Anicura Quality Report 2015 Preamble

AniCura Quality Report 2015 Preamble

This AniCura Quality Report is an important veterinary care for on average more than 20 years, milestone as it is the first quality report in and our oldest hospital has been helping ailing AniCura’s history and the first quality report animals for more than 100 years! As we constantly by a European veterinary group. The report witness the many benefits from working together provides a summary of many of the ongoing within AniCura, we felt the time was ripe to push quality initiatives within our organisation, as the boundaries even further by also comprehen- well as highlights areas in need of increased sively and systematically addressing the area of focus and improvement. For us, developing quality from a group perspective. quality is an ongoing effort! To ensure sufficient focus and progress, The veterinary care industry is evolving AniCura appointed a team of highly qualified rapidly, and AniCura is taking an active role and dedicated vets to lead the initiative, with in this development. In terms of quality, the the invaluable support from the many vets and industry has been relatively quick to pick up on nurses in our animal hospitals. The team’s first quality enhancing practices even though it has task was to identify best practices within quality historically been implemented clinic-by-clinic development, both externally in other industries based on individual preference and approach, at such as human healthcare, as well as internally times leading to relatively large local variations. through discussions and observations in many The most advanced expertise and equip- of our hospitals and clinics. The results of these ment making up the specialised segment of the efforts became QualiCura, our internally devel- veterinary industry is typically present in the oped companywide program for systematic larger animal hospitals and clinics that have quality improvement launched in 2015. become AniCura’s hallmark. QualiCura embodies many of the AniCura Just as in human medicine, where quality characteristics that we are so proud of. Working of care has played an important role in the together to enhance veterinary care, being past decades to both patients and practitioners fanatic about the importance of high quality, alike, the veterinary industry is now increas- sharing knowledge and best practice and being ingly looking at ways to systematically develop transparent about what we are up to. quality. This is further facilitated by many We hope that you will find this AniCura animal hospitals joining forces, as has been Quality Report inspiring to read. Thank you for the case within AniCura. showing an interest in the work that we do and For AniCura, quality is the number one the everyday continuous improvements we priority and our ambition is to provide the strive for at all our animal hospitals! highest quality veterinary care available. What is best for our patients always forms the basis AniCura – shaping the future of of our clinical decisions and we are dedicated veterinary care, together to provide the most empathetic care and the best veterinary expertise. The AniCura animal hospitals and clinics PETER DAHLBERG have been in the business of providing excellent GROUP CEO, ANICURA Contents

Background 7 Interviews 18

What is quality? 7 Improving professional 21 communication skills Introducing QualiCura 8 The AniCura Professional 21 Design principles 8 Communication Project

The QualiCura approach 8 Providing reliable 22 diagnostic medicine Organisation and resources 10 Laboratory Quality Assurance program 23 Encouraging professional 12 development and specialisation Ensuring wiser 24 antimicrobial use Specialisations within AniCura 12 Monitoring surgical Referral centres 13 26 site infections Creating and sharing 15 Securing proper infection best practice 28 prevention and control Clinical research 15 Promoting patient medical 29 AniCura Research Fund 15 record quality

Scientific journal and Patient medical record reviews 29 16 data base access Enabling good incident handling 31 Knowledge sharing 16 External controlling bodies 32 Journal clubs 16 Future development 33 Medical Interest Groups 17 of program Online knowledge base 17 About AniCura 34

Background

AniCura’s vision “Shaping the future of We believe improvements can be identified veterinary care, together” has been a guiding and implemented in all these areas by working principle since the company’s foundation. This together and applying a continuous improve- vision rests equally on two pillars; Quality ment methodology across AniCura. excellence and Customer service. AniCura Within this broad perspective, we have seeks to ensure both quality and service as initially chosen to focus on the medical these are intrinsically linked. aspects of quality, as the medical outcome for a patient is the ultimate result of quality in a WHAT IS QUALITY? long chain of decisions and actions, efforts The term quality can mean different things to and prioritisations. different people. AniCura has chosen to main- tain a broad perspective on quality, encompassing almost all of the actions and processes that our members of staff perform and that our patients receive and our customers appreciate.

AniCura Quality Report 2015 7 Introducing QualiCura

Continuous quality improvement has for a to enable comparative studies and make long time been at the heart of all the animal sure AniCura has a fact- and evidence- hospitals forming AniCura. Since AniCura’s based approach not only in the field of foundation in 2011, these efforts have been veterinary medicine, but also within quality made easier through sharing knowledge, development. best practice and ideas around quality improvements between the animal hospitals. QualiCura is initially focusing on areas that we In order to accelerate quality development, believe have a particularly large impact on the AniCura has in 2015 designed and launched a safety and medical outcome of our patients: company-wide program for systematic quality improvement called QualiCura. The principal • Encouraging professional aim of the QualiCura program is “To enable development and specialisation AniCura’s patients to receive safer care, with • Creating and sharing medical better medical outcome”. In essence, AniCura’s best practices quality of care efforts are patient-centred with • Improving professional a specific focus on patient safety. communications skills

DESIGN PRINCIPLES • Providing reliable diagnostic medicine In order to continuously and effectively identify • Ensuring wiser antimicrobial use and implement quality improvement initiatives, • Monitoring surgical site infections AniCura believes that this responsibility needs • Securing proper infection to reside at the local hospital as well as within prevention and control each individual working at AniCura. • Enabling good incident handling In terms of quality improvement, our overall • Promoting patient medical QualiCura approach is designed to trigger record quality relevant measurements and discussions at the hospital level, aided by comparisons across animal hospitals and over time. As everything For each of the focus areas AniCura sets (hospitals, individuals, processes, systems, etc.) certain input or output-oriented quality can always improve, the QualiCura program indicators by which the animal hospitals focuses on relative improvement over time, can measure themselves and compare their irrespective of starting point. progress over time and with other hospitals.

