Practice Standards Consultation: Arguments for and against

Re: Practice Standards Consultation: Section 3: Out of hours patient care

Julian Earl — Fri, 02 Oct 2009 11:13:44 GMT

We joined the PSS in order to continue with nurse training - that is mandatory is it not? Others seem to be suggesting that TPs do not have to join. Have I misunderstood?

I would not suggest that joining is without its uses though: fridge monitoring has proved revealing and useful. But being criticised for having handle on the door between the preps room and the kennels because there is no sink in the kennels seemed over the top. So now we have a swing door and a less secure kennels if a large dog gets out.

Why do I need to have written evidence that shows the staff have been trained in sharpening dental elevators? Nothing about not ramming one through a tooth socket into the orbit though. Okay, sharpness is good but for heaven's sake...

And temporarily having the biochemistry machine in the theatre was a no-no (fair enough), but not a word about the clinical waste holder in the same room (now removed anyway as bad practice).

And so on. All for something about which the client cares not one iota. It would be far better to concentrate on basics like clinical care, CPD/skills, hygiene, cleanliness etc., although even that would have its difficulties.

Re: Practice Standards Consultation: Section 3: Out of hours patient care

Richard Carter — Wed, 23 Sep 2009 17:50:38 GMT

hooray!! Second, third and fourth this!! I can see if we are not careful we are going to end up with rules that will prohibit 'normal' qualified vets from doing spays.

I don't know if I can speak for true 'general' practice but we are in serious danger of raising the standard too high - a spay on healthy bitch or even a pyo in an unhealthy one can be successfully managed with the most basic of surgical equipment and a good surgeon should be able to operate with an anaesthetic, scalpel and some suture material. All the rest are 'nice to haves' that make the job easier. Having trained in South Africa where kitchen table spays were the norm for visits to farms, charity work etc and where 80% of the population would not even be using a qualified vet for any work I do find the idea of minimum requirements requiring a stainless steel height adjustable operating table with all the rest of the recording of vital signs etc completely over the top.

Re: Practice Standards Consultation: Section 3: Out of hours patient care

james hunt — Wed, 23 Sep 2009 13:09:34 GMT

Your prerogative

james

Re: Practice Standards Consultation: Section 3: Out of hours patient care

Evelyn Barbour-Hill — Wed, 23 Sep 2009 13:00:47 GMT

[quote user="james hunt"]

[quote user="Hannah Wynne Richards"]

Best anaesthetic monitoring "device " I know is a really good nurse and an oesophageal stethescope

Wynne

[/quote]

I'd go for a diplomate with a finger on the (peripheral) pulse, but agreed the diligence of the person responsible for the anaesthetic is paramount.

[/quote]

I'd go for the good nurse and the oesophageal stethoscope. And it wouldn't matter twopence to me whether the nurse was a VN or "unqualified".

Re: Practice Standards Consultation: Section 3: Out of hours patient care

james hunt — Wed, 23 Sep 2009 10:51:42 GMT

[quote user="Hannah Wynne Richards"]

Best anaesthetic monitoring "device " I know is a really good nurse and an oesophageal stethescope

Wynne

[/quote]

I'd go for a diplomate with a finger on the (peripheral) pulse, but agreed the diligence of the person responsible for the anaesthetic is paramount.

Re: Practice Standards Consultation: Section 3: Out of hours patient care

Hannah Wynne Richards — Wed, 23 Sep 2009 09:47:56 GMT

Best anaesthetic monitoring "device " I know is a really good nurse and an oesophageal stethescope

Wynne

Re: Practice Standards Consultation: Section 3: Out of hours patient care

james hunt — Tue, 22 Sep 2009 23:57:05 GMT

[quote user="alex gough"]

We have discussed elsewhere the opinions of anaesthetists.

