help me get my arms around what I’m even looking at here.
Ken Yagi:
Yeah. So I’ve been looking into this quite a while and I have survey responses and things like that. When it comes to… One of the reasons why people don’t get utilized, it’s actually kind of surprising to see on the survey. There’s a response that says we don’t have issues with utilizing technicians, and that one actually gets picked the most.
And so it made me think about, well, maybe people don’t actually realize that just being busy and having people run around like crazy and trying to get things done is different from well utilized technicians because that’s just busy people that are trying to get everything done. And the other thing might be that they’re just not aware of what good utilization looks like.
I have a quick exercise that I just want to throw out there that’s sure for everyone that we can do, and that’ll be a good place to start. I’m going to read off 10 different things that could be done in a veterinary practice and the people who are listening, I want you to think about whether that’s gets done most of the time by a doctor or by your nurse, and keep track of that and we’ll tally it at the end.
The first one is IV catheter replacement. Next one is calculating fluid rates. Hospitalized patient assessment. Urinary catheterization for urine collection. Client education on diabetes. Ultrasound exam. Anal gland expression. Nasogastric tube placement. Creating an anesthetic plans and administering it. And then the last one is unblocking cats.
Dr. Andy Roark:
I’m at five. I’m just going with by what happens in the practice where I work. So I was like, I’m at five. I’ll be honest.
Ken Yagi:
Yeah, yeah, exactly. That’s what we want to be doing. So for you, five of those fit into technicians are doing it most of the time, is that correct?
Dr. Andy Roark:
Yes.
Ken Yagi:
Yep. So then if you take a quick tally of that, so that’s like 50% out of 100% for me, because all of these things should be able to be done by a technician with supervision, of course, but a well-trained one.
And so then I would say that you have 50% potential of utilizing technicians better in your practice.
Dr. Andy Roark:
Yeah. I believe that. I think there’s the possibility to get better. I think that’s why… Honestly, you write the book you want to read, the reason I want to have this podcast. What does evolution like that look like in the practice where I work?
And so yeah, I know that there’s upward possibility. So that totally tracks to me.
Ken Yagi:
So, the first step is to go through this thought process to take a look at what happens in your practice, which of those could be done by technicians that you’re not utilizing them for. And that gives you the awareness of how much more room there is to grow in your practice for utilizing technicians.
And that’s the first place to start. You need to know where you’re at in order to change it.
Dr. Andy Roark:
Yeah. No, I like that assessment. Just doing that, I go, okay. I love the questions as well because they’re concrete examples of things that technicians could do that they often aren’t. And I go, oh, okay. Yes, it is true that my techs could unblock a cat and they generally don’t. But they could and I get it.
So I like that there are specific examples and just the questions themselves open up your mind to how technicians could be utilized. I really like that exercise.
Ken Yagi:
And I also be a little bit cautious and say that unblocking cats, I’m putting it out there. Right? That’s one of the highest end things that technicians could do because it’s a high risk procedure. What if the urethra tears?
Dr. Andy Roark:
Sure, yeah.
Ken Yagi:
And I would definitely consult the Practice Act to make sure that what you’re trying to get technicians to do is definitely legal.
Dr. Andy Roark:
Yeah. Oh, well that’s important. Yeah.
Ken Yagi:
But with that said, there’s so much more that we could be utilizing our technicians for than we do today.
Dr. Andy Roark:
Yeah. No, I do think that’s good, but what I think… So I realize the sample, so let’s stay with this for a second. So we’re talking about unblocking cats. I think you put your finger right on the valid concerns that doctors have where they go, yes, I have technicians who could do this, but I’m the one who’s going to have to make the phone call if we punch through the urethra and now we’ve got real problems.
And it’s not even about saying, I think that someone else is better than me or not as skilled as me, but it’s almost like if I’m the one held responsible and there’s going to be a mistake made, I would like to be the one who makes the mistake because at least I’ll know then that I’m the one who messed up and now I have to deal with the consequences.