THE QUALICURA APPROACH QualiCura has chosen a holistic approach to quality in order to avoid sub-optimisation and silo thinking. This approach also caters to a wide variety of clinical settings in many different countries. Moreover, QualiCura is gathering data from the animal hospitals

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QUALICURA APPROACH: Each quarter, AniCura’s hospitals participate in various topical surveys, after which they receive their results and benchmarks together with best practice and guideline documents to enable further clinic-specific improvement discussions. Some focus areas and quarterly timings change and develop over time.

AniCura Quality Report 2015 9 Organisation and resources

The vast majority of quality improvement ANICURA’S SCIENTIFIC COUNCIL is conducted locally in the various AniCura The council promotes evidence based medicine and animal hospitals, but to further focus, structure clinical research within AniCura.

and manage this development, AniCura THE 2015 MEMBERS OF THE COUNCIL: has recruited a handful of highly skilled Anna Tidholm, DVM, PhD, Associate Professor, Dipl veterinarians with quality improvement ECVIM-CA (cardiology), AniCura Animal Hospital Albano, Sweden experience and academic merits, ensuring Stein Istre Thoresen, DVM, PhD, Professor in Clinical sufficient focus and execution. Pathology at Norwegian University of Life Sciences, Dipl ECVCP, Dipl ECVIM-CA, Group Medical Quality and Development Director

The 2015 QualiCura team comprised: Anneli Bjöersdorff, DVM, PhD, Business Area Manager Laboratory Stein Istre Thoresen, DVM, PhD, Professor in Clinical Pathology at Norwegian University of Life Sciences, Christina Strand Thomsen, DVM, Dipl ECVS, AniCura Dipl ECVCP, Dipl ECVIM-CA, Group Medical Bergen Nord, Norway Quality and Development Director Steen Engermann, DVM, Danish specialist veterinarian (Specialdyrlæge) in Oncology, AniCura Aarhus Anneli Bjöersdorff, DVM, PhD, Business Area Dyrehospital, Denmark Manager Laboratory Jens Häggström, DVM, PhD, Dipl ECVIM-CA (cardi- Ulrika Grönlund, DVM, PhD, Group ology), Professor of Internal Medicine, small animals, Medical Quality Manager Swedish University of Agricultural Sciences, Sweden

Peter Feledy, Chief Operating Officer

The 2015 QualiCura reference group comprised: ANICURA’S VETERINARY DEVELOPMENT COUNCIL Titti Sjödahl-Essén, DVM, Swedish specialist in Ophthalmology, Head veterinarian AniCura The council safeguards AniCura’s overall veterinary priori- ties by keeping abreast of trends and general national and Djursjukhuset Albano, Stockholm, Sweden international developments in veterinary medicine.

Birgitte Grann Greve, DVM, Veterinary THE 2015 MEMBERS OF THE COUNCIL: ophthalmologist, Member of the Norwegian Nanna Denneberg, DVM, Swedish specialist veterinar- Eye-panel (ECVO-examinations), Head Veterinarian, ian in canine and feline oncology, Head Veterinarian, AniCura Oslo, Practice Manager, AniCura AniCura Animal Hospital in Jönköping, Sweden Dyresykehus Oslo, Norway Bente Akselsen, DVM, Norwegian specialist Peter Masbøl Skov, DVM, Danish specialist veterinarian in small animal diseases (DNV), Practice Manager, AniCura Dyresykehuset Tromsø, Norway veterinarian (Specialdyrlæge) in Oncology, AniCura Odense Dyrehospital, Denmark Birgitte Grann Greve, DVM, Veterinary ophthalmologist, Member of the Norwegian Eye Panel (EVCO- examinations), Head Veterinarian, AniCura Oslo, Practice Manager, AniCura Dyresykehus Oslo, Norway AniCura’s efforts around quality and veteri- Henrik Strange, DVM, Danish specialist veterinarian nary development are also supported by two (Fagdyrlæge), Practice Manager, AniCura Gistrup councils: AniCura’s Scientific Council and Dyrehospital, Denmark AniCura’s Veterinary Development Council. Matilda Wallman, Registered Veterinary Nurse, AniCura Norsholms Djursjukhus, Sweden

Anneli Bjöersdorff, DVM, PhD, Business Area Manager Laboratory

Stein Istre Thoresen, DVM, PhD, Professor in Clinical Pathology at Norwegian University of Life Sciences, Dipl ECVCP, Dipl ECVIM-CA, Group Medical Quality and Development Director

Peter Feledy, Chief Operating Officer

Peter Dahlberg, Group Chief Executive Officer

10 AniCura Quality Report 2015

Encouraging professional development and specialisation

Veterinary medicine is developing at a fast in different disciplines. AniCura also edu- pace and formal continuing professional cates new national specialists (with different development (CPD) as well as on-the-job-training requirements in each geography) as well as opportunities are essential for keeping up European board-certified veterinary with this development and thereby providing specialists (Diplomates) as many of our animal better medical services. A prerequisite for hospitals are approved education institutions. giving the highest quality veterinary health When it comes to on-the-job-training, this care is also to attract, develop and retain is mainly done within each clinic, but being the most competent and passionate people. a part of a larger group provides increasing AniCura does this by encouraging and opportunities to arrange rotations between supporting each employee to develop an hospitals. individual plan outlined in cooperation with the hospital management in order to facilitate SPECIALISATIONS WITHIN ANICURA their competence development. AniCura’s As the veterinary medical field is moving quickly specialisation and continuing education in terms of development and advancement, and approach not only applies to veterinarians, many treatments that were not performed ten but also to technicians, veterinary nurses, years ago are today considered standard practice, biomedical scientists, physiotherapists, recep the demand for specialist veterinary competence tionists and other staff that seek to specialise is increasing in all countries. The specialist and develop further in their respective fields. accreditations can either be a national specialisa- The possibilities for CPD vary in duration tion, or an international accreditation, including and specification from short courses and board-certified veterinary specialist (Diplomate), consecutive series of courses in specific and Master and Doctoral degree (PhD). limited topics to formal postgraduate education AniCura encourages members of staff that systems such as national and international wish to develop and specialise. At present certificates. AniCura hospitals cooperate with AniCura is the veterinary care provider in specialised education companies and univer- Europe with most specialists within small sities across Europe and USA. animal veterinary care (i.e. dogs, cats and other In addition, we provide an increasing companion animals) and have across its animal number of internally generated courses where hospitals referral-receiving veterinarians in the either some of our own specialists or external following areas: lecturers provide us with the latest knowledge