[/quote]

Perhaps i'm glad I missed that discussion, but certainly to an extent I agree with you Mr. Gough, the draft practice standards manual states that, for a SA hospital:

"Monitoring must be available including pulse oximetry and capnography, blood
pressure measurement facility, and oesophageal stethoscope. Records of vital signs
and agents employed must be retained. Evidence of staff training in the use of
monitoring facilities must be provided."

Ok, well, yes these devices might well provide helpful information, depending on the patient, the pathology and the procedure. I suppose the subtlety is that the equipment must be available, rather than employed on every case.

Given a choice between the multi parameter monitor or an experienced anaesthetist I would save my electricity.

Best wishes

James

Re: Practice Standards Consultation: Section 3: Out of hours patient care

Hannah Wynne Richards — Mon, 21 Sep 2009 12:53:18 GMT

Far more of you are objecting to the PSS than to the VSA proposals !!!! Let's get this absolutely straight. You object to an elected body of veterinarians being in your opinion over-interfering, but have no objection to this power being given to unelected, unqualified political appointees !!! Logic ????

Wynne

Re: Practice Standards Consultation: Section 3: Out of hours patient care

Alex Gough — Fri, 18 Sep 2009 08:01:32 GMT

[quote user="Jonathan Wray"]

You've lost me here. Yours is a referral practice ergo you are marketing to first opinion vets. The RCVS Treasurer isn't tier 3 and markets to first opinion vets. I suppose this is a personal point of view, rather than a universal justification of PSS tier 3 status. Is that correct?

[/quote]

Correct.

[quote user="Jonathan Wray"]Again you've lost me. Is there anything to stop a practice using the PSS framework as a template without joining PSS? Is there anything to stop a non-PSS practice going beyond the "check list" approach, perhaps being a bit "Core" (Tier 1) here, a bit "GP" (Tier 2 e.g. TP) there, even a bit Hospital (Tier 3 ) with the right kit? [/quote]

[quote user="Jonathan Wray"]As for external verification, you've really got me on that one. The PSS inspection is intrinsically internal. It's done by RCVS apointed vets, inspecting vets. To represent it otherwise would be a terminological inexactitude. [/quote]

It's external to my practice.

All the best

Alex

Re: Practice Standards Consultation: Section 3: Out of hours patient care

J G Wray — Thu, 17 Sep 2009 15:57:07 GMT

Dear Mr Gough,

You wrote:

[quote user="alex gough"] I dont think it is essential that a referral practice is tier 3, I just think its good from a marketing point of view. [/quote]

You also wrote:

[quote user="alex gough"]Its just the practice standards provide a good check list, and I would imagine that if anything did go wrong, the fact that you had been externally verified as up to scratch would be useful to be able to point out. [/quote]

Again you've lost me. Is there anything to stop a practice using the PSS framework as a template without joining PSS? Is there anything to stop a non-PSS practice going beyond the "check list" approach, perhaps being a bit "Core" (Tier 1) here, a bit "GP" (Tier 2 e.g. TP) there, even a bit Hospital (Tier 3 ) with the right kit? That practice would be unclassifiable in the PSS and would be better off outside the PSS, literally.

As for external verification, you've really got me on that one. The PSS inspection is intrinsically internal. It's done by RCVS apointed vets, inspecting vets. To represent it otherwise would be a terminological inexactitude. If a practice has its VMR inspection by AMI then that really is external verification.

Regs

JGW

Re: Practice Standards Consultation: Section 3: Out of hours patient care

Alex Gough — Thu, 17 Sep 2009 15:34:41 GMT

[quote user="Jonathan Wray"]That's interesting. On page 38/82 of the PSS review manual this requirement refers to equine only practices.[/quote]

Mea culpa, just went and checked - i must have been cross eyed when I read that one! Yes only for horses that one.

In another section, where it states a hospital must not only have ultrasound, ecg, endoscopy, but provide evidence that training has been provided. I would think my CertVC should insure me for ECG and ultrasound, but do I need to dig out my 2002 endoscopy course certificate? How current does it have to be? Do I have to have refresher courses, and if so who is qualified to give them given there is no recognised qualification in the subject? Does it count that I teach other people in the practice how to perform endoscopy, or that our surgeon is editing a book on the subject?

