Investing in People

Quality& SUSTAINABILITY REPORT 2018

Wiser use of antibiotics INVESTING IN PEOPLE Improving patient safety CONTENT ”Together, we have a responsibility to run our operations with regards to their impact on society; on people, ENVIRONMENT animals and the environment” AniCura’s ambition is to provide veterinary care with respect for the environment. PETER DAHLBERG, CEO OUR PEOPLE Employee satisfaction and working conditions form an important part of 44 38 AniCura’s sustainability agenda.

4 MESSAGE FROM THE CEO

6 HIGHLIGHTS 2018 PROVIDING RELIABLE DIAGNOSTIC MEDICINE 20 7 ANICURA IN BRIEF In 2018, AniCura launched a new digital system where clinics can 8 TOWARDS SUSTAINABLE have medical images analysed by VETERINARY CARE board-certified radiologists sitting in 10 MEDICAL QUALITY AT ANICURA a different location. 12 Encouraging professional development and specialisation

16 Creating and sharing medical best practices

18 Improving professional communication skills

20 Providing reliable diagnostic medicine

22 Monitoring surgical site infections

24 Ensuring wiser antimicrobial use

28 Timeline 2018 24 32 30 Securing infection prevention and control

32 Enabling good incident handling ENSURING WISER ANTIMICROBIAL USE 34 Promoting patient medical In 2018, AniCura appointed record quality Antibiotic Role Models and ENABLING GOOD 38 OUR PEOPLE continued to decrease INCIDENT HANDLING the use of antibiotics. In 2018, a new system and processes 42 PREVENTIVE CARE to systematically reduce medical incidents were implemented. 44 ENVIRONMENT

46 COMMUNITY ENGAGEMENT

48 RESEARCH AT ANICURA

ANICURA QUALITY 2 REPORT YEAR 2018 ANICURA QUALITY 3 REPORT YEAR 2018 I hope the report will give you valuable insights into AniCura “Sustainable veterinary care and provide inspiration starts with our people and values” on how we, together, can develop a better and more sustainable veterinary care in the future.

PETER DAHLBERG Chief Executive Officer, CEO

FIGHTING ANTIBIOTIC RESISTANCE I am especially proud of our work Shaping the future against antibiotic resistance, one of the biggest global threats against human and animal health. Two years in a row, of veterinary care, we have reduced unnecessary use of antibiotics at the majority of our clinics, and at some clinics with more than 40%. Behind this development are systematic measurements, improved TOGETHER hygiene routines, educational initiatives and impressive in-clinic efforts to drive AniCura has rapidly grown to become a leading provider of behavioural change. advanced veterinary care across Europe. With this development comes a great responsibility to run our operations with FOCUS ON PEOPLE regards to their impact on society; on people, animals and In 2018, we engaged with customers and employees to understand their the environment. perspective on sustainability and AniCura’s impact on society. Quality and antibiotics, preventive care and working conditions for our employees QUALITY AND PATIENT SAFETY the program has generated tangible emerged as key areas. In this report, we Ensuring high medical quality and improvements within areas such as share not only our work within medical patient safety are our most important infection prevention and control, quality, but also how we as one of the contributions to society, and key to competence development, incident largest employers within European gain trust from employees, customers handling and use of antibiotics. veterinary care strive to become the and other stakeholders. For decades, most attractive employer in our ”I am especially proud of our quality development has formed a core industry. Our values and investments work against antibiotic re- part of the agenda for the 250 carefully sistance, one of the biggest in building a strong company culture selected veterinary clinics that are part global threats against human form the basis for this work. of AniCura today. and animal health” I hope the report will give you valua- From 2015 and onwards, our company- PETER DAHLBERG, CEO ble insights into AniCura and provide wide quality development program Close collaboration and knowledge inspiration on how we, together, can has brought structure and support to sharing between clinics are key develop a better and more sustainable our clinics. Over the past four years, enablers for this development. veterinary care in the future.

ANICURA QUALITY 4 REPORT YEAR 2018 ANICURA QUALITY 5 REPORT YEAR 2018 Highlights 2018 AniCura in brief

Wiser use of antibiotics AniCura values % PER PATIENT AND DAY AniCura is a leading European provider of high- TOGETHER quality veterinary care for companion animals. 55% RESPONSIBILITY & INITIATIVE AniCura was born out of the idea that independently. Through platforms for OF CLINICS REDUCED sharing resources creates opportunities knowledge and best practice sharing, CARE & COMPASSION THE USE OF ANTIBIOTICS for better veterinary care. The company all clinics draw upon the global was established in 2011 as the first veterinary expertise in our network. EXPERTISE & DEVELOPMENT 13 merger of companion animal hospitals A clear vision, strong values and a in the Nordic region. unique medical quality program HONEST & OPEN 11.7 Since November 2018, AniCura is ensures a joint direction and part of Mars Petcare, a family-owned structured quality development. company focused on veterinary care and pet nutrition. THE VALUE WE CREATE IN SOCIETY Every year, AniCura helps 2.5 million 2017 2018 Fewer infections WHAT WE DO companion animals to a better quality after surgery AniCura is a full-service provider of of life and improved health. Invest- veterinary care from preventive care to ments in improving medical quality Continued advanced diagnostics, surgery, rehabili- and patient safety through education, tation and intensive care with 24/7 ser- research, equipment and premises has 7.2% 25 000 high customer vice. The company also offers selected totalled more than SEK 1 billion since pets on preventive health plan pet nutrition and care products. AniCura’s inception. The company also satisfaction Meeting the increasing demand stands for a large part of the round-the- 5.5% INDEX across Europe for more advanced care clock emergency care availability in and better quality is at the core of what Europe. we do. The clinics that form part of Direct and indirect job creation in 2018 AniCura are carefully selected based the veterinary industry and adjacent 2017 2018 760 employees in on specialist competence and quality. sectors form an important part of communication 84 AniCura’s value creation. In 2018, 760 2017 HOW WE WORK AniCura contributed with social trainings At AniCura, decisions are taken close charges, VAT and corporate income to the patient and customer and clinics taxes of SEK 1 billion. 83 within AniCura operate medically

2.5 MILLION PATIENT VISITS

5 000 EMPLOYEES 86% of 10 COUNTRIES employees are We shape the proud of working future of veterinary 250 ANIMAL HOSPITALS at AniCura care, together AND CLINICS

2017 2018

ANICURA QUALITY 6 REPORT YEAR 2018 ANICURA QUALITY 7 REPORT YEAR 2018 TOWARDS sustainable veterinary care COSTS FOR VETERINARY CARE With greater opportunities to treat and IMPROVED SUPPLIER CONTROL In addition to the above four key areas, cure companion animals, pet owners Based on risk assessment in the Taking responsibility for the This report includes a description of “We all have a responsibility increasing household spend on veter- are faced with tough decisions around sustainability analysis, AniCura has our ambitions and efforts, as well as our for a sustainable future. The well-being of future genera- inary care was raised as an important treatment options and costs. Important also strengthened supplier control and challenges within these four areas, with environment needs it, pet area to address by both employees and areas for AniCura are, therefore, to con- reviewed the sustainability risks in the tions forms a natural part of special focus on our medical quality owners demand it and customers. tinue improving customer communica- retail assortment at clinics in Sweden, AniCura’s vision and strategic program including the work to ensure a employees want to contribute” In Sweden, specifically, total spend tion around quality and costs, actively Norway and Denmark. wiser use of antibiotics. ANICURA EMPLOYEE IN 2018 SURVEY agenda. on veterinary care has increased over support pet owners around preventive During spring 2018, a new supplier the past twenty years. This development health measures to avoid illness as well code of conduct was developed regu- Sustainability at AniCura is driven by several factors: as to engage with educational institu- lating human rights, animal welfare tions to address labour shortages. and testing, as well as environmental In 2018, more than 1 000 customers and An increased demand for more responsibilities for our suppliers. Our employees across five countries were Meet expectations Focus Working Antibiotics conditions advanced care aim is to have main suppliers signed up invited to give their input on AniCura’s High medical “Today, we can cure illnesses Perceived in 2019. To ensure a sustainable retail impact on society and which areas that quality More frequent visits to the that only 5–10 years ago were quality vs. assortment, an assortment guideline are most important for AniCura to focus price veterinarian fatal. We have the equipment Environment Preventive care will be distributed to clinics that have a on. Based on their input and an analysis to make accurate diagnoses Anti-corruption An ageing pet population with retail assortment. of AniCura’s value chain, four areas and we base our treatments on Community greater care needs emerged as key: engagement evidence, not guessing-games. Improved quality across the industry Patient safety in veterinary care Quality and antibiotics Equality and Supplier control diversity is revolutionised” Increased possibilities to treat People SANDRA GÖRANSSON, illnesses and injuries IMPORTANCE TO STAKEHOLDERS TO IMPORTANCE Retail assortment Maintain Develop VETERINARIAN ANICURA SWEDEN Preventive care OUR IMPACT ON SOCIETY Salary inflation due to labour Environment shortages