12 AniCura Quality Report 2015 • Anaesthesiology • Nephrology

• Cardiology • Neurology

• Clinical pathology (Laboratory • Odontology (Dentistry)

diagnostics) • Oncology

• Dermatology • Ophthalmology

• Diagnostic imaging • Orthopaedic surgery

• Emergency medicine and critical care • Rehabilitation and physiotherapy

• Endocrinology • Reproductive medicine and surgery

• Gastroenterology • Soft tissue surgery

• Infection prevention and control • Urology

AniCura Quality Report 2015 13 In countries where AniCura had a presence at patients are referred from other veterinarians. the time of writing this report, AniCura had The main reasons for referrals are typically a significantly higher proportion of either that more specialist competence is sought by national or board-certified specialists (Diplo- the referring veterinarian, that the pet owner mates) than each country on a whole. This demands a second opinion from a specialist or provides further testament to AniCura’s that the type or time of care required is una- position within high quality specialised vailable at the local veterinarian. Veterinarians veterinary care (see figure below). within AniCura also regularly refer patients to other specialists and the decision where to REFERRAL CENTRES send patients (internally or externally) solely Due to the large share of specialised veterinar- rests on the treating veterinarian’s view on ians, AniCura receives a significant number what is judged best for the patient from a of referrals from other veterinary care provid- medical perspective. ers. Across AniCura, approximately 1/3 of our

SHARE OF VETERINARIANS THAT ARE SPECIALISTS

AniCura Austria 57% (of which 14% diplomates) Austria (Total country) 6% (of which 3% diplomates)

AniCura Denmark 30% (of which 3% diplomates) Denmark (Total country) 14% (of which 2% diplomates)

AniCura Germany 48% (of which 4% diplomates) Germany (Total country) 35% (of which 2% diplomates)

AniCura Netherlands 39% (of which 39% diplomates) Netherlands (Total country) 4% (of which 4% diplomates)

AniCura Norway 10% (of which 2% diplomates) Norway (Total country) 4% (of which 2% diplomates)

AniCura Sweden 32% (of which 3% diplomates) Sweden (Total country) 27% (of which 4% diplomates)

AniCura Switzerland 43% (of which 43% diplomates) Switzerland (Total country) 16% (of which 13% diplomates)

0% 100%

Source: AniCura, Federation of Veterinarians of Europe, European Board of Veterinary Specialisation, Österreichiesche Tierärztekammer, Den Danske Dyrlægeforening, Bundesverband Praktizierender Tierärzte, Bundestierärztekammer, Koninklijke Nederlandse Maatschappij voor Diergeneeskunde (KNMvD), Den norske veterinærforening, Sveriges veterinärförbund, Gesellscaft Schweizer Tierärztinnen und Tierärzte Note that country totals include diplomates at University institutions.

14 AniCura Quality Report 2015 Creating and sharing best practice

Proper veterinary medicine has an evidence is cared for at the AniCura animal hospitals based approach, where research continuously and clinics constitute a great opportunity provides advancements and new knowledge. to accomplish clinical research. There are However, several areas of veterinary medicine also strict rules governing clinical research, still require much more research to provide such as gaining informed owner consent and answers around how to best alleviate and cure ethical committee approval. Research projects diseases. AniCura’s veterinary professionals can be financed by the researcher, the work possess significant experience in meeting place, and by external scientific funds. In 2015, and treating various animals. AniCura’s posi- the AniCura Research Fund was established tion is that quality is best achieved when this and AniCura employees were invited to apply experience is coupled with the latest available for research funding. To date, over 50 AniCura findings from research. AniCura therefore employees have published more than 300 seeks to promote the creation of best practice research publications in respected scientific knowledge, as well as making sure that this journals, only publishing articles that are knowledge is disseminated to others in an reviewed by external experts. Many effective way. AniCura’s professionals benefit researchers within AniCura have been greatly from belonging to a large group where selected to present their research findings knowledge is regularly shared across hospitals at various international congresses. and working groups. ANICURA RESEARCH FUND CLINICAL RESEARCH During 2015, AniCura together with three Research is vital for continuous advancement of its owners (the Animal Hospital Founda- of veterinary medicine and AniCura has many tion in Greater Stockholm, Fidelio Capital dedicated employees who devote time and and Nordic Capital) established the AniCura effort to conduct clinical research alongside Research Fund to support clinical research their everyday work. These researchers have conducted by AniCura employees. The sci- both formal and informal collaborations with entific screening and ultimate decision on leading medical specialists and university which research projects to fund lie with institutions across Europe as well as North AniCura’s Scientific Council. The Council America. Applied clinical research may be comprises veterinarians both from AniCura challenging as it often requires a high number as well as external experts, all of whom have of patients. The large amount of patients that extensive veterinary expertise and