Unfortunately there is a lot in the rules that appears to be open to interpretation.

"The RCVS Treasurer's referral practice is not PSS registered. I haven't asked him why not. Do you know?"

I dont. I had to go to the RCVS website to find out who that was. It's a while since I visited his practice, but it must be one of the best equipped and staffed private practices in Europe. I dont think it is essential that a referral practice is tier 3, I just think its good from a marketing point of view.

"[quote user="alex gough"]One is that it is a good check list to mean we have fulfilled all our legal requirements re employment law and health and safety.[/quote]

Do you think this is possible for practices who are not in PSS? It is a legal requirement after all."

Of course its possible. Its just the practice standards provide a good check list, and I would imagine that if anything did go wrong, the fact that you had been externally verified as up to scratch would be useful to be able to point out.

Alex

Re: Practice Standards Consultation: Section 3: Out of hours patient care

J G Wray — Thu, 17 Sep 2009 15:05:04 GMT

Dear Mr Gough,

You wrote:

[quote user="alex gough"]One of the recommendations for tier 3 small animal is that all anaesthetic procedures longer than 1 hour are monitored with direct arterial blood pressure monitoring![/quote]

That's interesting. On page 38/82 of the PSS review manual this requirement refers to equine only practices.

You also wrote:

[quote user="alex gough"]One is that it is a good check list to mean we have fulfilled all our legal requirements re employment law and health and safety.[/quote]

Do you think this is possible for practices who are not in PSS? It is a legal requirement after all.

and:

[quote user="alex gough"]Second is that as a referral practice, I feel we should aspire to the highest standards, and it is useful for other practices to see we have achieved them. However, as the inspection of our new, purpose built hospital, (designed with consultation with the BVHA to achieve all the tier 3 standards) draw nearer, I feel like we are sitting an exam, and I am wondering what missing piece of paperwork might be the difference between a pass or fail...[/quote]

The RCVS Treasurer's referral practice is not PSS registered. I haven't asked him why not. Do you know?

Regs

JGW

PS In another posting and somewhat off topic you wrote:

"..Nothing ever appears to be an accident any more, if something happens to a person, it must be someone's fault..."

Hmmmm. We were having a discussion at work about iatrogenicity the other day. We decided that we would, when it happened, distinguish between responsibility for the act i.e. culpability and action consequent upon the fact. In other words, we would minimise the cries of "It's not my fault", "It was an accident" and distinguish them from "I didn't mean it". We would distinguish guilt and mens rea. We decided not to just leave it at "it's an accident" because we, my vets and nurses hold a privileged position, we have a degree of knowledge which informs us over and above the general public.

We also agreed that recognising this meant we would have also to have very very clear mitigation in order to avoid more severe consequences than the norm.

Re: Practice Standards Consultation: Section 3: Out of hours patient care

Alex Gough — Thu, 17 Sep 2009 13:48:43 GMT

To add some first hand perspective to the debate, we are currently undergoing accrediting our new premises as tier 3. I have been helping the practice manager go through the paperwork. We are a big practice, encompassing around 20 vets incl full and part time at various branches, so we are lucky that we have enough admin staff that we can have our practice manager devote herself full time to the paper work for 2 months, because this is what is required to get certified from scratch. As for evidence basing some of the requirements and recommendations... hmmmm. I dont know how they came up with the clinical standards. Did they have someone from each discipline contributing their "must haves". I suspect that a committee all contributed their ideas. We have discussed elsewhere the opinions of anaesthetists. One of the recommendations for tier 3 small animal is that all anaesthetic procedures longer than 1 hour are monitored with direct arterial blood pressure monitoring! Given that I understand that sometimes it can take experienced anaesthetists 3/4 hour to find an artery and connect it up, is this really a sensible recommendation, and is there any evidence base that peri-anaesthetic mortalitiy is decreased by invasive rather than non-invasive blood pressure monitoring?