So I think that that’s a very valid emotional response that people have. And so that sort of brings me around to, I think there’s nuance here as far as what are we comfortable with? And in my impression, Rome was not built in a day. I think a lot of people expect that the path to tech utilization is a huge leap forward. Or one day we walk in and say, guys, the rules are changing and we lay down all of these things. I just can’t imagine that’s the case.
So let’s start to talk a little bit about what increased utilization actually look like as it takes hold in the practice. Can we do that?
Ken Yagi:
Absolutely. Yeah.
Dr. Andy Roark:
Where’s the push usually come from? Is it usually… I mean just in your experience. We’re talking a hundred percent anecdotally here. Is it usually, is it an owner, manager, up the chain sort of decision? Is this usually doctor driven where the doctors say, I want to let delegate more effectively to technicians? Let’s talk about changing our protocols? Or is it usually technician driven? What have you seen that has actually accomplished results?
Ken Yagi:
It needs to come from all different directions, but I would say that the push from the veterinary technicians and nurses side has existed for a long time. We’ve been saying we’d like to be utilized, and that hasn’t changed things too rapidly.
I think that the practice management is starting to look at it a lot more commonly now, because of the shortage that we have out there. We need to see as many patients or even more patients in a more efficient manner. And so, one of the ways that we can do that is through more efficiently utilizing every single team member, not just the veterinary nurses. So then we need to think about it that way.
And knowing that the path to retention is also to be able to pay these people better. Having a more efficient team that’s able to bring in more revenue through the utilization is seen as partial solution to the shortage that we have today. And so, I think we’re starting to see a lot more of the practice management paying attention to efficiently using the team members while balancing it with some of the concerns that come up, like the one that you mentioned regarding liability issues.
Dr. Andy Roark:
Yeah, that tracks with what I’ve seen. And now that you say that, I go, okay. Yeah, I get it. Well, I think one of the things that I have seen as a recent movement is, I don’t know if it’s driven by corporation of medicine and we suddenly have these outside entities that are very focused on business and operations in a way that… And most independent practices never used to be.
I don’t know if it’s really coming from them. I don’t know if our whole profession is just evolving. I don’t know if it’s a labor shortage that’s really pushed us, but the operational efficiency is a really big deal now across practices. And I’ve talked to a number of people who have voiced frustration to me where they say that we have this plan, we’ve come up with this way of getting things done. We’ve got these systems for delegating effectively to technicians and other paraprofessionals.
We’ve got all these things that we have figured out and the doctors won’t do it. And the doctors, they won’t delegate. They won’t delegate to the technicians, they won’t use them or they don’t want to use this system that we’ve come up with. So I’ve heard that. And again, I’m not in those practices. I don’t know. I don’t like to think that the doctors are probably the most likely obstacle to evolution this way, but it seems to me that they probably are as a doctor because they’re the ones who feel that they’re held responsible when things go wrong.
And so, I think it’s understandable that they would be the most hesitant to say, okay, I’m going to open this up. I’m going to step back from what I’ve done previously. And it’s not just about belief in our own skills, but it is… There’s a liability part to as well where I go, well, my license is the one that’s going to be come after if this goes badly.
Does that resonate with you, Ken, when I say that? Does that feel like what you’ve seen as well? Am I overstating the pushback that doctors tend to give to these initiatives?
Ken Yagi:
No, I think that it’s definitely true that doctors have the liability on their mind because it is under their supervision that all these things happen. And if something goes wrong with their patients and it goes to the veteran medical board, they are definitely the primary person that’s called up to defend. And so, there’s certainly that worry there.
I’m also going to say though, it’s not everyone that feels that way. I think that there are many doctors that are very pro-utilization and making sure that they can do their job better by having trained individuals that can help them to perform the procedures that they need to perform or that delegate the tasks that they need to delegate.
And I think that’s the key point is that yes, there is a liability, but the liability falls both on the doctor and the licensed professional, the RVTs, LVTs, CVTs that have their own license that they will ultimately need to defend, as well.
