Grow Your Medical Practice

The Top 5 Obstacles to Growing Your Professional Services Firm

(You Can’t Side Step What You Don’t See!)

Train Your Medical Practice Staff

Let’s start with a case study – Dr. Challa and the Kansas Medical Clinic, a large and growing medical practice with offices across Kansas. (They have been part of our medical coaching program for over five years now.)

Dr. Challa Medical Practice Owner

Dr. Challa and his team at Kansas Medical Clinic improved his practices systems and developed his management team to spark consistent growth in his multi-clinic practice.

As the practice expanded, Dr. Challa and his team began to experience the challenges of outgrowing the systems that had worked so well when they were a single-location GI clinic with close oversight from Dr. Challa.
Remember that old PBS television show called This Old House? Imagine you’re on it, working on a seventy-five-year-old house with its original electrical wiring and plumbing. What would happen if you plugged in to that house a full complement of modern electrical appliances? You’d blow your fuses, not to mention risk an electrical fire. And what would happen to your plumbing if you went from a well-water system to tapping into the higher pressure of city water? (Can you say “rain gear”?) 

The same is true for the systems you use to scale your medical practice. Too much growth that places increasing demands on old, outdated systems can put the whole operation under water. The systems that worked for a $2.5-million-a-year, single-office practice are no longer sufficient to cope with a $15-million, five-location practice, and not even close to being adequate for a $53-million-a-year multicity practice. At first, the additional sales will cause a few “leaks,” but before long, your practice will have burst pipes and water everywhere.

Of course the first major hurdle most practices face in efficiently and consistently running the various functional “pillars” of their practice (i.e., marketing, clinical, HR, finance, etc.) is that they don’t have formal business systems. Instead, they lean heavily on the individual ability and informal systems that a few key office team members hold in their head (or perhaps on sticky notes around their desk). 

What happens if one of these team members gets hurt? Of if her spouse gets transferred and she puts in her notice? Just like you want to protect your practice and all of your employees should anything happen to you, you need to protect your practice in case a proverbial “bus” hits one of your key employees. 

Your business systems are a crucial stabilizing factor to protect the practice, your staff, and your patients (not to mention all of their respective families, who indirectly rely upon the practice). So, just what are systems?

Systems are reliable processes and procedures that empower your practice to efficiently and consistently operate to profitably produce great health services for your patients. They’re documented best practices that increase your practice’s efficiency and reduce costly mistakes. Systems include documents and processes, such as the checklists your clinical team follows to ensure that patients get the optimal health outcome, as well as the orientation process you put all new hires through, the standardized contracts you use with your vendors, and even the scripts your phone team uses to convert phone inquiries into new patients. Your business systems include any company know-how of how to run and operate your medical practice that is captured in a tangible format versus locked in the brain of an individual team member.

Let’s return to Dr. Challa. When he first began in the business coaching program five years ago, one of the most impactful outcomes of
the program for his practice was introducing and institutionalizing the creation, organization, use, and refinement of formal systems across the practice. Up until that point Dr. Challa’s team had had a hodgepodge of business systems. If one of his clinics had a particularly skilled clinic director, that location developed powerful tools (i.e., systems) to help it operate smoothly and effectively. But thirty miles away, at a different location, those best practices might very well be totally unknown.

Think of how much Dr. Challa’s practice invested—in terms of staff time and attention—to create those systems at the first clinic. Yet those practices remained entirely siloed, unavailable to their team members down the road. Further, as the practice grew still larger, it needed its systems to grow with it, but there was no formal culture inside the practice of creating, using, refining, and sharing best practices across locations.

