Angie McGilvrey, PT of Apex PT had the opportunity, after a hurricane shut down her clinic in Florida for a prolonged period (sound familiar?), to revamp her clinic and create her ideal scene. One of the things she committed to when she opened back up was greater usage of social media to market her clinic and attract her ideal clientele - female athletes between 30-40 years of age. By focusing targeted messaging to her avatar on a couple of social media platforms and posting content consistently, she has been able to not only grow her clinic but see more of the clients she wants to see. Plus, she's created a reputation as being THE place for athletes to recover in her community. She's been able to niche down and grow because of it.
I've got a fellow friend and HODs or Hands-On Diagnostics owner with me, Angie McGilvrey, out of Florida. She and her husband, Joe, own Apex Physical Therapy in two locations. I want to bring her on because she's done a lot of great work in growing her practice and has used social media to do a lot of that work. I want to get into her story to share what she's done on social media and how it's been successful for them. First of all, Angie, thanks for coming on. I appreciate it.
Nathan, thank you for having me.
Before we get into the social media stuff, you've been an owner for many years, so congratulations. You’ve got multiple practices and you guys have been successful. I'm sure the story hasn't been sweet-smelling roses all the time. To give everybody a little bit about your journey, do you mind sharing your professional story quickly?
My husband, Joe and I, opened Apex Physical Therapy in 2005. We packed everything we owned up in U-Haul. We were from Chicago and said, “We're going to Florida. Forget this cold weather. We're going to give this whole PT private practice a try.” We are blessed to be here growing and being productive many years later.
Have you been in the profession for a while? Had you been practicing for a while before you decided to open your clinics?
We did. We were practicing underneath other owners for about five years before we decided to take the leap.
Did you practice in that area in Florida first and then open up your clinic? Or did you go to Florida and decide we're going to open from scratch?
We opened from scratch, cold turkey.
That takes some courage. You had some confidence and I'm sure you hit the bushes. You worked and marketed hard, all that good stuff. I'm sure you've pushed hard and it's part of your success. Are there any particular times along the way that were somewhat hard on you that turned out to be a learning experience and a success in the end?
Yes. I would say two large things come up. The first one being in Florida, we have a high Medicare population. I can't recall the year right off hand, but we went through a Medicare audit one where they put us on 100% prepayment review, which meant that in order for us to get paid by Medicare, they had to review all of our documentation first on 100% of our patient volume. I did learn how to document for medical necessity.
Florida got hit with that, didn't they? It's a Florida thing.
Unfortunately, there are some fraudulent things that happen. Secondary to that, everybody was looked at with high scrutiny. I am proud to say that we came out of that on the other side, but it is a huge learning experience and something that made me a lot stronger in understanding medical necessity, billing, coding, documentation and all those things that as PTs, we don't sometimes want to care about, but I figured out fast why we have to care about it.Social media, strategically utilized, instantly puts you in front of your ideal patient without dealing with a physician's referral Click To Tweet
How long were you under review?
It lasted about six weeks until we finally were able to get off of 100% and down a different percentage. We had to work with an attorney and all the things. It was rough.
How far into your ownership was that?
I believe it was about 8 or 9 years in.
You are going strong, but that’s a huge roadblock in the middle.
Medicare was our payer, like 75% of our population, especially the season is Medicare. This was a big undertaking.
That was number one. Did you have a second one?
My second one was in 2017. We were hit with Hurricane Irma and that was a big deciding point and a big pivotal point, which leads us into the conversation that we're having around social media in the sense that we chose after Irma to rebuild our practice. One of those building blocks that we used was growing and niching through social media.
Did you have to close down your clinic for a period of time?
We did. We had some damage. We had no power for about ten days in the entire Florida, which was 90% of our patient population left and evacuated. Even if we would have power and been ready to operate the day after, none of our patients were here. Everybody was gone. The whole state had been evacuated, especially in our area. That was a scary time to figure out how do we get through this. I do have to say with the COVID pandemic that we've all been dealing with, Hurricane Irma was the best thing that I could relate it to and figure out, “What did we do then to navigate?” Our practice went down to almost nothing. How do we use that experience to navigate through COVID? I'm grateful for them looking back because I know that they contributed to our successes.
It's not uncommon. As I'm working with clients or talk and interview people over the years, it's tough to go through those hard experiences and you wouldn't wish them on people or yourself, but after having done so you come through having learned so much and having grown stronger. In your case, you were able to create a different practice than what you went into Hurricane Irma with. That's relative nowadays, even with the pandemic. That was a lot of push over the pandemic as I talked to people on the show and my clients. It was like, “Here's an opportunity. It sucks, but how can we make the most of it? What can you do so that you can make the changes in your clinic to reflect what you want in your clinic? Who are the clients that you want to see? Who are the fellow team members you want to work with? Are you seeing the paramix that you want to see? Do you have policies and procedures in place that make things easier? Do you have time set aside for admission or tests?” I could go on and on, but taking advantage of these opportunities is what makes us stronger. It gives us opportunities in the face of challenges. As you did that, how did you then work social media to your advantage to create what you wanted? I would love to know what you did, why and what were some of the instigating factors? What was your clinic like before to what did it become?
The clinic was very much a general outpatient orthopedic, physical therapy practice. It has no different than any other outpatient orthopedic. If you looked out the window, it would look like all of the others.
We take all comers, whoever has got a script, we bring them all in.
We take them all, we do it all, we market to everybody, we take all the insurances. We do everything. We market 75% of the time to referral sources, mostly physicians and those others in the medical community. That's what we looked like going into Hurricane Irma coming out on the other side. One of the biggest things that the storm taught us was that, as you said, we have the ability to create change. We have the ability to reset this practice to what it is that we ultimately wanted to be. We wanted it to take more control and be more at the cause of the specific patient we were working and identifying our avatar. Also, be at cause at bringing those patients into the clinic without having to rely on a third party referral source. That's where social media started coming into play for us big time.
Social media is something that I wish I had more time to do that. Did you think about that in the past or was this something that forced your hand into, “How are we going to take advantage in social media came to mind?”
It was more the latter. I've never had my own Facebook, Instagram, Twitter, nor Pinterest. I was the person who fought social media for a long time until I started listening to a mentor who I've used in, Gary Vaynerchuk. I have to give him credit for what I've done and what I've learned through social media. I started to learn that if I wanted somebody's attention and especially my avatar's attention, I had to go where they were and they were on their phones. More specifically, they were on social media. I was like, “Angie, you better get your butt on social media.”
What's your avatar?
Our avatar is the 30 to 40-year-old female athlete, specifically the CrossFit athlete.
You're CrossFit as well. Are you performing CrossFit athlete yourself and Joe?
You can speak their language, you know what they're dealing with, you know the moves and the lifts, and some of the common injuries that go along with being a CrossFit athlete. That's exactly where you live in that space and it's easy for you then to talk to those people I assume.
It's a little counterintuitive to what I heard and that was to create where you live and that is, if you're on Facebook all the time, create a lot on Facebook. If you're on Instagram all the time, create a lot on Instagram. Maybe there's something to that, but you had to learn how to navigate and use some of these social media accounts. Was that a tough learning curve? Was that hard for you to adopt? Has it become easier for you?
It's like anything else in life, you have to start doing it. That was it. I had to start doing it. Joe was always involved with it on a small level, but it was when I decided that we had to put a ton into this and I wanted to be that driving force. I had to learn by doing. The first 500 posts that I made, it's like a therapist, the first 500 backs that I treated didn't do that great of a job, but the more we do, the more we learn. It's the way that it goes in. I still am learning all the time and I'm trying different things, seeing what captures attention, what is giving more value and what do people respond better to. It's a work in progress.People want to do business with people. Click To Tweet
To get into the weeds a little bit, are you using your own personal account or is it an Apex PT account that you're using on these platforms?
It is a business account. My practice is a small business and our philosophy is much that mom-and-pop small business family feel. We have in two locations. We know our patients and we develop meaningful and lifelong relationships with them. We infuse a lot of Angie and Joe's story, Angie and Joe's history and some personal things with Angie and Joe in there because people want to do business with people. That's what we've done.
How much time are you setting aside to do all these posts and get your stuff out on social media?
As a team, there are three of us that do this, myself, Joe, and one other gentleman in my practice. Between us, we can talk about what I mean by working, but this is working. The entire part of working social media, we do 5 to 6 hours a day collectively between the three of us.
You're each doing a small portion, at least an hour or two. When you're talking about that, you're talking either you're creating video or content, you're editing, posting a video in some form or another.
That side of it, but then also there's the other side of it and the engagement side.
Tell me about that.
We work from two different angles. It's the content creation and the posting, and then also the customer engagement. We will go through and literally either search through the #CrossFit or #Fitness or something like that. We'll see the accounts that pop up and you go on and somebody posts something and you comment on their posts. We’re engaging in two-way conversations with that avatar patient of ours. Sometimes this person could be across the country. You never know what that brings because maybe that person from across the country says, “Let me give you a follow.” They follow you. They see something cool you're doing. They post it and maybe they've got 100,000 followers and all of a sudden, you’ve got the attention to somebody down the street. With what technology has done in the way, it opens up our market so big to who we can create conversations and engage with and get our product out in front of them. It's not limited to our 10-mile radius like we used to think.
A Gary Vaynerchuk thing to do is to get engaged on all those hashtag groups and throwing your two cents and then people follow you and it cross-references each other. It sounds familiar. Do you use any gadgets to help you along the way with a few accounts and platforms running? Are you using something to help you out?
I tried to dabble in Hootsuite for a little while, which is a platform that lets you do all of the pre-programming and setting. It wasn't fitting for me. I know there are other people that use that, I don’t. We post to the date, to the moment like, “What is happening?” I'm like, “Look inside the clinics.” That lends itself to doing it on the fly sometimes.
If I see something on your posts, more than likely it's been done sometime in the last 24 to 48 hours, and it's not something that was done a week ago that was scheduled to post at a certain time, which Hootsuite will do for you.
Sometimes that does happen. We do have some scheduled content to create like, “I want to do some videos around musculoskeletal ultrasound. Let's make sure we get those videos.” The majority of it is me and/or others in my clinic being followed by a video camera. The way that I get my content is I have a videographer that follows me about 4 to 6 hours a week. Based on that, he creates content off of the rides me working with my team, working with our patients doing our thing. It's extremely authentic. It's not like, “Let's sit down and let's rehearse what we want to say about this.” It's seldom that we do anything like that.
What platforms are you on? To follow up, is that something you filter down to certain platforms after starting on a bunch or have you stayed on all of them? Where did you start and where are you now?
We started with simply Facebook because that’s the largest out there. However, when you start to look at some of the demographics, my avatar spends the majority of their time on Instagram. I do both. We put the majority of our stuff on Facebook and Instagram. I also do a personal page and an Apex page on LinkedIn, where I will reuse a lot of the same content or videos, but I would spin the messaging a little bit more knowing that I'm talking to another physical therapist or somebody savvier in my space versus talking to the general public about physical therapy.
In LinkedIn, you're talking to business professionals typically, and that's what they're looking for business-related stuff. You're sharing your story and what you're doing and I've seen many of your posts on LinkedIn and you do a great job. Do you also do stuff related to physical health and caring for certain injuries? That's a lot of what I don't see on your LinkedIn stuff. I'm wondering if you massage your content on Facebook and Instagram for injuries and diagnoses in particular as you're talking to your avatar.
Facebook and Instagram stuff is a lot more about like the last post I did. I was doing a contract relaxed technique with a runner's hip, but it was all talking about my youngest runners with hip pain, this is why it happened and this is what we do about it. It is basic.
You have a videographer, but for a guy who's maybe a smaller clinic size and treating quite a bit, when you first got started, was it simply you and Joe and an iPhone essentially?
We would be on the iPhone and we would be going throughout our day. I would look across the clinic and I would see a patient doing cool exercise and be like, “Let me pull my phone out.” Video fifteen seconds of that exercise, knowing that later, I'll post that and talk about what they're doing. I have a patient come in that I would have one of my CrossFitters. We were working on with the PVC pipe working on a lift and I'd say, “Let me video her or video me. I'm going to post that later.” It was not until within 2019 that I started having the videographer be with me.
Do you get consent from your patients to post those videos? Is that something that's part of the intake paperwork or do you let them know verbally ahead of time that this is going to get posted?
Yes, we have a video image release as part of our standard paperwork. On the days that he is there filming, they see that he's walking around or whatever, and I always make it a point to be like, “Is it okay that we get some of this on video?” I make sure I get that extra okay any time I do work with minors that are athletes as well. I always reask verbally mom or dad again to make sure everything is good. The cool thing about getting their consent and doing that is I make it a point whenever I'm posting about a certain athlete or there in my video to build that person up into talking about how they're inspiring this post and this is how awesome they have done.
I'm proud of them because that gives them a huge amount of value and self-esteem coming back at them. It's turned into, “That's cool. Apex posted my video.” It makes them feel good about themselves and their progress and that piece of it I love. Being able to tag them and say that is amazing for them. On the other side, it also drives business for us because then they will typically repost it with, “Thanks Apex. You guys are awesome or whatever.” Not that I'm looking for that, but when it happens, that's wonderful and I'm grateful for them to do that.
It's cool on two levels that you get to highlight these amazing people that come through your clinic and share how awesome they are because it's not all about Apex all the time. If you read, Building a StoryBrand, we are the guides in their hero story. The patient or us as we're looking at someone who can help us, we are the hero of our own story. We're looking for the guides to help us be better. That's what you're able to show in those videos. It's nice that you get some turnaround because these people who are more than likely your avatars are going to post on their websites to other avatars of yours with the people in your network that you would be able to treat as well. It's such a cool concept that you highlight them so much because a lot of what you see with PTs is, “This is what you do for your back. These are the stretches. Here's the anatomy.” That's not engaging. When you see other athletes performing, getting treated, exercises that they're doing, that’s somewhat engaging because you pulled into a little bit of a story there and that's cool.
I try to tell a little glimpse of each of their story, like, “She had this and now she has this. That's why we're working on this.” It brings it to real life.
Don't you use YouTube?Friends and family are always huge referrals. Click To Tweet
We do, but I need to be better at it. I was told by a digital marketer that it becomes the second search engine behind Google. We need to become better at YouTube.
We got into the weeds there a little bit. You made it intentional to use social media to your advantage and grow in a different way than you were before. How has it changed your clinic by niching down and using social media?
It's been awesome. The two pain points that we went into Hurricane Irma with were marketing to the physician as well as seeing anybody and everybody. I treat two days a week. I love treating. If I choose to treat. My entire schedule that is all I treat. I treat is athletes and most of them are CrossFit athletes, but it has blended into, “If she knows how to CrossFit and she knows how to treat Spartan racers, and she does CrossFit and Spartan Race then I know she can help me because I am a baseball player.” That's amazing as well as my practice has been branded in our area as the place for athletes to go, which is super cool.
I've heard that from various physicians in talking and communicating. We are having a PA or a physician say something to a patient and the patient comes and tells me, “They told me because I golf and I need to get back to golfing. I'm an athlete so I need to go to Apex because that's where the athletes go.” To hear that is super rewarding. It has completely flip-flopped our marketing. We market 80% now direct-to-consumer and 20% of it is massaging the relationships and the rapport that we have built over the past years with the various medical people in our community.
To be honest, the coolest flip of the table is when I have a CrossFitter who hurt her wrist doing a lift, doing a clean. She bent her wrist all the way backward and was like, “This is bad news.” The way she contacts us is she direct messages us through Instagram. I want that to be a point there in that this opens up a new line of communication for people to get it. She didn't go to our website. She didn't call our number. She direct messaged us on Instagram and said, “Can you help me?” I was like, “Yes, come in today at such and such time and we'll help.” That's huge. She came in and talks about what was happening with her wrists and the other.
We ended up doing an MSK or Musculoskeletal Ultrasound to look at her wrist. We're super concerned. I didn't do the MSK. It was my husband’s ball. I can't remember exactly what his major concern was, but he had one and he said, “You need to hang on a second. We're going to get you to the orthopod. You do need to be screened by an orthopedic before we go any further because I'm concerned about it.” He text messages in orthopod that we have a great rapport with, “I have an athlete here needs to see you.” He’s like, “Send them over at whatever time.” We fed the orthopod the patient versus buying the $700 lunch and begging for patients. The patient went to the orthopod and was cleared. Everything looked good. She came back to us and did rehab a couple of visits. We had her right back to doing CrossFit and she was super grateful and blessed. Her turnaround was within two weeks that we had this whole process wrapped up, had her back doing her thing. That is the power of that social media connection because she follows us on Instagram.
That goes to show the value and the power behind a direct to consumer marketing. It's something that I was pushing for during the shutdowns of the pandemic is we can't rely on referrals sources anymore. This is an opportunity for us to change our marketing patterns and go direct to the consumer because that's where more of the people are. What is often the touted stat? That only 10% to 15% of the people that have musculoskeletal injuries get to physical therapy. That means we're fighting for 10% as we're going to physicians when there are 90% of the people out there who need us. As you've changed your marketing, has it significantly changed your numbers in terms of the types of patients that you see? You said you were 70% Medicare. Are you still at 70%?
No, which is fantastic. In the beginning, I complain about having the risk in Southwest Florida of a Medicare audit. That was a basket that we didn't want to put all of our eggs in. In the heart of our busy season, we do have where all of our snowbirds come down from January to April. We ride about 60% to 65% Medicare. Outside of the season, those numbers dropped significantly to maybe 40% to 50% at the most. We've been able to change that demographic and diversify that payer mix.
You've been purposeful about it. Thus, where do you get a majority of your patients from? I don't know if you knew your numbers beforehand, maybe 95% of your patients came from physician referral. How has that changed by using social media and whatever else you're using? How many patients do you get from physician referral now compared prior to the hurricane?
I'm going to say pre-COVID because a lot of things changed with that. I would say that from a physician referrals standpoint and in just that small percentage of massaging those relationships, those things didn't change all that much. Friends and family have always been a huge referral pattern for us. That has always been above 50% of our referrals that has held there significantly. Between social media and us going to actual PR events and going straight to the consumer marketing directly to them, whether that be at a gym, a CrossFit box, community events. Before when you could have a race or a CrossFit competition that has boosted up into close to 20% of getting that specific that people are coming into our practice.
This is an additional revenue on top of what you are already getting.
We have to not think about what happened with that, but pre that, we were on a tear. I'm grateful to where we've bounced back. We're in a good place but we were going into that season.
I think there might be a fear out there that if an owner is going to start niching down, that they are going to do so at the sacrifice of the other patients that know, like and trust them. Did you find some of that or did you find that this is simply expanded your scope by niching down?
That was my worry in the beginning. I thought the same way. I thought I only niche and market to this specific 30 to 40-year-old female CrossFit athletes like, “What the heck am I doing?” It expanded my practice. I realized number one, we did have a strong foundation of friends and family, to begin with. That foundation was key. I also think that in doing that and being able to serve that avatar person and serve them so well, they will still recommend their brother, sister, mom, dad, their grandma or grandpa, the other person at the gym. They're going to become your ambassador even more so. The CrossFit athlete has been my avatar, but I would say my schedule, I have with school season and track season starting, half of my schedule is full of cross-country runners.
You might not have seen these people before in the past.
My entire schedule would have been 65 and older Medicare.
Has that also affected your recruiting and the PTs that you've brought on board? Do you have a different type of PT that works with you now?
One of the taglines or hashtags that we use is #AthletesTreatingAthletes. Putting somebody in that space and recruiting a PT or a PTA to treat that caseload, they need to be like me from the standpoint of they live in that world. They talk that talk, they are an athlete, they understand injury, the pain and the mental of, “I'm injured and I can't play. I can't perform.” They've been there. That's hugely important.
You not only niched your patient load, but you also niched your team members.
Some of the successful PTs I know out there like Sturdy McKee, he's got a practice in San Francisco. They won't hire a PT that hasn't played a team sport before. He thinks and their philosophy is that, “If you played a team sport, then you know how to work well with other people to be productive and achieve a goal.” That's one of their criteria. You might not necessarily have people on there that do CrossFit, but they need to be athletes. Is there anything else you want to share about niching down and how it's benefited you and your practice? You have shared a ton of great information already.
Coming from my story in 2015, it was the PPS Conference. I don't know if you were there Nathan, but we did the PPS Conference in Orlando. Gary Vaynerchuk was one of our keynotes. At that point, he asked everybody to raise their hand if they have Facebook. I was one of the five people in the room that didn't raise their hand because everybody had Facebook. I looked around and I was like, “I'm proud of this. I don't need that stupid Facebook. That's a waste of time.” To go from being that person to now seeing how powerful and utilizing this tool, it goes to show that if I can do it and use it to niche and build my practice, anybody can. Anybody that wants to do it and has the intention to do it, you can do it.