ANICURA QUALITY 8 REPORT YEAR 2018 ANICURA QUALITY 9 REPORT YEAR 2018 QualiCura MEDICAL quality at

roving pro – Imp fessio 88% of AniCura’s lity nal AniCura a c employees believe qu om rd m that patients visiting co u AniCura established its own, proprietary medical quality e Q n their clinics receive l r use 1: M ic a ial on at development program – QualiCura – in 2015. The purpose ic ob ito io high or very high d icr ri n e ng of the program is to increase patient safety and to improve quality of care. tim s s m n Feedback & u k t a Prepare rg il medical outcome. n r Discussion ic l se a s ie i l – s t w i P a g te r n Measure D J Measure p i i o r n v g u f e i n s d i n c Nine focus areas were identified as FOCUS ON IMPLEMENTATION DEDICATED RESOURCES t N F t i E i n o : o n g particularly important to fulfil the QualiCura is focused on implementa- To support clinics and drive positive 4 m s Q r tion and achieving actual change at change, AniCura has dedicated resources o e program’s dual purpose: r Feedback & l Prepare i P AniCura’s clinics. Apart from encourag- to develop veterinary medicine and a O M Discussion b Encouraging professional – ing a continuous improvement mindset, quality. l

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u and allocates funds from AniCura’s d o quality l i c n n g E Role models: After each QualiCura Research Fund. study, “role model” clinics are identified The work within each of these nine to share clinically proven examples of AniCura’s Veterinary Medicine focus areas during 2018 is covered in improvements. Development Council: The council this report. ensures that developments in the Quality conference: In 2018, AniCura industry are appropriately reflected hosted its first conference dedicated in AniCura’s strategies and addresses to medical quality. All clinics were ethical dilemmas. invited to share knowledge with focus on implementation barriers and pragmatic solutions in daily operations.

ANICURA QUALITY 10 REPORT YEAR 2018 ANICURA QUALITY 11 REPORT YEAR 2018 Encouraging professional development and specialisation Encouraging professional development and specialisation

PROFESSIONAL development strengthens patient safety

Patient safety is closely was launched in 2017. In 2018, more specialisation exists in some countries and linked to the level of than 35 ACE courses were arranged is equally important as specialisations across Europe. The courses covered a in different medical fields. professional competence wide span of veterinary sciences, from AniCura encourages employees in every medical situation. instrument care to urethrocystoscopy to specialise and clinics to become What did you do to develop and anaesthesiology. accredited teaching institutions for national and international specialisation professionally? SPECIALIST COMPETENCE tracks. More than 250 national and Encouraging professional development IMPORTANT international veterinary specialists and specialisation form an important Veterinary specialists are important to including around 100 European and part of AniCura’s medical quality pro- secure up-to-date and high standards American board-certified specialists KRISTINA BAU JENS STETTER, KATHARINA MÖHLER, gram. It is equally important for both HJELMARK, BIOMEDICAL VETERINARIAN AT VETERINARIAN of medical care. General practice (Diplomates) are employed by AniCura. SCIENTIST AT ANICURA ANICURA KALMARSUND, AT ANICURA veterinarians and nurses, as well as JELØY DYRESYKEHUS, SWEDEN KLEINTIERZENTRUM other medical staff. NORWAY HEILBRONN, GERMANY Within AniCura, the ambition is that every employee should have an Percentage of employees having regular discussions “My AniCura clinic offered me to “I needed tutors for my specialisation “I became a Fachtierarzt (specialist annual discussion around professional about long-term competence development participate in the ACE course track. Through AniCura, I got in touch in companion animals) in March development with his/her manager and “Clinical laboratory”. I had previ- with two experienced surgeons at 2018. It had for long been my plan, a clear individual development plan. 57% ously worked at a human medical another clinic, AniCura Djursjukhuset as I believe in quality and continu- 54% 53% Although moving in the right direction, 51% 50 laboratory so learning more about Albano. They now supervise my ing education. My clinic supported there is still a long way ahead. In 2018, 47% feline and canine diseases and specialisation and support my re- me by allocating supervisors and a 44% 43% 50% of employees had discussions 42%

NORWAY diagnostics was important to me. search project in surgery. I also spend network of specialists. My employer 39% 40 NORWAY SWEDEN around their competence development, 34% two working days per month walking also enrolled me in several courses SWEDEN The course provided me with good compared to 45% in 2017. NETHERLANDS THE next to these surgeons to learn. and advanced trainings.” 30 DENMARK

DENMARK case discussions and the lecturers AniCura really invests in me!“ shared their experiences and & SWITZERLAND & 20 GERMANY, AUSTRIA AUSTRIA GERMANY, ANICURA CONTINUING EDUCATION SWITZERLAND & knowledge in an inspiring way.” To further support professional devel- AUSTRIA GERMANY, opment, the educational programme 10 NETHERLANDS THE AniCura Continuing Education (ACE) % 2017 2018 2017 2018 2017 2018 2017 2018 2017 2018 Source: AniCura employee survey 2017 (1 780 participants) and 2018 (2 511 participants)

ANICURA QUALITY 12 REPORT YEAR 2018 ANICURA QUALITY 13 REPORT YEAR 2018 “Today, we can see tangible improvements across all areas of our quality program”

ANICURA QUALITY 14 REPORT YEAR 2018 ANICURA QUALITY 15 REPORT YEAR 2018 Creating and sharing medical best practices Creating and sharing medical best practices

Medical Interest Groups in AniCura

· Antibiotics and resistance MEDICAL · Cardiology · Dentistry best practices help us · Dermatology improve patient safety · Diagnostic Imaging · Emergency and critical care Sharing best practices scientific journals, webinars, a company- · Feline Medicine between clinics is a key wide chat and networking platform · Gastroenterology Yammer and various newsletters. enabler for quality · Infection prevention and control MEDICAL INTEREST GROUPS · Laboratory medicine development at AniCura. AniCura’s Medical Interest Groups are · Nutrition forums open to all AniCura veterinary · Neurology How do you professionals. The groups are focused · Oncology on different medical fields and share · Ophthalmology share knowledge? Knowledge sharing within AniCura best practices, provide advice in clinical · Physiotherapy and rehab takes place every day in the clinics, at cases and arrange medical courses. · Reproductive health meetings, in national and internatio- During 2018, the number of users on nal forums, working groups as well as the networking platform Yammer · Small mammals and exotics through digital platforms and tools. doubled to around 2 000 veterinary · Surgery and orthopaedics The digital platforms include a know- professionals discussing patient cases · Wound treatment CAROLINE HOEKE, ALEXANDRA ROSÉ, PETRA STOMPS, NURSE AT ANICURA DE VETERINARIAN AT NURSE AT STERKLINIEK ledge base, literature database with and sharing medical knowledge. · Urology WATERPOORT SNEEK, ANICURA TIERKLINIK DIERENARTSEN DEVENTER, THE NETHERLANDS HOLLABRUNN, AUSTRIA THE NETHERLANDS