The challenge wasn’t just a matter of formalizing best practices in writing, either. Dr. Challa’s team was consistently frustrated and wasting time on things as simple as trying to find a vendor contract because there was no central, organized storage location for all their developed systems. This lack of a structure to house and access their systems wasted time and hindered the efficiency and growth of the practice. “Somebody gives an important file a name and puts it in a folder,” Dr. Challa told us, “while someone else goes looking for it, can’t find it fast enough, and ends up creating another file.” This happened in lots of different situations. When his staff began interviewing to hire a new physician, they drafted a term sheet to summarize salary, benefits, bonuses, and terms of employment. They ended up conducting three interviews in a six-month period—but every time they
needed that document, they couldn’t find where they had put it. They recreated that term sheet three times!

This isn’t a sexy problem, but it’s exceedingly common—and costly. And even as the Kansas Medical Clinic was outwardly successful, and increasingly in demand among patients in their region, Dr. Challa knew they needed to solve this internal problem if they wanted to continue to grow their regional medical group to more locations.

Using Your UBS

In this chapter, you’re going to learn a powerful concept called your “UBS,” which stands for “Ultimate Business System.” It was a concept that David created close to two decades ago, when he was scaling one of his large companies. Your UBS is both the organized collection of systems you develop and use to run your clinic, as well as the term that reminds your team to make the daily use, storage, refinement, and sharing of systems part of the culture of your practice.

Most commonly, your UBS is an organized collection of digital folders of practice systems that are stored in the cloud. Your practice systems can include things like the following:

  • Checklists for new-patient paperwork, clinical procedures, and even the cleaning of an exam room
  • Standardized paperwork for new hires, HIPAA releases, and post-procedure release documentation
  • Databases of key information on referring medical groups, reimbursement-coding “cheat sheets,” and vendor pricing
  • Documented processes and step-by-step instructions on how to use your EMR system, collect and process co-pays at patient checkout, and send out your monthly patient e-letter
  • FAQs for new patients as well as common Q&A documents and instructions for staff on how to handle common situations, how to create more consistent service results from your vendors, and any
    number of other topics

Think of your UBS as the doorway through which to introduce systems thinking across your team. This UBS tool will also give you a coherent and scalable way to store the systems your team creates, so that your entire team—even if members are spread across multiple locations, like Dr. Challa’s—will be able to instantly access your systems from wherever they are.

“It took us four months to build our UBS,” said Dr. Challa. “Whether it’s fee schedules, invoicing, vendor contracts, HR materials, or step-by-step processes for how we do our work, it’s all itemized in the UBS. It’s been a lifesaver. Now, when I want a document, it’s on my desk within three minutes.”

That efficiency was a great help to Dr. Challa as he built the Kansas Medical Clinic into what it is today: a practice that spans four specialties and has nine locations with 120 employees spread over a hundred-mile area. “Put it in the UBS” has become a company mantra.

And it’s not just Dr. Challa. By implementing a UBS at your practice, you’ll change the way work gets done. Now it’s time to get into the mechanics of how your practice will build and leverage its own UBS.

Replace Chaos with Stability and Scalability

If your practice lacks a UBS, you generally have a random collection of files spread across a dozen different team members’ computers, or worse, stored informally in their heads. When your office manager finally comes up with a better, wrinkle-free process for onboarding new patients, that process will live in her head and nowhere else—unless you have a UBS where she can record and file it. When an administrator determines an effective strategy for dealing with a particular insurer, he may jot down some reminders on a sticky note—but if he leaves the practice, that knowledge will leave with him. Unless you have a UBS. To be clear, your UBS is not a policies and procedures manual (which few employees will ever use!).

Your UBS is an organized collection of tools in one central location that captures the actual everyday know-how of your practice in a searchable, accessible, and editable way. It’s stored inside a simple hierarchy of digital file folders, generally in a cloud-based system, and includes things like your checklists, spreadsheets, proposal templates, training videos, and sample marketing pieces. Your UBS is the master system for how your practice structures, organizes, stores, accesses, and refines its internal knowledge. It’s a way to gather all of that information in one place and give your whole team access to it.

