Standard of Scare

You're probably wondering what sort of actual, factual organizations and standards bodies are standing by your pet during his or her next veterinary excursion. Prepare to be surprised.

You've probably seen the AAHA Accredited stickers outside your local vet clinic, but you probably never considered what it meant. You may also have had to visit an emergency hospital and wondered what, if anything, veterinarians think an emergency hospital is supposed to be. Today you're going to go on a journey where you can learn about all that and come to your own conclusions. You're also going to meet some of the organizations behind all those processes, as accreditation in veterinary medicine is totally voluntary and also usually directed by the same organizations that represent the veterinary business. From an outside standpoint, imagine if human medicine rolled the responsibilities of something like the Joint Commission (responsible for hospital accreditation and standards) and the American Hospital Association (industry trade group) into the same organization and expected that somehow it would all just work out.

AAHA! Meet the American Animal Hospital Association

One place to begin your journey is with the American Animal Hospital Association (AAHA). They're the major trade association that represents veterinary hospitals and their mutual interests. They're also the self-appointed and totally optional accrediting agency that goes around and certifies the standards of those very same hospitals. Imagine if human medicine rolled the responsibilities of something like the Joint Commission (the primary body responsible for hospital accreditation and standards) and the American Hospital Association (the industry trade group) into the same organization. You might find that concerning. Your veterinarian might not. In any event, you're supposed to treat that AAHA accreditation on the window as a gold standard; the sad fact you're about to learn is that none of us can really know, but we'll get to that.

The AAHA "is the only organization that accredits veterinary practices in the United States and Canada" and "unlike the human health world, accreditation of animal hospitals is voluntary" according to its own website. Some of their touted benefits include "a strong indication that a veterinary practice delivers quality medicine" and "raises the bar," yet the actual bullet points consist of decidedly nonmedical outcomes like "fewer lapsed patients," "more new customers per year," "clients who choose more care," "higher customer loyalty and retention," "better staff utilization," and "more annual revenue." You might assume things like fewer readmissions, decreased morbidity, and decreased mortality might be on that list, but they're apparently not relevant or not viewed as selling points as of press time. People sometimes compare vet clinics to car dealerships, and perhaps their gut instinct is not entirely wrong.

Being a member also comes with a variety of member benefits for your clinic and staff, including discounts on classes you can take regarding their own guidelines. You can even earn an "Anesthesia Champion" Credly badge for your four-hour totally-online anesthesia safety class built around their standards. By the end of the course you'll be competent with "creating an atmosphere of mutual trust and understanding" with pet owners, most of whom probably won't know how you got that badge.

As far as what it takes for you to actually get your hospital accredited? There's a seven-step process for hospital accreditation starting with an initial review and payment of $695 to begin the process. At that point you get six months of initial access to AAHA services and are assigned a dedicated sherpa to get you up to the top of this particular rock while you submit supporting evidence. If you don't make it, the evaluation visit is converted to a courtesy visit, and you can go back and remedy any deficiencies. It appears that the final evaluation visit need not even be done in person. Since the age of COVID they're apparently willing to do the final sign-off on your hospital over a webcam during a virtual evaluation!

What does the evaluation entail, you wonder? To actually become accredited you have to meet the AAHA accreditation standards, but out of 900 apparently only about 50 are mandatory. The rest are done on some kind of points-grading basis. What are the standards they're being graded against? None of us get to know: "AAHA Standards of Accreditation are copyrighted and exclusively available to AAHA-accredited and preaccredited members." (While AAHA Guidelines on the diagnosis and treatment of particular conditions are published for free on their website, that's a totally different matter entirely.) One thing that's not a requirement is employing certified staff according to their FAQ: "employing credentialed technicians is not a requirement for your practice to become accredited." Another thing that's not are written protocols even though elsewhere they're listed as being part of the accreditation process: "Written protocols are not mandatory to achieve AAHA accreditation."

Fortunately, we do get a sneak peek at what some of the basic requirements are so you can check yourself before you apply. Some of those requirements include that patient care must happen "under the authority" of a licensed veterinarian and that the surgical suite can't be cluttered with other things like radiology equipment. You also must be a "full-service hospital" and be able to refer out emergency patients. During anesthesia, you must use at least one of a respiratory monitor, pulse oximeter, blood pressure monitor, continuous ECG, or esophageal stethoscope to monitor your patient. Other requirements include always considering pain management, having cages that animals can't get out of, and the ability to provide oxygen on at least a periodic basis. Most people probably assume things like that are the bare minimum to being able to open a veterinary clinic rather than the industry's self-proclaimed gold standard.

What do you do to maintain your accreditation once you've reached the big time? You keep sending them dues, and every three years (two years for new facilities), they'll send someone out to check up and reaccredit the hospital. There's no suggestion so far of anything else, such as reporting of statistics, in the meantime to see if anything's gone haywire in the absence of their onsite or virtual inspector.

So do they collect any kind of statistics to see how well they're actually doing? They have some "open standards" related to financial reporting and consistent coding of medical terminology, and that ties in to some of their proprietary revenue-focused data offerings through a partnership with Chewy Health (formerly Petabyte). Their benchmarking system, only available to veterinary clinics but not apparently limited to AAHA practices, helps you with practice management and data analysis. Some of the information includes comparisons with other clinics' anonymized data to derive dashboards and SPOT (Sales revenue, Producer performance, Opportunities, and Trends in medicine). A wise man once said that a veterinarian is a person who converts a pet into an annuity; it appears the AAHA's here to help maximize returns.