ANTIBIOTICS NOT ALWAYS NEEDED of blood and bacterial culture of “I think it is important that we all “I started using Yammer shortly after “I visited another AniCura clinic to Best-practice In general, there are many mis- urine, collected through cystocen- share knowledge with each other. I was employed at AniCura. It gives get new ideas on how to improve study: FLUTD conceptions regarding FLUTD, for tesis, should always be performed. Especially in specialised areas, so me and my colleagues an amazing patient safety and did a presen- example if it is an infection or not. Before catheterization, the perineal that we can advise our customers opportunity to share cases, get each tation at our staff meeting. I took In 2018, a QualiCura study was Bacterial infections are not com- area should be clipped and cleaned in the correct way.” other’s opinions and specialists’ advice. photos of things that we needed to improve in our clinic and used them performed to understand the mon and best practice is to treat a to prevent infection. These four best Caroline has a special interest in canine Often outcomes are posted which compliance to medical best patient who has FLUTD complaints practices were followed in only 16% nutrition. When she noticed that knowledge provide very valuable information for in my presentation. It really kicked practices in diagnostics and treat- with analgesics and stress reducing of the 183 included obstructive about some products was scarce, she all involved veterinarians.“ off the discussions on how to imple- arranged an evening seminar for her col- ment best practice. I also created ment of feline lower urinary tract measures rather than automatically FLUTD cases. Alexandra is a Diplomate of the American leagues and also posted information about quizzes to challenge my colleagues.” disease (FLUTD). The diagnostics prescribing antibiotics. This proce- A guideline with evidence- the products on AniCura’s digital forums. College of Veterinary Internal Medicine and the head of the small animal internal and treatments of 870 cats with dure was followed for 49% of 870 based best practice around Petra is a quality coordinator and respon- medicine department at AniCura Tierklinik sible for infection control and prevention symptoms of either/or stranguria, studied patients with FLUTD. FLUTD patients was developed Hollabrunn. in her clinic. She visited AniCura Strängnäs hematuria, pollakiuria, periuria, by AniCura’s Medical Interest Djurklinik and Aros Veterinärcentrum in passive urine loss or symptoms LOW COMPLIANCE TO Group in Feline Medicine and Sweden to discuss and share experiences of urinary obstruction were BEST-PRACTICE distributed to AniCura clinics of implementing quality improvements. included in the study. Obstructive FLUTD can be a alongside feedback from the study. life-threatening situation. Analysis

ANICURA QUALITY 16 REPORT YEAR 2018 ANICURA QUALITY 17 REPORT YEAR 2018 Improving professional communication skills Improving professional communication skills

Insights from a communication trainer

HELEN ØVREGAARD, VETERINARIAN AT ANICURA ASKØY DYREKLINIKK IN NORWAY, WORKS PART TIME AS A COMMUNICATION TRAINER WITHIN ANICURA

What results have you seen from communication trainings? The most important effect is the sense of improved control, over both time and information flow, which in turn increases the feel- ing of competence among employees. Less complaints from customers as complaints often are results of poor communication. For example, we could see how the customer satisfaction score (NPS) showed a direct increase in clinics where a majority of their staff had attended a communication course.

What part of the trainings are most COMMUNICATION appreciated? The role plays are very appreciated! Talking about prices and costs is difficult for many vets and nurses, and the tools to facilitate skills impact medical this communication are highly valued. Conveying bad news to our clients can also be tough, and this is something our course participants are happy to learn more outcome about, as well as handling complaints in the best possible way.

Good customer communication is highly important to both Can communication trainings medical outcome and customer satisfaction. improve medical quality? YES! Using the course skills in daily operations enable us to build trust in a better way which increases the chances that the owner will follow our advice regarding treatment Scientific studies in human medicine COMMUNICATION TRAININGS AniCura offers communication train- and follow-up. have shown that trust built through Training communication skills is not ings to employees with customer conscious communication has a strong only beneficial for the interaction with contact. The trainings are based on well impact on the actual medical outcome patients and their owners, but also has documented models. During 2018, 760 of treatments, e.g., through increased a positive impact on reducing work- AniCura employees received commu- compliance to the advice provided by related stress as well as reducing risk nication training in various forms and the physician. The challenge within of medical incidents which quite often AniCura also held discussions with uni- veterinary care is even larger as the find their root cause in unclear commu- versities about adding communication patients cannot speak for themselves. nication. courses to their veterinary programs.

ANICURA QUALITY 18 REPORT YEAR 2018 ANICURA QUALITY 19 REPORT YEAR 2018 Providing reliable diagnostic medicine Providing reliable diagnostic medicine

How did you improve diagnostic medicine?

SANNE ROSS SØRENSEN, PRACTICE MANAGER AND VETERINARIAN AT ANICURA GISTRUP DYREHOSPITAL, DENMARK

“The newly developed AniCura guidelines within laboratory diagnostics are an important tool to secure the quality of our daily diagnostic work” At AniCura Gistrup Dyrehospital, a standardised approach to the diagnostic DEVELOPING evaluation of a patient was implemented in 2018. Furthermore, the staff worked on systematising the protocols around regular monitoring of chronic patients and companywide pre-anaesthetic blood work. best practices

Diagnostic quality is essential for better patient safety and better medical In June 2018, AniCura launched AniCura to patient safety and relies outcome in your clinic?”, half of the Telemedicine, a digital imaging service KATJA OLESEN, clinics answered “introducing routines open for any veterinary clinic in Europe. BIOMEDICAL LABORATORY on proper sampling, handling SCIENTIST AT ANICURA and best practices”. In 2018, additional Through a web-based system, clinics can DIAGNOSTISK and interpretation. companywide guidelines and recom- send images to be assessed by board- LABORATORIUM, NORWAY mended protocols were developed and certified specialists, e.g. within imaging distributed. or neurology depending on the patient “We continuously strive to monitor case. Within four to 24 hours depending Most of the errors in laboratory medicine and improve our laboratory quality. ANICURA TELEMEDICINE on urgency, the clinic receives a complete occur due to human factors, mainly Amongst other measures, we moni- Several scientific studies have report and analysis. during the period from sampling until tor daily analytical performance to highlighted the importance of specialist detect any analytical errors” analysis. During 2018, AniCura increa- competence in diagnostic imaging to sed focus on reducing the occurrence AniCura Jeløy Dyresykehus and Anicura ensure accurate analysis of medical Diagnostisk Laboratorium have recently of preanalytical errors and introduced “By using AniCura Telemedicine images from for example x-ray, magnetic moved into brand new facilities in Rygge, guidelines for correct sampling and for second opinions of our CT 2 resonance (MRI) and computed Norway. The laboratory is 350 m and handling. scans, we get a quick response staffed with four biomedical laboratory sci- tomography (CT) examinations. In and a professional evaluation of entists, one molecular biologist in addition ROUTINES AND BEST PRACTICE human medicine, every radiological our images, also often including to a veterinary clinical pathologist. During In the field of laboratory diagnostics, exam is evaluated by a radiologist, but relevant references to new 2018, the laboratory personnel have worked on standardising methods and routines as literature or peer-reviewed the motivation to secure high medical most veterinary clinics do not have a well as selected an external program for quality through standardisation is signifi- radiologist available in-house, and it is articles” quality assurance. cant. When AniCura clinics were asked typically the treating veterinarian that CLAUS BUNDGAARD NIELSEN, PRACTICE the question “What single action would evaluates the images. MANAGER AND VETERINARIAN AT ANICURA AARHUS DYREHOSPITAL, DENMARK bring about the greatest improvement

ANICURA QUALITY 20 REPORT YEAR 2018 ANICURA QUALITY 21 REPORT YEAR 2018 Monitoring surgical site infections Monitoring surgical site infections

FEWER

LARGE VARIATION IN THE USE OF ANTIBIOTICS infections Although the occurrence of surgical site infections is similar across countries (see figure), the use of antibiotics still differs after surgery substantially. In Sweden, antibiotics were prescribed for 21% of the surgeries, while Many complications after surgery can be avoided through better in Germany, antibiotics was used in 82% follow-up of patients and improved preventable measures. of the surgeries. However, there was no in-clinic correlation between the rate of How did you prevent surgical surgical site infections and the use of surgical antibiotic prophylaxis. site infections? To reduce surgical site infections, it is from the surgeries. important to actively follow up surgical Clinics that took part in this survey “Many vets are still using too much antibiotics in surgery. I call patients after discharge from the clinic. both 2017 and 2018, showed an average for a more thoughtful mindset The outcome of a surgery should ideally reduction in surgical site infections* and improved routines for be checked one week as well as one from 7.2% to 5.5% of all surgeries. The hygiene” month after surgery through reappoint- positive development is a result of ULRIKA GRÖNLUND, ment or other contact with the pet better infection control and more active GROUP MEDICAL QUALITY MANAGER owner. surveillance of surgery patients. After systematically reviewing the SARAH LOUISE LUND PETERSEN, NURSE AND MARIA SÖDERBERG, PRACTICE MANAGER AND TOSCA NEGGERS & JACINTHA BURGHARD, clinic’s results from several patients, QUALITY COORDINATOR AT ANICURA SYDVET ALEXANDRA DAHL, NURSE AND INFECTION VETERINARIANS AT ANICURA DIERENKLINIEK THE STUDY IN BRIEF: routines can be improved to ensure Results and DYREHOSPITALER, DENMARK CONTROL PRACTITIONER, AT ANICURA ARBOGA EERSEL, THE NETHERLANDS DJURKLINIK, SWEDEN better surgical outcome and patient development • Surgical site infections at AniCura clinics decreased from 7.2% to 5.5%. “Make sure that patients receive “Clip the patient’s fur right safety. A scientific study has shown that Percentage of surgical site antibiotics within 60 min of “Better routines for before the surgery” one third of all surgical site infections • Too many patients undergoing clean surgery infections per country (%). received antibiotic prophylaxis (39%). instrument handling is one surgical incision, if the patient AniCura Dierenkliniek Eersel has decided to are not discovered when patients are reason to our success” at all needs antibiotics” do the following improvement steps: 7.0 • 58% of patients received antibiotics at the not properly followed up. AniCura’s 6.8 correct time (60 minutes before incision). AniCura Sydvet Dyrehospitaler realised after AniCura Arboga Djurklinik significantly • More careful use of antimicrobial surgical ambition is that all clinics should have decreased the SSI rate to 0%. prophylaxis and use it only in surgeries • 70% of the patients had a body temperature the survey a need to improve their protocols