And so, at the very highest level, I would say that nobody should be doing anything in the practice that they’re not trained well enough to do. Not an all or nothing thing where we say all of a sudden everyone should be doing a hundred percent of what’s legally possible and let’s just start doing that tomorrow.
And I think getting there by good training and also starting with the maybe smaller things, lower risk items that will be comfortable enough for the team to start allowing the nursing team to be able to do and gradually getting to the point that you have higher end things being done by the entire team would be good.
But there are probably individuals within each of those teams that are very high caliber that won’t be satisfied with the lower level of utilization that you want to retain. And so a more individualized plan on who’s the person to have these tasks appropriately delegated to them and identifying that within the practice would be important.
Dr. Andy Roark:
If you dream of doing team training with your team, getting your people together, getting them on the same page, talking about how you guys work together in your practice, I’d love to help you. You can check out DrAndyRoark.com and check out the store. I have two different team training courses. These are courses for teams to do together to get on the same page and to talk about how you do things. I have my Angry Clients Course and I have my Exam Room Toolkit Course, and they are both available and there, so come out. All right guys, let’s get back into this episode.
So there’s a couple pieces of this I want to unpack. So first I really like your idea of starting with lower stress, lower risk things that people can get on board with and just starting to build the habit of delegating and letting people do more and start to grow in small steps. That totally makes sense to me.
Talk to more about what an individualized plan looks like in practice in a way that doesn’t hack people off. It’s not like, hey, we’re going to let Amanda do this, but we’re not going to let David do it. And go.
So yeah, help me… What kind of messaging is around that? Because it makes sense to me where you say, I do have some people that I think could do it. They’re licensed technicians. And I have some people who are licensed technicians that I’m like, I’m not comfortable doing this, at least to start. What does messaging around that look like where I say, we’re going to try this with one or two people as opposed to, yes, you have your RVT and so now jump in and go for it?
Ken Yagi:
I can definitely see your point in if we individualize it to the point that only a certain people are able to do certain things, then it would create some tension within the team. I think trying to do this more systematic way would be good.
What we’ve done is we’ve put together a path of growth for people. There are different categories of individuals on the nursing team. There’s something called hospital assistants who might have very little clinical experience and they’re coming in and serving as true assistants that don’t do a whole lot of clinical work. So that’s one type of people.
And then we have veterinary assistants who are not licensed but have gained enough practical and clinical experience that they can function at a higher level in the clinics. And then people who have become credentialed from there that are veterinary nurses. We only hire credentialed veterinary technicians to be our veterinary nurses and draw a line there who are also very clinical in nature. They have knowledge of the why behind the things that they do that allows them to determine when their patient’s in trouble, be able to troubleshoot when things go wrong, and they have the knowledge set to be able to do so.
So just as a basic. Then there’s VTSs, too, right? Veterinary technician specialists that have higher experience and knowledge level and they went through a certification process. So let’s just say there’s four different buckets that people fall into. So then hospital assistants can be utilized in this fashion. Veterinary assistants can be utilized in this fashion. Veterinary nurses are utilized in this fashion. VTSs can do the highest end things.
So if we can bucket them into different categories and then assign the types of tasks that each of these people would primarily be able to be utilized in, then you have a starting place to say it’s not just that I like this person and how they do this particular procedure, so I’m going to let them do that. But this person, maybe I don’t have a good enough relationship with, so I’m going to shy away from working with that individual and then creating a very antagonistic feeling.
Dr. Andy Roark:
I like that. And I think that makes a ton of sense. Also likes about the personal development path. I think that that’s like if you want to keep people engaged and talk to them as an individual about where they’re going and start to lay those things down, I think that that’s such a healthy approach in keeping people growing and growing.
So I want to circle back to, there was three pieces I wanted pull out of what you said earlier, and the first was small steps to start. The second one is this individualized plan. And the third part is the skill training that we talked about. And so, I think back to when I graduated from vet school and my skills were pretty darn ephemeral at the time, meaning if I didn’t get into practice and start using those skills, I don’t know that I would’ve had them a few years later. Because we learned a lot in vet school, we learned a lot in vet school, but you don’t get to do a whole lot.