It takes work and you have to set aside time specifically for it. If you don't, it's going to easily fall through the cracks of your “busyness.” I'm sure you schedule the time, make sure you hit it every day. It's about consistency when you're talking about social media.
It is my habit.When you're putting stuff online, just give value and entertain people. Click To Tweet
Do you post every day or do you post three times a week? What's your schedule?
If I count Instagram, Facebook and LinkedIn separately, including posts and stories, we do close to 100 posts in a week. I would like to even do more, but we didn't start that way by any means. This is building. We started with one post a day to multiple and multiple people doing it and posting stories and all of that.
It is cool to see how you've grown and used social media to your advantage as an owner, especially among physical therapy owners. I don't think that's utilized as much. Our profession is usually about a decade behind everyone else, so it's cool to see how you've used it, and thanks for sharing. If people wanted to follow you, what are some of your social media addresses?
Instagram is @ApexPhysicalTherapySWFL and Facebook is Apex Physical Therapy. Those are the two places that are the best to find us. It's Apex Physical Therapy on LinkedIn or me as Angie McGilvrey on LinkedIn as well. Thank you.
Is there anything else you want to share with us, Angie, before we sign off?
When you're putting stuff on there, give value and entertain people. That's what I try to do is give them as much value, think about what they want and entertain them. That's what has made it successful on my end.
It doesn't seem like they necessarily want to know all about physical therapy and every injury. I've had clients who have posted pictures of sunsets and I've gotten more engagement from the picture of a sunset than they did about anything else they posted. It's funny how it works. Thanks for your time and for sharing. Congratulations on the growth and all the great things that you do. I love seeing your posts on LinkedIn. They've been motivational and inspirational. It's awesome to see how you're using it to your advantage.
Thank you, Nathan. It was such a pleasure to be on. I appreciate you.
Physical therapy and fitness is my passion! Leading my team at Apex, we empower athletes of all ages and levels to move better, feel better, and live better!
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There is no perfect formula for growing and expanding your PT business, but as with most other industries, the way to learn is to look at those who have been there and succeeded. Jeff Ostrowski, PT is an owner/partner of 35 clinics across SE Pennsylvania, starting from a single clinic 30+ years ago. Over the years he has taken on partners, added more clinics, expanded existing clinics, and merged and purchased other clinics. He has experienced almost all the possibilities for a growing and expanding practice. Nathan Shields brings him on the podcast to discuss some of the most frequently asked questions about PT business expansion, such as "when is the best time to add another location", "when is the best time to add another PT", "when should I consider adding more square footage", etc. Jeff has been through enough over the years that he knows what has worked for his growing company. Listen in as shares his insights on the podcast.
I'm excited to bring on Jeff Ostrowski. He is the Owner and Partner in Excel Physical Therapy in Southeastern Pennsylvania. They have 35 clinics and continue to grow. We'll get to his story, but I want to bring him on about some important topics in regard to growth and expansion that a lot of new owners and even long-time owners have questions about. He has been around the block a few times. First of all, Jeff, thanks for coming on. I appreciate it.
You're welcome, Nathan. It’s good to be on the show. I enjoy your show. It's good and helpful. I'm glad to contribute.
Thanks for being a part of it and for taking the time. We haven't met each other that much. We talked on the phone a couple of times, but you've got a lot of wealth of knowledge and wisdom. I know you are a big part of the P2P group and PPS in getting that established. First of all, thank you for your efforts in doing that. That's huge to establish that kind of networking and network. It's a great resource for the physical therapist. Thanks for doing that.
You're welcome. It's a wonderful resource for private practice owners. If you have readers that are PPS members and they're not in the Peer2Peer Network group, they ought to join that too. I've been involved in PPS for a long-time. I was on the board of directors for seven years and the editor of IMPACT Magazine for three years. I served on a whole bunch of different committees and task forces. Like you said, I've been around PPS long-time and this Peer2Peer Network thing is one of the most valuable things that I've seen come along. I want to do a little endorsement for everybody who's reading. I certainly can make myself available to your readers to talk more about it if they have questions about PPS or Peer2Peer afterward.
Tell us a little bit about you. You've been in the industry for some time. You've been an owner for a while as well. Tell us a little bit about your professional story and what got you to where you are with such a large company.
I started the practice back in 1990. I've been a practice owner for many years. I've started by myself. I brought on one of my best friends and business partner within a few months of opening that up. We grew that up and then we merged with another company in our area back in 2011. That was a great experience. It was an awesome company that we merged with. We've had good success. We probably doubled the size of the company since we've merged. I've gained a bunch of great friends in those partners from the other business that we merged with as a result. We took what was good about our company and their company, put those things together with a lot of humility and no pride of authorship.
I took the best of both worlds, put them together and created something special in our industry and that's where we are. It might be of interest to your audience that I’m semi-retired many years ago. We hired on a management team, CEO, CFO, some regional directors and some other management talent to run the day-to-day operations of the company. My partners and I were able to step out of day-to-day operations and move into a retirement mode. We still work. We're on the board of directors and we handle special projects in the company and do stay very involved and very aware of what's going on, but we have a good leadership team in there so we're off doing other things now. It's pretty neat.
Congratulations on getting to that point. Through your experience as an owner, you've seen all the stages, it seems like. You've not only brought on the next PT, which was your friend, but you also opened up another clinic. At some point, I'm sure you had some leadership team that you guys worked with either before or after you merged with the other company. It seems like you've gone through essentially all the steps of building a corporation so you can go back and give us some good advice.
There are two things we can talk about there when it comes to growth, what's known as the same store growth. That's how do you grow a clinic from 1 to 2 to 3 therapists and so on and then there's the growth through a new clinic, startups, de novo clinics. There's a lot of different nomenclature for that out there. There's the growth through mergers and acquisitions, but I think our success has been in the first two, in the same store growth and then opening up new clinics. There are lots of similarities between the two.
Let's start from the beginning. For a lot of physical therapists, whether they're new or have been around a while, if that initial step of going from one PT, which usually is the owner, to bring on that next physical therapist, bringing on that added expense then, “How am I going to keep them busy? What am I going to do? How am I going to offload patients? How am I going to rent myself back up? How do I handle all that?” What would be your advice for that initial step to bring on that other physical therapist?
I'm reflecting on the days when I was the only PT and the practice was growing. It was extremely exhilarating at that time because patients were coming in and I was like, “I can't believe people are coming in here and I'm having so much fun. I'm enjoying this.” Although we weren't very good, we are getting paid back then. It was a great time to grow. It does take a certain trust or jumping off the cliff to bring on the next PT because I fully understand the mentality of, “I'm the owner. It's my name and reputation at stake here. I don't know if I can find someone to do it the same way that I want it done.”
A lot of times the owner is very overwhelmed with day-to-day. They're seeing tons of patients and then they also have to run the business and they don't necessarily have time to invest in training new staff, a new PT. Even hiring seems pretty daunting sometimes because you have to interview and it's a very competitive market to hire therapists in the last several years. It's tough. You got boxed into a corner and the way out of that is a couple of things. Number one is in this day and age, the schools, at least in Southeastern Pennsylvania near Philadelphia, are putting out much more qualified therapists now than they have since I can remember. The PTs that are coming out of school are ready to work. There's been an improvement and advancement in the profession as far as that goes.
You still have to train them. You’re still going to manage them, monitor their performance and their statistics, but it's much easier than it was many years ago, in my opinion. You have to be capitalized too. You have to have some money in the bank because when you bring that new therapist on, it's going to put you underwater financially for a while until you can get their schedule filled up with patients. They're self-sustaining in terms of their contribution to the revenue of the business or the clinic. You've got to be ready for that. Meaning, you have to have some cash reserve. You have to have very carefully mapped out financial plans and budgets so that you know what you're up against and what your cash position is going to look like as you bring this person on and you ramp that up.
That probably gets in the way of a lot of people early on. It certainly did for me. I didn't understand the idea of capitalization as much as I do now. You've got to have that. A mistake that's often made, if I look back at my history, I can see it very clearly is when times are good and your schedule and therapist’s schedule is filled, you can be very profitable in that area. If you watch closely, you will start to see signs of stress on your business. When everybody's schedule is filled up, you'll start to see your charges per visit go down. You'll start to see the time that patients wait to get an appointment starts to increase. You'll start to see that patients don't schedule as frequently as they did on a per week basis.
You also start to see that your quality measures and there are many of those. There are outcomes measures, Net Promoter Score and patient satisfaction. You'll start to see those things slip a little bit because when it gets busy, patients don't get as much attention from your therapist. They don't like it as much when it's busy and although the owner right in that zone can be very profitable, that is short-lived, because what happens is all the hard work that they have done starts to fall apart. During that same period of time, they probably slow down their marketing a little bit because everybody is busy and you don't have time for it and that falls off. You then get on this up and down roller coaster phenomenon and you never break through to that next therapist in your clinic.
That’s one of the reasons why I push some of my clients to consider bringing on that physical therapist because they, as the owner, need the time to manage those things. Our natural tendency is, “I am productive when I'm seeing patients.” That changes when you have an ownership hat and a lot of those holes in the bucket start forming as you take your eyes off of the business. One of the things I try to stress is to make sure that you know your financials. Talk to your CPA or bookkeeper often so you know exactly what hit that PT will make on your business.The amount of time that you spend in your policy, procedures and training gives you a huge return that doesn't show up monetarily. Click To Tweet
You can get certainty on what the environment's going to look like, but also have a little bit of faith knowing that this is another investment. When you started your business, there's no guarantee that your business was going to succeed. There's no guarantee this other physical therapist is going to succeed. When you do bring that physical therapist and it gives you time to work on the business market and be carefully managing all those statistics that you're talking about, then things can go much more successfully. You can grow successfully as well without slipping in all those areas that you mentioned.
You said that well. I'll add to that is as the owner who can't get to that next level of managing the business because they're so busy, they're overwhelmed and they're underwater. They start to not like it. The owner gets tired, burned out, jaded and cynical. That early enthusiasm that you had when you first opened your doors quickly, you get beaten up. That starts to go away after a while and you get embittered. That has cascade throughout your company. It's you, as the leader of the business are showing up for work every day with a negative outlook and a bad attitude and, “This is horrible.”
It's hard to attract and retain good staff when you have that kind of mentality. When you go home to your family and you're all salty about how bad your day was, maybe you feel like kicking the dog. If you had one, it will be hiding under the bed when you walk in from a day's work, but it's definitely not fun to live that way either. I can tell you this from experience and a lot of your readers probably have lived through this too. That's a very important part of all this. We want this practice and business to enhance our lives and not detract from it.
The stress of hiring that first PT and this is my theory that I've built up over the past couple of months. You're going from one PT yourself to two PTs. That's a 100% increase. The stresses could be about the same, at least financially. Maybe that's not a 100% increase in your expenses, but it's a significant change in your expenses. Going from 2 to 3 PTs, that's a 50% increase and it's not as hard to bring on that third person. It doesn't hit the expense account as much. As you add more physical therapists, the expense ratios are a little bit different, but in doing each of those steps, as long as you keep your eyes on the business and train your therapists appropriately, recognizing that you need to step back in your treatment availability and time spent. You can do that successfully and each subsequent hire can be a little bit easier to tolerate both in terms of money and energy. Do you find that to be true?
That's exactly right. You spread out the overhead of the business over more revenue-generating PTs. Each one has less of an impact on your bottom line if you will. As you're doing that too, you're developing systems, whether they're marketing systems or operational systems, hiring and training systems, so that each time you bring someone on, not only is it easier financially to bring them on, but you have systems in place that makes it easier to get them onboard and productive as quickly as possible. Those are key things. Those investment and building training systems, especially building, hiring systems, having a marketing program that runs on autopilot so that you're not running around with your hair on fire all the time with those other things.
That's one thing that my company had been very successful at. My partners are amazing. We've spent a lot of time putting those programs together. My one partner, Todd, could be one of the smartest hard-working guys I've ever met in my life and probably is. He uses this ecology, “Your business is an ecology,” and everything works together and contributes to the health of the whole organization. It's not one thing, it's a lot of everything and they all need to work in alignment. That sounds like a lot of big words and it sounds easy to do. It's not. It takes time and effort to build all those things, but those investments pay off extraordinarily well once you get them in place.
That's what a lot of young owners or newer owners don't recognize is the amount of time that you can spend in your policy and procedures and time spent on training materials is a huge return that doesn't show up monetarily. It is multiple times more productive than treating that patient. It is a grind to put some of that stuff together, but for the sake of the business and for your mental health, it's a huge step in the right direction. It makes things easier.
It's another reason why an owner who wants to grow can't be gobbling up all their time treating patients because these things that we discussed, it all takes a lot of time to put together. If you're 40 or 50 hours a week in the clinic, you're not going to have time or the energy to do this other stuff.
In terms of stepping, not just into adding another physical therapist, what advice would you give to owners in terms of considering moving up to a significantly larger space or finding another location? Is there a formula that you've used in the past, in your company or yourself to say, “We're performing at such and such rate? Now is a good time to expand, get a significantly larger space or a new space altogether.” How would you address those situations?
Let's talk first about the larger space. There are some metrics out there that people use in terms of a square foot per full-time equivalent and they're all over the place. Those metrics depend a lot on what's the payer mix, net payment average per visit in your market and stuff like that. That's going to be very individually based, but it's the same mentality that I described before when you bring on a new PT. If you're going to get to the point when you walk into it, first of all, it's going to look and feel very busy. There's a buzz in the air.
You might have patients waiting for pieces of equipment. You might have patients waiting longer in the waiting room because there's not enough space for everybody in the building who is who's coming in. You will also see that manifest in your statistics and the same thing is going to happen. You're going to see the visits per referral are going to start to go down because people don't like being in this busy space. This happens a lot. The therapist also feels very busy and they feel bad about that for patients. I've hired thousands of PTs over the years and we want to go to work and have success. We want to be able to take good care of people.
Most of us went to PT school with this vision that, “I want to help people. I love this profession. I love what I do. I make a difference and it feels good. When I go home at night, I might be tired because it was a long day, but I feel I lay down at night and put my head on my pillow feeling like, ‘I did good work.’” That feeling is what we want to capture here and preserve and fight to preserve. If you try to cram a lot of patients into a small space and the schedule is busy, the PTs don't feel like they can have success. They start to not feel good about going to work after a while. They get burned out and they don't do their best work. It's nothing conscientious that they do. It's just a natural erosion of their enthusiasm.
It shows in the statistics.
It absolutely does. The patients come in 1 or 2 less visits than they would before. Their cancellation rates go up. The friend and family and past patient referrals that you were getting before might start to go down because people aren't as happy with the care as they once were. You might have more turnover amongst your therapy staff. Watching those statistics in the same way, it'll point you to the same exact thing like, “We're bursting at the seams here. It's time to take on some new space.” That's a tough decision because most of the time, you're going to be signing leases that are about five years on average. You've got to map out your growth for five years to make sure you don't run out of space in a year.
Again, you've got to have good financial planning, good budgets, good advice and a good understanding of what your growth rates are going to be so that you know that if I have three therapists now, several years from now, I'm going to have 6 or 7 in this clinic. I need maybe not 2,500 square feet, but 5,000. It's like you described before when you hired that new therapist on. You're going to have a little suppression in your cashflow in the beginning until that therapist builds up. It’s the same thing with taking a new space. You're going to have to budget it in there, “We have more space than I need for a while here until we grow into it.” That's how we always looked at it in terms of taking on new space.
It's very much about feel, but a lot of the feelings do translate into the statistics. Patient compliance goes down a little bit, therapists aren't pushing the patients to come 2 and 3 times a week. They're okay if the patient only comes once a week. They're not seeing the results. Whatever your measure is, whether it's your square footage or your efficiency, the number of appointments that are filled on a PT schedule on average. If you're running about 80% to 90% clip on a routine basis or regular basis, then that's a good time. If you continue to work hard at that pace, people are going to get burned out.With the right people on board, growth comes easily and becomes inevitable. Click To Tweet
It's a good time to consider either a larger space or if you are looking at another geographical location nearby, that's a good time to do it because you don't want to do that when you're running it 60%. Even though you might have these great ideas, “There's this perfect location over here that I want to open up.” You don't want to extend yourself and open up that new location or get that greater space because it's a great opportunity if you're not maximizing the efficiency of what you currently have.
That's going to put you financially underwater. It's tough to resist those temptations. You've got to optimize your current setting before you go expanding into new locations. There are a couple of things that are important. You need a referral base there. You need to know that there's going to be some patients that are willing to come in and maybe some physicians that are willing to refer. I think the most important part of a new clinic is the leadership of that clinic. Who is going to go in and run that clinic? That goes back to your hiring, training processes and leadership development. Because I think you could take a perfect location with an average leader and you'll have an average result and conversely, you could take in an average market location, put a strong dynamic leader in there and you'll have a fantastic result. The leadership development piece of this is absolutely critical.
That builds off of a comment that Steve Anderson made in the previous show. It’s exactly what you said. Even in the Northwest where he was, they found when they open up clinics, it wasn't the location so much that they were looking for as much as who. First is who then the where or the what. Once they established, “This person has been with us many years. We vetted. They're a high producer and they have the desire. We've worked them through the leadership management program that we have or whatever that might be. Now, that we have the person let's go look for the location.” Whereas some people might say, “I've got the perfect location. I need to find somebody to fill it.” That's not the way to go.
That's great wisdom by Steve. He's had great success. I couldn't say it any better. It's the person first, the location second.
Did you ever purchase clinics even in a young stage where you might've had 2 or 3 clinics and then you’re looking at possibly purchasing another?
Yeah, I have. I've purchased two other businesses in my career.
Tell us a little bit about that. Looking back on your experience, what advice would you give owners nowadays? Honestly, I've got a couple of owners who even at their current size one, maybe two clinics talking with or being approached by people locally in the community who are looking to get out. What advice would you give yourself in that scenario when you're considering possibly purchasing something at a young stage?
This is a financial discussion. You have to map this purchase out financially. How are you going to pay for it? How much are you going to pay for it? How are you going to pay for it? Can you afford it? The difficulty that most acquisitions run into or acquirers run into is the integration of the business that they bought into their business. In my experience, it's much harder than I thought. It takes longer and it's more expensive to integrate. You've got to put all that and factor that all into your financial planning. You may find when you do it that it's more advantageous to go and open up new clinics and hire new therapists than it is to buy other businesses.
We've learned some hard lessons in the acquisition area. We’ve made 1 or 2 mistakes with some acquisitions, not accounting for the integration costs. There’s also this cultural piece of it. You run your practice one way and this runs a little bit differently. How do you put those two together without alienating the people and having to start over again with hiring new people and all the rest of it? Tread very carefully here. It's very sexy to go out and buy businesses and it's a way that some of the big companies in our industry are growing dramatically through acquisitions, but the difference is they have capital partners. Meaning they have a lot of cash to use.
They have teams of people that integrate businesses and they have a lot of experience doing it. How a business is going to fit and how that's all going to work much more than smaller practices do? I don't want to discourage people from doing it because it's done and I know people that have done it successfully. The smaller you are, the more pressure it's going to put on your organization financially and culturally. You got to go take it carefully. Don’t fall in love with the idea of it without falling in love with the financial side of it first.
I talked to a friend about that because he was considering the purchase of a clinic. I said, “There are simply pros and cons to it.” When you're looking at purchasing a clinic, you're buying a book of business that is running. It probably has referral relationships, has contracts and has a team that's already working. You want to be tight with a good CPA that knows about mergers and acquisitions. How to read financials and teach you about it as well.
The cons are the things that you may not consider when you're talking to a CPA and that is, “Is it a cultural fit? Are you value-aligned? How's the team going to take it if I manage them differently? Are the benefits going to be the same? Are they going to lose if I purchase them because my benefit package is different than theirs?” There are many things that you might not be looking at right off the top, where maybe the pro of opening up your own clinic instead of purchasing one might be a better way if you simply have the right people. It's going to cost less, but you don't have the immediate revenue flow that an established clinic might have. If you have the right people, you will stand that and you can be very successful.”
We know this is a people business and this happened to me. I've had patients call saying, “I want to see Joe.” “Joe's not here anymore, but you could see Mary. She's a good therapist. We have her.” “I like Joe. I want to find Joe. He was my guy. He's my therapist.” It's a people business. Patients tend to follow their therapists. If you're buying a business where the owners or the staff, for whatever reason, decide not to stay with the new business, you're going to regret the fact that some of those patients are going to go away. That's something you've got to factor into it too. There's going to be some loss of patients there because it's a people business.
That brings up another thing. To go back in terms of stages and where owners are at with ownership, how do you deal with stepping out of treatment care and telling patients who liked what you did, especially when you're the owner and your partner that you were no longer treating? How did you make that transition and highlight your staff? You wouldn't tell them, “I've got a great staff and I've trained. I'm still on site.” You want to almost allay their fears, especially when the referring physicians are saying, “I want you to go see Jeff.” In my case, they almost didn't remember the name of my clinic. They said, “I want you to go see Nathan.” They knew that I had other physical therapists on staff, but that's how they knew of my clinic because I had that relationship. How did you successfully make that transition out and tell those patients that wanted to see you?