processes for surveillance after surgery. 5.5 5.5 NORWAY where an infection would be severe above 37°C, which is better than in 2017 for surgical antibiotic prophylaxis (SAP) both • Alexandra underwent an ACE course in 5.1 DENMARK • Add active surveillance at four weeks and where 58% of the patients had a body above to become stricter in which patients should instrument handling and educated the for implants at one year after surgery FEWER INFECTIONS AFTER SURGERY 37°C. Too low body temperature during get SAP as well as improve timing of when rest of the team SWEDEN In 2018, AniCura measured the occur- 3.7 surgery increases risk for complications prophylaxis is given. This will be added to • All surgical instruments where checked their anesthesia protocol.

and damaged and/or rusty instruments rence of surgical site infections for the afterwards.

ANICURA AVERAGE ANICURA were replaced third consecutive year. 1 915 dogs that • 33% of clinics use surgery safety checklist, a THE NETHERLANDS THE • The clinic implemented new or revised underwent surgery at 102 different proven tool to decrease complications. This routines for instrument handling

& SWITZERLAND & is a higher proportion compared to last year clinics participated in the study. The • New or revised protocols for autoclave GERMANY, AUSTRIA AUSTRIA GERMANY, when 23% of clinics used such a list. and washer-disinfector use were dogs were checked seven days and • 83% of clinics use an anaesthetic protocol. implemented thirty days after surgery to allow detection of any infections resulting Source: QualiCura Q1 study 2018

*SSI defined according to guidelines from the Centres of Disease Control and Prevention, USA

ANICURA QUALITY 22 REPORT YEAR 2018 ANICURA QUALITY 23 REPORT YEAR 2018 Ensuring wiser antimicrobial use Ensuring wiser antimicrobial use

REDUCED use of antibiotics Antibiotics are becoming In total, 336 of the 2 898 dogs received the mean incidence per country differed less efficient and we must antibiotics during the measured day, from 5 to 20%. The significant country which equals 11.7% compared to 13% in and clinic differences were addressed in use them wisely. 2017. the feedback to clinics, and guidelines The incidence of antibiotic use varied on how to use antibiotics consciously among hospitals from 0 dogs treated to were distributed for implementation. 44% of the canine patients. In addition, AniCura clinics see more than 2.5 million patients every year and together, we have significant impact on the use of antibiotics. With wiser use of Percentage of dogs THE STUDY IN BRIEF: antibiotics and compliance to infection given systemic • More than 55% of clinics reduced use of antibiotics compared to 2017. control routines and by treating patients antibiotics during 34% reduced use with more than 30%. with the right substance, unnecessary one day per country • Surgical prophylaxis was the most common use can be reduced. Furthermore, by indication for dogs receiving antibiotics (%). 16.9 sharing our experiences within AniCura, 16.7 (22%) followed by wound infection

more employees feel safe when treating including abscesses (18%), gastro-intestinal disorders (13%), skin infections (dermatitis, fewer patients with antibiotics. 13.7

DENMARK furunculosis etc) (7%) and upper respiratory

11.7 SWITZERLAND & diseases (5.4%).

LARGE SPREAD IN USE OF ANTIBIOTICS AUSTRIA GERMANY, • The most commonly used antimicrobial ”The majority of our For the third year in a row, AniCura class was beta-lactam antibiotics (70%). measured the use of antibiotics among 7.1 clinics have reduced NETHERLANDS THE • Most dogs were treated empirically, i.e. 2 898 dogs at 107 clinics across Europe. 6.0

ANICURA AVERAGE ANICURA without any diagnostic aid like bacteriology The clinics recorded for one day what and/or cytology results. the use of antibiotics” SWEDEN

antimicrobial substance they used NORWAY • Duration of treatment varied from 1 to 42 in dogs for systemic treatment or days with a median of 7 days. prophylaxis, together with indication for this use. Source: QualiCura Q4 study 2018

ANICURA QUALITY 24 REPORT YEAR 2018 ANICURA QUALITY 25 REPORT YEAR 2018 Perspectives from a researcher

Antibiotic Role Models In 2018, AniCura appointed Antibiotic Role Model clinics. The clinics have actively ensured a wiser use of antibiotics, and LUCA GUARDABASSI their methods are shared across AniCura to support others. Luca Guardabassi, professor at the Faculty of Health and Medical Sciences, University of Copenhagen and at the Royal Veterinary College in London. He is a European specialist (Diplomate) in veterinary public health and specialised in antimicrobial resistance.

CHRISTINE & CHRISTIAN NEES, ANICURA HEIDI HAUGHOLT, KLEINTIERMEDIZINISCHES ZENTRUM DR. NEES ANICURA RISING DYREKLINIKK Why should vets use antibiotics more carefully? The clinic AniCura Kleintiermedizin- AniCura Rising Dyreklinikk in Antibiotics are essential drugs for managing isches Zentrum Dr. Nees reduced Norway, had a low and responsible bacterial diseases and rational use is therefore instrumental not only due to public health their use of antibiotics with 15 use of antibiotics two years in a risks but also to preserve clinical efficacy in percentage points. Christian Nees, row. We asked veterinarian and our animal patients and minimise the risk practice manager and veterinarian practice manager Heidi Haugholt for spreading resistant bacteria to humans working and living in close contact with and Christine Nees, veterinarian and how they achieved it. companion animals. ANTIBIOTICS quality coordinator, tell their story. Have you actively worked to What will happen in veterinary care How did you decrease the use of decrease the use of antibiotics in if we do not take action? antibiotics in your clinic? your clinic? Over the last decade, many new multidrug- resistant bacteria have emerged in veterinary We prepared guidelines for antibiotic use and Yes, we talk about antibiotic use in our veteri- in focus nary meetings. Furthermore, I am myself very care. These bacteria pose a serious risk to the discussed it at veterinary meetings. health and welfare of our patients and some The guidelines state that no antibiotics dedicated to prudent use and trying to lead of them can colonise and infect humans too. should be used for routine surgery under by example. My employees say they feel that If no action is taken, we might face the situation, 1.5 hours (tumour surgeries, castrations), I am sitting on their shoulder whispering in In 2015, AniCura set out on its mission where no drugs are available for management The global spread of antibiotic The consequences of irresponsible use and no antibiotics in advance of many other their ears how to use antibiotics. of bacterial infections, with severe conse- and overconsumption of antibiotics have to actively and significantly reduce un- surgeries. We have also set a limitation All treatments with antibiotics should be in quences on morbidity and mortality in both resistant bacteria is one of the of antibiotics in everyday clinical practice line with the national recommendations. resulted in a rapid spread of resistant necessary use of antibiotics. As a group, human and veterinary medicine. for treatments like cough, diarrhoea, skin biggest threats against human bacteria across the globe. In Europe only, the goal is to reduce antibiotic use from patients etc. Have you encountered any and animal health. it is estimated that 33 000 persons die 11.7% per patient and day in 2018 to 5% drawbacks? What is your view on infection control and antibiotics in veterinary every year from infections caused by in 2030. The work includes systematic Have you encountered any The pet owners understand this very well care today? resistant bacteria. drawbacks? and are positive. We have had some post-sur- We have had a few isolated uncomplicated gical wound infections, but no serious ones. Infection control and antimicrobial steward- VETERINARY CARE PLAYS AN “Antibiotics are one of our most wound infections (whether coincidence They have been treated with drains and ship are the two most effective strategies IMPORTANT ROLE important pharmaceuticals. or due to the lack of antibiotics remains cleaned with chlorhexidine. for control and prevention of the spread In a survey among 1 000 AniCura Every second, every minute and unclear). of resistant bacteria. Even though in some What are your top tips to other countries significant progress has been made employees and customers, ensuring a every day they save lives” “AniCura’s goal What is your top advice to other clinics? over the last years, infection control and more responsible use of antibiotics was ULRIKA GRÖNLUND, antimicrobial stewardship are still neglected GROUP MEDICAL QUALITY MANAGER clinics? All clinics should focus on this important is to reduce ranked as one of the top three sustain- topics in veterinary medicine at the global Use written protocols on strict indications for topic and preferably have one person who level. ability areas important for AniCura to the administration of antibiotics and review is responsible for making good treatment It’s time for a change. Simple infection antibiotic use by address. The advancements in veterinary follow-up of antibiotic use, educational the antibiotic routine for standard surgeries. procedures. Discuss routine treatments control measures like hand washing have within each area, start with those where you medicine with more complex surgeries, initiatives, improved infection control Most important is to discuss antibiotic use tremendous impact in reducing the risks with employees so that everyone’s fears and use a lot of antibiotics; for example, cat bites, associated with carriage and spread of more than half” intensive care or cancer therapy also imply guidelines, hand hygiene and additional worries can be addressed! dentistry, skin disorders and surgery. resistant bacteria within clinics. that we are dependent upon effective focus on preventive care for companion antibiotics. animals.