AniCura Quality Report 2015 15 documented scientific merits (see page 10). SCIENTIFIC JOURNAL AND The Scientific Council reviews applications DATA BASE ACCESS for funding to projects of high scientific Access to scientific journals is a key to enable research standards with potential of being more evidence based medicine to be practiced published in scientific journals. The AniCura within AniCura. To facilitate this, AniCura Research Fund has an annual application and is subscribing to an advanced research data- grant reviewing process. The AniCura Scien- base with access to biomedical and health tific Council currently has a mandate to grant care journals for the benefit of all employees. funds of up to SEK 1 million per annum. Subscriptions to several veterinary medicine The application process for 2015 attracted journals are also organised. The research data- applications from many merited researchers base provides access to assembled metadata within AniCura. Research projects in 2015 that indexed content from many world-wide data were funded by the AniCura Research Fund base providers including PubMed, Web of include projects concerning cardiology, Science, AGRIS and SCOPUS. neurological conditions, infection diseases and coagulopathies. KNOWLEDGE SHARING “Knowledge is the only thing that grows when • Development of mitral insufficiency in the it is shared” as it was wisely put by old Sanskrit Norfolk Terrier, Anna Bodegård, DVM, PhD, poets 2 500 years ago. Knowledge sharing is AniCura Albano Djursjukhus, Stockholm, fundamental to AniCura’s values and how we Sweden. operate, and as such is something that we try • Gene therapy for dogs with epilepsy: The first to reinforce and encourage as much as possi- clinical trials, Rikke Fast, DVM, PhD, AniCura ble. This obviously has positive effects on the Aarhus Dyrehospital, Aarhus, Denmark. quality of care offered by AniCura hospitals. Not only are best practices shared across all • Phenotypic classification of breed related medical disciplines, but also examples about myelopathies in Pugs, Cecilia Rohdin, DVM, how to best address and implement various Dipl ECVN, AniCura Albano Djursjukhus, improvement opportunities are shared and Stockholm, Sweden. discussed. • Seroprevalence of tick-borne encepha- litis virus (TBEV) antibodies in clinical JOURNAL CLUBS healthy dogs in South-east Sweden, To encourage study of scientific research arti- Mikael Svensson, DVM, AniCura cles many AniCura animal hospitals arrange Läckeby Djursjukhus, Kalmar, Sweden. “Journal clubs”. In these clubs veterinarians • Evaluation of whole blood hemostasis gather to study and discuss new research find- with thromboelastography in Cavalier ings and their implementation in clinical situa- King Charles Spaniels with different tions. Journal clubs are led by committed pro- severities of myxomatous mitral valve fessionals, often with an advanced academic disease, Josefine Öberg, DVM, Dipl background. Besides the training in critically ECVCP, AniCura Regiondjursjukhuset reviewing scientific papers, these meetings Bagarmossen, Stockholm, Sweden. also encourage the habit to discuss clinical situations with colleagues and take research into account in the daily clinical work.

16 AniCura Quality Report 2015 MEDICAL INTEREST GROUPS of veterinarians and nurses within particu- The AniCura Medical Interest Groups provide lar disciplines as well as provides access to a great opportunities for knowledge and best network of specialists that can be easily con- practice sharing as well as general information tacted regarding more complicated cases. It within specific disciplines. Any member of also provides a great way for less experienced staff may join an interest group to discuss and veterinarians and nurses to get acquainted share cases and insights and develop further with various fields, and be inspired to pursue within various medical fields. In 2015 AniCura a specialisation of their own. ran 12 medical interest groups, and new interest groups are established consecutively for ONLINE KNOWLEDGE BASE new disciplines. To further improve the medical quality level, Leading an interest group is a very AniCura has created an online repository of important responsibility and this is typically best practice documents regarding different shouldered by one or more persons possessing types of diseases and treatments. These docu- deep knowledge in a certain medical field as ments are often created by AniCura specialists well as a true passion to share and dissemi- and/or medical interest groups, and contain nate knowledge in the wider AniCura com- best practice treatments in each medical field munity. Whilst the detailed working forms of made available through research findings and the groups vary, they all provide a home for applied knowledge. Documenting and discuss- the different medical disciplines, and spread ing best practices are an improvement process current knowledge in each field. Examples of in itself, as competing lines of thought can crys- activities in the medical interest groups range tallise with a continuously improving result. from arranging courses and medical quizzes, Providing quick searchable access to these developing and disseminating best practice documents makes the condensed knowledge protocols, discussing cases, and arranging of various specialists available at the finger- physical group meetings. The activities are tips also for less experienced colleagues. The documented on AniCura’s Intranet so that knowledge base documents are intended to they are easily available throughout the provide a reference point which clinicians company. can use. The case-specific medical decisions Through the medical interest groups, however, always reside with the local, responsi- AniCura stimulates competence development ble veterinarian.