It's a strange thing to behold. In general, terms like "accreditation" and "hospital" tend to be thrown around, along with other words like "certification," "guideline," and "site visit," but to what effect? We have an accreditation process that looks more like a Scientology audit than something from a hospital accreditor; nobody but select people who have already bought in even get to see the copyrighted Tech Levels, and then you get some guy from Vet Org that helps you get all the way up to Operating Thetan. If a suppressive person or potential trouble source starts asking questions, well, it's all copyrighted and illegal for you to own or distribute. The difference is that in this case the actual marks are the customers; you're supposed to shop around for "AAHA Accredited" on the door but you're not permitted to know what, if anything, that actually means, and apparently it doesn't include having certified help or having protocols written down anywhere.

Emergency!

Much like the AAHA behaves as sort of a simulacrum of the accrediting process in human healthcare, there's a veterinary equivalent of the certification process for emergency and trauma centers. The Veterinary Emergency and Critical Care Society (VECCS) groups facilities into Level I, Level II, and Level III facilities, and unlike the AAHA, they do publish their guidelines. Recently, they even re-opened their accreditation process.

First a bit of history. The published standards from 2021 run a scant 22 pages including a table of contents. Several pages are devoted to required bedside references and textbooks, while other sections relate to continuing education requirements for staff. Some key requirements to be a Level I center include having a veterinarian with at least two years of practice experience (or less with an emergency-focused internship or residency) available at all times, along with having a board-certified radiologist available by some means. Most people probably think any of the major veterinary hospital centers have all this stuff at their disposal, not just the crème de la crème.

At some point there must have been a problem with their process, as in late 2023. At that time they declared a "temporary pause" that went on "until further notice" and continued to remain paused for a while. More recently the notice went away and the accrediting process is back in business for the cost of $500 per submission. According to the website, you can expect to receive your certification (if all is well) in about four to six weeks, just like the typical as-seen-on-TV product of the late 1980s.

Along with being back in business was a new set of standards, this time clocking in at 20 pages. You should read it yourself, but just to give you an idea of the flavor, one of the standards requires all Level I (the top) trauma centers to have an emergency generator or backup in case the power goes out; to prove it, you need to send them a photo of it. Level I and Level II centers need to have a defibrillator; photos are also required. All centers are required to have RECOVER CPR posters posted in the triage area and anesthesia areas; Level I and Level II facilities need to have one of their posters up in at least one other location in the hospital. Again, photos are required. Among other notes, they also define "evaluate" as literally looking at the patient and taking a history, as some animals and conditions may not be amenable to actually handling them (in an emergency clinic).

One thing that they note on their website is that the accreditation process has nothing to do with the actual care provided by the critical care facility and it's all done on the basis of a checklist: "VECCS and the Committee have no intention to judge the quality of medicine that is practiced within a facility, or to evaluate their business decisions, policies and procedures. To perform its evaluation, the Committee completes a checklist audit." As a practical, if somewhat contrived example, what they're saying is that they score you on what you have at the hospital, not what you do with it. In other words, if your Level I emergency vet made a blood sacrifice to Mephisto as part of his treatment plan, one wonders if that would affect their facility's certification. My guess is that they'd tell you it's merely a matter to report to your state veterinary board.

And no trip to the veterinary establishment's emergency hoedown would be complete without a trip to VetCOT. VetCOT, not a theme park, is is the Veterinary Committee on Trauma. While not the same as the VECCS, they're all in the same general orbit, and all survive and thrive within the American College of Veterinary Emergency and Critical Care (ACVECC) milieu. VetCOT has their own three-level system of trauma centers that builds on top of the VECCS standard as the entry credential, and they also publish some of their checklists for membership; this process is known as verification. You can view one of the REDCap surveys at this link. Some of it sounds like a hospital.

VetCOT is also notable in that they do collect actual statistics from their approved trauma centers. In theory, this could be similar to a real-life trauma registry. You could look at trauma cases that come in, how they were doing, how they ended up doing, and where it happened at. In fact, in many states, trauma registry statistics (once anonymized) can be viewed by the general public, and it's one of the few real windows we have into the performance of our health system. Boarded emergency vets, as you probably guessed by now, went in a different direction. They have a registry and they require their affiliates to send information to it, but the actual data is kept hidden even from the vast majority of its members. Only ACVECC Diplomates (or residents in training under an ACVECC Diplomate) who apply for access to the registry as part of a research project and successfully score enough points on the submission form get to really poke around in there. (You get 10 extra points on your application to see the data if you actually work at one of their verified trauma centers!)

So what?

As with other veterinary matters, a first glance gives the impression that many of these organizations employ a variety of serious-sounding terms but may not necessarily be carrying through on the public expectation they're setting. From my standpoint, it reads like a group of Junior Achievement business kids employing the economic canon from Smith and Hume to Galbraith and Hayek while operating a lemonade stand. It certainly sounds impressive, but on closer inspection it may not be what it appears.

I'd also be particularly curious what people working in the human equivalents of these centers would have to say after reading the linked sources. Does it read more like an attempt to upskill a profession, or does it read more like an attempt to seek rent and potentially defraud? Would you expect, for example, that if you spent thousands of dollars a day at a Level II Veterinary Trauma Center, that they're not required to have a backup power source if a storm blows in? Do you feel safe knowing that the only veterinarian on premises at your certified emergency center may have only been in the biz for two years?

More importantly, after reading what it takes to meet the above (completely independent and nonenforceable) standards, would you entrust a dying pet to that system? Do you think it meets your standards? And if not, could you look into your pet's sad eyes and know you did your best by sending them there? Then again, where else would you take them?