ANICURA QUALITY 26 REPORT YEAR 2018 ANICURA QUALITY 27 REPORT YEAR 2018

In 2018, we passed important milestones in patient safety and antibiotic use. More than 2 000 employees took part in our conference Togetherness and we ANICURA2018 improved employee satisfaction. NOV FEB SEP AniCura presents 2 287 employees meet at AniCura Patient Safety strategies on how to AniCura’s Togetherness MAY Improvement System fight antimicrobial event in the Globe in 11 research projects is launched, allowing resistance for the Sweden from four countries clinics to report and Nordic Council of receive funding from analyse incidents within Ministers, the Swedish 392 participants and AniCura’s Research Fund the clinic, on national Antibiotic forum 22 lectures at the level and across and the Swedish international AniCura New leadership AniCura Veterinary Institute’s Medical Interest Group framework AniCura research summit on Congress in Stockholm Excellent Leader is antimicrobial resistance launched AniCura Quality Report 2017 is published New QualiCura results New QualiCura results about hand hygiene and show a decreased use instrument care of antibiotics at AniCura clinics

Renewable energy is procured for AniCura’s Scandinavian operations JUNE APRIL +100 quality DEC JAN coordinators attend 3rd AniCura employee First QualiCura visit to 21 practice managers AniCura Quality OCT survey measuring graduate from global Spain, AniCura’s 10th Conference New QualiCura employee satisfaction leadership program country results about Accelerator AniCura Telemedicine best practice is launched – digital compliance in service for specialist FLUTD cases analysis of medical JULY MARCH images AniCura’s New QualiCura preventive health results about surgical plan AniPlan is site infections, use launched in the of alcohol-based Netherlands hand sanitiser and instrument handling

ANICURA QUALITY 28 REPORT YEAR 2018 ANICURA QUALITY 29 REPORT YEAR 2018 Securing infection prevention and control Securing infection prevention and control

IMPROVED hand hygiene Clean hands are the single most important tool to minimise spread of microorganisms including antimicrobial Use of alcohol-based resistant bacteria. hand sanitiser per country (ml per How did you improve patient and day). AniCura works actively to secure INSTRUMENT HANDLING hand hygiene? proper hand hygiene routines among In 2018, AniCura also studied how SWEDEN 12.3 all employees. For the third year in a clinics handle surgical instruments row, a study about hand hygiene was from cleaning to sterilisation including ANICURA AVERAGE 8.4 performed at 80 AniCura clinics. test of instrument cleanliness and quality checks of equipment like NORWAY 7.7 “The purpose of our study is autoclaves and washer-disinfectors.

to highlight the importance 87 clinics participated in the study DENMARK 7.2 of good hand hygiene to all about instrument handling. 34% of veterinary professionals” clinics used a washer-disinfector for THE NETHERLANDS 7.1 BERTHOLD MENZEL, PRACTICE MANAGER AND JANNICKE KROGDAHL, NURSE AT ANICURA MAJA NYBERG ÖHMAN, HEAD VETERINARIAN cleaning and disinfection while almost VETERINARIAN, AND ANDREA CARIUS, QUALITY DYRESYKEHUS OSLO, NORWAY AT ANICURA FALU DJURSJUKHUS, SWEDEN The results revealed an average COORDINATOR AND HEAD NURSE AT ANICURA as many clinics still clean instruments GERMANY, AUSTRIA RECKLINGHAUSEN, TIERÄRZTLICHE KLINIK FÜR & SWITZERLAND 6.3 “Hygiene is a recurring “We do self-assessment checks consumption of 8.4 ml hand sanitiser manually, a method with unreliable KLEINTIERE, GERMANY topic at the hospital meetings” around compliance to hand per patient and day, which is higher quality as the results vary between 2018 Q2 survey QualiCura Source: “To increase compliance to hygiene routines” compared to 7.3 ml per patient and day individuals. After manual cleaning, Inspired by an ACE course in infection hand hygiene routines, we prevention and control, we introduced In the veterinary group, we looked at the in 2017. The increased use of hand sani- cleaning in household dishwasher or THE STUDY IN BRIEF: remind each other” a questionnaire regarding basic hygiene, results from last year’s QualiCura survey and tiser follows the implementation of in- ultrasound bath, instruments need to • 75% of the clinics had a designated as for example personal appearance and discussed how we could improve our use All new employees are introduced to the fection control guidelines across AniCura be disinfected to reach a sterile result person to coordinate the local infec- hand hygiene. The purpose was to increase of alcohol-based hand sanitisers and came tion control work. importance of clean hands and to the clinic’s awareness of hygiene among all employees. together with annual measurements of in the autoclave. However, proper up with ideas. One was to put up even more written instructions on how to perform At the same time, we made dispensers for • On average, the clinics had 1.0 dispensers. hand hygiene to raise awareness and disinfection was only performed at half correct hand hygiene. To make it easy, alcohol-based hand sanitisers more readily dispenser per room for patients. drive usage of hand disinfection. of the clinics in the study. All clinics in dispensers for alcohol-based hand sanitiser available. are available at many places in the clinic. the study received feedback including • 57% of clinics have increased their use of alcohol-based hand saniti- AniCura’s guidelines on infection ser - an important sign of improved prevention and control. hygiene routines.

ANICURA QUALITY 30 REPORT YEAR 2018 ANICURA QUALITY 31 REPORT YEAR 2018 Enabling good incident handling Enabling good incident handling

Learnings from AniCura Djursjukhuset Albano

ANICURA DJURSJUKHUSET unknown to us before we started using the if the incidents are not handled properly. ALBANO WAS ONE OF THE system. Now we have been able to imple- Second-victims are traumatised by the inci- FIRST CLINICS TO TRY THE ment actions and set routines preventing dent and feel personally responsible for the ANICURA PATIENT SAFETY also these from re-occurring. unexpected patient outcomes and doubt IMPROVEMENT SYSTEM. their clinical skills and knowledge. VETERINARIAN TITTI SJÖDAHL-ESSÉN SHARES Why is it important to report HER PERSPECTIVE. medical incidents? Does focusing on incidents have other benefits? What did you see when you started By reporting and analysing incidents, we visualise issues. Through the approach When identifying deficiencies in our oper- using APSIS? we can find root causes and identify ations and focusing on how to improve our We have seen more incidents reported as improvements to prevent them from routines, we also identify new ways of work- “near-misses” than we expected, i.e. things occurring again. Another important reason ing, which in turn can improve workflow and that almost happened but never caused is to reduce risk of second-victim-syndrome increase efficiency in our clinic. any patient harm. These incidents were among our staff, which can be common