AniCura Quality Report 2015 17 Voices of AniCura

Christina Strand Thomsen, Veterinarian, Madelene Holappa, Veterinary nurse, AniCura Bergen Nord, Norway AniCura Veterinärboden, Åkers styckebruk, Sweden Why is it important for AniCura hospitals and clinics to monitor surgical site infections? Why is infection prevention and control important for patient safety? “The main argument for monitoring is that if you are not aware of a problem, you cannot do anything about it. “From an everyday perspective, I want our patients The easiest and by far the best way to detect a leaving the clinic to be healthier and in a better condition problem at an animal hospital is to have a documented than when they arrived. This of course includes that no infection control program in place. This has become transmission of micro-organisms should occur to the more and more important as the hospitals have been patient during the stay. In a longer perspective, I believe getting larger, more advanced and invasive procedures good infection prevention and control is essential to are being performed and as we see more immuno- reduce the need for antibiotics and thereby development compromised animals. Also with the emergence of of antimicrobial resistance enabling humans and animals multi-resistant bacteria (some with a potential to spread to receive adequate health-care also in the future.” to humans), the general public will expect that we as veterinarians will do our utmost to protect not only their pets, but also themselves.” Anna Tidholm, Veterinarian, AniCura Albano Djursjukhus, Stockholm, Sweden and Chairman of AniCura’s Scientific Council Bente Akselsen, Veterinarian and Practice manager, AniCura Dyresykehuset Tromsø, Norway Why is evidence based veterinary medicine important? Why is communication important to quality? What learning did you find most valuable in “Evidence based medicine in veterinary science is your communication training? essential for the development of the skills and knowledge that is required for every-day clinical work and “We find communication important in every aspect of sound decision making. Traditionally, both human and our clinical work and customer service. The way we veterinary sciences have mainly been based on clinical communicate amongst ourselves – sharing knowledge, experiences rather than on scientific evidence. In the planning our daily tasks and performing our work is 1970’s and 80’s scientists began to seriously question of importance not only for the atmosphere we have at the evidence behind many of the clinically based the clinic, but also for the quality of our work. Being “truths” that were agreed upon in the medical commu- a small animal hospital means working in team and nity, which resulted in the “Cochrane collaboration”. good communication is essential also for the safety Evidence based medicine has its origin in this collabo- of the patients. Personally I find that good internal ration, and can be defined as the awareness of a general communication leads to a good atmosphere that also lack of scientific evidence in every-day clinical decision is visible to our clients. Client communication is of making and the strive to increase this proportion.” course very important – showing empathy, applying good pedagogic skills to ensure compliance of a treat- In what way does a company such as AniCura ment and for simply providing good customer care. Our promote evidence based veterinary medicine? communication training had a very practical approach and was based upon clinical cases and good examples “Evidence based medicine requires large scale clini- from our everyday work at the hospital. It was evidence cal trials and investigations. Today, many veterinary based and we were given great communication tools we practices belong to companies that might provide the started using immediately.” environment for the development of evidence based

18 AniCura Quality Report 2015 medicine in the veterinary field. AniCura in particular Jens Ruhnau, Veterinarian and Practice promotes this development by allocating substantial manager, AniCura Tanddyreklinikken, financial support for scientifically sound clinical studies Copenhagen, Denmark and by providing the infrastructure for sharing know ledge and extensive collaboration within the company.” You have been very active in giving odontology courses within AniCura – why is training in dentistry so important? Helena Karlström, Biomedical scientist, AniCura Västra Djursjukhuset, Gothenburg, Sweden “Sharing knowledge is free. All AniCura clinics see many dental patients, so increasing our skills in this Why is quality within laboratory field creates better treatment options for many patients diagnostics so important? and thereby improving animal welfare. By sharing knowledge we can make more exact diagnoses, and “Laboratory diagnostics in veterinary health care hence give more accurate treatments. All clinics can be should be of the same quality as diagnostics in human trained to perform correct basic treatments, but also to health care. As more and more pet owners wish the diagnose more special conditions and refer to a relevant veterinarians to treat increasingly serious diseases in specialist for optimal treatment.” their pet, the quality level of the laboratory diagnostics needs to be unquestionable. Furthermore, pet owners should get the quality of the diagnostics they pay for. Hans Nieuwendijk, Veterinarian and But having the right quality assurance of the equip- Practice manager, AniCura De Tweede Lijn, ment is only one thing - the quality level of the labora- Willhelminaoord, Holland tory performance is also dependent on the competence of the laboratory personnel working in the laboratory Why do you think it is important for patient safety as well as the veterinarians correctly interpreting to reduce the amount of antibiotics we use within the results.” small animal veterinary care?

“Using antibiotics always puts a strain on the Thomas Rieker, Veterinarian and Practice manager, AniCura Kleintierspezialisten Ravensburg, Germany individual bacterial flora of each patient. For that reason alone antibiotics should be used with caution. Moreover, unwarranted use of antibiotics contributes How has the way you work with quality to the continuous ‘race of arms’ against the bacteria. changed since you became a part of AniCura? Whenever an antibiotic is used we aid in the development of antibiotic resistance.” “In Ravensburg, we have worked for high quality care for many years, but joined AniCura as it shares our vision of focusing on quality development. We appreciate the QualiCura approach which focuses on themes that we find really important such as hygiene and infection control as well as laboratory instrument quality and medical record keeping. We also like the fact that so much of the work is clinic-oriented and not “paperwork”. Quality development must take place in the clinics and we all have an important task of talking to each other about how we can improve things further. Setting and communicating clear goals and implementing them together with the staff in the clinic is key.”

AniCura Quality Report 2015 19

Improving professional communication skills

Research indicates that ineffective communi- The AniCura Professional Communication cation among human health care profession- Project focuses on pet owner experience and als is one major cause of medical errors and understanding with the aim to ensure that patient harm. Therefore, good professional clinical staff attains a correct understanding communication is a quality issue directly of the problem(s) presented by the pet owner. linked to patient safety. There is no reason The project is based on communica- to believe that this is different in veterinary tion trainings with AniCura staff members medicine. The problem presented by the involved in client communication in a clinical pet owner has to be recognised correctly to setting and also covers telephony. This impor- be solved. Medical staff must also be confi- tant first line communication helps ensure dent that the owner properly understands that the right choices are made throughout the implication of the medical issue for the the visit and treatment. A pilot communi- patient; the follow-ups, the prognosis and the cation project comprising several seminars recommended treatments as well as the costs. was launched in 2015. Feedback from the participants provided clear learnings about THE ANICURA PROFESSIONAL the importance of improving communication COMMUNICATION PROJECT skills in the professional daily work, as well as For the above reasons, the AniCura Profess- a good understanding on the best means of ional Communication Project was initiated training, supporting our decision to further during 2015. roll out the program across AniCura.