Someone asked the question, why are people signing up to it? Two reasons for me as a partner in a first opinion and referral small animal practice. One is that it is a good check list to mean we have fulfilled all our legal requirements re employment law and health and safety. Whether this is something that the RCVS should be monitoring is another question...

Second is that as a referral practice, I feel we should aspire to the highest standards, and it is useful for other practices to see we have achieved them. However, as the inspection of our new, purpose built hospital, (designed with consultation with the BVHA to achieve all the tier 3 standards) draw nearer, I feel like we are sitting an exam, and I am wondering what missing piece of paperwork might be the difference between a pass or fail...

Alex

Re: Practice Standards Consultation: Section 3: Out of hours patient care

Alex Gough — Thu, 17 Sep 2009 13:28:58 GMT

[quote user="Hannah Wynne Richards"]I agree that a lot of "elf and safety " in unbelievably petty , and forces us to treat staff like toddlers, rather than intelligent adults, but this is the fault of the HSE not Royal College.[/quote]

I heard a HSE executive on the radio not long ago. She was saying, dont blame us for the ridiculous H&S rules in companies. HSE says that advice must be tempered by common sense. However, companies often go further than that for fear of litigation because of the rise of personal injury lawyers. Nothing ever appears to be an accident any more, if something happens to a person, it must be someone's fault.

Alex

Re: Practice Standards Consultation: Section 3: Out of hours patient care

Mike Martin — Thu, 17 Sep 2009 11:39:42 GMT

[quote user="Jonathan Wray"]

As per, you have asked a question. Do your clients get questions or answers? - question mark, if you see what I mean? - question mark

[/quote]

Jonathan, you do get tooooo cryptic for me at times? I've no idea what you're getting at.

[quote user="Jonathan Wray"]

........you can't uninvent the PSS; it's here to stay.

Do you think the RCVS is open to influence......

[/quote]

Yes I agree it is here to stay.

So should we not try to influence the end product? I need to have faith that we can have influence and create change.......rather than give up. I've talked to a number of colleagues who have influenced their inspector and got them to change their assessment of some really daft perceptions and ideas.

Re: Practice Standards Consultation: Section 3: Out of hours patient care

J G Wray — Thu, 17 Sep 2009 11:16:51 GMT

Dear Mike,

As per, you have asked a question. Do your clients get questions or answers? - question mark, if you see what I mean? - question mark

The genie is out of the bottle; the cat is out of the bag; you can't uninvent the PSS; it's here to stay.

But, the RCVS could be a tad more honest about its purpose, its value, its merits, don't you think? The RCVS could be a bit clearer who drives the PSS and where it is going, don't you think? Do you think the RCVS is open to influence, or merely professes such, bearing in mind it acts in the public interest?

Regs

JGW

Re: Practice Standards Consultation: Section 3: Out of hours patient care

Mike Martin — Thu, 17 Sep 2009 09:22:42 GMT

Does anyone else feel that there is an inevitability about all this. In particular the RCVS will not withdraw something that is already up and running and for which 50% of practices have already subscribed and 'supported'? Should we maybe discuss aspects of the requirements to meet PSS and maybe influences changes that could maybe make it more tolerable?

Re: Practice Standards Consultation: Section 3: Out of hours patient care

Ian Mostyn — Tue, 08 Sep 2009 17:50:24 GMT

I learned a lot about our practice becoming a training practice but we gain a tangible benefit from that, as do our clients and patients in terms of better staff training. Why can't a TP be a tier 2 practice automatically and just have one scheme? The RCVS is over-stepping the mark, interefering in things that are the remit of the HSE or HMRC. They should stick to animal related issues.