That was a tough one. I remember that I was very nervous about that. I know a lot of owners are because you feel like you have an owner mentality and you're probably a good therapist, number one. Number two, you have this owner mentality where you take good care of people and you relate well to people and all the rest of it. To get out from under that is difficult. You're going to have some loss during that period of time. There's going to be some patients who are upset by that, but I found it was very few. In the beginning, I would have to talk to every single one of them and say, “I picked this person that you're going to see. I trained them. They do it exactly like I do. In fact, in some cases, they're better than me for A, B and C reasons. However, I will be watching and monitoring. I'm always here for you when you need me.”Once you’ve build a reputation for your business and your practice, it will see you through even in times of transition. Click To Tweet
The vast majority of patients were willing to take that leap of faith and trust with me if it was explained that way. The physicians were the same thing. I remember those days with the prescription. They don’t say, “Go to Excel, go see Jeff.” It was the same conversation. I had to go to each one of them and explain, “I am getting busier. I am growing. I can't see all these patients. Can you allow you some of your patients to see new therapists that I bring on?” Most of the physicians were fine with that. They understand completely because they're in practices that are growing too and they understand how that works. Sometimes, they would want to meet the therapist and then that was cool.
It was a great marketing opportunity. Eventually, the prescriptions or referrals, they didn't say see Jeff anymore. They said, “See the other therapist.” That was a great day for me. I was very proud when that happened. There's nothing better as a PT that when you develop your own reputation, were physicians and patients identify you as a therapist and it's an awesome feeling. It's something to cultivate in your staff and that creates great culture and great momentum. It enhances your reputation as a business and practice when that word spreads that way.
There is a lot of anxiety and fear in making that handoff, but I think a lot of it honestly is pride because you have results. You've built something up and that could be the one thing that’s stopping you from making that jump is thinking, “Everyone's coming to see me.” There's a little bit of a pride element to that because it is what you've established for maybe over a few years.
Not a lot of good things happen when you're too prideful. I've learned that lesson. It is trust. You have to trust other people. Some of the trust can be built by picking the right people and training them properly and your trust level goes up and you do that.
I never tell that to people that I'm talking to that you've got to get over your pride. It's more about laying their fears. There might be people that will stop seeing you, but that means that they have to go to another place and establish a new relationship. I don't know if a lot of patients are willing to do that if they're that upset, but there is that possibility that there's going to be a few. I say, “Brainstorm and work with your front desk,” because they have to believe the story that they're telling patients that call them and say, “I want to see Nathan.” We need to figure out a story so that they are completely confident and believe the story that they're telling the patients, otherwise, it's not going to carry very well.
You build a reputation. If you lose a therapist or you bring on a new therapist, the reputation of your practice, if it's cultivated, nurtured and worked on all the time, it will carry you through those transitional periods. That goes back to where we started this conversation about having the systems in place, investing in training, accountability and management and how do you fix a PT who's off the reservation with one of their statistics and get them back on the reservation. How do you pick the right people with the right values that align with your practice? That's the ecology that my buddy Todd always talks about.
With you, as an owner, I'm assuming you went into it without a lot of business experience. How did you learn the statistics, numbers, measurements, how to develop policy and procedures and hold people accountable?
I had a little bit of a knack for it because I had that analytical brain from a statistical perspective, but along the way, I've had some mentors. I have a friend that is like a brother to me. A guy that I grew up with who got a practice up in North Jersey. He started his practice right around the same time I did. We helped each other. I learned a lot from him. That was one thing that helped me. I have a couple of consultants along the way. I moved into a new neighborhood many years ago and I got to be real good friends with one of my neighbors and he had an engineering business, but then he went into financial consulting.
He was the first guy that set me up on the whole P&L statements and balance sheet and taught me how to read and look at all those things. That was Brian and he changed my life at that point because that was when I finally though a light bulb went off about how to run a business. A couple of other PTs that I've had along the way. Kim and Michelle come to mind. People that were good with organization, administration and details. Edward was another one, a sharp guy. When we merged with the company I mentioned earlier, they had a lot of intellectual property in terms of systems and financial statements that took us to a new level.
Not knowing your story that much in-depth, I assumed that there was a point at which you came across someone who could teach you the ropes and you could get some training. My mantra with the show is if you want to expand, grow, get the freedom and profits that you want, you have to step out and meaning step out of training, you have to reach out and find some coach. Executive coach or consultant to teach you how to run a business and you have to network and work with other people who might be in similar situations, even if they're not in physical therapy. I assumed that it was probably part of your formula as well.
Our industry has a huge array of very talented consultants out there. There’s plentiful advice out there that you have to pay for. In many cases, it's worth it. It certainly was to me over the years to pay for that advice. It's your tuition. You can learn it the hard way. We're smart people. We can learn it, but why not take advantage of what's already out there? Even in PPS back to the private practice section, there's a wealth of resources in there. There are all training and different tools for marketing, finance, operations and so forth that weren't available many years ago. We have come a long way. I want to give some more accolades to PPS. The taskforce, work and tools that they put out during the COVID-19 crisis and pandemic was an amazing work that the board did during that period of time. That stuff is all still available. If there are people out there who are still working through recovery, which most of us are, I'm going to point out PPS and say there’s a lot of good tools there for you to use.
Looking back on what we've covered and we've covered a wide expansive of growth avenues, is there anything you want to go back and add to, or anything you want to add here towards the end of the program?
When you're busy in a clinic, that's a point where you're probably making good profits because you're busy and everybody's loaded up with visits. That could be a very attractive place for an owner to try to live because the profit margins are high. However, that's going to come with consequences that things are going to start to break. It is inevitable. When you're super busy, things are going to break. Watch those statistics, everybody. If you're starting to see those pressure points start to break down, that's a sign that you need to hire on new therapists or expand your clinic because you're going to start to come down the other side of that and your profitability is going to start to erode and you're going to spend a lot of money to build it back up again. Keep that kind of growth curve going smoothly up into the right and not herky-jerky rollercoaster-ish. That's the key to success.
Take that as your cue to take the next step and then take that step in faith, knowing that what you've done so far has been successful, continue to add to it. Thanks so much for your time. It was great talking to you in sharing your wisdom, your knowledge and your great help. I appreciate your work with PPS and Peer2Peer. If people wanted to get in touch with you or reach out to you individually, are you willing to share your contact information?
The best way to reach me was with my email. I'm happy to answer emails and if I don't know the answer to it, I know a lot of people out there. I can put you in touch with them. They would probably do know the answers. My email is JOstrowski@ExcelPhysicalTherapy.com.
I recommend people reach out if they have questions. You're available and you've got plenty of experience in the space. I appreciate your time. Thanks for coming on.
Thanks for having me. You are doing a great job. I love what you're doing, love this profession and there's so much opportunity out there for us if we work together and we share our knowledge. There's a wealth of opportunity out there. We're doing great work. We have value. Let’s grow this pie as big as we can and we can all get a big bite of it. Good luck, everybody.
Professional: B.S. in Biology Juniata College, Huntingdon, PA 1984. Graduate of the Thomas Jefferson University Physical Therapy program, 1986. Founder of Excel Physical Therapy, 1990. Partner in E&A Therapy, 2011-present. Licensed Physical Therapist in Pennsylvania 1986-present.
Volunteer: Board of Directors of the Private Practice Section (PPS) of the American Physical Therapy Association (APTA) 2011-2017; Treasurer PPS 2017-2018; Managing Editor of the PPS APTA member magazine Impact 2008-2011. Past President (2011-2014) of the Southeastern District of the Pennsylvania Chapter of the APTA 2011 -2014; Board of Directors of the Pennsylvania Chapter of the American Physical Therapy Association 2011-2014; past member of the PPTA Finance Committee 2014-2017; PPTA Legislative Ambassador Key Contact; APTA PAC Ambassador in Pennsylvania; APTA and PPS Legislative Key Contact.
Personal: Lives in Glen Mills, PA, a suburb of Philadelphia; married with two children, ages 23 and 21; Enjoys sports, fitness, cycling, golf, drawing and reading.
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After doing 100+ episodes and interviews with successful PT owners and industry leaders, Nathan Shields has recognized some commonalities between their actions which have led to their success. On this episode, he decides to share those secret actions they take (which aren't so secret) which, if all owners did regularly, would make them successful as well. As a bonus, he brings back Will Humphreys, PT to get his insight and compare his top 5 with his top 5. Discover if they’ll come up with the same things, or if Will sees things a different way?
I brought back Will Humphreys. Will, thanks for coming on again.
Thanks for having me back, Nate. It’s good to see you again.
We had you on a couple of episodes ago, The 3 Fatal Flaws PT Owners Make in Billing/Collections, which was well received. Thanks for coming on and joining us for that. You shared a lot of great information. I don't think I covered some of those stats that you were covering, the projections, how to measure what your collectors are doing for you.
It was so great. There's something cathartic around being able to go back and share these things. Everything that we've talked about is a lesson that either you and I have learned the hard way. If you and I talk about something and it creates value for a reader in a way that prevents an ounce of the pain that we've done or had to go through, it's totally worth it.
If we could maybe charge commission on what people can save by reading stuff like that when it comes to collections, it's hard to go back and learn those lessons or think about those lessons. I don't know about you, but I think about the tens of thousands of dollars that’s probably lost along the way.
It's more than tens of thousands. I got emotional once after I hit a six-figure estimate of what we probably lost over the years. I can't think of it that way. That was an investment in our education.
I did a webinar with Hands-On Diagnostics group about the five things that successful owners do or those actions that they take that make them successful PT owners that many PT owners don't do. That's what started the episode that we had regarding billing and collections. A lot of owners don't do these things. They're not projecting. They're not assessing the staffs appropriately, but there's more to it than that. It's not the billing and collections. There are other aspects of the business that many owners aren't taking steps and approaches. This is where I thought maybe we could come together and share notes. I've put together my five successful actions. For the readers, I've asked Will to do the same and we have not collaborated prior to this point.
Will has his five things and I have my five things. We're going to have some overlap and some ideas of what's most important. You can get there in different ways as long as you're taking the time to do these things. Let's start with a caveat and we both agree that these successful actions are not the first things you do. The first thing you do should you be a business owner is that you've already established purpose, vision, values and goals. That's a given. Many owners don't have those fundamentals. When I start coaching with clients, if those aren't clear and if they're not being lived, that's one of the first things we get into.
It's tough going to get into that a little bit because many clients don't feel like they're gaining traction when they're establishing those things. It's imperative that they're established because the actions that you build off of later on down the road when you hold people accountable, when you hire or fire, when you make business decisions, “Should we do this? Should we do that?” are dependent upon, are they aligned with our purpose, vision, values and goals? Nonetheless, the caveat is those are already established. We don't have to say those are one of the first things.Successful PT owners may not do ALL 5 (or 6) things well, but they do them regularly. Click To Tweet
Building on what you said, when you're coaching people, that's the first thing you establish even though most of the time it's not there. When I talk to people about either billing or oftentimes, I get questions on recruiting, it's another thing that I'll help people with. They want a copy of the ad that I helped create for another person who went from four interested candidates to 40 pre-COVID. COVID is a little bit different. We're getting a little bit more people out there. They want like, “Give me your ad. Let me copy and put it down there.” To your point, it's essential that everyone has that foundation established. It's upon that that you build these other systems and processes with power. Without that, to reiterate the importance of being able to do that prior to any of these top five things that other successful PT owners do.
We’ve established that, set it to the side, now the five actions that successful PT owners take. The first thing I came up with is they track their statistics regularly. They've got daily stats. This isn't just them. This is them and their team should they be big enough. They're tracking some daily stats, weekly stats, monthly stats, maybe quarterly stats, and at least annual stats as well. We could do a deep dive into stats. We're not going to do that now, but it's important to recognize there are statistics and then there are sub stats. When you're talking about collections, it's one thing to say gross revenues but it's another thing to say, “What is our percentage of over-the-counter collections? Are they coming across or are they being collected?”
The second thing that goes into collections, what is our AR aging? That would be a sub-statistic. Those are some things that you might look at in terms of collections. In terms of visits, there's total visits, but the things that influenced total visits are arrival rates, frequency of visits per week, completions of plan of care, all those things can also affect total visits. We have stats. We have sub-stats. Those are some examples. A couple of stats that we use to follow closely was skilled units per visit because that tends to be a statistic that is lesser than what you think it would be as an owner. If you're not tracking it, that can influence your bottom line.
As you said before, Will, PTs tend to be compassionate billers. If they have the choice between billing four units or three units, they'll err on the side of three units thinking that's okay, not recognizing what effects that might have for the clinic, insurance contracts and how we're perceived. We would look at skilled units per visit as one I'd highly recommend people follow. I'd also recommend frequency per week. We all think, if you have a patient, how many times per week should you be seeing them if they have a musculoskeletal injury? A typical therapist would say 2 to 3 times per week.
Inevitably, when you measure that stat as owners, it's usually around two and less than two when it should be closer to like 2.3 or something like that. Those are a couple of stats that I would recommend sharing. Successful owners are tracking these regularly and looking at them regularly, recognizing when they're trending downwards, when they're going upwards, what do we need to change if it's going down and what do we need to add on or do more of if they're going upwards. How did that affect you when you started measuring statistics in a more specific, detailed manner?
I don't think it's a coincidence that we both have that for our number one. The way I worded it was successful owners manage by statistics, not by emotion. For every PT owner, who's been in a discussion where there's been tears, there’s that awkward feeling of like, “What am I doing in this situation?” It's getting rid of the drama and putting in facts. Dealing with objective information, minimizes or eliminate so much of the difficulty and the pain of owning a clinic. To answer your question in a very long way, when we put statistics in, it was the day that I started growing without having to bear the burden of it. You and I were able to finally start expanding our growth, but in a way that didn't feel harder. The more you grow, the more you have to have some of those hard conversations and the more emotion comes in.
It makes the conversation so much easier. It also gives you certainty. You're coming from a place of, “They're my best provider.” Maybe you look at those stats compared to other providers and you think, “Maybe they're just average and I like them.” It's nice to have some real data in front of you. Speaking of skilled units per visit, in one of our clinics, our skilled units per visit average was okay. When I broke it down by provider, there was one provider that significantly produced less than the minimum expectation.
Without that statistic, I'm thinking everything's hunky-dory when that provider needed to be addressed. It not only helps those conversations go more smoothly because they're objective. It also helps because you recognize that you need to have conversations to begin with. It allows you to open that door and say, “FYI, your patients are expected to be here 2 to 3 times per week, but your patients on average are coming like 1.8, 1.7. We can talk about what can happen if they're not coming 2 to 3 times per week and less than that.” It allows you to start having the conversation to begin with. It doesn't have to be emotional. I love that you shared that.
You gave a good example there. I remember one specific case where you and I were looking at a PT that was working for us. We were super stoked because he was seeing high number of visits per week. He was doing a number of evals per week. He was billing appropriately. We thought he was a rock star. When we dove deeper, his average number of visits for each patient episode of care was between 3 and 5 visits. They were disappearing. He was hurting our company and we didn't even know it. On the front end with the primary stats, it looked like he was killing it. We're bonusing him and high fiving, “You're killing it,” then there's a whole bunch of people who aren't getting better and going, “Physical therapy didn't help me.”
Imagine all the number of visits that we lost and the lessened impact that we had in the community because of that. We agree on one. The next one is tied to it and that is, they take the time to measure their stats and run their company. Many owners out there think that their value and their production lie in the care of their patients when it's not that at all. Number one has to be the business, and they short sell the business in order to provide more patient care. When that happens, their business can and will suffer, especially if they want to grow. They have to take the time that the business needs of them to run smoothly, effectively, profitably and with less drama. I remember back in the day when we first got consulting. They're like, “Take half a day, 4 to 5 hours. We're going to eat this elephant one bite at a time.” I take that afternoon, do my chart notes, pay some bills. I did stuff that had nothing to do with running the business.
You did your busy work that was building up.
I started checking off to-do lists of things that I thought were super important, but they had nothing to do with running the business. If you could take those 4 to 5 hours to gather your reports and gather your data and see where you're tracking, that alone in that 4 to 5 hours would make the time worth it. Did you find it hard to take that initial step?
The biggest thing I tell PT owners when I talk to them is like, “The hardest thing you'll learn to do is transition into leadership because when you're a provider leader, you don't even realize how much you can do on the fly because you're on site. The second you open a second location, it becomes clear how effective your leadership is if you're still treating. The way it's perceived because of our fear-based industry is, “They're stepping out of treating.” That's the narrative. You're stepping out of providing care, when the story is, I'm stepping into leadership, which sharing that second message with a team is a lot more powerful than the first. You're telling people you're progressing.
When they start benefiting from your lack of confusion and overwhelm, that's when they'll appreciate that. You and I both had people who were like, “No, you're good. Stay away.” Keep working on the business because their lives were easier. What's hard for us as well is we define ourselves as providers mostly. When we don't get the cookies from our patients and we're stepping into care and we don't know what to do with that time at first, it becomes hard.
I have to say that was my second thing. Number two, and the way I worded it was to protect their leadership time. Managed by statistics then you protect your time there. For anyone who's reading who’s like, “What will I even do?” or someone who is doing some of leadership time, but they're not sure if they're using that time productively, just be consistent. Consistency will allow you eventually to figure out what you need to. Think of time like space. You're creating a space for you to be able to let things come and go. You'll have to get used to that for a while, but then it will start very quickly filling up with important urgent things that you should have been working on a long time ago.
We need some of that time to decompress initially. You brought up the point of it's hard because owners aren't sure what to do with that time and don't know how they're going to fill it up. It's probably good to simply step away and take that time so that you can allow things to come to you. There are things that are going through your head I'm assuming as you’re treating patients like, “I need to get that done,” or “Maybe I should be doing annual reviews on my employees or at least give them some feedback,” or “I want to talk to so and so about such and such policy that's not being followed,” or “Maybe we should have a new policy regarding blank.”
Those are all things that will come to you when you set aside that time and space to work on it. That's what your team wants from a leader. They want the leadership. As I work with clients and they start giving more of their leadership time to the team, to have meetings, to have one-on-one sessions, to strategize together and maybe talk together about policies that they're having issues with, their team is eating it up. Their team loves it that they simply give them that time.
It's imperative to start with at a minimum, 4 to 5 hours in a day. It gradually becomes two half days. It gradually becomes one full day and maybe a half day. That's where you have to put your foot down and say, “No, this is my schedule. If patients want to see me, this is when I see them. I do not see them during admin times. If you want to see me and talk to me about blank issues, you can do it during these hours during my admin time.” Protect your space because no one else will.Any success you have is directly proportionate to the number of difficult conversations you are willing to have. Click To Tweet
Number three is successful owners. I've done over 100 episodes. I've interviewed close to 100 people who were successful in the industry and outside of the industry to a tee, and 99.999% of them have a coach or consultant of some kind or other. They have someone who's showing them the ropes. We all went to PT school. We did not go to business school. We thought, “I'm a great PT. I'll hang out my shingle. Things will be great. Patients will flock to me. I have this relationship with that doctor. Everything's going to be hunky-dory.” We’re not truly recognizing the work that it takes to own the business. We simply continue down that road, thinking everything will be great. Soon thereafter, we get someone that we heavily rely upon at the front desk to give their two-week notice to us and we are lost.
We don't know what to do or someone comes in late and we're like, “How do I handle this now?” Coaches, consultants, number one, give you feedback, help you organize, give you encouragement, question your perspectives. They do all of that because we don't have anyone to answer to because we're at the peak of our organization. Who do we answer to? That's where a coaching consultant can come across and help and be a mini-board of directors for an individual owner. That's my third one. Does that match up with you?
I didn't list mine in terms of priority. It coincidentally hit that. It wasn't the third one I put down, but it's on my list. It's have a coach. You and I both know that's when things pivoted. To put it in perspective, people oftentimes don't hire coaches for two reasons. Number one, they don't even know how to find an appropriate coach. That term coach is a generic term to be applied to many types of individuals who “coach.”
A lot of owners that I talked to don't know what a business coach is or what they do.
How do you define one if that's the case? How do you even hunt them down? Here's what Tim Ferriss says about that, who's a bit of a guru on coaching. He says that the coach that you hire should be someone who has either done what you're trying to do or physically themselves had gone professionally where you want to go and/or helped others do what you want to do and go create. If I want to create a business that's a lifestyle business, a multi-locational, multimillion-dollar practice, and I want to be able to work myself out of it, I would look at Nathan Shields because he has done that. There are people who call themselves coach who go out there, and to be honest, I've never had a bad coach. You and I have had multiple coaches over the years. Having someone hold the space for you is in and of itself incredible. It’s useful to have someone challenge your thinking and give you a space to speak into, but to have someone who has done it is worth its weight in gold.