AniCura Quality Report 2015 21 Providing reliable diagnostic medicine

Veterinary medicine may be challenging as the invested in MRIs, CT-scanners and advanced patients do not describe their predicament and medical ultrasound machines and placed due to normal animal behaviour sometimes them in a large number of AniCura animal try to hide symptoms of disease or pain. hospitals. By the end of 2015, AniCura had 35 Experienced eyes and hands of professionals MRIs and CTs in operation. Individual training are together with the patient history provided of involved personnel have been performed in by the pet owner the most important parallel to the installations. AniCura radiology components for enabling good medical care. specialists combined with continuous In addition to these, diagnostic medical education for employees in evaluating procedures provide an increasingly important medical images, secure high level diagnostic tool. procedures. In addition to having several board Diagnostic medicine comprises diagnostic certified AniCura radiology specialists, we imaging as well as laboratory medicine. also use the services of specialised external Diagnostic imaging encompassing radiology institutions to decipher more complex images. (X-ray), ultrasound, magnetic resonance According to a study*, laboratory medicine imaging (MRI) and computed tomography diagnostics produce 94% of all objective data (CT), is a prioritised development field within in a patient record and 60 – 70% of all critical AniCura. Images not only support diagnosis decisions depends on data from the laboratory. made by veterinary professionals, images also This explains the efforts that AniCura makes aid the pet owner to understand the situation, within quality based laboratory medicine. which is crucial for compliance and successful Advanced laboratory instruments are available treatment. Diagnostic imaging also enables at all AniCura animal hospitals. Upgrades trained specialists to perform more minimally and new instalments occur continuously. invasive surgery techniques (e.g., arthroscopy, Laboratory medicine courses are provided laparoscopy, urethroscopy, bronchoscopy) with internally for all medical laboratory scientists lesser pain, shorter recovery time and fewer as a complement to the externally held complications as a typical result. courses in haematology, clinical chemistry AniCura invests substantially in advanced and cytology that AniCura personnel attend. medical equipment, development of skills and Regular case studies and webinars handling training to achieve high quality veterinary interesting cases inspire and enhance care. During the past three years AniCura has knowledge throughout AniCura.

* Evidence based pathology and Laboratory Medicine; Ed. A.M. Marshevsky and M.R.Wick, Springer 2011

22 AniCura Quality Report 2015 LABORATORY QUALITY All AniCura animal hospital laboratories ASSURANCE PROGRAM perform regular quality control procedures Accurate and reliable test results are essential on their equipment and have maintenance in providing the high quality care that is the agreements for their instruments, and more signature of AniCura. The AniCura Laboratory comprehensive documentation and SOPs are Quality Assurance program was put in place to being developed continuously. In 2015 several maximise the accuracy of laboratory results. AniCura hospital laboratories participated The program includes: in external quality assurance programs. The instruments at smaller AniCura laboratories • Documentation of processes, mainte- are remotely monitored and audited. nance and sampling procedures • Standard operations procedures (SOPs) for the methods and instruments used for the analyses • Quality control procedures used for each assay to ensure valid test runs and reliable results, e.g., kit controls and quality control samples • External quality assessment schemes

AniCura Quality Report 2015 23 Ensuring wiser antimicrobial use

Accurate veterinary treatments form an inte- ans within AniCura are requested to follow their gral part of AniCura’s focus on patient safety. national guidelines, but they are also engaged Antimicrobials/antibiotics are an important tool in promoting lesser and smarter use, which in the veterinary armoury to improve animal often means to challenge his or her own habits. welfare by defeating infectious diseases. These AniCura lends extra attention to the following drugs kill or inhibit bacterial growth and can be statements: life-saving. However, antimicrobials should be given with caution. They are not always benefi- • Antimicrobial therapy is only initiated if cial for the health of the animal. the patient is affected by a bacterial infec- If the patient with a severe infection receives tion that cannot otherwise be resolved the wrong antimicrobial substance or dose, it without being hazardous to the patient can impair the well-being of the individual or welfare. even be life-threatening. In addition, antibiotics • Initiated antimicrobial therapy is accurate given to a patient on erroneous indications will in substance, dose and dosing. The dura- be a disservice to the individual as an antimi- tion is kept to a minimum. crobial treatment harms the individual’s normal • Surgical antibiotic prophylaxis never flora lowering the natural immune system in the makes up for poor hygiene or lack of sur- body and the patient becomes more susceptible gery skills and is only given to qualified to resistant bacteria. Antimicrobial resistance is patients and must be given at the right also stipulated as the biggest threat to human time before incision. health according to the World Health Organi- • Local case-based discussions on patients zation (WHO) and it is therefore of significant needing or not needing antimicrobial concern also within veterinary medicine. Resist- treatments are regularly held to share ant bacteria are today affecting the welfare of knowledge and experience within the dogs and cats across Europe. All antimicrobial animal hospital. treatments, given to humans or to animals, will favour these bacteria, because other susceptible bacteria are killed. In turn, resistant bacteria To be able to further support and guide AniCura spread over country borders, between animals veterinarians to make wiser antimicrobial deci- and humans and among individuals. Hence, sions, QualiCura investigated the actual anti- a misuse of antibiotics to pets will not only be biotic prescribing behaviours. During a set time a danger to the individual itself, but also for period in the fall of 2015, veterinarians were humans such as pet owners, for employees and asked to fill out which canine patients received the community as a whole. systemic antibiotics; on what indication, what AniCura is operating in several different substance, duration of treatment, and if diagnos- countries and each country has its own tradition tic aids like cytology and/or bacteriology were concerning antibiotic use. Therefore, veterinari- used to support the treatment.