NEW SYSTEM Meet Catherine Oxtoby, to learn from mistakes researcher in patient safety

Learning from mistakes and systematically preventing CATHERINE OXTOBY IS A Mistakes can be difficult to talk about, but failure and cognitive limitations are the most VETERINARIAN WORKING they are a rich source of learning to help commonly reported causes of preventable them from reoccurring improve patient safety. WITH THE VETERINARY protect both patients and clinicians from mistakes. Type of reported DEFENSE SOCIETY IN THE inevitable human errors and the system UK. SHE HAS A PHD IN failings which contribute to them. Open, incidents into APSIS PATIENT SAFETY AND IS ONE honest and supportive discussions of error What is your most important advice in 2018 (% of total) OF FEW VETERINARIANS In general, the veterinary industry has (APSIS) was rolled out to most clinics WHO DOES RESEARCH ON are also effective ways to build learning to clinics trying to address incidents working cultures, promote teamwork and limited experience of documenting within AniCura. APSIS is a simple to INCIDENT HANDLING IN more systematically? VETERINARY CARE. drive quality improvement in veterinary and learning from medical incidents use system where employees quickly 33% practice. When identifying deficiencies in our opera- 23% Medication in a systematic way. By working many can register the most important Treatment tions, we traditionally focus on the person clinics together, there is significant characteristics of an incident. What are the most common causes of who ‘touched it last’ and this can contribute to a sense of blame and shame around clini- potential to learn from each other’s Significant improvements to patient incidents in veterinary care? Why should veterinary care increase cal mistakes. Human factors and structured mistakes and improve patient safety safety can be achieved when teams its focus on medical incidents? Human errors are the best explanation of investigation using techniques such as root at many locations simultaneously. analyse the root causes behind the causes of incidents. Most significantly, cause analysis, enable us to look past the Every other safety critical industry relies on ‘cognitive limitations’ – limits of working person and identify the system issues which Against this background, AniCura incidents. An open culture where active incident reporting to learn from and memory, cognitive bias and focus, in com- contributed to their behavior. decided in 2017 to invest in a medical incident-related discussions are centred 4% prevent errors – the veterinary profession is bination with ‘system’ issues such as poor Also, for every investigation, be sure to Patient incident handling system and joint around mutual learning rather than accident 20 years or more behind! Aviation, nuclear communication structures, lack of clinical identify one thing you can change to make processes. assigning individual blame is key 23% power and human healthcare all utilise leadership skills and badly designed drug an improvement and try to share that learn- Other adverse event reporting to understand why packaging or equipment were frequently re- ing throughout the group. Make sure your to succeed. With APSIS, important 7% things go wrong and develop evidence-based ported causes of error in veterinary practice. reports lead to changes – no matter how EASY SYSTEM AND OPEN CULTURE Anaesthesia 10% conclusions on prevalence of certain Diagnostics strategies to manage future risks. Also in human health care, communication small – and shout about your success! During 2018, the digital AniCura types of incidents can be drawn across Patient Safety Improvement System the company.

ANICURA QUALITY 32 REPORT YEAR 2018 ANICURA QUALITY 33 REPORT YEAR 2018 Promoting patient medical record quality Promoting patient medical record quality

SYSTEMATIC WORK to improve medical record writing

High quality medical records MEDICAL RECORDS IN THE What did you learn by reviewing are important, not only for NETHERLANDS In 2017, AniCura clinics in Sweden, medical record writing? patient safety, but also for Norway, Germany, Austria and the pet owner and the refer- Switzerland participated in a project ring veterinarian. to improve medical record quality by standardising routines and establishing ENNE KWANT, FLOOR STEMBERT, MARJON SCHELLEKENS, best-practice. In 2018, the project was VETERINARIAN AND VETERINARIAN AND OFFICE MANAGER expanded into the Netherlands. PRACTICE MANAGER, PRACTICE MANAGER, AT ANICURA STERKLINIEK DEVENTER, ANICURA DIER DIERENZIEKENHUIS In a medical record of high quality, Around 20 clinics in the Netherlands THE NETHERLANDS MEDISCH CENTRUM TILBURG, colleagues can easily understand each participated in the project and over KENNEMERLAND, THE NETHERLANDS THE NETHERLANDS other’s documentation of the patient’s 4 000 medical records were evaluated. history and condition, and continue the The clinics received a monthly report “Within AniCura’s healthy record “During the year we checked over 400 “We started this project in May and treatment and diagnostics as planned. A based on their data with improvement project in 2018, we evaluated patient records and set clear goals for were really motivated. The first two high quality medical record will ensure suggestions for each clinic. These over 500 medical records and the whole team to improve the quality months we evaluated more than a better customer service, reduce medi- suggestions were discussed in the found that some topics had to be of the medical record writing. Every 200 medical records and immediately cal errors and provide valuable infor- team meetings at the clinics to raise discussed within the team and that month we discuss the results and saw things we could improve in our mation for research purposes. Working awareness among employees about the new guidelines were needed.” improvement suggestions.” medical record writing like better with templates or set headlines in the importance of a proper medical record. recording of patient’s history.“ different sections of the medical record are important steps towards ensuring good medical record quality.

ANICURA QUALITY 34 REPORT YEAR 2018 ANICURA QUALITY 35 REPORT YEAR 2018 “We have a responsibility for future generations to ensure a wise use of antibiotics and good working conditions in veterinary care”

ANICURA QUALITY 36 REPORT YEAR 2018 ANICURA QUALITY 37 REPORT YEAR 2018 OUR PEOPLE OUR PEOPLE

EMPLOYEE satisfaction in focus AniCura’s ambition is intended to serve as guiding principles HIGH ENERGY AND MOTIVATION throughout the organisation. To address employee satisfaction in a to be the most attractive Managers within AniCura are trained structured way, AniCura introduced an employer within the to work according to AniCura’s values annual employee survey in 2015. veterinary care profession. and are equipped with tools to actively implement values-based thinking Results from the employee in their teams. Around 60 managers survey in 2018 showed: take part in two-days values trainings High energy levels and motivation As one of the largest employers in the every year. In total, around 200 AniCura European veterinary care industry, managers have been trained since 2014. An increased share of employees AniCura has significant impact on Following each training, managers are willing to recommend AniCura as working conditions and satisfaction expected to inform and train employees employer among veterinary professionals. The at their respective clinic. More satisfied employees at clinics work spans across four areas: In addition to values trainings, meet- that have been part of AniCura for ings to build culture, share knowledge a year or more Building a values-based and strengthen relationships between Leadership and team efficiency organisation and strong culture all employee groups are arranged in (planning, performance feedback each country several times per year. In Strengthening leadership and conflicts handling) need to February 2016 and in 2018 respectively, be improved Ensuring sustainable working all AniCura employees were invited to conditions a two-day conference called Together- All managers are expected to present ness. In 2018, 2 287 employees from and discuss the results in their teams. Building structure around nine countries joined Togetherness in The employee survey clearly shows that competence development Stockholm. teams that worked with their results, scored a higher employee satisfaction A STRONG CULTURE MADE BY YOU than other teams. DRIVES SATISFACTION “Togetherness underlines the passion that lives within Building a strong sense of togetherness our group and made me and investing in the company culture remember how proud I am of forms a core part of AniCura’s identity being part of the AniCura team” as an employer. The company values EMPLOYEE AT TOGETHERNESS 2018 provide the foundation for this and are

ANICURA QUALITY 38 REPORT YEAR 2018 ANICURA QUALITY 39 REPORT YEAR 2018 OUR PEOPLE OUR PEOPLE

86 % are proud of working at AniCura 86% identify with AniCura values 87% are motivated at work

In 2018, 2 287 employees from nine countries joined the conference Togetherness in Stockholm.