I love that you said that they don't know where to go because I've asked my audience if they are looking to possibly get a coach or see if it's time for them to get a coach, you name it, what are their wants and needs? I'm more than happy to share coaches that I know. It's not uncommon for me to share the contact information of other coaches that might be a better fit for that individual than for me specifically. It's important to talk to people, use your network, find ways or start googling things. There are people that will come up nowadays.
I've interviewed Greg Todd, Jamey Schrier, Sturdy McKee, Shaun Kirk and guys at Measurable Solutions. Go back to past episodes, you'll have a wide range of people outside of myself that do coaching and consulting. The whole idea behind it is to help you achieve your goals. That's what it is. You reach out to a coach, not only to gain information, to have a sounding board, you name it. One of the most important things is to establish, what are your goals and how am I going to get there? That's where a coach can be your Sherpa or your guide to help you achieve what you want to achieve.
Another tip to finding a good coach is to look for what's out there in terms of free content. Any powerful coach is going to create free content. Greg Todd, for example, has YouTube and Instagram and all those things. Nathan has this show. For me, I do a YouTube channel where I share those same secrets and some things that I had to pay others for to help build a multimillion-dollar practice. You go find those free stuff that's out there. From there, you can see what services they offer. Not all of them are going to be coaches. Some of them will coach specific things. Others will have other services that they offer.
The thing I would tell you is that be expected on the second thing. The other thing that holds PTs from moving forward with coaching is that it's an unusual purchase for them. It's a high dollar amount that they've never had to consider spending money on before. What's a good price range for a coach? It depends on the coach and the program, but when I came home from Europe after a six months sabbatical, the first thing that I did was I went out and I dropped $50,000 on a coach for the year.
Before I knew I was going to do a billing company, before I did anything else, I hired my coach. It was the first thing I did when I came home. The reason being was because I had learned which coach is way up. A lot of coaches are going to do introductory fees of $1,000 to $5,000, depending on their timeframe, but you should anticipate budgeting $10,000 to $20,000 a year in either a coach or coaching services through like a group in order to invest. If you think that's a lot of money, let me ask you, “Would you pay $10,000 to be given $1 million in 1 to 3 years?” That's the exchange on investment when it comes to it. It's a mindset shift for all entrepreneurs. Inc. magazine says, “That's one of the two things all major successful CEOs go through.” Steve Jobs had a coach. It's a necessary step in progression.
To make an easy analogy, Michael Jordan had a coach the entire time and he was the best, yet he still had a coach when he was at the pinnacle, five rings and all. They have their coaches and it's imperative to get some support and advice. It's expensive. You said $50,000. I didn't bat an eye because I know you and I have spent six figures on coaching in the past. It's an unexpected expense and price tag. Jamey Schrier, I was talking to him at lunch one time, he's a coach as well. He said, “If I can't get $1,000 a month, if I can't get you one more new patient a month for my coaching services, then I'm not a very good coach to begin with. You should not pay me,” but you can’t look at it like that. There's got to be some return on investment, whether it's immediate number of new patients. Your clinic is going to be X times more valuable because you simply established it better. That's what a coach and a consultant is going to be for you.
Number four, and like you said, mine aren't necessarily in order of priority. They're all super important. The next thing is that successful owners have reproducible systems and processes that are not dependent on them individually. They established processes and procedures that other people can do and replicate, and they are not the final say. They get other people to own their jobs, own their positions and start establishing a bunch of mini-owners within their clinic who own their jobs and then report appropriately to their supervisor or whatever the name is. Blaine Stimac, he's one of our mentors or one of my buddies in our network, but also seemingly a mentor. Every time I talk to him, the guy has some wisdom to share with me. It's all about reproducing the system, reproducing the process. You could say it's a McDonald's model if you want, but getting somebody in there that can repeat the process over and over again and do so successfully productively. My next one is reproducible systems and processes.
I don't have that in my top five. Without a doubt, it should be. It's such a vital piece. That's the whole point. E-Myth Revisited by Michael Gerber, the whole thought is if you want to be a company that’s process dependent, you have to get away from being people dependent. That's one of those emotional problems that we all face as owners. What if so and so leaves? If you've got the playbook on how to do that job at a high level, and you can recruit from other processes, you don't care if people leave as much. You're very able to make those harder decisions. You'll see what I put in there as important.
I can expand the size of the nest. Maybe it's six successful actions. Maybe it's not just five. We'll make room for you, Will. I love what you said that the power that it gives you when you have processes in place makes things so much easier. You're not people dependent. It goes back to Gerber and all the issues that he comes up with the story in E-Myth Revisited about the owner that is running with their head cut off. They don't want to do this anymore. They're burned out and frustrated. It's because there's a lack of process and procedure. A lot of HR questions that come across to me from clients, they'll say, “So and so put the wrong number of hours on their time sheet.” I'm like, “What's your process around that?” They’re like, “We don't have one.” That's a lesson learned. You might have to pay them for the added money that they put on their time sheet. Now establish a process that says this is when you can check in and check out.
There's a lot of power behind that. I'm excited to hear what your other one was that took the place of processes and procedures. My last one, my number five, it's not something that was essentially taught to us like these things were. We were taught stats and setting aside admin time. We went out and got coaches and consultants because people told us to. We were taught by our coach and consultant to start with establishing processes and procedures. The thing I'm noticing as I'm coaching clients is that the ones that do well and move forward faster with less drama, they're not escaping the drama, they're facing it head on, are the ones that act with impatience.
They're impatient. One of the more frustrating things is to come across people who have read all the books and done all the things, yet they're still losing money. They're not taking time to work on their business like they know they should and they're putting things into action. It comes into not only the actions that they take like, “This is what I need to do for my business.” You start doing it. “I'll implement it next week or next month, maybe when it's a little bit nicer outside,” I don't know what slows them down. They also do it with their people, with their team.
They act with impatience in a compassionate and empathetic way, not in a mean and angry way like, “I’m impatient with you and I'm going to sternly work with you.” They address the issue immediately. I learned over time that I'm slow at making decisions. I have to sleep on things. I have to mold them over and see what the different options are and think about them. That's where you and I work well together, even though I know it could be frustrating for you. You're able to work through those things quickly and see all the options and whatnot. Still, taking the next step to make the action significantly improves my life. The drama subsides. The mental gymnastics that I'm going through at the time, trying to mull over decision minimizes, lessens the amount of energy that it takes.
Simply, I have to remind myself, if I have option A and option B and I choose option A, if it's the wrong option, I'm going to find out quickly, then we can pivot over option B and recognize that most decisions aren't final. They can be learned from and pivoted from pretty quickly. They act with impatience and they see their stats and they make corrections. They see something out of whack and they immediately address it. They're not afraid to confront. Does that fall in line with what you’re thinking?The more we grow, the more we can impact people's lives. Click To Tweet
That's it. The way I worded it was trainable and willing to have crucial conversations. There's a trainable next. Remember one of our coaches, Scott Fritz, he used to tell us, “I can help anyone as long as they're trainable and willing to implement. We're talking about, in your case, that word you weren't saying that kept coming to mind was urgency. They're hyperfocused on the result and they're urgently making changes because they know what's at stake if they don't make changes. We're all in progression and it's not like we don't need to be coming from a place of panic. The second we see clarity in learning from a book, a podcast or a coach, and we don't implement right away, the reasons for not confronting those problems become insurmountable.
One of the things I've said is that any success I've ever had is directly proportionate to the number of crucial and difficult conversations I was willing to have. We all know what those are. I promise everyone reading, if they ask themselves, “What are the conversations that I should be having that I'm not?” There are immediately 1, 2, 3 things coming to mind. Those are the three things that are holding you back from your dreams. Those are the things that are monetize wise. I think about a room with $1 million in cash piled up. There's a door there. The door is open through that crucial conversation. It's not about the money. In that same room where the money is, there's greater patient results. There's a better impact in developing your team as people.
It comes through this challenge of having that conversation urgently. As you said articulately, if we're not willing to implement those things impatiently in a way that you know what's at risk and what's possible. It's two things. You know what's at risk if I don't and you know what's possible if I do. That mindset is there. We all struggle and we all sit on problems too long. Stop, get off your butt and go have the conversation. I've learned doing it the wrong way. It's better to do it wrong than not at all. “I shouldn't have done that. I shouldn't have said it this way. I think I hurt their feelings accidentally.” That's how you learn to get better at it. The product was still momentum. It was still progression.
Even something as simple as starting this podcast. I didn't have confidence that I was a good podcaster and thus decided to start a podcast. I thought I want to do this podcast. There's something within me wanting to do this. It was scary as hell for a number of episodes. Even at times now I get scared prior to going into an interview, even though I've done over 100 of them. The confidence doesn't come first. Action comes first, confidence comes later. That's when you start becoming more powerful as you continue to have those crucial conversations. As you start to make faster decisions, you'll start to get better at making decisions on the fly. These aren't decisions that are simply decisions on the fly.
These are decisions that we have some data behind. We have enough data. Many times, we're waiting for more data when we don't need more. We simply need to get what's in front of us, understand the situation clearly, and then move forward. When we do so, things turn out so much better. You and I both agree that we've never fired someone too soon. It's always easier to have that crucial conversation first and move forward later. As you continue to make faster decisions, you'll start to get some intuition. Some of that just grows. Some of that is experience. Some of that is hunch in the gut, and sometimes it's okay to work off of those things. The faster we can make those decisions, the better for our business and our employees.
The two things that I would say on how to narrow that learning curve as short as possible, it goes back to getting a coach again. Having a coach help you work on developing your voice in a crucial conversation is huge. We're going to have to learn their voice through trial and error. You can trial and error with a coach in a way to where you dramatically shorten that learning curve. The reason that's important is because even though having that crucial conversation wrong is better than not having it at all. What's possible is if you can have that conversation powerfully, like we have once let an employee go and they posted positive comments on Facebook the next day. That’s what's possible when we can step outside of ourselves and determine how we can serve people, even in those moments. A coach is huge in that. Secondly, as you said, being willing to make the mistake and try. There has to be movement. The picture will appear when the car is in motion.
I listed my five: tracking stats, setting aside admin time, hire a coach or consultant, establishing reproducible systems and processes and lastly, making quick decisions or moving with impatience. What is the one outlier that you've got, Will, that didn't fit in the top five, but now we'll call it the top six?
The sixth most important successful action is to join a network. Sometimes coaching networks get put together so maybe that's one of the reasons I separated it out. It’s worth at least talking about what's a network. A network is a group of individuals that are people you know, that you maintain a relationship with. It can be any kind, but sometimes they're organized like Hands-On Diagnostics seminars. They have this business, but it's also a network. They have weekly webinars from other people that have nothing to do with diagnostics.
It goes back to two phrases that I don't believe get emphasized enough even though we all know them. It's "Who you know, not what you know” and "Your network is your net worth.” I have a friend who is worth tens of millions. He's not a PT. It's a non-PT business. I asked him what his number one successful action was. He goes, “Have you ever read the book, Never Eat Alone?” I said, “I've heard of it, but I've never read it.” He goes, “I've never read it either. I read the title and said, “Yep, I got it,” and started scheduling lunches every week with people he either wanted to know or people he thought he could help.
He told me once about a lunch that turned into a referral that was worth $250,000 to him. I would say that as you and I look back in time and we look at finding the right coaches down to opportunities for growth, it was a matter of knowing the right people first who led us to the right opportunities. People don't build their network because they don't know the value of it. They don't understand that it makes it more fun and they don't know where to start. I challenged a young entrepreneur to reach out and try to get lunch with the CEO, especially now that everyone's doing Zoom all day. People are more willing to meet with you via Zoom since it's not a full lunch.
Just reach out to someone you want to get to know and to say, “I love what you're doing. I'd love to learn from you and ask you some questions because I want to do something similar. I think you're great.” Everyone who's successful has a coach, been coached and been in a network. They are all about supporting those types of people. If you ever get shut down, you didn't want to network with that person. You didn't truly if they’re like, “I'm too busy for you.” If you do reach out to someone who's super popular and big, you have to do your research. You don’t just hit them up on LinkedIn or whatever. You want to find out what interests they have, what organizations and charities do they support. You want to reach out from a place of, “CEO so-and-so, or Mr. so-and-so, or Mrs. so-and-so, I understand that you support such and such. I'm a huge fan of that. I'd love to get with you and pick your brain.” That small difference separates you from these automated spammers who are constantly trying to meet up, network and grow in a way that's tacky versus value-based. That's what I put as my fifth.
I can say that I had thought about it. I thought about putting it in my number five or in my top five. You know me, my mantra is reach out, step out and network. I left network out of the top five. The network was a huge game changer for us, not just the consulting, but also the networking that we did through entrepreneur’s organization, the networking that we did with Measurable Solutions owners, the network we did with Hands-On Diagnostics owners were all super pivotal for us in the last number of years. They still are. I still lean on those guys. Starting up the podcast was a matter of, “I wanted to create this resource for PT owners,” but it was also, “I have a ton of successful PT owners in my network, our network. There's no reason they shouldn't be sharing their successful actions with other PT owners across the country. How can we do that?” That's why I interview these guys. If you want to know who they are, look at a lot of my first episodes. There were some of the more influential owners that affected us in a positive way.
Your podcast is a who's who of amazing people in our industry. If people went back through your podcast list, if you ask me personally like, “Who were the most influential people in our industry?” they've been on your podcast already.
I've had a ton of them. They're great people. They're willing to open up their time. At first, they're like, “Who are you? Why are you reaching out to me?” I say, “I interview people. Here's the link to someone who I interviewed and here's the website.” I am legitimate. They are busy people. They're super productive and they value their time. They filter accordingly. You have to expect that, but don't let that stop you from taking the step and networking. I'd recommend if you can get with an organized group of some kind or other that puts people together, that's helpful as well. There is BNI, but that's a bit more of a marketing juggernaut across the country, but Entrepreneurs’ Organization, we're big fans of. There's Vistage out there that not only helps you network, but also can provide you some small amount of executive coaching/mentorship.
There's Peer2Peer through APTA’s PPS where you have a bunch of PT owner peers that you can get together. I've had Randy Roesch on the podcast talking about Peer2Peer as well. There are opportunities out there. At the very least start talking to some friends and neighbors, go to church, ask some people out to lunch. That can be awkward if you don't know them that well. I know who we're talking about when you're sharing the story about the guy who took guys out to lunch. This is a guy who had his own small business. Through his networking efforts, he completely changed his lifestyle and his life altogether. His wealth was amazing because of the networking that he did.
I love how we're talking about this because this is it. If anyone's reading, this is the way to go. It’s to be able to focus on those 5, 6 things yield. That's the 20% that you can do that will get you 80% of the way there. Everything else, you can figure out in route because this is a framework, this is a foundation. You’ve got to start with the values, the vision, the purpose. As you grow, it's interesting, the more you serve, the more fun it is, the more money you make. Those things aren't separate. Those are connected. The more we grow, the more we can impact people's lives. The more money we make, the more freedom we have. It becomes easier, not harder. That's the mindset of an entrepreneur. It takes change and effort to get there, but without a doubt by doing so, you can greatly improve your whole world.
The owners that are having a hard time being owners and they're getting burned out, it's because they stayed static for too long. They didn't make those quick decisions. They didn't recognize some urgency when it came to making some changes in their business. It starts wearing them down because I recognized, for clinic owners who get to the point where they're like, “I can't see patients anymore,” it's doing my business a disservice. It does my patients a disservice because I'm distracted thinking about the business while I'm treating patients.”
It's not until they get to that point that they finally say, “I've got to figure out a way.” Why they get to that point is because they've subconsciously recognized and I'm able to iterate it, but maybe they aren’t. Their purpose no longer aligns with their actions. They've gotten to a point where they recognize that, “I have a greater purpose in this business and it's not treating patients. I can do more for more people in my community if I lead out in this business and align myself with my greater purpose.” That's when they start to see significant changes and start taking some of these actions that we've laid out.Thinking like an entrepreneur is something anyone can learn how to do. Click To Tweet
If you're reading right now and you're thinking, “I don't know if this is me. I've always been like this,” you've been doing it maybe a certain way for a long time or you don't even know where to go. I want to highlight the main thing, which is that thinking like an entrepreneur is something anyone can learn how to do. It is like a talent in a sport. Some people are born with this God-given ability to be able to perform at some crazy level. There are entrepreneurs who were born that way. That wasn't me. I do feel like the urgency to communicate the hope that anyone can have in being able to do what you and I have done. The one thing that we've been able to do has come through help. That's why you and I both are committed to wanting to help like others. It wasn't organic or natural, at least for me. As we grow, we can say, “If we can do it, you can.” Believe in yourself and start trying.
I love getting coaching calls from guys who have owned their clinics for 1 or 2 years. I'm like, “You're so smart. I wish I could go back and tell myself to do the same thing.”
They will never know how much easier their life became because they did not.
How many years they've accelerated their business and their life by doing that. It would be cool if we had some things that we disagreed on. There were some back and forth, but that didn’t come up.
It would've been neat if we could disagree. Let's pick a topic and start arguing in another episode for the heck of it.
Thanks for joining me. If people want to get a hold of you, how do they do that? Remind everybody how do they get in touch with you, Will.
If you're looking for a unique and powerful way to handle your billing and collecting, what I say is that we make billing and collecting fun and easy. Without a doubt, next to treating patients, the highlight of your day should be collecting your cash. I have a billing company called In the Black. You can go to InTheBlackBilling.com and check us out. For me personally, I have a YouTube channel that I am changing the name of. This is the first time I'm announcing it. I'm going from The Profitable PT to The Profitable Provider. The reason being is because Nathan and I have recognized that our information is being received almost 50% by people who aren't physical therapists and other healthcare spaces. You can go to The Profitable Provider on YouTube and learn lessons that cost me years of money and time learning. I give them away to help you become profitable.
I'd like to highlight that you're still offering the free audit of their billing and collections.
On the profitability side, your first pillar of profitability is always your billing and collecting space. This is truly a service that I offer. If you are not interested in changing billing companies and you just want to check either your in-house solution or outsource solution, you can do something called the Free Profitability Breakthrough Audit. What we do is we take a look at everything within your company that directly impacts your profitability, billing and collecting being the primary one. We analyze that through our systems and give you a readout. We've had people go through who've had pretty good billing solutions. We've had others who didn't realize that there was a six-figure amount of money that was sitting in their accounts receivable that was easily obtainable. That was a six-figure phone call. If you want to know, there's no pressure to do anything else with us. If you are considering looking at an outsource solution, this is a good way to get to know us as well. There's no pressure to do anything on that.
Thanks for sharing. I think that profitability audit would be huge. I wish that we had something like that back in the day. Thanks for your time. I always appreciate it, Will.
Will is the CLO and co-founder of In The Black Billing company and has been a PT for 20 years. He owned a multi-locational outpatient practice for 12 years before starting In The Black Billing with Katie Archibald.
He is a father of 4 boys, married for 20 years and a part-time comedian. He is passionate about physical therapy, entrepreneurship, and the freedom that is created through profitability.
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Steve Anderson, PT has owned clinics and managed a large PT organization in his past. Thus, he's primed to expound on the challenges that owners face when they own and manage multiple clinics. Although the thought of expansion is exciting, it takes a different level of leadership and management from the owner(s). In this episode, Steve joins Nathan Shields as they cover some of the key aspects to consider if you're running multiple clinics or looking to do so in your future.
I've got a returning guest, Steve Anderson. He was with me as we talked about PPS and the Peer2Peer network. Thanks for coming on. I appreciate it.
You're welcome. I’m glad to be here.
If you want to hear about his story, you can go back and read that prior episode. In a nutshell, Steve is the ex-CEO of Therapeutic Associates, which has almost 100 clinics in the Pacific Northwest. Now, he is working as an executive coach under Orange Dot Coaching and also the host of his own podcast, Profiles in Leadership. I'm excited to bring him back on. Based on his experience, he was the CEO of an almost 100-clinic company in the Pacific Northwest. I figured it was important to bring him on because I wanted to talk with Steve about the differences between what it takes in leadership to own multiple clinics versus a single clinic.
Some of you might be in that stage where you're thinking about expanding, or maybe you have two clinics. It's wearing your thin or pulling you at both ends and burning the midnight oil. I've been there before. I thought I'd talk about some of the things that we can do to improve our leadership capabilities when it comes to owning more than one physical location. Steve, what’s the big difference between someone who owns a single location and someone who has multiple locations? How do they manage their time better? How do they do better as a leader? What do they need to be aware of in order to make that transition?