As you move toward the goal of building an owner-independent practice, your UBS will be a key ingredient in making that possible. Your UBS is a means of implementing controls in the daily work of your practice—not control in the sense that you or another manager will oversee every little thing, but controls—plural—in that reliable procedures will govern your team’s daily work.

Few people enjoy being micromanaged, so the UBS plays the important role of making key information easily accessible, and therefore turning the default behavior into the right behavior. The more your controls help individual team members make decisions on a daily basis, the more smoothly and efficiently your practice will run, regardless of whether or not you’re physically present. When you empower your team with strong systems that give structure to a process or responsibility, and train your staff on how to use those systems, you’re setting your team up to win.

Based on our work with thousands of practices and companies across North America, what’s clear is that systems are not a matter of “one conversation, and you’re done.” Instead, they must be an ongoing, living theme that you champion in your practice, not only until you get genuine buy-in from your staff, but until your staff members internalize how to create, use, refine, and share these best practices as a normal part of their office day.

As Dr. Challa’s example illustrates, the UBS is a way of starting this important dialogue at your practice. You’ll know you’ve won when you regularly hear team members say, “Did you add that to the UBS?” and “Great solution! Can you UBS it?”

Hire the Right People

Finding quality staff is a perennial challenge for medical groups. Whether this be front desk people to check in your patients, to medical assistants to prep the exam rooms and take down vitals, to mid level providers and physicians, to back office schedulers and billing specialists. Here are the three biggest mistakes we see when it comes to medical practices finding, hiring, and onboarding talented team members to help grow a medical practice.

Mistake One: Being Unclear on Exactly Who You Need to Hire

Most physician owners or practice managers mistakenly rush their hiring. “We need someone now!” they say. But when you factor in the cost of a bad hire (reported by Northwestern University to be 30% of their salary) rushing your hire is just too costly.
We get the medical groups we coach to invest 30-45 minutes to create their “pre-hire profile” so they radically reduce their rate of bad hires.

First, write out the specific role you are hiring. What specifically will this person do? What does great performance in this position look like? How will you measure, track, and evaluate your new hire’s performance?

Based on that clear role description, step two says clarify in writing who this person would need to be in order to be extremely successful in this role. What skills, experiences, qualities, and credentials do they need to have?
Step three says reduce this long list of what you want into the 4-5 “Must Haves”. What are the 4-5 non-negotiable qualities, skills, experiences, or credentials this new hire must have in order for him or her to succeed in this role. (See below for more on your Must Haves.)

Can you see how by taking 30-45 minutes upfront to get clear on who you need to hire you greatly increase your odds of hiring a better person?

Mistake Two: Hiring for the Wrong Reasons

With your “must haves” in hand, you need to make sure your interview process focuses heavily on seeking out those qualities. What questions do you need to ask in order to evaluate whether a candidate has or doesn’t have one of your must haves? The medical practices we coach actually rate every late stage job candidate on a 1-5 for each of the position must haves. This allows them to objectively compare candidates and make a smarter decision on who to hire.

Mistake Three: Thinking You’re Done When You’ve Made Your Hire

Too many office managers and physician owners think they are done when they hire and give too little (or no) thought to how they will onboard and train their new hires.

Remember, you invested thousands of dollars of time and direct cost to find your new hire, so make sure you invest a little bit more to give them a systematic and sound onboard.

The good news is that 60-70% of your onboard process is the same for every employee, whether it be a new scheduler, nurse, or provider. By documenting the onboard process you can start to make incremental improvements that both save you time and improve the quality of the onboard for your new hire. Think checklists, standardized documents, video modules & more.

Engage Your Staff & Get to Know Them

Dr. Lara discovered that by empowering his key staff, he could grow his medical practice while reducing the stress and hours he used to work.

Does developing your UBS, hiring great people, and onboarding them effectively sound like a lot of work? It is. But here is the best-kept secret for how the physicians we’ve coached for years were able to both grow their practices and radically reduce their working hours: they engaged their team in the process of growing your medical practice.

