Client Expectations, Rights, and Responsibilities: Setting Client Expectations to Protect Practice Culture

When it comes to workplace culture, it’s tempting to focus primarily on the behavior and attitudes of veterinary practice team members. But given the link between practice culture and patient safety, it’s risky to ignore the importance of client interactions, too.

Rights and responsibilities documents let clients know what they can expect from healthcare professionals and what is expected of them in return.

by Cyndie Courtney, DVM

When it comes to workplace culture, it is tempting to focus primarily on the behavior and attitudes of veterinary practice team members. But given the link between practice culture and patient safety, it is risky to ignore the importance of client interactions.

In a blinded study in 2016, neonatal intensive care unit (NICU) teams participating in a training exercise were randomly assigned to either the “neutral” or “mildly rude” parent comment group. The rude statement significantly impacted that team’s diagnostic and treatment scores as well as their ability to work together as a team. These findings are consistent with other research showing how toxic behaviors and lack of teamwork can increase medical errors and patient mortality.

How prepared are practices for this threat? How would a team member respond if a client states that they decline to see a particular veterinarian because they felt his name sounded too “ethnic” and expressed doubt that the veterinarian would speak fluent English?

Practices can set up client interactions for success so that they are more likely to reinforce, rather than undermine, a positive practice culture.

Preventive Care for Practice Culture

One of the reasons conflicts occur is that “civility” isn’t one size fits all.

Broad moral themes against harming others (especially the less powerful), injustice, disgusting actions, betrayal, disrespect, and oppression are relatively consistent, but conflicts between these principles may result in ethical dilemmas and disagreements. What people interpret as polite behavior also varies by culture, experience, and current context. For example, those unfamiliar with Deaf culture may not anticipate potential cultural misunderstandings over how to get someone’s attention, how to describe people physically, or how long to say goodbye.

For some veterinarians, it’s no big deal if a client forgets their professional title, mispronounces their name, or even gives them a cheeky nickname. For many others, one or all of these are offensive. Social interpretations can be colored by life experiences, but even when people have similar backgrounds, empathy can take effort. People may actually be more judgmental of those enduring a hardship that they themselves have already overcome.

Even perceived social slights can cause social pain, and social pain shares significant neural pathways with physical pain (Eisenberger & Lieberman 2004). As a result, mismatched social norms can trigger emotional distress that boils over into an escalating cycle of destructive conflict. This cycle is even more common when parties respond with defensiveness, blame, or judgment.

Please note that while different social norms may be one explanation for conflict—and thus a target for treatment—they are not an excuse for causing harm. It may also be tempting to see differences as a liability that can lead to conflict, which, if left unaddressed, might cause the practice to veer off into homogeny.

Instead, practices should take advantage of the creative and problem-solving benefits of diverse perspectives to build collaborative guidelines that define practice-specific behavioral expectations and boundaries.

Some practices have already started creating and maintaining new social norms—sometimes by establishing core values or by outlining expected behaviors more explicitly. Reasonable guidelines can be extended to other regular practice contacts, including clients.

Client Rights and Responsibilities

Letting clients know what they can expect from their healthcare team and what is expected from them may not only decrease conflict but also improve trust and increase client participation in medical decisionmaking.

Human hospitals started offering a patient bill of rights in the 1970s, at least partly in response to horrific cases of at-risk patient exploitation by scientists and medical professionals. The term “patient bill of rights” seems to have fallen out in favor of “patient rights and responsibilities.” Additionally, in the US, focus seems to have shifted away from patient rights awareness to promoting medical advocacy and health literacy so patients can take advantage of those rights. Unfortunately, medical discrimination is still a concern with devastating impacts.

Rights and responsibilities documents let patients know what they can expect from healthcare professionals and what is expected of them in return. What can be done to prevent this from becoming another document that clients will not read? While their human counterparts run from two to nine pages, veterinary practices should aim for a concise one- to two-page document. Prioritize sharing expectations to prevent harm and promote practice culture. Another approach is to hand all clients a summary of expectations with the option to review a more detailed policy. Write with simplicity in mind, considering that that most people read at an eighth-grade level, comprehend at a sixth- or seventh-grade level, and prefer to read at even lower levels when they are stressed and/or reading health information.

Given the diversity of local legal obligations, it is also recommended that practices review completed documents with a lawyer.

What Can Clients Expect from the Practice?

Practices can explore, summarize, and cite resources like:

Practices should set realistic expectations—promising what they can’t deliver will only create more conflict. That being said, this is also an opportunity to assess where practice policy may need to change to match not only veterinary ethical and legal obligations but also what clients want and need.

Mutuality is key. For instance, practices need clear information to diagnose and treat patients, so they should provide clear information to clients who are making decisions about their pet—whether that means providing it verbally, printing it in a larger font, or translating it into Tagalog, which, in 2010, was the fourth most common spoken language in the US (US Census Bureau 2013).

Thinking about client expectations is also an area where practices can stand out from their competition—what benefits can clients expect from this practice that they won’t get anywhere else?

What Does the Practice Expect of Clients?