models at our German clinics. We are Driving change harmonising labour contracts, improving scheduling of especially night shifts and LEADERSHIP IN FOCUS In addition to Accelerator, there are agreements are country specific. Initia- and recruitment but also ethics, whistle- in Germany implementing a better system for time In 2015, AniCura took a strategic deci- national leadership trainings targeting tives during 2018 include new software blowing and anti-corruption. In Germany, AniCura is driving a reporting. We are also running a new leadership program, and specifically sion to invest significantly into develop- all levels of leaders. and routines for better scheduling, stress change program to ensure sus- address teams with lower scores in the ing clinical leadership, and in 2016, the A new global framework, AniCura management prevention programs and COMPETENCE DEVELOPMENT tainable working conditions. employee survey. global leadership program Accelerator Excellent Leader, was developed in 2018 standardisation of working contracts. AND TRAININGS Nicolas Haas, country manager What will the future look like? was established. To date, 71 managers and will be implemented across the In Sweden and Norway, a two-day Competence development and trainings for Germany, Austria & Switzer- land shares his reflections. Over time, we will see a change from old at AniCura have graduated from the organisation over the next years to help training called AniCura Readiness Camp, are highly prioritised at AniCura, and also hierarchies and legacy structures, to a integrated into AniCura’s medical quality program. The program is comprehensive all managers work in the same direction help recently recruited veterinarians and What are the challenges in more modern workplace with structured and focused on further developing and apply similar leadership behaviours. nurses get a smooth transition into the development program. Read more about German veterinary care? development opportunities, a culture of leadership skills and insights, as well as daily clinical work at AniCura and for competence development on page 12 and 18. empowerment and learning as well as more As the veterinary care market is growing, sustainable work arrangements. strategy implementation and business SUSTAINABLE WORKING CONDITIONS instance tackle topics such as hygiene, veterinarians – and particularly those with acumen. Ensuring sustainable working conditions work-related stress and customer advanced specialisations – are becoming increasingly scarce. There is also a rising NICOLAS HAAS, is a key priority for AniCura, and in some communication. EMPLOYEE SURVEY RESULTS demand for part-time and flexible work COUNTRY MANAGER countries a challenge facing the entire Sick-leave and work-related injuries solutions. With the labour scarcity, stress GERMANY, AUSTRIA & SWITZERLAND “Accelerator gave me deeper industry. are tracked on clinic level. In Sweden, 2017 2018 levels become high and heavy workloads are not rare. Especially offering 24/7 insights in how to interact In 2018, new human resources man- eNPS* 12 14 clinics representing around 660 employees emergency care has become a challenge with my team, and a fantastic agers were recruited to several countries had an average sick-leave of 5.6% in Engagement index 78 77 for several smaller clinics. international network” to start build structure around human 2018*, similar to statistics from human Leadership index 69 69 BENTE AKSELSEN, PRACTICE MANAGER resources and support to clinics. The health care. How is AniCura addressing work- ANICURA REGION NORD, NORWAY Team efficency index 69 68 ing conditions? efforts around working conditions are In 2018, a new global employee hand- We are committed to become a force for mainly conducted on a clinic and book was introduced to set companywide *eNPS = Employee Net Promoter Score, an international KPI based on the question: ”Would you recommend this company good in this market. In 2018, we initiated national level as regulations and collective standards around employee development as an employer.” General benchmark is 9. a project to establish best practice work

*Sick-leave measured as % of total hours worked

ANICURA QUALITY 40 REPORT YEAR 2018 ANICURA QUALITY 41 REPORT YEAR 2018 PREVENTIVE CARE PREVENTIVE CARE

ENGAGING IN preventive care

Preventive care has signifi- By preventing illnesses and infections, NEW PREVENTIVE HEALTH PLAN cant impact on the quality of pet owners’ costs for veterinary care To further strengthen focus on pre- life for companion animals. over a lifetime can also be reduced. ventive health, AniCura launched a Besides the physical meetings with preventive health plan called AniPlan in veterinarians and nurses at clinics, 2016. The purpose is to offer pet owners AniCura offers digital veterinary advice a simple and cost-efficient way to AniCura has an important responsibility through a searchable database on each ensure good preventive care and detect Welfare diseases to improve pet health through better country’s website as well as information diseases at an early stage. AniPlan was on the rise compliance to health check-ups, vaccines campaigns focused on preventing over- introduced in Denmark in 2016, and and parasite prevention but also to weight and ensuring proper nutrition. following good feedback from Danish pet Like in human health, welfare diseases increase awareness around the impor- owners, AniPlan has now been launched among pets are increasing. Studies on tance of exercise, good dental health in Sweden, Norway and the Netherlands. overweight and obesity among com- and proper nutrition. panion animals in Europe indicate that between 30 and 60 % of all dogs and ANIPLAN: cats are overweight. Consequently, a ® number of health issues arise as for example Preventive health plan offered to AniCura AniPlan diabetes, certain forms of cancer and AniCura’s customers as a subscription orthopaedic problems. Many dogs and at a subsidised price cats also suffer from gum diseases and  AniPlan includes for example yearly undiagnosed dental problems, causing health checks, dental checks and severe pain or permanent damages. vaccinations

 AniPlan also offers customers discounts on selected products and services, for example pet food

ANICURA QUALITY 42 REPORT YEAR 2018 ANICURA QUALITY 43 REPORT YEAR 2018 ENVIRONMENT ENVIRONMENT

A GREENER veterinary care AniCura’s ambition is to Implementation of several initiatives day or week. By analysing in-clinic order provide veterinary care with across these areas are planned for 2019 flows and order frequency, there is and the results are expected to be ex- potential to reduce the number of trans- respect for the environment. panded in scope over time. ports needed. In 2019, a pilot project with select suppliers and clinics in one

MANAGING WASTE country will be conducted to identify The development of veterinary medi- Waste is an area where AniCura along- best-practice around order flows and cine with for example more advanced side other health care providers impact transportation. as floors, tables, cages and surgery theatres, and energy consuming equipment and the environment, primarily through the Greener cleaning as an alternative to traditional cleaning with increased use of consumables to improve daily use of consumables and phar- GREEN ENERGY detergents. Cleaning is an important recurring infection control, highlights the impor- maceuticals. Laws and regulations set Lighting, heating of facilities, powering Repeated bacterial tests were taken after cleaning, task in the daily clinic operations tance to consciously address the environ- basic standards for waste handling in of tools and advanced equipment within all showing satisfying results. Microfiber which typically drives significant use cleaning also proved to be more reliable as the mental footprint of veterinary care. each country, but more can be achieved AniCura such as magnetic resonance of chemicals. New, modern methods manual dilution of chemicals often results in Many clinics within AniCura address through improved waste sorting and imaging (MRI) and computed tomo- prove that a microfiber cloth and too much detergents and sticky surfaces where environmental impact locally. Over time, recycling. graphy scans (CT) all drive electricity water can be as efficient. bacteria easily are stuck. AniCura’s ambition is to become a role In 2018, AniCura procured a joint consumption. In 2019, microfiber cleaning will be implemented model in the industry in taking environ- supplier for waste handling in Scandi- In 2018, renewable energy agreements Microfiber is today well-known for its ability to at clinics in Sweden and over time rolled-out mental responsibility. Four areas have navia, enabling the company to start were arranged for AniCura’s Scandinavian efficiently absorb particles and bacteria, and across AniCura. the textile has a long lifetime. Only water should been identified as key initially: measure waste generation with the aim operations. In 2019, renewable energy be added for cleaning. In human health care, to over time decrease waste and the will be procured for AniCura in the In 2018, AniCura’s clinic in the cleaning method has been bacteriologically “For both infection control Waste purposes and the environment, share of unsorted waste. Netherlands and Germany, thus Reutlingen, Germany built tested with very good results. using microfiber for cleaning is Procurement ensuring that the vast majority of new premises and installed solar In 2018, AniCura signed an agreement with better than chemicals” REDUCING TRANSPORTS clinics within AniCura can use green panels. The solar panels generate a preferred supplier producing high-quality Transport microfiber mops and cloths. AniCura Västra ULRIKA GRÖNLUND, Today, many suppliers receive orders energy. 100 kW per hour, meaning that the Djursjukhuset and AniCura’s central quality team GROUP MEDICAL QUALITY MANAGER Energy from AniCura clinics several times per clinic is self-sufficient in electricity. tested the cleaning method for surfaces such