For example, when we first started working with Dr. Lara, owner of a successful four-clinic weight-management practice in Florida, he did something very smart. From the beginning of his participation in the program, he engaged four of his key practice managers and leaders in the program as well. That meant that, rather than Dr. Lara teaching his team to create his practice’s UBS, he had these four team members work directly with our coaching staff to learn the key business growth tools and strategies, and then implement them directly into the practice. Those team members created a draft of their UBS, implemented an improved hiring system, and executed on their patient growth strategies, not Dr. Lara.

What this meant was, his staff was doing the heavy lifting and owning much of the growth process of improving his practice. It wasn’t all on his shoulders.

This is why encourage any physician owner we work with to make building a more “owner independent” practice a stated goal of your business. Stop trying to do it all yourself. Give your team a voice and a stake in doing the key work with you.

Increase Patient Satisfaction

Start by focusing on strengthening your core—how your practice and team produce your actual medical services.

Step One: Create Your Flowchart

What would it look like if you followed a patient walking around your office, mapping out their every sequential step as you welcomed, examined, treated, and checked them out? Map these steps into a simple flowchart—box to box to box—of all the steps they went through and experienced in the course of their interaction with your practice.

During a typical office visit, the patient checks in, waits in the waiting room, is brought in by a medical assistant, has vital signs checked, is brought to an exam room to be seen by a provider, and then proceeds to check out and exit. Depending on your type of practice and the types of procedures you perform, your patients may follow a similar path or it may be quite different. In either case, the first step to strengthening your core requires you to become clear on the visual steps of how your practice flows from the perspective of your patient. This will help you understand how to improve efficiency and productivity as well as patient
satisfaction and quality of care.

Once you’ve laid that process out visually, do the same thing from the perspective of your most expensive providers: your physicians. While you can later look at your process through the eyes of your mid-level providers, nursing staff, and even office staff, for now, just focus on your most expensive and difficult-to-replace team members: your physician
providers. Follow them through the flow of what they do and where they go, step by step, as they treat patients and perform procedures. With this raw information in hand, it’s time to move on to step two.

Step Two: Audit the Process

Gather together a small team of your key people in a conference room for ninety minutes to take a fresh look at the way you produce your core medical services. Put your two flowcharts up on the wall. Start with the patient-view flowchart, and ask the following questions:

  • What jumps out at you as not making sense about this process? For example, is the waiting room simply dead time rather than a place where patients receive valuable education? Do you have doctors physically moving in a chaotic flow back and forth to both ends of your facility, and does this chaos eat up extra minutes of every day each week? Are physicians handling parts of the process that medical assistants could do instead?
  • How could you reduce the number of steps in your overall process? For example, could you show educational videos in the waiting room so that nurses are not tasked with conveying the same educational material to every patient? Could you reduce wait times?
  • How could you spend a little more money and get an exponential increase in production efficiency? For example, could you hire a medical tech to team up with each physician to speed up charting and note recording in your EMR system as each physician progresses from patient to patient? What about installing better Wi-Fi or upgrading your computers to speed up your providers’ access of the EMR system itself?
  • What frictions are there in the process that are bogging everything else down? How could you streamline your process to remove or at least minimize these factors? For instance, could you employ a scribe who accompanies a provider, so that provider can give full attention to the patient without typing into the EMR?
  • What steps are missing that, if you added them to the process, would improve the efficiency, consistency, and/or quality of care for your patients? For example, could you create an enrichment center next to the waiting room so that patients can be educated, entertained, and/or engaged? Could you have medical assistants do preliminary screenings and then leave a note to bring the physician’s attention to the reason for the visit?
  • What are your most expensive constraints to seeing more patients or performing more procedures? Is it your physical space? Or a lack of key providers? Or perhaps a lack of certain systems or automation? Identifying your most expensive constraints will give you clues about how to refine your core workflow to maximize around these constraints.