You are sort of didactically learning and learning and writing notes and sort of taking in. But then there’s the getting into practice and getting that repetition. So if I have… Let’s say I have a technician and he went to school and he got his credentials and he’s come into a practice and he didn’t really get to do a lot of the more advanced work for a couple of years.
And now we start to say, now we’ve got some opportunities for you. I want that person to be successful. Can you talk to me a little bit about how you would look at skill training for technicians when I’m actually… We’re actually going to let them do it now.
I feel like we’d been setting them up for failure if we said, “You were trained three years ago. Jump in there and do it.”
Help me bridge that skill gap.
Ken Yagi:
Yeah, so I think that one of the first places that you need to start is defining what that task really is. And that if it’s as simple as IV catheter replacement, for example, what does that mean? How is it done? Is there a standard that’s set in the practice that people are expected to do it a certain way? Because if one of the reasons why doctors don’t necessarily delegate to a certain technician might be that it’s faster to get it done themselves or get it done right if they do it, in the exact way that they want to see it happen, then we need to be able to communicate some of that to the team members on how a certain thing is being expected to be performed in that part of your practice.
So do you have guidelines? Do you have protocols? That needs to exist first in order to train against. And then the next step is the training part, which can also be somewhat challenging. That if you have a shortage of people and you’re struggling to keep up with the workload that you have, how do you gain the time in order to train these individuals appropriately? And that’s a harder one to tackle.
But having a system first, having standards set, having assistants trained, do you have somebody who’s dedicated to coordinate the training? Have you established a peer-to-peer training type culture within the hospital that allows people who are knowledgeable enough and well-trained enough to do the training, actually do it?
And then the rest of it is people having each other’s backs to find the time to help each other grow and that being a norm.
Dr. Andy Roark:
Yeah, no, that makes sense. It’s basically figure out what done looks like and then make an action step plan to get to done. And that’s super simple advice, but I’ve found it to be true again and again.
Ken Yagi:
And I guess one more thing that I’ll insert with that is, I think there’s maybe a little bit of a tendency for us to, when we set guidelines and protocols or certain ways that things are supposed to be done, being too rigid in it. And that there’s probably things that we want to make sure happens. If it’s a IV catheter example, we want it to be done in a aseptic manner. We want the catheter to stay in that. We want it to be painless as possible for the patient.
And there’s probably things to pay attention to do that, but how exactly do we need to tape the catheter or dictating it to that very micromanaged level is probably not the way to go. And so I just want to make sure that we’re aware that protocol or guidelines doesn’t mean exactly how it needs to be done, because there’s more than one way to get the goals accomplished.
And I think that’s a trap that we fall into sometimes, too, that makes it a unpleasant experience for the people who are learning.
Dr. Andy Roark:
I love that you said that. I have been… I actually am… I’m halfway through writing an article right now on the difference in protocols and context and leading with protocols and context where it’s a balance. So there’s so many people… I love what you said and just, I have a hundred percent worked at places where it was like, this is how many pieces of tape we use and this is how they go.
And I understand because it’s about consistency and quality control. And at the same time, if you hire smart people who are very good at what they do and you take away their agency and their ability to look at the situation and adapt to what is best in this specific case, the ultimate outcome is less than it would be.
I always say don’t hire smart, great, motivated people and then put them into a system that doesn’t let them make any decisions or affect the outcome on the ground.
And the same thing as don’t hire smart people and give them no guidance and then be frustrated when things are all done every different way. It is a balance of that. But I don’t think I’ve ever had anyone say that the hyper-nuanced, anal-retentive way of this tape, pieces of tape, and this is how we did it. I’ve never had anyone push back against that, but it’s always bothered me of what are we doing here really?
I don’t know. I love that nod towards balance. Let me… Last question. Are there any pitfalls that you see with practices that are starting to utilize technicians? How does this blow up and go off the rails and end up just locked back down tighter than it ever was before?