The first thing you have to say is that you can't do it all. You think, “We have one location now. I'm doing great. I'm going to do the exact same thing in the other location.” You probably don't have double the time to do that. I'm very big on identifying what is your intent to open another clinic or a number of clinics. Do you want to do that as a business strategy so that then you're going to have multiple clinics and then sell it to somebody else as a business strategy? Do you want those new clinics to be part of your organization, grow but keep it within your ownership style? Understanding what your intent is important because you could approach it in two different ways.
If you want physical sites down that do pretty well, and then you're going to sell that down the road, you'd probably want to keep the ownership piece of it tight because you'd want to benefit from that leveraging and selling. If you want to build more of what I would call maybe a legacy company or a company for your career, you'd want to make sure that people that you put as directors in those clinics have the skill and the ability to learn and grow. They can be successful as you are in the practice that you're in so that you can grow that way. I think being intentional about what you're trying to do is the first step.
It sounds like it goes back to what your purpose is, what makes you want to do this in the first place? Going back to what's your personal purpose and make sure your business is in alignment with that, and then taking the next step to make sure that you are putting yourself in a position or a role that aligns with that purpose. We often see people who find some success in a single clinic and see an opportunity in another community and want to open up another clinic without thinking ahead too much about, “I can't do it all.” You’ve got to figure out, “I can't treat full-time and manage two clinics. That's going to spread me too thin.” For some reason, we might even be a little bit naïve to think that, “If I hire the right PT, they can run it. I'll collect the cash and make sure everything runs as I do here.” That's not the way to go.
No, it's not. The strategy that makes the most sense to identify a good director for this new clinic or more clinics than your own. You have to invest time and energy into mentoring them and helping them learn and grow in that position. You can't assume that because they're a good PT that they know how to run a clinic or they know how to manage people as it grows. That's where you come in as a mentor-coach type of relationship with those people. It takes time again away from your practice to do this. You have to create opportunities for you to help them learn and grow. People make the mistake, “I'll put this person over here in this clinic and I'll keep doing what I'm doing and they're going to do great.” They may or they may not, but I guarantee you they'll do better if you take the time to mentor them and help them learn and grow.Managing multiple clinics requires a committed purpose, solid policy and procedure, and a dependence on objective reports coming from a leadership team. Click To Tweet
You brought this up in our mastermind meeting. It was valuable and it made me recall some of the more successful PT owners that I know and that I've interviewed. Their system is such that they have a seating system. They have a leadership development program. I know that's how you developed it within Therapeutic Associates as well. They have the same thing there and that is they open up clinics, would you say after they've established the right person? They find the right person first and develop them and then move them onto that opportunity instead of finding the location first and then hoping to build someone into that?
That's the best way to do it. It's all about the person. One of the executives in TA always used the horse, the track and the jockey and what's the most important. The jockey is the most important thing. You need to make sure that you have somebody for that position. A lot of people used to ask us at Therapeutic Associates like, “Why do you guys keep expanding? Are you trying to take over the world or what's going on?” The easy answer is that we have some great people in that organization. We want them to have the same opportunity that I had when I came through, which is a chance to have your own clinic, be the leader of it, build it up, and be successful.
If you don't have opportunities for people like me and others that were seeking that out, we're probably going to leave and do it ourselves or go with somebody else who gives us that opportunity. Getting back to your question, the best directors are the ones that you know, that have worked with you, that understands your culture, that understand what you're trying to do. You provide them with a growing opportunity by putting them in a different clinic so that they can do that. You still need to mentor and work with that person going forward and you can continue to grow this business.
If you're interested in multiple clinic companies, there's somebody else that comes along and you keep finding these opportunities for them. Geography is important. Being aware of what's in the community and what the community needs are, is very important. I can tell you that the TA, Therapeutic Associates, probably turned away more opportunities than I can remember because we didn't have the right person to put in there. We knew that you can't put a subpar person in there and do well. It didn’t work.
It's interesting that those people who are trained up, know your system, are value-aligned and are highly productive and properly incentivized, geography is secondary. You could almost put them anywhere and they're going to succeed. That's the important part. I think we underestimate the importance of that training program. I don't think for most owners out there, it takes a lot to develop a leadership program of our own. It's time-intensive once we have it, but to establish the structure and say, “This is a blank PT’s leadership program and follow it.” You can put some time into polishing it up and making it better but it's the books that you read. It's the reports that you look at. It's maybe sitting in on what one-on-one meetings look like. It's showing them how someone is held accountable. Maybe if you've got some consulting or coaching in the past, sharing that same coaching or consultants, or what you've learned from them in the past and also transferring that knowledge onto them. How do you see it in developing a leadership program for these smaller owners to create?
It starts at different levels. At Therapeutic Associates, I developed robust and sophisticated certain levels and all that is because we had the numbers and we had the people. When you're a smaller organization, I still think it's important to do it. It starts with having a regular, not if you have time, scheduled meetings with those other directors so that you can discuss things. It may be HR training or it could be how to communicate better with your people and what cultural things are we trying to do to have those discussions.
The next step would be to have some classes or some organized meetings. You brought up a book. “This is a great book. Let's read it all together. Let's get together and discuss it for a couple of hours and try to understand what the author is trying to do and how that could maybe help our practice. As you get bigger, often your best teachers are already within your organization. It's not something where I'm going to bring a ton of people in from the outside to tell us how to be leaders and how to run our practice. It's good to do that once in a while to break things up. There are some great people out there that can provide insight.
From a different perspective, they can look at what you're doing and say, “You might want to try doing this or this is odd.”
You can build it and develop it as you go. My experience has been with a lot of private practice PTs do is they get very caught up in the day-to-day and the going of their business. They can't imagine that there would be time to do this, how could you block out time to do that? My theory on that is that the time you spend now preparing for 3 to 5 years down the road exponentially is going to be much greater. You have to find the time and you have to dedicate the time. Even though it feels like, “I'm letting some revenue go by doing this.” It'll come back to you tenfold if you do it in the right way.
Sometimes we might think that leadership development is maybe a 3-month or 6-month process. As the leader in developing leadership, you need to look 1, 2, 3, even 5 years down the road and start that program. Start pushing people through and finding out if they're capable or not. Some of them might be able to reach a certain level and not go further. You need to recognize that quickly. Maybe someone is a good clinic director but it doesn't necessarily mean they're going to be a great partner in another location. You have to test, prove and show their worth in order to make those kinds of jobs.
There's no end goal in leadership. I'm still learning something every day. You keep learning. It's not like, “We're going to do this. In six months, we'll have this product.” This is not that. It's ongoing for everybody involved to continue to learn and grow. With that mindset, you'll do better.
What do owners need to be aware of as they start growing? As the number of employees increases and if they do have another location, what are some of the pitfalls that you can see that owners need to be aware of?
This isn't new information, but it's all about communication. You imagine your day-to-day in the clinic and you put your head down. You're treating your patients and you give all your energy to your patients. You're going on to the next patient or whatever, but you've got to find some time and energy to put into your staff all the time too. It can be little things. It can be things like, “What can I say to this PT aid now that they can make them feel a part of the team and make their day?” It can be going by and saying, “I appreciated how you handled Mrs. Smith when she came in this morning, and that was a difficult situation, but you handled it like a pro. Thanks for being part of the team.” That takes fifteen seconds, but it makes people feel good about what they're doing. You're building a team. You're building culture. If you can imagine, what can I do all day long every day to keep the communication strong between my team? If you let it think it's going to happen without any attention to it, it will probably not.
I wonder, as an owner, I wasn't quite sure what I would if I wasn't treating. We didn't have a lot of business training coming out of physical therapy school. If I'm not treating, what am I doing? One of those things is to check in with your team either during the course of their work or also with one-on-one meetings with those people who are a little bit more “important.” You want to stay close to your providers especially the ones close to your leadership and clinic directors. A lot of it is meetings. I'm surprised how many owners don't have regularly scheduled meetings with their billers to stay on top of their money. One-on-one meetings to help people grow. When you have leadership or people who you have tabbed for leadership, you want to take the time aside to talk with them and mentor them and maintain the communication through the company. A lot of that will help things move better, improve the flow and culture of the business as well.
We can't assume that everybody knows exactly how to do that. You, as the leader, need to help people discover those certain pieces. There's a great book that a lot of people are familiar with, written by Daniel Pink called Drive. He talks about the three things in there that motivate people. It's serving a greater purpose. It is some amount of autonomy and self-mastery. Those are the three things. As a leader, I would look at that as, “How can I help the people that are working with me identify and know what those three things are in their lives?” You can't assume that everyone says, “You may have the greater purpose of I'm going to provide all these services for my community, make my community, stronger, help the health of my community, or whatever your greater purpose is. You can't assume everybody else understands that unless you talk about it. Unless you help them identify that as well. Helping them identify those three specific areas and how you can help them develop more into those three areas will help keep your people motivated and inspired going forward.
I would even go so far as to say when you're talking about communication, that having the written systems, policies, and procedures or video examples of this is how we do things is also a form of communication that can minimize the wrong communication. Inevitably as an owner, there are plenty of people, if you're sitting in the office, that are going to knock on the door, “Do you got a minute?” and those are distractions to you as an owner. That's not the communication that you necessarily want.Often your best teachers are already within your organization. Click To Tweet
When you have systems and procedures in place and you have given them some autonomy to come up with their own solutions without having to check in with you or redirecting them to their supervisor, instead of coming straight to you, because you're simply under the same roof, those are communication pitfalls that could crop up that need to be addressed. It can be addressed if you go through the grind and put together some policies and procedures and establish the right forms of communication.
Also, it’s not to put some of that stuff on the shelf and never look at it again. If you go through the exercise and the hard work of coming up with core values and you do a good job of making your core values an action-oriented type of core values. One of the things that you can do when you're having meetings with a group and you're talking about, “Should we do this?” You can always come back to and say, “Does this speak to our core values? Are we living our core values by doing this?” That's how you get people to understand the culture and understand the core value. How many people in a company can reel off the core values of the company they work for? If you talk about them all the time and interweaving it in the decisions you're making, it then becomes second nature. I think that's important.
What advice would you give people when it comes to the possibilities? I hate to use the word embezzlement, but as you get bigger, as more people are touching your money, and as you may become a little bit separated more from the money collections, what would you recommend to owners to stay on top of that and minimize the possibilities for a loss?
You need to come up with a few key indicators that you can look at on a weekly basis or a monthly basis, or whatever timeframe that you want to do it, and have someone to train you to understand 3 or 4 key indicators in the revenue cycle. “If this says this, we're okay. If it says something different, I need to question it.” You don't have to be an expert in billing, collections and all that stuff, but you have to know enough to ask the right questions. You have to be aware and you can't let somebody BS you. I remember a story. There's an accounting guy that sometimes I would ask a question and he would answer it. I would ask a deeper question, which made him uncomfortable. He would go into accountant speaking. He knew that wasn't my speak and how do I argue with current ratio and this and that or whatever. I was like, “I know that he’s BS-ing me. He's speaking the language that I don’t.” I'd say, “Tell me in my language. If I don't understand it in my language, then I'm going to look further.”
The mistake a lot of people make is they have somebody that they like and trust and they never pay attention. That person realizes that, “I'm a little short this month. I could borrow this and put it back in, and no one's ever going to know because he doesn't look at that detail.” One thing leads to another and you've heard all the stories. I remember that when I became the CEO of Therapeutic Associates, I was worried that I'm running this huge company and I don't have a background in finance. I was a PT. I need to know about finance.
I went and hired someone from Moss Adams to teach me the piece of finance or whatever. After about 1 or 2 hours, this woman said, “Why are you here?” I said, “I need to know this stuff.” She goes, “Are you the CFO?” I go, “No.” She goes, “Unless you're the CFO, you don't need to know this detail. Here are a few things that you need to look at and be aware of and look at trends and whatever, but you don't need to know this detail because that's not your gift. That's not what you're doing. That's not what you should be doing. You should be doing what you're good at.” It was a good lesson to me that I was getting bogged down in the weeds, trying to learn stuff and know stuff that this isn't what I'm here on Earth to do. I need to know some basics so that I can ask the right questions. If I don't get the right answers, then I look deeper.
It's timely that you brought that up because I did an interview with my business partner, Will Humphreys. We talked about some of the key statistics that you could look at with your biller to see if they're performing to an adequate level. If you go off some basic things as you talked about, then you can tell how your money flow is doing and if your bill is performing well or not. That's important. Maybe we don't have to be as specific and detailed as we may have been in the past, but we can't separate ourselves enough to not look at some of the reports that would give us key indicators as to how well we're doing and where the money is. In our situation, our biller, she had a good connection with our front desk coordinators. The front desk coordinators had a daily report sheet that they had to fill out in terms of the over the counter collections.
My biller is only responsible for insurance and patient balances. She's responsible for all collections, even the ones that come over their front desk. They had to report to the biller the front desk collections that were received. We could match that up compared to the EMR. The EMR would tell us who should have paid a copay, who has money that's owed. They could have that. That was nice to have because there was some accountability and there was even a daily reconciliation and that made us more feel more comfortable. I only met with the biller once a month, maybe once a week, if we had some issues that need to be dealt with. It was up to her then to report up to us about how collections were going and where the money was going. She also had reports that were given to me that showed her performance. I could find out quickly if she was performing well or not. It wasn't until we got to that point that we recognized greater profits in our business.
The other thing to think about too, since we started out talking about multiple clinics, the beauty of having multiple clinics is that you can have those key indicators for each of the clinics and say if you have a spreadsheet with the 5 or 6 clinics on one side and then these key indicators. You can compare it to other clinics. That brings up things too like, “How come you're collecting this much copay at the front desk? I'm only collecting a small portion of that. What am I doing wrong? What could I do better to reach more of that level?” You have directors that can ask each other, “How come your cancellation and no-show rate is much lower than mine? What's going on here? What are you doing?” You can learn from each other. That can help with the embezzlement piece because if somebody is way off compared to the other clinics, then you can say, “Let's ask the question, why is this different?”
It's imperative to have that and compare side to side because there should be similar reimbursement rates per visit. The demographics are probably between communities if they're within driving distance. It's applicable to have those comparisons and see exactly how things are going.
It’s not that they know that they have to be the same because of what you mentioned. They can be different. You ask the question and if the answer back is appropriate and believable, then you move on. If it's the BS answer, here's a red flag. Let's check into this further.
That's the cool thing about having a leadership team is if it's a one-on-one meeting, you could probably BS me. I'm not the smartest guy around. You could probably tell a great story and I'd fall for it. When you get into a group of people, it's hard to BS a group of people. That's the cool thing. When you have a leadership team, it can start calling their peers out in a kind way. The owner coming down on that person, it's their peers that are talking to them about, “We're doing this. Why can't you do that?” That carries more weight.
That's why regular meetings are important to that group. If you never meet, then you never have an opportunity to do that. If you have a group of five or six directors, how often do you meet with that group and talk about those types of issues? I would recommend that you do it probably more often than you think you should because it's usually valuable. That quarterly, or is it monthly, or there are some people that have the ten-minute huddle on Monday morning. They do that often. There's not a secret formula that the key is that meet and learn from each other because you're going to learn faster.
It's important to commit to doing the meetings because at one point we got to a point where we had so many meetings, we recognized how many meetings and hours each month that we were spending in meetings that we had to scale back. Once we did that became powerful, but I don't we regretted the fact that we had too many meetings. At the time period in which we had all those meetings, they served their purpose. Over time, we started shrinking them down and made them more effective and powerful. The meetings worked out and we got as much done in a shorter amount of time. The pendulum swings one way, we brought it back the other way, but it all worked out well.
It depends on how big the organization is, but when you get to a certain level, as an executive in that organization, meetings, that's what you do. There are meetings. What PTs struggle with is I call it the achiever mentality. We're so oriented to checking off tasks as we do them and even our patient loads are that way. That's not a high-level leader that’s checking off boxes. A high-level leader is working within a group to make everyone in the group reach a higher level. That takes the meeting. That takes being together. You can't do that by yourself in the office with the door closed. As you get bigger, you're going to have to start doing more and more of those things because that's what makes it work.
Talking about that, we both would agree that if you're going to have a couple of clinics, you would recommend that the PT owner not be treating patients full-time. They need to be stepping out and being the leader of their companies. With that admin time, how do you recommend owners and smaller scenarios prioritize their time most effectively? What are some of the things that they should be working on? If they’re like, “I don't know what to do first so I'm going to maybe catch up on my notes and pay some bills?” What should they be prioritizing? How should they be prioritizing their time?There's no end goal in leadership. You just keep learning. Click To Tweet
It's those touchpoints. Your greatest gift to your staff or your company in a leadership position is to grow other leaders, to help them learn and grow. Getting caught up on emails and things like that, it usually doesn't fit into that category. What you want to do is create a culture. We all know how it works. You as the owner and director, you're the most productive. You see the most patients. All the doctors want you to see their patients. We know all those things. If you develop your people and train your people, the best scenario would be that they should be busy all the time and I should have time to do the other things because that's what I'm good at.
Nothing's worse than a PT director/owner being busy all the time and the staff is not. They're sitting around doing things that aren't productive when I'm treating the patients, but I could be doing other things that would benefit the company. You have to build a culture where your people are comfortable with the fact that they're doing what they said they do and they're supposed to do. You can then maybe create more time to do the leadership things that you need to do.
Some of that is maybe hard for us to overcome. As achievers, we are the most productive and that's where our training lets us that if I treat a patient, I get reimbursement and thus we recognize our value. Our value comes from being immediately productive. I know that I treated that patient. I know I got so much money and that thus I am productive. Thus, I am this valuable. To do administrative tasks and leadership responsibilities doesn't have that immediate or obvious return on investment. It's hard for us to make that transition and recognize that acting as a leader, whether it's a strategic planning or developing processes and procedures, or following a strategic plan or creating a strategic plan for marketing or for increased productivity is equally if not more valuable than treating the patients.
You have to keep asking yourself a couple of questions. One is, “Am I following through on my gift doing what I'm doing?” If you're starting a practice and you're building your reputation or whatever, then it's legitimate to say, “Yes, I'm treating all the patients. I'm being productive. I'm building up whatever.” That’s fine, but you have to go down the road and say, “Am I using the highest level of my pay grade,” if you think of it that way. There are other people that could be doing some of these things that maybe I'm spending my time.
The second question I would always ask myself is, is this sustainable? If I'm being that productive, being overwhelmed and whatever is this sustainable over the long run. We've all had situations where let's say our superstar PT is out on maternity leave for three months. We can gear up, treat more patients and do more things during those three months waiting for that person to come back. That has a start and endpoint, but I see a lot of PTs get to the point where they're on the treadmill. If they ask themselves that question, “Is this sustainable?” The answer's probably no. If you answer no to that question, you've got to find a different strategy. You've got to find another way to do things.
I've shared this story before that for the first ten years of owning a practice, people would ask me how the business is going. I'd say, “I love treating patients, but I hate running a business.” It's the HR and all that stuff that I hated doing. It wasn't until I changed my intentions and recognize that I truly was the owner. If things were going to change my business, it was up to me to change it because I was at number one. Until I set aside time to work on my business, that I see the change and the growth in my company, and also a change in myself where I started enjoying owning a business. I found value and a lot of pride in improving the business aspect of my company. It grew because of that. The people who worked with me and for me also grew as well as I took that helm and became a leader of the company. It made a change.
Most of our peers go through that at some point. The other option would be I love treating patients. I love doing this. This is my gift. This is what I do. You have to hire a business person then to do the business side. Some people may be comfortable with that and a lot aren't. That's the other alternative, but you can't do it all usually and be successful. It gets back to The E-Myth thing. You have to also work on your company, not just in your company.
Even if you brought on a business person, you still have to have meetings with them. You have to train them on how you do things and what your expectations are. A lot of times we might think that we're delegating when in some aspects we're advocating and not appropriately following up. That's something we have to recognize as leaders is that when we delegate and when we train people up, the next step is to follow-up and make sure that they're following the policies, procedures and systems that we established and cheering them on. Not abdicate that thinking that they're trained and they're ready to go.
You always got to pay attention to.
Is there anything else you want to share about multi-clinic ownership that maybe we didn't cover that comes to mind?
My career was in a company that had multi-sites. I believe in that concept. If you have a very specific niche or you're very aware of what your goals and intentions are, having one stand-alone clinic can work. I think from a business perspective that it's easier to do exciting and important things when you're bigger. You can get through situations easier because you've got some support. When one clinic is down for whatever reason, you've got others to support it. If you work together as a team and me personally, again, it's a personality thing, but I find a lot more joy when I'm working with a group of people, as opposed to working on my own.
There are some real advantages to it. You have to decide at what level you want to do it. If you want to build a legacy type company, then my feeling is you probably have to get to give some ownership pieces in there and some governance roles in there for other directors. You want to hire someone like yourself, who has your motivation and inspiration and dedication but if you don't give that person the right incentives, they are then going to say, “What am I doing here? I'll go and do my own thing. I'll go with somebody who appreciates that.” You’ve got to give up a piece of the pie, in my opinion, to enjoy the fruits of the bigger pie.