Ian

Re: Practice Standards Consultation: Section 3: Out of hours patient care

J G Wray — Tue, 08 Sep 2009 13:30:17 GMT

Dear Mrs Walden-Till,

Thank you for your comments, especially the analysis:

[quote user="Mary Walden-Till"]So to sum up, undertaking the work was worth it for us because of what we learned about ourselves but we won't feel proud when we get our plaque for the wall.[/quote]

Are there any other PSS protagonists, who can offer their reasons for being in and staying in PSS?

The inspection process is integral to the "validity" of the PSS. Mrs Walden-Till's comment that:

[quote user="Mary Walden-Till"]but we have had to challenge the RCVS on some of the things they required us to do after inspection by pointing out that these things weren't in the standards! They backed down and apologised but it made us even less certain that the PSS was a worthwhile scheme.[/quote]

is noteworthy, not just because the inspectorate is a group of volunteers, but because of the additional areas the PSS inspectors are moving into, taking their reported levels of experience and consistency. PSS inspectors are now part of the Disciplinary system as investigators. Page 10 of the RCVS 2009 report has an account of how a PSS inspector made this transition to an investigative role.

Others find it curious how we have a single body responsible for the investigation and prosecution and sentencing in disciplinary matters, when the judiciary is separate from the police in life. The PSS has provided the staff for this agenda.

Regs

JGW

Re: Practice Standards Consultation: Section 3: Out of hours patient care

Mary Walden-Till — Mon, 07 Sep 2009 11:41:49 GMT

[quote user="jamie winstone"]

This thread has shown why so many people have decided not to join the PSS scheme, namely that whether or not they become accredited, the standard of care that their practice gives will not be improved one jot.

However, there are a large number of practices who have decided to join the scheme. The vast majority of those in favour have decided not to articulate their reasons for joining.

Now that they have spent a large amount of time, effort and cost joining, it is likely that they will wish the scheme to become mainstream and to progress.

This is illustrated by the regulations involved for all practices listed on the drugs register, which has been dovetailed with the PSS scheme, therefore putting pressure on those practices that had intended to stay out of it.

I am now concerned that the PSS scheme will eventually become compulsory and force unwanted red tape on refusniks like myself.

[/quote]

I'm newly signed up to this site although my husband is a vet and has been a member of vetsurgeon.org for some time. I am joint director of the practice with him.

I joined in order to comment on this PSS thread as we decided last year, after huge discussions, to join the scheme despite all the down sides to it. The main reason for joining the scheme was that as we had to comply with the new drugs regulations we thought we may as well get a certificate out of the situation as well. We would not wish to see it become compulsory as Jamie fears although I can understand why he thinks that some people would.

For us it has been worth doing even though we are a small practice with 1 full time and one part-time vet, and my husband as director and occasional vet :-) We have hated almost every minute of the work we have had to do for it, and are still doing to comply with the areas where we 'failed'. However, it has had benefits as it has focussed our minds on what we want our practice to be in all of the modern areas of regulation and I feel we have further improved our already well respected and long established business. We think it has been worth doing even though a lot of it is either filler or duplication of H&S legislation, but we have had to challenge the RCVS on some of the things they required us to do after inspection by pointing out that these things weren't in the standards! They backed down and apologised but it made us even less certain that the PSS was a worthwhile scheme.

So to sum up, undertaking the work was worth it for us because of what we learned about ourselves but we won't feel proud when we get our plaque for the wall.

Re: Practice Standards Consultation: Section 3: Out of hours patient care

Richard Carter — Fri, 04 Sep 2009 09:25:30 GMT

sorry - Been away looking up 'totemic'

So can some of you clever computer bods put together a poll/ survey which addresses the following:

1. there is a real or perceived lack of professional care in the veterinary profession,

2. this could be addressed with a minimum standards scheme as opposed to regulating the qualified individuals

3. this scheme should be run by the RCVS

then all the other bits that help classify who has answered eg age, qualifications, whter vet, nurse, pet owner, non- pet owner

if vet then years since qualified, position in practice etc. I'm sure there are specialists out there who can do alkl the right statistics etc

Re: Practice Standards Consultation: Section 3: Out of hours patient care

Paul Dowie — Thu, 03 Sep 2009 23:37:32 GMT

I believe the apparent aim of improving practices is laudable but the hypocrisy and box ticking entwined in the PSS condemns it.The dropping of the tier systems confirms that that aspect which the public never understood was devisive and was apparently stating that one practice was better than another.