24 AniCura Quality Report 2015 STUDY RESULTS AND NEXT STEPS: the longer treatments. These results are in line The survey took place in Norway, Sweden and with guidelines. However, median duration for Denmark at 36 animal hospitals, representing surgical prophylaxis was 2 days, which is not 85% of the total number of patients received according to recommendations and should at AniCura during that time. During the study be shortened. Only few of the antimicrobial period, 339 dogs received systemic antibiotics, treatments were based on diagnostic analyses which means that about 5% of the canine (below 10%), which could be a drawback for the patients got treated. Mainly old substances patient’s welfare. of beta-lactam antibiotics were used, like The results together with comments and amoxicillin and amoxicillin-clavulanic acid. To specific tips on how to make wiser decisions our satisfaction, the use of newer and critically on antibiotics were communicated to the important antimicrobials as defined by WHO, like participating hospitals for the veterinarians to fluoroquinolones (Baytril) and third generation discuss. This survey also initiated educational cephalosporins (Convenia) was rare, only given case-based seminars to take place in the fall to 5% of the treated dogs. The main indications of 2016, formation of a new medical interest were wounds together with abscesses followed group on wound treatments and a request for by skin infections. Here we identified room for the surgical interest group to put prophylaxis improvements; with increased knowledge and guidelines in place. This study was unique in experience in wound treatments, some of these scale and scope, and will be followed by similar cases could have recovered well without systemic studies of antimicrobial use within AniCura to antibiotics. The median duration of treatment enable our veterinarians to continuously make in this study was 5 days and ranged from 1 to 30 wiser decisions around antimicrobials. days where patients with skin infections received

AniCura Quality Report 2015 25 Monitoring surgical site infections

An important part of veterinary medical surgical parameters and then to check up quality is to monitor health-care associated on surgical patients after surgery through infections (HAI). One of the most fundamental visits, telephone calls or emails. If the surgical HAI to monitor are surgical site infections wound had not healed as expected, it had (SSI). Without data on SSI, it is difficult for the to be sampled for bacteriology culture and animal hospitals to evaluate their surgical susceptibility testing. The bacteriological outcomes and to improve their surgical result is essential because it gives information procedures if needed. In addition to patient about the causative agent and if the suffering and frustration for pet owners and antimicrobial prophylaxis is correct. In members of staff, SSI cause unnecessary costs. addition, compiled bacteriology results can One challenge with this type of monitoring reveal an outbreak at an earlier stage and is the follow-up of patients that have been thus be handled more promptly. This is the discharged from the animal hospitals. If the first multi-centred survey on SSI performed hospital relies on pet owners coming back across several European countries within a in case of complications, the number of companion animal health care group. unknown cases will be high. The pet owner may visit a different hospital or veterinarian or the infection may heal by itself. To get accurate data on SSI, surgical patients need to have a proactive follow-up. To initiate local improvement processes for surgical outcomes, in the first quarter of 2016, QualiCura focused on SSI, and a survey of SSI incidence was launched including an investigation of risk-factors. The AniCura hospitals were requested to record certain

26 AniCura Quality Report 2015

Securing proper infection prevention and control

Infection prevention and control is an essen • Tasks and mandates of ICPs tial tool to reduce the risk of microorganism • Personal appearance transmission including multi-drug resistant • Hand hygiene bacteria in health-care settings, and thereby • Personal protective equipment minimising the risk of patients visiting • Laundry AniCura hospitals to develop a health-care • Cleaning and disinfection of associated infection. An infection control environmental surfaces program is a preventive measure, designed to • Cleaning and disinfection of medical protect patients, but also to reduce the spread reusable equipment of infectious agents to pet owners, veterinary • Surgery personnel and the community. This has been in the last decade an increasingly • Dental procedures important focal point for hospitals within • Patient handling including work at AniCura. Already in 2011, joint AniCura isolation area or ward guidelines were discussed and disseminated • Surveillance of health-care to complement the local on-going infection associated infections control programs in the hospitals. As AniCura • Staff compliance measurements has grown, the best-practice guidelines have been updated and disseminated in The activities mentioned above are to be docu- countries outside Sweden. New guidelines mented, and together form a local written infec- were completed in the beginning of 2016 tion control manual for all members of staff to and approved as AniCura’s Infection Control recognise and comply with. If the local activities Program by AniCura’s Scientific Council. significantly deviate from AniCura’s Infection Every animal hospital within AniCura Control Program, an improvement plan is to be must have an infection control program and made and implemented by the ICPs. Group guidelines are meant to be a support for the development of local programmes. In AniCura’s Infection Control Program, we The program is coordinated by one or communicate the importance of frequent use of more members of staff, so-called infection alcohol-based hand sanitiser. Research* shows control practitioners (ICP). They are the local that good hand hygiene is the single most resource for infection control issues and they important preventive measure to stop transmis- are appointed by hospital management. In sion of micro-organisms. Use of alcohol-based AniCura guidelines, there are also protocols hand sanitiser is more effective compared on how the following work should be carried to washing with soap and water; in killing or out to minimise spread of micro-organisms: removing microorganisms and in maintaining hand health and skin integrity.