I'm glad that you brought that up because I've recognized the same thing. Those same guys that have been successful with multiple clinics are the guys that not only had leadership development and found and developed the next partner in their company. They've also incentivized or at least given some profit sharing, equity sharing in that clinic to help them feel like they own something. It’s like they're a part of something bigger and that can be incentivizing, but inevitably those companies that have those kinds of structures have done well and are some of the more successful ones that I know of.An ownership mentality is everything. Click To Tweet
An ownership mentality is everything. It doesn't have to be exact ownership, but you need to develop that ownership mentality. You want that director to feel like this is their thing and it depends on them. The success and failure of this are going to be about them. You need that. I'm not a fan of having two partners in the same clinic. I think that causes problems. I don't care how good a friend you are, whatever, but somewhere down the road, there's always one partner that thinks that they're working harder than the other one. They're doing more of this stuff and whatever and it causes problems. If you're at a clinic by yourself as that leader, you don't have those tensions as much, and then you still have the benefit of working with others being in a bigger group. That's why I like the multiple clinic style. There's so much opportunity out there. If you're good at what you do, why not spread it around to more people.
That's the definition of power. It is the ability to influence more people with the same amount of work. If you can be as influential as a physical therapist, treating patients one-on-one, but now you can treat thousands of patients through multiple clinics, then you're that much more powerful. Everyone wants to have a greater impact on their community, their surroundings and their environment. That's why we did it in the first place. Thanks for your time, Steve. I appreciate it. You're doing some great work or you have been in the PPS and Peer2Peer. Thanks for your efforts in that. If people wanted to reach out to you individually, how would they do that?
I'm happy to give my contact information. My email address is SteveAndersonPT@Outlook.com. My phone number is (206) 683-5051. You can also go to my website, OrangeDotCoaching.com. There's a place in there that you could reach out to me on that website as well. Many of those things, I'd be happy to talk to anyone and help them.
Thanks for your hard work. Thanks for your time. I appreciate it.
Thank you, Nathan. I appreciate it.
Steve Anderson is the former CEO of Therapeutic Associates, a physical therapy practice with more than 80 outpatient clinics in Washington, Oregon and Idaho that also serves as a major hospital contract in Southern California. Therapeutic Associates was formed in 1952, and Steve was only the 3rd CEO and held that position for 19 years, beginning in 1998 after 16 years with the company.
In addition to his day-to-day responsibilities, Steve is also active in national organizations related to physical therapy, including the American Physical Therapy Association (APTA) and as a Board of Trustee for The Foundation for Physical Therapy. He also served as the President of The Private Practice Section of APTA for 6 years between 2002 and 2008. He received his section’s most prestigious award, the Robert G. Dicus Service Award, in 2010.
Steve received the APTA Leadership Advocacy Award in 2006 for his efforts in Washington D.C. and Washington State in the legislative arena. In 2012 Steve received the Distinguished Alumnus Award from Northwestern University Physical Therapy School. In 2016 Steve was awarded Physical Therapist of the Year by PTWA, the APTA chapter for the state of Washington.
Steve earned his bachelor’s degree from Pacific Lutheran University. He went onto physical therapy school at Northwestern University in Chicago. He has been a physical therapist since 1980 and worked for Therapeutic Associates until the end of 2016. He resides in Seattle, Washington with his wife, Sharon.
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Are you 100% confident that you are collecting every dollar your clinic has worked for? Frequent flyer and CEO of In The Black, Will Humphreys, joins Nathan Shields to challenge owners that any answer other than "yes" is a fatal flaw in your business. He then gives out two more fatal flaws often made in billing and collections that keep you from maximizing your profit. Furthermore, Will shares a couple of things you can do to get a better gauge on whether or not your billing department is working effectively or not.
I've got a frequent flyer, Will Humphreys, on with me again. Will, thanks for coming on.
It's an honor as always, Nathan. It's great to see you. This is how we communicate since you've gone to Alaska is through the show. This is perfect.
That's how we stay in touch. It's our communication time.
These are our catch-up conversations.
You were last on with me for the second anniversary of the show and we reminisced and talked about some things there. In the course of the interview, you shared with the audience what you're doing nowadays and that is your billing collections company. I figured it's important for you to come on and join me because you are seeing things amongst the PT owners that you're consulting and working with that would be valuable to share with the entire audience. Whether they have their billing departments or outsourcing their billing that would significantly improve their gross revenues and net profit margins if they simply stayed on top of them a little bit better. You see some things that if they can focus on those money lines a little bit more, they could generate more cash.
It's interesting you say that because as a private practice owner, when we were in partnership and we were running our in-house department, and at times when we outsourced, we have a specific experience around that. There was an evolution where we bring someone on. They do your billing. Maybe you try outsourcing it a couple of times. It always feels like it's more expensive so you bring it back in-house. After a while, you feel that you've got grips at it. You feel that you have a handle on it. You get to that point where it's becoming this thing that you manage but it’s on the side because your main focus is usually on sales, marketing, and care.
Now that I stepped out of that and I stepped into billing full-time from an outsource solution perspective, I'm doing this thing called the profitability breakthrough audit where people who are either in dire straits and they don't know why they're in dire straits with their billing. More commonly, people who are comfortable, but not confident in every dollar they should. They'll reach out to me and we'll do an audit and it's mind-blowing what I'm learning about billing and collecting from the same call. It's one of those blind spots for most private practice owners.
For all of us, essentially as PT owners, we have no training in how to handle insurance companies and the billing collections aspect and any rules or regulations around it. Most of the time, we naively either bring somebody on, expect them to learn it on the job, but if they've got some experience, we completely trust them to tell us about our money situation. If we outsource it, it’s the same thing. We completely trust them. They've got all the experience to tell us the situation. What's funny is they didn't come at us with statistics and reports that could show their work. They simply said, "Things are going well and these people owe us money and I'm reaching out to them." Even if they did show us reports, we didn't know what we were looking at.
I remember being at those meetings and looking at an aging AR report and listening to my biller say, "This is what this is and this is good." Me going, "I'm making payroll and I'm paying myself. I guess things are great because I remember when I couldn't even do that.”Without proper billing, the money you lose isn't just income; it’s profit. Click To Tweet
“We see our accounts rising and we're covering our bills. Financially, we're okay. There are no concerns and no one's talking to me complaining about their bills. You’ve got it handled.” Can you imagine how much money we lost over the years by taking that perspective?
I got chills when you said that. It makes me sick because the money we lost wasn't just income, it was profit. It was 100% money that would have gone into our pocket. I was barely braggy about how well we were doing in those days. It's scary.
That's money that goes to your household, your retirement and funds your kids' colleges. It could have been another vacation, not necessarily from a self-centered perspective. You could have done more for your business and handing out more bonuses. You could have done more culturally relevant things to enhance the culture of your company, promote people, hire someone on, and do those things. That's all money that went down the toilet because we trusted other people blindly. As you've gone through that audit, can you confidently say that people are losing X amount of dollars or X percentage of their revenues because they're not focused on tracking their money lines?
Yes. We haven't done hundreds of these. We've done twenty of these profitability breakthrough audits. In every single case, even when people were confident that they were collecting every dollar, the least I've seen is $20,000 of profit that was in their company right at the moment that was easy to get. It was right there, "We're doing great." That's the difference they might be doing good. This is this message and I'm hoping everyone will hear this who has any relationship to the billing department, whether it's outsourced or in-house, is that the difference between good billing and great billing is tens of thousands of dollars in most cases of pure profit. It's not any extra work. The purpose of what I want to share is to help people be successful where they are. I believe that PTs can learn the 20% that they need to in order to comfortably navigate and manage 100% of their billing and collecting. At least know what's going on because accountability will automatically result in greater collections.
Can you break it down for us? You've got the three fatal flaws that affect owners and their billing.
As the name of this show, we’re are right into it, three fatal flaws. These are things that I've lived. I want to say we've lived because I don't want to throw you on the bus, but we've lived them. We have gotten them as business owners, but ultimately these are things that have become crystal clear to me as I've stepped into this new role of trying to disrupt billing and that's what I want to do. The whole reason I'm in billing as a physical therapist is to disrupt it because next to seeing our patients and our company's progress, collecting our money should be the best part of our day. It's the worst in some cases because even when we get it, we're like, "Is that all? Is that it? Should I be expecting more?" I want to make billing fun and easy. That's it. The more I've done this, the more I've learned it's possible.
The first flaw that I've seen, both that you and I have lived, and what I've seen with other clients is that people are thinking and not knowing that their billing company is doing an adequate job. There are people who are in dire straits, but over here where most people are, they're like, "No, I'm doing good with billing. Things are going great. I loved my in-house team. I love my outsource solution." When I ask, "How confident are you that you're collecting 100% of every dollar owed to you?" They look at it and that shifts it from being confident. They're more comfortable. Being comfortable is where that blind trust that you spoke of comes into place because it's a matter of like, "I'm meeting my bills. Maybe I'm even running above the 8% profit margin, which is what our industry's running these days. We are either 10% or 15%.” They're thinking, “I'm crushing it,” and there is still $20,000 or more that could be in their pocket or in their house.
That reminds me of the first sentence in Good to Great is, "Good is the enemy of great." If things are going well, “My bank accounts, okay. I'm comfortable paid my house payment, my car payments, my kids, wife, and husband's happy. We're good.” That's the enemy.
Ultimately, that's the first flaw that is totally about mindset. The other two are more specific. I'm excited to share these with your readers because these are tools that I want them to go back and immediately can be more successful. The first thing is the mindset because there's this curtain between PT owners and their money that I didn't see as clearly until I was on the other side of the curtain. I am super incentivized, Nathan, to not show all my cards all the time to my clients, because it makes it easier for me to navigate this crazy thing called insurance reimbursement, which has its own blend of absolute chaos. Insurance companies greatly impact how things come in and if you don't know every little detail and trust that the outcome is okay, why would I provide you with excessive data on that? I am motivated not to do that, which is not what we do. That curtain is there for a reason. People are on one side not trained to run it and on the other side, incentivized not to pull it back for you.
I love the fact that you're willing to share and talk to them about it because there are things that PT owners need to know and do in order to make sure they're tracking all of their money. It doesn't take a ton of effort. It takes intentional effort set aside specifically with the biller at minimum once a month with some follow-ups in between 2 or 3 times. We got to the point where we were meeting with Katie.
I want to throw that out there. The reason things shifted for you and me was Katie Archibald. She is one of your greatest hires. You've made many great hires but one of your major contributions was her. She came in and she challenged the notion. She saw things differently than the average in-house biller. She would sit down with us and say, "I don't think you are getting this. You should expect me to do this." She challenged all of our preconceived notions of production. She was like, "When it comes to this metric, you should expect this, and this metric should be that. If I'm not meeting it, this is what you do." That started the journey of that and that's why I partnered with her in my company.
It was also a matter of, I knew I had the right person because Katie is an honest person and I was able to say, "If you wanted to screw me over and take my money, where would you do it?" We talked about that with the help of Howe, who was our bookkeeper and managing a lot of our financial reports. We started generating reports that would show where every dollar was on every day that was collected across the front desk and coming from the insurance companies because a lot of money is missed there at the front desk. You can all lose some money from the insurance companies but we got to a point where and a tracking system where things all reconciled. We were able to track every single dollar with the reports that they were able to start putting together over time.
It was weird how little it took for us to get there. What Katie did, this is what I'm hoping to challenge in terms of your reader's notions about billing and collecting. There's truth to this. That's why this is confusing is that we weren't trained for billing and collecting. We went to school for something else. We should hand that over to an in-house or outsource solution and let them deal with it. There's truth in that but the problem is that if we are neglecting our accountability to it and we aren't learning the 20% that allows us to govern the process cleanly, then we are beholden of something else.
What I love about Katie is she's incredibly patriotic. She should be comfortable with me sharing this. Her family on the 4th of July, they did a Declaration of Independence in the American History quiz with each other. She's inspiring to be around. She tells me, she goes, "I see what we do as freedom fighting." PTs and PT owners and medical professionals are beholden to what they don't know. The billing companies are like, "Don't worry. We have a proprietary process. It's a secret algorithm." No, it's not. It's something that you can learn.
Those are the mindset, let's get into the weeds. What are the other two things?
The first flaw is feeling comfortable, but not confident that you're collecting every dollar of your schtick. The second flaw is not forecasting your income. This one blows my mind a little bit because any other industry when there's finance, it's like, "If I'm hiring you to go and get my money or I'm doing anything to help an in-house solution, go get my money." Anywhere else, you're going to expect them to set targets for what they do the following month.
If there's an invoice and you're expecting to collect $50,000 and only $40,000 comes in, then you know there's an issue, but we don't do that with physical therapy. We might bill out $50,000 and a lot of times, we don't even know how much we're billing out per month. We're completely incapable of figuring out how much we should expect the next month.
Ultimately, what I mean by forecasting is it is simple math. To take what you've done the previous month and then you multiply that by the average collection per visit. Your billing team should be accountable for that amount the following month. What I recommend is that PT owners, in particular, we at least do a monthly deep-dive where they review the previous month's target and how they did and why they exceeded or didn't exceed that number? They establish a new goal for the next month because the number one metric we don't measure is the percentage of collections of forecasted collections. That's one of the simplest numbers. This does an easy gift to the audience is that most billing and collecting that we do in terms of review is retroactive. It's in arrears. It's already happened. It’s a postmortem. It's too late to do anything about it and meanwhile, by the time we get caught up, those monies are subject to timely filing claims and all these different rejections that ultimately will permanently take our money away.In finance, the empowerment comes through forecasting. Click To Tweet
I did it with my mastermind group and it's surprising how simple it is to the point where some clinic owners are like, "Is that it?" All it is, "What were your total visits in the month of July multiply that by the average reimbursement rate per visit." That's something that you might not inherently know, but you can look in your past months and billing software and simply take your gross revenues divided by your total visits. Do that for a year and then average it and you have your average reimbursement per visit.
Take the month of July. Let’s say 400 visits in the month of July, average reimbursement is $100 per visit. You should expect your biller the following month to collect about $40,000. It's that straightforward and that's your pass or fail. That's your measure. That's your litmus test. I did 400 visits and I know I collect a $100 a visit historically. You should be able to collect $40,000 next month. It's simple and PT owners, aren't doing that on a regular basis because we know reimbursement timing is going to be somewhere between 3 to 6 weeks. It works out over time. It's an easy bar to hold your billers to whether they be in-house or outsourced.
It's easy and it reflects that mindset shift. The first mindset shift is that "This isn't something I can handle or something I can manage that I have to feel beholden.” In finance, empowerment comes through forecasting and often because of the complexities of an AR complex, I'm not saying that getting your money isn't hard because it is but the only way we manage things traditionally is retroactively instead of proactively. As we prepare for growth, as we look for future potholes to step over, being proactive with our finances, by simply forecasting, our income empowers us to know where we're going and hold our teams accountable. It's an easy thing to do when things were a little bit off in our company. We would do weekly fifteen-minute billing meetings that were all about, "This is how much we were forecasting for the month. You broke it down by week and this is how much we collected." You can get in real time, super easy. That discussion alone raises accountability to that team, to where that low-hanging fruit isn't the only thing that they're going for.
Imagine how powerful that makes an owner simply by knowing that statistic. If you know that statistic, I should be collecting $40,000 next month. Hopefully, readers to my blog also know where their break-even point is financially speaking, and know that, “If I'm collecting $40,000 and I know my break-even is $42,000, I've got to get $42,000 to meet all my expenses. I'm going to be at $2,000 loss this next month.” Be prepared for it but at that point, as the leader or captain of the ship, you can start making decisions, “I'm going to have to cut back hours a little bit to make up for this negative that's coming here this next month. I'm going to have to look back at expenses that I can pare down. Maybe I don't buy that piece of equipment this month until we get some positive cashflow in the upcoming months.” You can make a cascade of decisions based on that one metric if you use it so and make you more powerful looking forward, instead of looking back.
It's something that we do organically within our company. It's fun because most of our PT clients that we work with, they're not used to it and half of them don't get it. They're like, "You're telling me how much you should be collecting next month." Initially, they're like, "That's nice." They don't know any difference, but those who've been through the wringer, they look at that and go, "That is helpful to know where my money's at." I would say quickly the one variable in that equation is your average collection per visit, because there are some that go into that from your payer mix to various other factors.
The skilled units per visit that you're doing on the regular and that stuff.
In that case, there are some additional items that influenced this or directly outside of the billing domain but I would say that those are things that can be learned, and the easiest way to overcome that is through networking. This is more of a direction to what you offer in terms of coaching and also with the show is. There's a lot of information out there. It's not hard to get. Information we're sharing here is a lot less commonly known. That other data it's well-known and in your area, what I always recommend is developing relationships with other private practice PT owners in your area as synergistic so that they're not competitors.
You get comfortable if you start sharing this data and although there are still variations on what they collect per visit, having that information, challenges, these preconceived notions we have of what we should be collecting for a visit and maybe it's more. Maybe we're the best in our network, in which case we're sharing with them, what we do that's special on the charges but either way, there's ways to figure out that average collection per visit. Even if it's not where it should be, when you start forecasting, at least, you know what you can expect down the road. That leads us to number three. I felt like that's all I have to say about that.
I usually want to add on, but I'm like, "That's about it."
The third fatal flaw is that people practice owners and PTs are either reviewing the wrong stats as the primary stat or not looking at the right stats at all.
Tell me about that.
The second flaw is the beginning of that, not forecasting and looking at that metric, but in our industry, what's interesting is the easiest statistics to understand are the ones we typically use. Back in the day, the main ones that I would review would be collection per visit, my total collections, and my percentage of collections versus my charges. Those are good metrics. We navigated well before Katie in that. The problem with those is that all three of statistics, and just to go over them in case that wasn't clear, looking at how much we collect per visit on average, what our total collections were and then the percentage of our collection versus bill charges is that they're retroactive and they're not proactive.
By the time we measure those things, we find ourselves in a position where what needs to have already been corrected in some cases can't be corrected. What is the way to go apart from forecasting the right stats for always within the aging accounts receivable? In a weekly process, if that's a brand new term. My biggest concern in doing this show was using any of these terms because none of us have typically been trained on them. If I say aging accounts receivable, there might be a percentage of your audience who glazes over. They heard of it, but they've never had that explained. Maybe they're not even using those other three stats, which are still important.
It's the AR aging report. If you don't know the name of the report, you might've seen it before because your biller or your software is going to show you what 0 to 60 days, 60 to 90 days or 0 to 30, 30 to 60, 60 to 90, 90 to 120 above. You'll usually have five columns of where your money is sitting. You said something important. I want to add to it and that is, there are many times that you can't go back and collect those monies. That's true that it's hard to collect money after the fact sometimes but the other thing to think of is as your money sits out there, it's been shown that you tend to collect less and less of that dollar owed.
If you build for a dollar and you're expecting a dollar, if you get it at the time of visit, you're certain to get that dollar. As soon as they leave the office, the likelihood of you collecting the full dollar changes. The rates come down to you. As a whole, you start collecting $0.86 on the dollar if it's 0 to 30 days. If it gets out to 90 days and 120 days, we're talking $0.30 to $0.40 on the dollar that was owed to you at that time. If you have a $10,000, 120-day AR, you can expect maybe to get $2,000, $3,000, $4,000. That's the national industry average. A lot of times, waiting to collect that money means you're losing pennies on the dollar.
Collecting money is a lot like recruiting. It's all about speed. It's about efficiencies and speed. I look at money like you're trying to recruit somebody. You don't wait a week to respond to their email. You get back right away. When it comes to billing and collecting by virtue of letting it sit out there, it starts to go down, which is why when I look at most of those stats, the first three I do use in a monthly post-mortem like, "This is what happened. This is what you did." In real-time when we do weekly meetings or when we're projecting future income as well. I live with my clients around the projected, forecasted collections, as well as the aging accounts receivable. It's that report that has it broken down by time periods. It can be done differently, but I'd like to quickly review some common breakdowns and what those expected percentages should be.
I have guys in my mastermind and my coaching clients ask this all the time like, "What should be an acceptable 90 days and above or 120 days and above." I'd love to hear what you have to say.
This is going to challenge some people legitimately because the first time I sat down with Katie on one of these statistics that I'll start with the back. I'll go from the end backward. Greater than 120 is typically a category on this report. I used to tell her, I'm like, "Twenty percent is the lowest I've seen it." She's like, "No, Will. You should expect that to be below 10%." That's what I loved about her is she thinks differently. Like, "No, Will. You've got to understand that your aging report is greater than 120 days, that total should be less than 10% of the total outstanding money that's out there.”Waiting to collect money means you’re losing pennies to that dollar. Click To Tweet
When it comes down to 90 to 120 and then 60 to 90, those two categories, you want there to be less than 5% of the total money's outstanding. From 0 to 60 days, we want them to be greater than 80% of our money outstanding. To your previous comments, we want almost all of our money that's outstanding to be in the first 60 days. That's an easy way to understand it. It's sitting there. We're collecting on it. The minor inevitable issues that exist are going to be less than 5%, 5% the pool at the end is less than 10%. It's an easy way to remember it, greater than 80%, less than 5%, less than 5%, less than 10%.