What are the mistakes that get made that really just tank initiatives to empower technicians?
Ken Yagi:
Having a plan on gradually improving utilization is the first point. And I say that because if we try to go from zero to 60 in a snap of a finger to get everyone utilized and we start letting people do all these things and they should just teach each other and just get it out there and put it out there, mistakes are bound to happen.
Mistakes as in something affected patient care. The client complained because they had a poor experience. The doctors got reinforced in the feeling that they should have done it themselves, because look what happened because I delegated this particular task this person.
So I think doing that in a more planned, gradual manner is the first thing that I think about when I think about that. But also being tolerant in understanding that there will be mistakes that will happen when we start letting people do new things and making sure that people understand that as we try to push the boundaries here a little bit, whatever that boundary is for your specific practice, there are going to be unideal situations that will arise.
But the point of that is to, when something like that happens, the important thing to think about as you approach it is not to then say, oh, see, it didn’t work, so now we have to revert. Let’s not let anyone place nasal gastric tubes ever again. Or doctors will always have to do urinary catheters or something like that, and doing a little bit of a knee-jerk reaction to that.
Instead of doing that, you really have to take the time to evaluate, well, what went wrong here? Was the person not trained well enough? Did the doctor not provide good enough instructions? Was it a difficult case that was going to happen with regardless of who was doing it? And just evaluating each of those situations, learning from it, adjusting for the next time, and providing the right guidance that each of these individuals need to do it better the next time, I think, is one thing that I want to make sure that people understand.
That it won’t always go perfectly. We just need to improve it for the next time. And that gradual improvement as you do it more and more is what will get you there.
Can I throw in one more thing?
Dr. Andy Roark:
Yeah, sure.
Ken Yagi:
When we talk about utilization and issues surrounding it, we often point to the doctor is not letting the technicians do this or the practice management isn’t paying attention to utilization enough and creating systems and whatnot.
But I think there’s a third piece to that, and that last piece is that for all the veterinary nurses out there that are wanting to be utilized better, I think we should self-reflect a little bit too to say, are we the type of people that foster good trust that allows people to delegate the task to us?
Do we have the knowledge and skills that allow us to appropriately do this? And are we making sure that we’re not overextending ourselves and putting patients at risk? Do we follow through and deliver when tasks are delegated to us and make sure that it’s done instead of forgetting it or dropping the ball sometimes? Are we treating the doctors respectfully and creating a safe place for them to come back and ask questions about how things were done or clarifications about the things that we’ve done without us getting defensive? Because that could definitely prevent doctors from wanting to delegate further.
And so, it’s always… I guess it’s more than a two-way street in terms of making sure that utilization is something that naturally happens in the hospital. So for all the veterinary technicians and nurses out there, be that person, is a message that I want to send.
Dr. Andy Roark:
Yeah, I love that. It’s definitely a dance that we do together. We want to be trusted and we want to be empowered, and then we need to make sure that we’re able to accomplish the things that we set out to do.
You know what I mean? And trust is cyclical that way of we give trust to someone else and they validate and reward that trust and we continue to spin up. So anyway, I love that point.
Well Ken, where can people find you online? Where can they learn more about you and/or VEG?
Ken Yagi:
I’m on LinkedIn, Instagram, and Facebook, and happy to chat through any of that.
Dr. Andy Roark:
Awesome. Thanks so much for being here.
Hey guys, take care of yourselves, everybody have a great weekend.
And that is our show. That’s what I got for you guys. I hope you enjoyed it. I hope you got something out of it. As always, if you did, share it with your friends, write me an honest review wherever you get your podcast. That always means the world.
Thanks again to Ken for being here. Guys, take care of yourselves. I said at the end of the recording with Ken, like, have a great weekend. It’s Wednesday. I don’t know why I said that. I’m think I’m done with this week.
I’m sure other people know how that feels. And regardless of what day it is, have a great day and a great next two days as if it was a great weekend, even if you’re listening on Monday.
Anyway, that’s all I got. Take care everybody. Bye.