* “WHO Guidelines on Hand Hygiene in Health Care”

28 AniCura Quality Report 2015 Promoting patient medical record quality

Proper medical record documentation The goal of problem-oriented recording is to facilitates diagnosis and treatment and keep writing at a minimum and only record communicates pertinent information to what is relevant to the patient’s health prob- colleagues within the same hospitals or at lems and important for communication referral hospitals to ensure patient safety and and continuity of care. A problem-oriented reduce medical errors. The complexity of the approach is especially useful for records patient medical record has evolved in line of patients with multiple diseases that are with the development of more comprehensive observed during long-term follow-up. and advanced diagnostic and treatment options, making the process of completing the PATIENT MEDICAL RECORD REVIEWS patient medical record more challenging and To identify and disseminate best practices increasingly important. within patient medical records, AniCura QualiCura focuses on patient medical animal hospitals are encouraged to perform record quality by emphasising the following regular reviews of their records at staff key points: meetings. Reviewing normally comprise randomly chosen records, as well as selected • Update or complete the patient medical cases e.g., new diseases, new diagnostic record without any unnecessary delay or treatment procedures, morbidity and adjacent to the consultation or the mortality rounds, etc. medical procedure performed Medical record quality is a focus area • Document every action related to the within QualiCura and is being measured patient’s medical status and discussed in more detail across AniCura during 2016. • Organise the medical record in a problem oriented structure

Enabling good incident handling

An incident is an unexpected and unwanted incident handling procedures will improve the occurrence that interrupts normal procedure general performance and reduce the need for or function. Depending on the circumstances, “firefighting” by applying root cause analysis an incident may lead to damage, disaster, after undesirable events are experienced. or loss with a possible or obvious negative According to a QualiCura survey impact on the patient safety, client satisfaction conducted during 2015, 54% of measured and/or working environment. Human AniCura hospitals (representing 65% of patient resources issues related to staff interactions visits) had some kind of incident handling and work conflicts are not included and are procedure in place. QualiCura will support handled by other procedures. the sharing of best practice in this field, and The reasons for focusing on incident encourage additional clinics to start working handling procedures at AniCura hospitals with incident handling procedures. Best are to ensure the existence of procedures for practices identified within AniCura should restoring normal service operation as quickly describe the sequence of steps that begin as possible and minimise the adverse impact. when an incident reaches the staff and ends The aim is to ensure the best possible levels of with implementing needed corrective actions, patient safety and client satisfaction, as well but should also be designed to require as as working environment. Well-functioning smooth administration as possible.

AniCura Quality Report 2015 31 External controlling bodies

In addition to the comprehensive internal professionals received admonitions during quality improvement work AniCura’s animal the year. These have been handled locally, and hospitals perform within or outside the commensurate measures have been identified QualiCura program, the veterinary medicine and implemented to minimise the risk of the field in which AniCura operates is governed incidents occurring again. and controlled by various external and gov- Providing high level veterinary care ernmental bodies. These structures are dif- in many varying situations to more than a ferent in each country, with varying modus million patients a year unfortunately means operandi and degrees of transparency. that mistakes sometimes are made. This AniCura welcomes external bodies, and coop- requires well established and systematic erates with these in all countries, e.g., Ansvars incident handling procedures. AniCura is nämnden (Sweden), Rettsrådet (Norway), Forbruger confident that its QualiCura programme and klagenævnet (Denmark), various veterinary the activities set forth in this report leads to chamber bodies (Germany, Austria, Switzerland) higher patient safety and medical quality. and VTC (the Netherlands). Most of the above bodies In addition to the above, several AniCura do not disclose rulings publicly, but in the case of clinics participate in the various quality ori- Sweden, Ansvarsnämnden’s rulings are non-confi- ented schemes managed by the national vet- dential and can be broken down as follows (rulings erinary organisations in each country, such provided at meetings held during 2015): as “Svensk djursjukvårds kvalitetssigill” (SE), “Norske Veterinærforenings sertifiseringsord- • Revoking license 0 ning for dyreklinikker” (NO), “Gute Veterinär- • Warning 5 medizinische Praxis” (DE), “Centraal • Admonition (“Erinran”) 15 Kwaliteitsregister Dierenartsen” (NL), etc. AniCura encourages animal hospitals that • Acquittal 63 in addition to the internal quality work wish No veterinary professionals in AniCura to have it externally recognized and tested in Sweden received a warning. Two veterinary their respective markets.

32 AniCura Quality Report 2015 Future development of program

This AniCura Quality Report is mainly focusing We value input from colleagues within and on already ongoing initiatives within AniCura. outside AniCura, and welcome innovation and Every day, every hour, we are getting smarter apply resourcefulness when faced with new on how to structure and systematise our quality challenges. The journey of improving quality programs and improvement projects. AniCura was started a long time ago in AniCura’s many is a learning organisation, and future prospects animal hospitals. When we now have the within the area of systematic quality develop- opportunity to work together in a larger setting, ment are exciting and full of opportunities. we witness over and over again how we inspire Our ambition is to be the leader within and help each other to progress and to develop high-quality veterinary care. AniCura is faster and more accurately than before. striving for quality excellence by continuously Looking ahead and bolstered by the posi- challenging, analysing and improving the way tive feedback we are receiving, AniCura will we work. We believe that continuous quality continue to explore and develop the QualiCura improvement is an ongoing effort that requires program as we analyse our learnings and seek transparency, teamwork and integrity. By to push the boundaries even further. Working cooperating, sharing knowledge and best with quality improvement is an ongoing practice we benefit from the latest available process involving all our animal hospitals and findings, and realise new ideas earlier. members of staff, every day, every hour. About AniCura

AniCura is a family of well-known animal care, surgery and orthopaedics. AniCura also hospitals and clinics specialised on veterinary provide rehabilitation, physiotherapy and care for companion animals. Born out of the dietary advice and offer selected pet food and idea that sharing resources creates opportuni- care products. ties for better veterinary care, the company For information on how AniCura is working was established in 2011 as the first merger of to shape the future of veterinary care, please companion animal hospitals in the Nordic visit our website www.anicuragroup.com region. Today, AniCura is a role model within specialised veterinary care and a valued partner for pet owners and referring veterinarians across Europe. The company offers a wide range of high quality medical services covering preventive and basic health care as well as advanced diagnostics, internal medicine, intensive

34 AniCura Quality Report 2015 AniCura AB Rinkebyvägen 21B | 182 36 Danderyd | Sweden www.anicuragroup.com