Now take a second pass at these questions, and this time, focus specifically on the physician’s flow diagram. After thirty to forty-five minutes of brainstorming ideas with your key team members, move on to step three.

Step Three: Pick Your “Sweet Spots” to Implement

Based on our experiences in coaching practices through this process, at this point you’ve got an overwhelming mass of ideas that you know you “should” do to improve your core practice flow. But let’s get real; there is simply no way you and your team can implement all these ideas at one time. In fact, doing so would be so disruptive to your current activities that your practice would actually suffer.

Instead, go back over your list of possible practice enhancements and flow fixes, and apply the “Low-Hanging Fruit” and “Home Run” filters you learned about in Chapter 3. Go through the full list and ask yourself, “Is this a Low-Hanging Fruit?” In other words, is this idea easy to put into practice, and are you fairly certain it will work? If it is, mark that idea with an “LH” for Low-Hanging Fruit.

Then, do a second, separate pass and ask of each item on your list, “Is this a Home Run?” In other words, if it works, will it have a BIG impact on the efficiency, consistency, or quality of the way you produce your medical services? If the answer is yes, mark that item with an “HR.” Now go back to your list and pull out all the items you’ve listed that are both Low-Hanging Fruit and Home Runs. These are your practice’s core Sweet Spots. If you have a manageable number, which is rare, then you can jump to creating your execution mini plan. Likely, though, you still have too many Sweet Spot ideas to execute over the next ninety days. That’s great, since every Sweet Spot idea is, by definition, a high-leverage idea. As your starting point, pick one to three of them to implement over the next ninety days.

Remember, start with less, but make sure that the less you start with matters more. By doing it this way, not only will you implement these fewer ideas better and faster, but you’ll also be building your team’s ability and motivation to bite off the next bunch of Sweet Spot ideas from this list next quarter, to continue the process of strengthening your practice’s core. Take your few Sweet Spot ideas and turn them into a mini game plan to execute on them. Who needs to do what by when?

Step Four: Formalize Your Winners

After you’ve implemented your first few core process-improvement Sweet Spot ideas, observe which of the ideas you’ve tried have worked well. We call these your “winners.” The strategic principle is to “Feed your winners; starve your losers.” When you find a core process improvement that clearly works, formalize it. This means building a formal system for it and adding it to your UBS. It also means training all of your team on its use.

Essentially what this does is help your practice institutionalize the best of your workflow refinements. Now the key knowledge to run your practice isn’t in the hands (or heads) of only one or two experienced team members, but, rather, it has been absorbed by the practice itself. Next quarter, repeat this process of picking your next round of Sweet Spot enhancements and formalize the ideas that have been proven to work.

What You Really Want from Your Practice

Most physicians who own and operate a private practice want growth, but they hold themselves back because they fear that to get that growth, they’ll have to sacrifice their lives. As you’ve gotten a sense of from this in-depth article, the only way to sustainably grow your practice is to reduce its reliance on you and instead base your growth on system, team, and internal controls. Done right, you get  growth and you get your life back. For over a decade now, we’ve helped thousands of physicians just like you build thriving owner-independent practices.

If you’re intrigued with the idea of getting expert, outside perspective and the structured support and accountability to rapidly accelerate your practice’s success, then talk with one of our senior business coaches.

In fact, we believe so strongly in the value of coaching to help you grow your practice the right way that we invite you to get a complimentary coaching session with one of our senior business coaches. Let’s be clear, we’re talking about a real, working session on your practice and the best path to reaching your business and financial goals.

We’ll conduct this private, one-on-one, ninety-minute coaching session by phone or web conference. We’ve learned that this is the best way—by actually doing a real coaching session—for you to determine if coaching is right for you. You’ll gain a greater sense of clarity about the best strategies and path to growing your medical practice.

Schedule your next business coaching session today!