Some of us may have come across practices who have qualified under the PSS and yet would make the practices in the recent tv expose look like angels.That dos nothing for our reputation.

Also I have discovered that the RCVS considers that a fee of £500 plus the taxi fare for a Sunday house visit and euthanasia is perfectly acceptable,at by a corporate.

I believe we are being bullied into joining and it is only adding to our workload.

Our job is to provide a service for the General publics pets and aim for the highest standards possible respecting the trust they give us when the visit us.

Paul Dowie Companion Vet Clinic Newark

Re: Practice Standards Consultation: Section 3: Out of hours patient care

Noweia — Tue, 01 Sep 2009 17:32:52 GMT

[quote user="Emma Jarratt"] I looked into accreditation schemes for garages and picked one that was accredited by a professional body.

I know nothing about garages so may be wrong - but I would have thought that some degree of checking workmanship, even mystery shopping, may be involved. Also, these plaques would be likely to be on the wall in a big chain, but less likely in a small garage with one or two mechanics. Is that because the quality of service is different, or because the big chain has got a lot more marketing support? From what I can see, the PSS seems to be more to do with H&S, facilities and equipment than customer care. [/quote]

I totally agree with this but I feel that it is in this way that it is unfair for practices who have opted out of the PSS over over costs, time involved etc.

You don't have to have a degree to be a mechanic in this country, so there is no regulation for people entering that trade. So in that sense it is good that there is some regulation or accrediting body.

However everyone has to pass a pretty tough test to become a vet in this country and to be eligible to be an MRCVS - surely that is what people need to see?

Re: Practice Standards Consultation: Section 3: Out of hours patient care

Hannah Wynne Richards — Tue, 01 Sep 2009 14:31:20 GMT

I have by now built up a rapport with some referral veterinarians, who are very good at advising me whenever I feel stuck. As far as the clinical audit for the inspection was concerned, there were only 2 cases which had gone catastrophically wrong in the last year. Both rabbit anaesthetics which died on the table. Both premeded with a dedetomidine containing mixture. I thought the first was "just rabbits ". The 2nd made me think. I rechecked my BSAVA manuals. 2 relevant ones, that on anaesthesia, and that on rabbit medicine and surgery. 1 advised a much higher dose of dedetomidine than the other,and I had used the book advising the higher dose. This was all written down, and approved of by the inspector

I agree that good veterinarians will always think over disappointing cases, and also do at least the recomended amount of CPD, which is one of the reasons I have also enrolled on the CertAVP, but without practice standards, there is no compulsory audit, and no one checks CPD, unless a complaint is received, so there is no way for owners to be certain that a veterinary surgeon is compliant

Re: Practice Standards Consultation: Section 3: Out of hours patient care

Gillian Mostyn — Tue, 01 Sep 2009 12:26:58 GMT

[quote user="Hannah Wynne Richards"]Gillian, clinical audit is part of the scheme[/quote]

As far as I am aware, this is simply done in-house. Concientious vets will always ask their colleagues questions and go over cases which they feel could have been handled differently. Again, how will the PSS enforce any change in those who don't want to review their cases? Who will be going through their caseload to check them? Does the inspector actually read through the notes of audit meetings to check the vets????

I feel this is just another way where those vets who do these things already, will have a hard time scheduling specific meetings (rather than discussing cases 'on the hop') and writing notes. Those that need it most are unlikely to discuss their failures openly.

Hannah - as a single-man practice, who do you do your clinical audit with?