ANICURA QUALITY 44 REPORT YEAR 2018 ANICURA QUALITY 45 REPORT YEAR 2018 COMMUNITY ENGAGEMENT COMMUNITY ENGAGEMENT

MIA JUHL, NURSE AT ANICURA SYDVET DYREHOSPITALER, DENMARK COMMUNITY “We know how important pets are for homeless, vulnerable and lonely humans – pets provide safety, engagement closeness and love” Mia was inspired by other AniCura clinics and decided to organise her clinic’s first day of open house for homeless pet owners. On the 10th of November 2018, more than for pets She contacted organisations for homeless 160 vulnerable and homeless pet owners and they handled booking of appointments. FREE VETERINARY CARE FOR HOMELESS Suppliers and existing customers donated came to AniCura’s clinic in Oslo to receive Many clinics within AniCura clothing and other dog utilities. Offering a day with free veterinary care free veterinary care for their loved ones. are actively engaged in the for vulnerable and homeless pet owners community to improve has become an annual and appreciated animal health. tradition at many AniCura clinics. Ten

years ago, AniCura Västra Djursjukhuset CAROLINE HOLTET, in Sweden, was one of the very first animal PRACTICE MANAGER AT ANICURA DYREKLINIKK hospitals to organise a day with free GRÜNERLØKKA, AniCura’s community engagement is veterinary care. Since then, many NORWAY mainly conducted on a clinic level and AniCura clinics have followed their based on the needs of companion animals positive example. ”This is the fourth year we do this in different regions. Several clinics provide The days are organised together with veterinary care to animal shelters at a local associations for homeless and in Oslo, and it has grown into a big discount and others collaborate with clinics typically treat between 40 and event. It feels wonderful to be able foundations to help pet owners living 200 patients on each occasion at no cost to help so many” under tough financial circumstances. to the pet owner. Pet owners who are Caroline is the initiator of the open house On country level, AniCura supports offered free veterinary care are either for homeless and vulnerable pet owners in the Oslo region. In 2018, 220 patients were various companion animal organisations homeless or live under tough financial treated on one day in Oslo. Several patients such as animal shelter organisations, circumstances. The clinics involved offer had to return for surgery or more complicated therapy dog associations and organisations free health-checks, vaccines and dental treatments, and Caroline organised financing through a crowdfunding campaign on Facebook. working to spread knowledge about the care and some patients are also invited She raised 25 000 Euros and established a positive effects of companion animals back for further treatment or surgery. fund to support pet owners in need. on human health.

ANICURA QUALITY 46 REPORT YEAR 2018 ANICURA QUALITY 47 REPORT YEAR 2018 ”Potential of interference of ”The faecal microbiome sig- the novel monoclonal anti- natures of dogs with chronic bodies (mAbs) Lokivetmab inflammatory enteropathies” used in atopic dermatitis in BART RUIJTER, AMSTERDAM, THE NETHERLANDS serum protein electrophoresis The faeces of both human and other and immunofixation protein animals contain numerous organisms, like electrophoresis” bacteria, protozoa and viruses. Several studies have shown the importance of this NEOKLIS APOSTOLOPOLOUS, AUGSBURG, GERMANY so-called microbiome and its relation to all Canine atopic dermatitis is a chronic, kinds of diseases. The aim of this study is inflammatory skin disease mainly affecting to investigate the microbiome of healthy genetically predisposed individuals. This dogs and those with chronic vomiting and/or study aims to assess if and how a new diarrhoea due to causes like food intolerance. treatment with antibodies (Lokivetmab) This could improve our knowledge on these interferes with other pharmaceuticals diseases and aid the clinicians in forming a commonly used in veterinary medicine. diagnosis. RESEARCH ”Anaerobic bacteria in deep in AniCura infections in dogs and cats with focus on bacterial species and With 2.5 million patient visits, AniCura is in a unique position independently evaluates all appli- their susceptibility patterns” ULRIKA GRÖNLUND, STOCKHOLM, SWEDEN to advance veterinary medicine through clinical research. cations to the research fund and allocates money to the projects that In severe infections it is paramount to imme- assure high scientific standards and diately start antibiotic treatment with the right antibiotic substance. This study aims have the potential of being published at finding out what bacterial species are AniCura has many veterinary Since then, almost 40 clinical research in an international peer-reviewed involved in deep infections in dogs and cats professionals that devote part of their projects have received funding. In total, scientific journal. and what substances they are susceptible to. time to research. In 2015, AniCura AniCura funded research projects of During 2018, the following 11 The results will guide veterinarians how to choose the right antibiotic. established the AniCura Research more than SEK 4 million. projects were granted funding from Fund with support from its owners. AniCura’s Scientific Council the AniCura Research Fund:

”Oxidative erythrocyte damage ”To assess the efficacy of ”The role of sex hormones in ”CT assessment of the arthro- in dogs after several days of hyposensitization in cats idiopathic epilepsy in dogs” scopic treatment of canine therapy with either meloxicam, diagnosed with allergic form SOFIE VAN MEERVENNE, KALMAR, SWEDEN medial coronoid disease” carprofen or metamizole” of asthma” CARINA RENNER - BABENHAUSEN, GERMANY KATARINA VARJONEN, STOCKHOLM, SWEDEN Epilepsy is one of the most common neu- JULIA LIESER, AUGSBURG, GERMANY rological disorders in veterinary medicine. Medial coronoid disease (MCD) is the Feline asthma is a common and debili- In human medicine, the effects of sex NSAIDs are frequently used drugs in veteri- most common cause of forelimb lameness tating disease affecting up to five out of hormones on seizures and epilepsy are well nary medicine, especially after surgical inter- in large dogs. Arthroscopy is the gold a hundred cats. Cats can be difficult to documented, but in veterinary medicine the ventions or for pain management in acute standard not only for diagnosing but medicate, and we are aiming to assess information is scarce. As a part of Sofie’s PhD and chronic painful conditions. Various side also for treating MCD. The study aims to if cats with an allergic form of asthma project, the epidemiology of seizures in dogs effects of these drugs are already described evaluate the completeness of arthroscopic would respond to immunotherapy and will be investigated with focus on sex and in humans, as well as in small animals. The removal of MCD. if this treatment would allow less other goal of this study is to investigate if commonly neuter status, by analysing sex hormones in medications to be used compared to used NSAIDs negatively impact the red blood salivary and blood. patients receiving only conventional cells’ oxygen-delivery capability. asthma treatment.

ANICURA QUALITY 49 REPORT YEAR 2018 ”Comparison of enterography findings from ultrasonography and computed tomography (CT) with results of endoscopy and full thickness biopsies in 25 canine patients with gastro- intestinal disease” ”As part of the AniCura family, SUSANNE BOROFFKA, UTRECHT, THE NETHERLANDS we are committed to develop and Ultrasound is routinely used to evaluate the intestines, but their contents may disturb the image quality, especially in large dogs. improve veterinary care” CT-enterography is routinely used in humans allowing a global evaluation of all abdominal organs. In veterinary medicine, there have not been many studies describing CT- KONRAD JURINA, PRACTICE MANAGER AND VETERINARIAN AT TIERKLINIK HAAR, GERMANY imaging of the normal and abnormal GI-tract. In this study, we will compare the imaging pathology of both CT and ultrasound and thereby understand GI-tract imaging better for future patients.

”Evaluating male dog fertility ”Prevalence of using anti-Müllerian hormone hypersomatotropism in cats (AMH)” with concentric left ventricular

HELENE ALM, STOCKHOLM, SWEDEN hypertrophy”

In this project, we want to study if the MARIEKE KNIES, DORDRECHT, THE NETHERLANDS fertility of a male dog can be estimated from The aim of this study is to determine if a blood sample, as semen samples are more hypersomatotropism is common in cats difficult to collect and to interpret. In both with hypertrophic cardiomyopathy without blood and semen samples, we will study a concurrent diabetes mellitus, as is the case in specific hormone that is produced in the humans with hypersomatotropism. Identification testicles, anti-müllerian hormone (AMH) and of hypersomatotropism is important as investigate the relationship between AMH concentric left ventricular hypertrophy might be and fertility. reversible with treatment.

”Dose escalating phase I and II study of doxorubicin and temozolamide for treatment of canine hemangiosarcoma”

IRENE FLICKINGER, HÜNENBERG, SWITZERLAND

Hemangiosarcoma is a rapidly growing, highly invasive cancer that occurs almost exclusively in dogs, typically with poor prognosis. We wish to compare results of hemangiosarcoma treatment with two different drug combinations; doxorubicin or doxorubicin in combination with temozolamide. By following two different patient groups we will be able to measure differences in time to tumour progression as well as overall survival time.

ANICURA QUALITY 51 REPORT YEAR 2018 ANICURA AB, VENDEVÄGEN 89, 182 32 DANDERYD, SWEDEN | WWW.ANICURAGROUP.COM