It is not possible to prevent all client catastrophes by setting strict client expectations. The attempt would result in an endless document, which would put clients on the defensive. Instead, start by sharing what the practice hopes to achieve and how clients can help.

For instance, consider the case of a practice that wants to support clients with immune suppression while maintaining client privacy. They can ask clients to disclose whether a pet is in contact with any people with a suppressed immune system, but the client doesn’t have to disclose the cause of the immune suppression or who is immune suppressed.

Again, practices can create mutuality by balancing practice expectations with client expectations. (See the table below.)

Another important point is to share potential consequences for not meeting client expectations, especially the most abused practice policies, including:

  • Payment
  • Work-in or after-hours emergencies
  • Late, no-show, and cancellations
  • Prescription refills
  • Ending a veterinary-client-patient relationship
Practice team is expected to . . . Clients are expected to . . .
Use desired titles, names, pronouns Refer to clinicians as Dr. Last Name
Take pet owners’ perspectives seriously Respect veterinary medical training and experience
Provide discrimination-free veterinary care Refrain from making discriminatory complaints or service requests (e.g. “Daisy has always seemed afraid of Black people, can we see another veterinarian today?”)

A Living Document

The client rights and responsibilities document augments, but does not replace, a positive practice culture and meaningful policy.

Mary C. Gentile, PhD, of the University of Virginia Darden School of Business and founder of Giving Voice to Values argues that often the primary challenge for confronting ethical dilemmas is not in recognizing that something is wrong, but in not knowing how to respond. This is particularly challenging for team members when there appear to be conflicting priorities. If established practice norms include avoiding conflict and keeping clients, team members must figure out how to integrate this with setting clear, kind boundaries.

Prepare team members to act on these new guidelines by walking them through ethical challenges. While role play is ideal, they can also write down or discuss how they expect to feel and respond, potential concerns or obstacles they might face, and resources they can use.

Client rights and responsibilities will evolve over time as norms change and as the team recognizes which elements are most useful and important.

Conclusion

How could writing, sharing, and training the team using an antidiscriminatory client rights and responsibilities document have helped in the case of the racist comment at the beginning of this article? The document could potentially do the following:

  • Prevent the comment by
    • Helping toxic clients self-screen away from the practice
    • Signaling to new and returning clients that certain behaviors are unwelcome
  • Empower the team member to
    • Recognize that the client’s behavior is clearly inappropriate and ask for help if needed
    • Practice possible responses to situations, including questioning the client’s assumptions and setting boundaries
  • Outline clear consequences for the client, which, dependent on practice culture and/or the impacted employee’s preference, could be asking the client to transfer patient care to another facility

Practice culture is important, but it is also vulnerable. Set client expectations from the outset to proactively protect your practice culture and with it your team, patients, and practice performance. 

Resources

Barnett MD, Steven. “Clinical and Cultural Issues in Caring for Deaf People.” Family Medicine 31:1 (Jan. 1999), 17–22.

CDC. “Simply Put: A Guide for Creating Easy to Understand Materials.” (April 2009).

Eisenberger, Naomi I, Liberman Matthew D. “Why rejection hurts: a common neural alarm system for physical and social pain.” Trends in Cognitive Sciences 8:7 (July 2004), 294–300.

Haidt, Jonathan. The Righteous Mind: Why Good People are Divided by Politics and Religion. New York: Vintage, 2013.

Hocker, Joyce L., William W. Wilmot. Interpersonal Conflict, Tenth Edition. New York: McGraw-Hill Education, 2018.

Riskin MD, MHA, Arieh; Amir Erez, PhD; Trevor A. Foulk, BBA; Kinneret S. Riskin-Geuz, BSc; Amitai Ziv, MD, MHA; Rina Sela, CCRN, MA; Liat Pessach-Gelblum, MBA; Peter A. Bamberger, PhD. “Rudeness and Medical Team Performance.” Pediatrics 139:2 (Feb. 2017).

Ruttan, Rachel, Mary-Hunter McDonnell, and Loran Nordgren. “It’s Harder to Empathize with People if You’ve Been in Their Shoes.” Harvard Business Review (Oct. 2015).

Safeer MD, Richard S. and Jann Keenan Ed.S. “Health Literacy: The Gap Between Physicians and Patients.” American Family Physician 72:3 (Aug. 2005): 463–68.

United States Census Bureau. “Top Languages Other than English Spoken in 1980 and Changes in Relative Rank, 1990–2010.” (Feb. 2013).

Bonus Content

Download a free Client Rights and Responsibilities document template.

Cyndie Courtney
Cyndie Courtney, DVM, founder of The Jerk Researcher, is a small-animal associate veterinarian and recovering toxic team member practicing south of Kansas City. She researches, writes, speaks, and provides coaching on using conflict prevention and resolution to improve wellbeing and performance. She received the 2019 World Small Animal Veterinary Association Next Generation Award for her service to the public and the profession. As a doctor with epilepsy, she also brings her perspectives on disability to her work and her writing. Find her online at thejerkresearcher.com.

 

Photo credits: FG Trade/E+ via Getty Images, Aja Koska/E+ via Getty Images, DenGuy/iStock via Getty Images Plus 

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