Less than 10% for your 120. Less than 5% for your 90 to 20, 5% and less for 60 to 90. That's a great way. When I pushed people on that or I share that information with them like, "Over 120 days should be less than 10%." They're like, "Wow." There's much money for some clinics sitting out there waiting to be collected if they put in the effort, make a few calls, rebill, send it in with the prescription. Whatever they need, do it and then you'll get your money because inherently, the insurance companies don't want to send you the money. You have to do the footwork. If your biller is simply sending out the claim and it's coming back and getting denied, and they're not willing to put in the effort to do what they're asking you to do, then the insurance company has won and you've lost your money.
The people don't realize there are good people at insurance companies. There are great concepts being driven but when you're on this side of it and you're fighting for people's reimbursement, you see the corruption, the tyranny. That’s why in our company we don't call ourselves billers. We call ourselves financial providers. We do financial therapy. We don't do billing and collecting because we're rehabilitating a broken system. I tell my billers that they are care providers as they help their clients get their money in order.
We only work with PTs because I do think there are variations outside of PT but the similar connection in terms of our healthcare system is the same. We have one group in particular that we submit and get the same rejection notice every time that we haven't submitted things appropriately. We've done this for years and we know. We are submitting things finally we resend the same document and it gets accepted that the policy on that insurance company's end to automatically deny the first time, no matter what. It's interesting to see the game and people’s profits is what they're gambling with.
Knowing this information and then statistics that you shared the 80%, 5%, 5%, and 10% is powerful for an owner to then go to their biller and say, "This is what I expect out of you." Many times, we sit at the feet of the billers and tell us, "Please tell me that it's going to be a good month or that you're not having any billing issues and I can pay my expenses next month." Expecting wisdom to come down from them and tell us how things are going, you're the owner you should know. Having information like this, both the projection stat that you're talking about and knowing the AR aging expectations, it says, "This is what your responsibility is and this is what I expect out of you. You need to make our AR aging reports look like this."
That's a minimum expectation level. There are going to be those outliers that have a ton of lean patients, motor vehicle accident patients, or worker's comp that trail on forever. Those are possibilities, but the biller needs to be telling the owner, "That's why our numbers are off and I need to see each line item of the patient case as to why and for someone who came in for a regular visit and had UnitedHealthcare, there's no reason they should be in the 120. I need to see all of that information." It puts the power back in the owner's desk to know the number one thing you talked about, "Am I confident that my biller is doing everything they can and we're collecting everything we own?"
You and I share a brain because where I was wanting to go with this. What do you ask the readers? What do you do? You're listening to this on the way into work and then you ask your biller for an aging report. You're looking at the percentages and they're nowhere near what we're talking about. What do you do from there? It's all in the story and I'm not talking about explanation or excuse. I'm talking about the objective measurable story around it because any biller worth their salt is going to be able to objectively explain to you why those things are off.
You know the difference without having to know every last detail of billing when someone's making an excuse and dancing versus legitimately concerned because X, Y, and Z are happening. That was what Katie did for us as well. In a perfect world, there is a major variation with that percentage of projected income that forecasted number. It's an easy number. You're looking for 100%. There were weeks or months where we'd be at 120%, but there were months where we're 80% to 90%. Katie would say, "Here are the individual case by case issues we're having.”
Sometimes it was a global thing with specific insurance. Other times, it was a perfect storm of smaller, independent, relationships, and even client issues that were completely impacting that flow for the moment. What cool about it is that if the story isn't an excuse, the action is easy to describe. She would say, “This is what's happening with the insurance. This is what I've done to counter that.” Over time, when I started to trust, that's when we collectively, you and I, knew we were 100% confident that our money was where it needed to be, which was in our pockets. I want to highlight, how do we know this for sure? It goes back to our story when you and I merged with other companies and went to sell our company wasn't the biggest in terms of volume. We had fewer patient visits to our locations, Nathan, than two other locations, but our company was valuated the highest because of our net profits. A lot of it came from this thing that we're talking about.
The focus that we put on it only helped make Katie even better. She's one who appreciated the accountability. She enjoyed putting together the reports and showing her worth and her work. That's the person you want. Not only do you want someone who's bulldogged in collecting every dollar, but also someone who's not wanting to hide and is willing to look objectively at the data and say, "This is what's happening and this is why." Be willing to present and it shouldn't be an emotional conversation, “This is what it is and this is what is expected.”
The thing I want people to realize that most billers and Katie is a diamond in the rough I've learned because she was that person who challenged you and me to expect more and so forth. We've hired our eighth person. We've had eight hires in our company and I could be dingy. For every hire, I'm looking at 300 resumes. What I've learned is that most billers who come across have a high degree of ethics. They want to do a good job where they fall short is in our leadership to them. We don't want to look at it like we're coming down on them. It's not an emotional conversation.
We're freeing them from their environments because most people, given a lack of accountability, aren't going to show up as powerfully. It's not personal. If we give them that accountability, they get to rise up and be the best version of themselves, which a lot of billers I've learned are their personality trait. They're detail-oriented. They want to, "Why would they go the extra mile if you don't know or care?" If you know what the extra mile looks like and you care, you're going to get a much happier in-house biller or a more satisfied outsource solution. I'm hoping to promote these other solutions that exist because there's a great need for it.
There's a certain personality type amongst the best billers that I've had and they take it personally when the money's not coming in. Do you find that? They get mad when they can't collect on that $7.60 copay that the insurance should have paid. They're like, "It's $7.60." They're like, "No, they owe that to us. They need to pay it and I'm going to keep going after them until they do." I'm wasting my money but I love your attitude. We hit on a lot of your topics, but what I love about Katie is also her willingness and insistence to make sure that things were going well at the front desk when it came to over the counter collections too. One of those other statistics was what percentage of the expected copays was collected?
I know a lot of EMRs are set up for that maybe not for that specific statistic, but you can track who should have paid copay and who didn't. That was something that she was able to then work in collaboration with the front desk and especially the front desk managers to make sure that, "So and so didn't pay their $20 copay. You need to call them the day after their appointment and collected over the phone because we're not going to let him walk, wait and hope that he comes in next time and somebody remembers to have him pay $40 next time he comes.” We were dogged about that. We found as we were doing our weekly meetings, that we would also measure that. How much were we collecting over the counter? How much should we have collected over the counter?
Going back to fatal flaw number one, feeling comfortable, “I'm sure that I'm doing well, but not 100% confident.” One way you can tell if you're collecting solution, whether it's outsourced is collecting every dollar it should is that there is a positive relationship between the biller, the front desk, and the providers. There's a natural dichotomy that exists when the person at the front desks errors greatly impacts how its biller performs. It's common. We've seen it 100 times and I had six different solutions in the years. Three of them were outsourced and three of them were in-house. It didn't matter if it was outsourced or in-house if the relationship was nonexistent.
If they didn't have a contact that they felt emotionally like a person that they knew on the extreme other side, where people were agitated by each other, constantly the biller by the front desk and the PT, that's the biggest indicator that you are not collecting everything you should. It takes a team and a village. That's why I think most PT companies prefer in-house versus outsource without even being conscious of it is that it's easier organically to create relationships from the front desk, the back office. They end up running a separate business within their own business, without even knowing it because having relationships organically increases the ability for that company to collect.
If there are any disharmony and lack of clarity when we outsource, that was the most common thing it's like, "I've got this contact name, but I don't know her/him well." The biller that's where Katie shines the most is that she comes in or she came in our case everyone loved her and her team because they saw them as people helping them do their job better. It's a big thing. That's one of the things we do that's different in our company is that Katie harnesses that end of it and then I represent the PT side of it. I've done everything speaking at a team meeting about effective billing practices because the practice was grossly under billing down to 80 holding seminars. We've had those where we've gone into people's clinics and had all the front desks in there either virtually or literally if we can, and describe what's needed because that little bit of information changes the dichotomy increases the connection to the relationship, which brings in every dollar.
We went through this entire thing and you didn't even share the name of your company.Collecting money is a lot like recruiting, it's all about efficiency is speed. Click To Tweet
Isn't that weird? I don't care nearly as much of trying to disrupt the whole damn thing.
There's such valuable information. You wish all the PTs would know it and harness it because it's not hard. They just don't know and you want to get that info out.
To be specific, I'm particular on who we bring on as clients. I don't have a vision at this stage in my career of having hundreds of clients. I rather go a mile deep with people who meet my criteria that I can super meet and help them. I love working with you whenever we've shared clients. The benefit with your coaching with what I do on the financial piece, it's unstoppable. I want to help everybody, but I can only serve. I can go that mile deep with a select few. I want to give information to everyone to be better and more successful and have that freedom against the tyranny of their own and what they don't know. We are looking to take on new clients. Eventually, we've stopped taking clients until October, but we project that we'll do openings in October. My company is in the black. We get you in the black and if they're already there, then we increase the curve of that.
What's unique about it is this whole relationship between me in the back office, Katie in the front office, and then a powerhouse billing team that's 100% American. I've got zero judgment for people who outsource overseas. I think that’s a workable model, but Katie is my partner. We are 100% American. As a result of that, my margins are smaller than others and what I would tell you is that we want to see these companies grow over time. We're looking for long-term relationships and to completely change the dynamic of how people view outsourced physical therapy. We only do PT. We do some OT as well. I will say that but that's it.
That's awesome that you're willing to share because you shared some valuable knowledge so that they can manage their billing department, wherever that is, or their billing person, whoever that is. I know that you're more than willing to do audits with people and share more insight if they're willing to reach out to you. If they did want to reach out to you directly, can they do that?
Yeah, most definitely. It's Will@InTheBlackBilling.com. I also have my YouTube Channel at The Profitable PT. I love doing profitability audits in most cases that help us qualify people as potential clients. I've told people no because of whatever reason, but for me, the owner has to be coachable for this model to work. We don't want customers who want to outsource it and not have a relationship with us. If they want it to outsource and forget about it. There are a lot of good companies that do it. Honestly, I can do a great job. We're trying to go a mile deep. They can reach out to me. I'd love to do profitability audits. In most cases, that's how we found that a handful of our existing clients. I'd be happy to do a profitability audit. We have a system that is super easy. You send your data over. We break it down. I show you where your potholes are. It takes an hour. It's not hard.
Thanks for offering that and that's cool. I'm sure we're going to be in touch again here soon. We'd bounce ideas off each other. It might not be more than a couple of weeks before they hear from us again on the show.
I'm honored. Whenever I'm out and about, and people are like, “Do you know Nathan Shields?” I'm like, "Yeah. He was my partner." I'm not even kidding. It's cool that your show is doing well.
Thanks for joining us. You've made it that much better. Thanks.
Thank you for the opportunity. I appreciate it.
I will talk to you later.
Will is the CLO and co founder of In The Black Billing company and has been a PT for 20 years. He owned a multi-locational outpatient practice for 12 years before starting In the Black Billing with Katie Archibald. He is a father of 4 boys, married for 20 years and a part time comedian. He is passionate about physical therapy, entrepreneurship, and the freedom that is created through profitability.
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The COVID-19 pandemic has turned the world upside down, forcing many of us to leave behind our old ways and adapt to the new norm. Speaking for those in the PT industry as we are in the thick of it, Nathan Shields takes us into his follow-up episode with Avi Zinn, PT, DPT, OCS, the owner of Druid Hills PT. Here, we get the chance to see how Avi worked through the COVID-19 pandemic, how his coach helped him through it, what dramatic changes he made, and what he's looking forward to now that they're scaling back up. Don't miss out on this conversation as it leaves great insights into navigating through these uncertain times without being left behind.
This is episode three of my reality series with Avi Zinn, the Owner of Druid Hills PT. We're following along the course with Avi, as he has decided to take on coaching in this practice. Not particularly with me, but we want to follow along and see how coaches helped him as an owner so you can get an idea of what a coach or consultant might do for you as an owner as well. It is cool to see the growth of a relatively new owner. You've been an owner for how long now, Avi?
This is for a few years now, Nathan. I’m pretty new.
I usually recommend people get their feet underneath them maybe for a year or so, and then maybe reach out to a coach or consultant at that time after they've gotten someone established. They can start earlier, but I thought it might be interesting to follow along on your journey here as you're doing the coaching. Thanks for joining us again, Avi. We have time to catch up on. I looked at our notes and the last time we spoke was March 6th, 2020, and the episode released on March 24th, 2020. We all know that March was like the hailstorm of the COVID-19 pandemic. I don't think we even touched base on it. It might not have even been thought of in our minds last time we spoke.
I don't think it was at all.
We didn't even make reference to it. One of the previous episodes was about telehealth and COVID-19 if you need to do that. The one right after you was how to save your business financially with Eric Miller, which had a ton of views on my show. We were right in the thick of it. Tell us a little bit about what happened with your clinic, with COVID, and the surrounding area with your business.
First of all, thanks for having me back. It's always fun doing this. When we did our last episode, it was before anything happened in the States. Right around that time, I was speaking with someone, a friend, a chiropractor, she was anticipating closing down because of Coronavirus. I thought that she was crazy. Why would it even be a thing? Three weeks later, it all went down. In the middle of March, probably right after our episode, when things were starting to get intense, I made the decision to close the office to in-person visits.
Lots of people stayed open. Some people didn't. For me, it felt like that was the thing that we needed to do. We’ve pushed over to telehealth. I believe I listened, if not before, at least after to that interview you did with Daniel. I did reach out to him and talked to him a little bit to see if he could give me some advice on it. We did switch over to telehealth probably from March through sometime in June, we were doing mostly telehealth. We did have a few patients stay on. Even from the beginning, we didn't close 100% because there were like four patients that were post-op. We made the decision that we would keep them in the office, but no one else. There were four patients coming and the rest of the visits were telehealth. We had to pivot and figure it all out.
Out of curiosity, how did telehealth do for you? I know some people tried it. Some people had some success, some people didn't.
Honestly, to the credit of my team, the PTs, and the front desk, they made it work. They were able to transition to it quickly and got it going. Our caseload, for sure, dropped probably like 50% or so, maybe a little less even. For March through sometime in June 2020, we were full with telehealth and we were treating and the PTs were figuring it out as we went along how to treat differently because it's not the same. They were seeing results and people were continuing to make follow-up visits. Even a lot of the patients that were right before COVID continued until their plan of care and they were discharged through telehealth. It was all to the credit of my team. I pretty much removed myself from treating and they did it all. They figured it out and it was impressive to watch them do that.Times of crisis are opportunities in disguise. Click To Tweet
That's super cool because what I came up against, as I've talked to clients who are trying to implement telehealth, is that they had a hard time convincing the patients that it was going to be beneficial. The patients lost that connection or were skeptical about its capabilities and the results that they would get with telehealth. What were your people able to say to convince patients that this was okay and they were going to still get results?
I think it was more of like, “This is what we've got. This is what we're working with. This is what the world is now.”
This is better than nothing.
Yes, but in a more positive spin on it. Not better than nothing, it's almost as good. It just doesn't have a few components. If you have to think of it differently, most of the stuff we can still get accomplished. Maybe a little bit we can't because we can't do some of the manual stuff, but we can still do this. A lot of PT anyway is trying to talk through a lot of these problems with our patients. You're a PT and most of the time are simple as far as what to do, but it's how to figure out to get them to understand, be committed, and know that they have to commit and they have to do these things. A lot of times, it's not the manual treatment that's going to get them better. It's talking them through things.
You can do that with telehealth. I don't know why that worked better than some other people had. I know some other people didn't have luck with telehealth, but at least, we were able to get people to stay. Who knows? Maybe they liked the practice because a lot of them were continued on patients from before it started. Maybe they were like, “I already got some results from my therapist. I'm already seeing it. Why not continue? If they're telling me it's going to continue to get better, then I believe them because they've already shown me. I've gotten a little bit better already.”
Are you still doing some telehealth?
We are, but very little. We're back to probably 90% or something in-person. There still are some telehealth visits. What's nice though and that's something that moving forward after all this goes back to some kind of normal. I would love to be able to keep telehealth as part of the practice. Forget about Coronavirus, let's say someone has got to stay home with their kids because they're sick or something. It's a good option for people to have like, “This week, I'm not going to be able to make it into the office, but at least, we can still touch base and do some of the treatment through telehealth.” Hopefully, we can keep that.
If someone's on vacation or something like that, they could still call-in. They don't want to on vacation, but there are extenuating circumstances in which you can continue to use telehealth and not miss that visit.
Hopefully, we can continue to have that as part of our practice and the whole world will continue. There are many opportunities now that we all can take and we all are. Besides PT, this is for everyone. I've got kids. Our kids had to do remote learning and everyone and my wife is working from home. This whole world is figuring out how to do this stuff remotely and hopefully, we'll all see that. Some of this could be more of a benefit than not and we hope to use that to make things more effective or more efficient.
I think telehealth can change a part of our practice if we are intentional about using it. You mentioned that you transitioned out of patient care. Were you still seeing patients a little bit back around that time and were transitioning out fully or had you been out of patient care by that time?
I had been treating still. I've always been trying to reduce my treating hours. That was one of the first goals of coaching was to reduce. I don't know if I ever thought I would have to completely take myself out, but I always knew I had to do less treating. Once this all started, it was like, “There is so much that I need to deal with now, I cannot be treating.” Almost overnight with Coronavirus, I was treating and then I was down to no treating. It was good for me because if it wasn't for something like this, maybe I would have always reduced my hours a little bit, but maybe I would never go fully out to zero treatings. That force me out, which I'm not saying I won't go back ever, but it's clear to me that I need to not be treating and focus on all the other stuff of the business.
It's interesting that you pivoted in that direction because I've talked to plenty of clients who didn't have the telehealth success that you had, but they let go of a number of their team members to the point where they had to treat. I love the fact that you saw it not as the owner and as a leader that, “I can't afford to treat. I need to focus on the business and pivoting us to a point where we can stay afloat until things get back to normal.” Whereas, a lot of owners have the mentality that I need to let everybody go and do this all myself. It's interesting that you gained that mentality that your ownership and leadership in the business is more important than you treating patients. That's a cool mindset that you had. Over the course of time, you gradually pulled yourself out of treatment. Did you start with half days or full days here and there to gradually work your way down to the point where you were before COVID?
I don't remember exactly, but it was reducing hours. There would be half days because I was also doing billing. At some point, I also had not to treat certain hours so that I could take care of the billing. Once I was more proactively reducing my treating hours, I was maybe chunking time every Monday, Wednesday, and Friday morning. The rest of the time I'll do billing and other business stuff and slowly reducing to maybe just Tuesday and Thursday. When I was treating, I was trying to at least have two days a week so that if someone needed to come in more than once a week, I can still see them. I was slowly reducing hours and trying to make it an efficient way to do that. I would chunk times where I'd be treating some, but the rest of the time would be more business stuff.
There's a concern with some owners that I talked to that the team around them is going to look at them oddly or think differently of them if they're not treating and they're pulling themselves out to work on the business. Did you have any pushback from your team or did you have to explain yourself to them very much?
I did not get any pushback from my team. I didn't have to explain myself, but I often felt like I should. That might be a common experience that owners have when they start pulling themselves out that they have to justify what they're doing. I think I'm lucky that I believe my team knows that I'm still working even if I'm not treating or at the office. It's clear that I'm still doing a lot of stuff. I don't think that they feel that way but I could be wrong.
I know that's a fear that comes up often. Maybe it's an unrealized fear, but it's something that within the owners that I talked to. I went through it myself. “What are they going to think about me when I'm sitting back in my office? What if I'm not here for hours at a time between 7:00 AM and 6:00 PM, what are they going to think about me? I need to at least show my face and step foot in the clinic.” I think those are fears that often go unrealized. I'm glad to hear that you had a similar experience that it wasn't all that difficult and there wasn't a lot of pushback at all. They understand. Tell us a little bit about what your coach has done with you during the course of the pandemic? How did your coach help you through those few months?
I'll give a little bit of background on the coach. It's part of a group. There's coaching. I get one coach and we have bi-monthly calls. In addition to that, there are quarterly workshops. There was a workshop on March 18th and that got switched over to a virtual workshop. I think we closed our doors the day before or something and there was a workshop which was good timing because we all got together. We were able to talk about all the issues. I would say the first thing that we talked about was to focus on yourself. Focus on making sure you're safe. Not necessarily safe from Coronavirus, but safe financially, knowing that you have some type of a line of credit or emergency fund. First, look over the numbers and make sure you know what's going on.
You had Eric Miller on a while back and he was talking about profit first and money management system. I started reading and implementing some of the practices. Even before this all happened, I was already creating some small type of emergency fund. When this all happened, I didn't have to stress immediately. It wasn't like it was stress-free, but I had a little bit of reserve that I was setting aside. You need that because of something like this. That was very helpful. The second thing that we talked about at that workshop was after you first look at yourself and your finances and the business, and make sure you're safe, then make your team feel safe.After you first look at yourself, your finances, and the business, then make your team feel safe. Click To Tweet
I talk to them about, “I've got this emergency fund. I'm applying to the PPP. This is how I think we're going to do things,” to make sure that they know that their job is secure or how we're going to proceed with that. Those two were big because I wouldn't have known to do that. Having that guidance and the ability to talk it through with other people in the same situation was huge. There was one other thing that I can't remember. There was another main point that I remember from that initial workshop. After that, moving forward, I still had my calls with my coach. Before Coronavirus, we'd probably talk more about strategic stuff and how to fix operating procedures. Now is more of like, “Let's take this week by week and figure out what we need to deal with.” If there's something that comes up and how to do anything, how to feel you’re not so overwhelmed that the business needs to close down.
It was interesting talking to clients because no longer were we talking about KPIs and your stats so much that we normally would have. Those were out the window or implementing new programs and stuff like that. Things change week to week. You weren't quite sure what was up and what was down. You handled it as it came up very much more reactive to the situation. You would talk about, how are you doing with the funds? How are you doing yourself? I also stressed more with my clients, maybe considering what are you going to do differently when you open up? What are the things you would consider changing? Are you going to bring all your team back or just those who are well aligned with you? Over that time, did you work on your business quite a bit, thinking forward, like, “When I open up, I'm going to do things differently,” or were you so ingrained that you had to deal with the day-to-day?
That was the third thing and you’ve been saying that in the show. It was like, “Take this time as a reboot and focus on your business and think about what you could be different and what you could improve.” Thankfully, I got the PPP funds early on. Once I got that, it made everything a lot less stressful. We're able to focus on the business. I did focus on the business a lot. One of the things I wanted to do for a long time was to get a billing company or hire someone to do billing.
It didn't make sense to do an in-house and train them. It didn't seem appropriate anymore. I reached out to Will Humphreys after hearing him on your show about how he was starting a billing company. I reached out to him and it seemed like a good fit. I also got in touch with you about it and you said it could be a good fit. We went ahead and that was one of the big changes for me, but also for the business because there were many things that we were doing that probably were inefficient. Having an experienced billing company take over was much better for the business. That was certainly one of the things we did. The other thing since we had a little more time, their caseload was down, we switched to EMR software. That was also a big thing to take over.
Can I ask you what you switched to and from?
We switched from WebPT to Prompt. It is a newer company. They are a young company, but I can see that they're going to continue to develop their software to potentially be the best or one of the best. In full disclosure, I don't think they are the best yet, but I think that they will be or at least better than a lot. I felt it was a good time to change because things were a little slow. Honestly, we had a little bit of time because we've had PPP funds and that's what it's for. I paid my staff and we had a little extra time to learn about our new system. Whereas if it was regular time, it would be overwhelming. You have a full caseload, and to try to switch over to a new EMR software is not a fun thing to do.
It is a huge transition. It is time-consuming, energy-consuming, emotional, and all that kind of stuff. I have to give you kudos for taking the opportunity to make some significant changes in your business. I know you are personally doing the billing, but making that billing decision is huge in and of itself. Maybe we can talk to your mindset as you went through that a little bit, but also changing EMR. Most of us probably know what painstaking process that is. For Prompt, I've had the owners on before. I liked their platform and they're going to do great things because they are quite capable of responding to the needs of the owners. I think it's going to bear fruit and become a great system.
As a side note, I liked the fact that they're focusing on project management or company management in obtaining the data that you need and the KPIs that you're looking for and the reports that you need to manage your business. I like that part because a lot of EMR are lacking when it comes to providing the owners the reports that they need. To go back, what was your mindset? Why didn't you simply hire on an experienced biller and instead bring on a billing company? Even in my experience, I'd usually recommend people have their own billing departments so they can manage it and oversee it immediately and have people that are aligned with them. In your situation, I thought maybe that was a better move for you to hire out. What was your thought process in going with a billing company over hiring someone?
I had a few different thoughts. One was the nature of the global pandemic. I didn't want to take on more risks of hiring someone, take the time to train them, who knows if they get sick, who knows if they're going to be good. I didn't want to add another stress. If I could find an experienced billing company that I know that they're going to do a good job from the beginning and I don't need to train them, it would make it a lot less stressful. I think this helped persuade me a little bit to go with Will and Katie. It’s that Will offered some coaching along with the billing company. Obviously, I'm into the coaching aspect of things. I thought that was cool to get an additional coach out of it.
I think that could have been the thing that tipped the scale. At this point, one of my main reasons is I don't want to have to worry about training, what if they do a bad job, and then I have to start over. The third thing was I just started with them and there's no way to know. I believe from what they showed me, they were going to provide reports, check-in, and tell me all the things that they were working on and what they're collecting. That's what they were all about. “We want to communicate with you as much as possible and perhaps overly communicate to let you know what we're looking at and what we're collecting.” Those are some of the reasons why one would want an in-house so that you can better manage and know what your biller is doing. I got the sense from them that they were going to provide that and stay accountable for what they said they were going to do.
I can see the dilemma that you have there. When you consider bringing on a billing person for the first time, you're taking a big leap of faith that that person has the experience that they can do the things that they say they can do. Add that to your payroll and benefits that you might have to provide and trusting in them to honestly provide you the reports that you need. That's not necessarily even in our wheelhouse. Most owners don't know how to tell if their billing person is doing well. They're relying on the billing person telling them, “We're doing well.” There's always that question in the back of your mind, “How do I know?” You have to go on faith.
In your situation, especially as a small business owner to bring on that one person is a big leap of faith. Whereas if you have the opportunity to go with someone that you can trust, at least you know that they have a ton of experience coming in behind them with billing and PT-specific billing, you don't have to go through the hiring process. You can trust that they know the language, that they know physical therapy, that they know what they're looking at when they're looking at your EMR system, and the financial reports that it pushes out. You don't have to train them on the EMR system at all. All those things can be to your favor, especially as a small clinic owner like you are instead of bringing somebody on. I'm interested to follow along and see how that works out for you, but I'm confident that it will.
I think you would probably know more than anyone else.
I can trust Will and Katie, especially Katie did great things for us in our billing. She was our billing department head. I'm sure they'll do well. It's important that you also take the time and effort like you did to sit down and weigh the pros and cons before you make that decision. You have to put so much emphasis on that money line and make sure that you have full control of it.
The truth is for months, I was putting out job posts for billers. Hiring is hard in general for all the reasons. I was putting it out on Indeed and I was getting thousands of applicants. It was hard to even weed out any of them to determine if they're good or not. Half of them didn't even have any billing experience. I also got burned out from that process too. It was the part where I was like, “I need to hire someone. Here's someone who's going to do a good job.” If it wasn't for me feeling confident that they were going to do a good job, obviously that would be a different story, but I got the sense that they were going to do a good job. They were going to report and communicate. Those are the things that I would want. Maybe it's cheaper, maybe it's not. That wasn't the biggest concern because as much as every dollar matters, especially during these times, I needed to have certain things work well. I needed it to work so that it was worth spending a little bit more. It may not even be a little bit more. It depends.
You've opened up since June 2020 and we're in the middle of July. How have things gone ramping back up? Have you had any hiccups in opening back up or things that have maybe changes that you've made that have worked out well?
Some of the changes were by the very nature of us already being a small clinic. When Coronavirus started, we only had two PTs plus myself. When I removed myself, we had two therapists. The office is set up that we can basically have two areas. We have one PT and their patients on one side of the office and one in a completely separate area, a different room. We tried to follow CDC guidelines and make it safe, clean, and try to set up protocols to prevent as much overlap of patients. Telling them to wear masks, to not come in and wait in the waiting room, all that type of stuff.
Those were the logistical things that we had to figure out. The nature of us, the size of our clinic, it worked to our advantage that it was seamless. Other than that, we were already treating one patient at a time. We didn't have to change our model or anything. For the most part, things were okay with that. It was more trying to come up with protocols. We had someone who called in and said they want to be a patient, but they had a positive Coronavirus test. The question is, at what point are we allowed to let them in? We don't know these things and we have to figure them out as they come along.The best thing a leader could do is invest in their team, so they all become even stronger. Click To Tweet
Someone calls and said they had Coronavirus. They did test positive, but they're not showing symptoms. Are we okay with that or not? Honestly, I don't think there's the best guidance out there from anywhere. We come up with these policies. We're trying to figure it out. We're consulting with other medical professionals and trying to do the best we can. We're trying to be as safe as possible. We are trying to figure out all those things, but the biggest challenge moving forward is knowing that it's probably going to keep coming up.
Are you getting a lot of your new patients from doctor referrals or our doctors back in your area and treating and referring patients or have you had to change some of your marketing strategies?
Most of our patient referrals are not from doctors. It's hard to say, but I would guess at least half of our patients come new referrals come from direct marketing through Google Ads. To answer your question about the doctors, we don't have very many doctors that consistently send, but a few of them, once they started doing surgeries again, started sending patients. The Google Ads was interesting because from March 2020 through June 2020, the ads were not performing like they used to. That was something we were having to figure out if it was because of Coronavirus. Did Google change something with their analytics? Google did change stuff. Even with getting Google reviews, they weren't posting your reviews right away. If a patient wrote a review, I don't know why they did it exactly. They did some extra process of screening the reviews for whatever reason or maybe they had fewer steps.
We all rely on those reviews. That was interesting to see, but I wonder if they changed something with the ads as well. Whatever it was, we went through this process of testing ads, changing the website, and tracking things differently. Eventually, I think once, people became a little bit less scared to go out in public things, it became a little bit back to normal on the ad side of the thing. It could have been that people weren't wanting to come anymore because no one knew what was going on and people wanted to stay home.
Did you have to change your message much on your Google Ads?
No. Even throughout the time when the ads were running, most of the conversions were coming from the regular ads and not the ones promoting virtual therapy. Even if they were calling to make an appointment through telehealth, they were still clicking on the original ad.
What are your plans going forward as you're looking forward to the end of 2020 and the beginning of 2021? How have your goals changed? What are your projections? What are you thinking is going to happen here towards the end of 2020?
To be honest, my answer is probably the same as it was at the end of the last interview. I'm focusing on my team because I realized more even now than ever how important it is to have such a strong foundation. Foundation doesn't mean that your systems are in place. It means that your team is there and that they're able to function and take the business where it needs to go. Just like I saw, they were able to step up, be super proactive, do the things that we needed to do for our business to survive this. Interestingly enough, we had another workshop at the beginning of July. Before that workshop, I had my first coaching call with Will.
Will recommended that I start reading the book, Start With Why. On the workshop, they started talking about Start With Why, which was cool because then it's a little bit of reassuring that different coaches are talking about the same thing. That's nice to see. Ultimately, coming up with the why and my purpose statement, trying to differentiate that with my vision, our mission statement, and our values. I've been focusing on that because I want to get my team involved. I want to have them help with creating that vision and us all figuring out not just what I want from the visits, but I want to know what they want to get out of it. How are they? Could they be doing more? Do they want to be doing more? What do they want?
That will help us all be even more of a team because we all know exactly with the end in mind, what we're trying to achieve. I want to focus more on my team. Now, I don't know if it's the right time to hire or not. That's the biggest challenge I have. I don't know how to figure that out because who knows, you hire someone and two weeks from now, there's a second wave and everyone shuts down. You have to furlough or lay off and you just hired someone. That might be another stress that I don’t want to deal with. At the same time, I want the business to continue to grow. It's a hard thing to figure out but I do recognize that with the team that I have, they're a great team. I feel that the best thing I could do is invest in them so we all become even stronger. On the other side of this, everything has to be easy after this.
I love that both of your coaches started talking about purpose. Simon Sinek’s TED Talk is one of the more popular ones for a reason. That was many years ago and it’s about Start With Why and he has a book from it. It's super popular as well, but it all comes back to your purpose and making sure you're aligned. That's one of the first things I do then with my clients is to make sure that they have a purpose professionally and recommend that they find one personally as well. Also, incorporate values and getting the team involved with that. In that way, you're aligned and you start working with team members who are value-aligned. You start bringing on more people who are value-aligned and the growth can then accelerate exponentially.
I think you recognize what people who are in alignment with you do for you when troubled times come up. Those people who aren't aligned with you, they would have been the people who were like, “I'm just going to hang out. I'm not going to do as much. There's nothing to do. I can't get these patients to respond.” Whereas your team, thankfully, you've got some great team members who were focused on, “No, we're going to push through this. We're going to get the patients the care that they need. We're going to make this telehealth service thing work.” I think it's a great place to start and focus on your team and making sure you have a firm foundation to build off of. It's awesome to hear that you're heading in that direction. Going forward, what are your goals then for 2021? Are you keeping things at bay for a little bit until you see that we're out of the woods here?
Yes, keeping things at bay, but the next goal is hiring to grow. With some of the things that I've been able to accomplish when it's time to hire, I think we'll be ready. Getting myself out of treating, getting the billing taken care of, we've got the new EMR that we're working on, that we're getting more comfortable with. Personally, without the team, I'm working on the purpose and the vision. The next step would be to do that and try to develop that with them as a team. I think our foundation is going to be super strong.
We can grow exponentially from that. When that happens and also when it feels a little bit, maybe more certain or safer to hire on someone else and take it to the next level. One caveat though, it's also a little bit hard to figure out how to bring on more people. If we're trying to figure out safety protocols and keeping distance, it's hard with the space that you have. If I bring on another PT, where do we put them so that we can still maintain that space between the patients and the other therapist? That's also another hard challenge to figure out. Moving forward, when things slow down a little bit, become a little bit safer, more certain, my next goal is to hire and develop those senior PTs and clinical directors. To give them a little bit more not responsibility, but more overcharge on what they're doing at work and allowing them to also grow the business. Not just for the business, but for themselves professionally as well.
I see the same for you. I think your next step is to gradually get to the point where you're bringing on other people and starting to develop a leadership team. You're doing all the leadership, but for you to move up, you need to start building up people who can take on responsibilities on your behalf and start managing and being responsible for more than treating patients. That's when you start developing the leadership team. A lot of PTs are looking for that opportunity. You're going to be able to provide that for your team and they'll be excited about it. That's a cool next step. It takes some time and some effort, but it looks like that's where you're going.
I'm excited about it. It seems like that's where we're heading almost not just naturally, but also putting in a lot of work to get it there and the coaching and everything. I feel like what you just said, I think that my team wants it too. They want to be doing more and they'll thrive at it.
Congratulations on the changes that you made. What's cool about your story is that looking back, the time that you were shut down sucks, but you took advantage of the opportunity to make some positive changes in your business and going forward, you're optimistic. You can look forward to more changes in the future now that things were somewhat normalized. Also, you seem to be prepared if things don't go back the other direction. You've been through it. You're even better established now. You know what you would need to do if another shutdown occurred. Congratulations on better establishing your business and making some positive moves forward in light of the pandemic. It's cool to catch up with you.
It's always fun talking to you.
We'll catch up again. I’ll talk to you later.
Thank you, Nathan.
Dr. Avi Zinn, PT, DPT, OCS is the owner of Druid Hills Physical Therapy in Atlanta, Georgia. He opened his practice at the end of 2017 and has slowly built it up—transitioning from a staff of one (himself) to a team of administrative staff and treating therapists. He continues to grow the practice gradually. Avi’s main mission for Druid Hills PT is to provide high-quality, personalized care to each and every one of his patients.
Avi has his doctorate in physical therapy from Touro College, and is a Certified Orthopedic Clinical Specialist. He lives with his wife and three children in Atlanta.
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Joining Nathan Shields, James Savas is back in this episode to share what PT owners need to do to filter out those team members that are bringing down the culture, morale, and productivity of the team - from communication protocols to exit interviews and everything in-between. Communication is the key, followed by value-centered action. No one likes this part of the business, but putting a little effort into it will allow your rock stars to stand out and the rest to find the exit.
This is part two of my interview with James Savas. He is the Deputy CEO at Hands-On Diagnostics. He is a Senior HR Professional with specialty in Business Development. He's also a certified Educator and Executive Coach. We're talking about a ton of stuff HR-related that, for me, was the bane of my existence as a young PT owner. I didn't want to deal with all the HR headaches. I'm excited to bring him on and share some of his wisdom for us PT owners and help us through this. James, thanks for staying on.
It’s good to be here.
Thanks for taking the time out. I appreciate it. I’m breaking this down into two episodes because you've got a ton of wisdom to share. In the first episode, we talked about the recruiting, hiring and onboarding of a team member into our clinics. A lot of great information that you shared there, but we want to go through the entire life cycle of an employee's experience on our teams. In saying that, we finished off by talking about what it's like to onboard someone or train somebody to bring them on and to be successful. People who are reading this probably have someone on their team where you said, “Is there anyone that you'd like to get rid of?” They'd probably say, “Yes. I know who that is,” or “Is there someone that would be a lot easier if they weren't around?”
More than likely, they have 1 or 2 people in mind. Before we get to that point, I don't know if I’ve ever spoken on the show about how to have appropriate disciplinary procedures. For example, a team member will come in late. How do you handle that? You spoke to them. What if they consistently do it? What's next? When I have coaching clients, they'll say they come in consistently late and I'm like, “What are you doing?” “We said one thing to them once, but we haven't done anything since.” I'm like, “You probably need to determine what your procedure is.” How can you guide us as we take someone through the disciplinary process? Maybe their infractions aren't so much that they should be let go, but how do you hold them accountable?
I have three children myself and look at how I’ve trained, I use that loosely, them. Any good employee, we're assuming that you've gotten good employees in here. Maybe not. Maybe you have some people there that need to go. A good employee, they're on the same terms, same purposes. We'll take discipline and go, “Sorry about that.” The way you are I might like, “I'm sorry. I screwed it up. I apologize. It won’t happen again.” Once you're told what the policy is and you're slapped on the wrist gently, you change your behavior and you fix it. You apply the right steps to go, “You’re bad. Don't do that anymore,” or “Get the earlier bus,” or whatever. I'd worked in New York and knew all about buses and subways. Montana is very different.
Number one is good employees. New employees will be receptive to basic disciplinary actions. If they're not, I would challenge that they’re not good employees. If they give you a lip for bringing up, “Cindy, but she always,” “I don't care about them. We're talking about you. You were late today.” As you can probably tell, I jump on if I observe something I don't like, whether I'm wrong or right. I don't mean to jump on like, “Rah,” but I’ll communicate about it immediately. If I see someone come in late, “Let’s go talk. What happened?” “It was,” “Understood. Don’t do that again. We can’t have you late. You're a role model. It's important. Cool.” Here's the thing. If I see them do it again, it's easy because I can go, “What's going on now? This is day two.” It's case by case. If I don't see it, then I don't know.
A big part of the disciplinary point is we need reports to happen. You need all the staff educated that I'm writing reports is a good thing. That's fine. That's a challenge because I don't want to tell on her or him. With professionals, it's a little easier to get them to do it than the administrative staff in my experience. Not one for one, but most of the time. It has to start with the team understanding. On the onboarding side of this, understanding that you're writing reports to HR or to owner or to me is important to me. I'm not going to tell them that, “Cindy told me you were late.” I'm going to say, “You were late.” Training your staff to know that that's okay and communication is good is important because now if I get a report that she was late a second time, that person, then I’ll go and see them.
I know an owner and in many of your cases with your clients, they probably are not going to go, “Hold on, stop. You were late.” They're not going to stop doing. Here's a tip that I find on discipline. When you’re thought well by your staff, when you are opinion-leading, generally amazing dire girl, you do a lot of good and they know you do good. They know you're there to fight for them. They know you've got their back. When you have a very high affinity on both sides, all you have to do as an initial disciplinary point is withdraw a little bit of that affinity, a little bit of that care.
It’s the same way that when you go home with your loved ones, and a little cold shoulder. Their antennas are like, “What happened? Are you okay with that?” You immediately feel something's not right here. I’ve had success training owners and myself as an executive, withdrawing a little bit of that care, a little bit of that love for the employee. A little bit of, “Good morning. They didn't like that. They didn't like I didn't look them in the eye.” Eight out of ten times it will prompt a conversation, “Are you upset?” “I'm not upset, but you're late again.” That's one way to do it. You have to maintain that inspiring high tone individual. When you want to withdraw a little bit of that care, it affects them and they don't like that kind of initial disciplinary step.Our team members want communication - how well they stand in the company. Give them the open communication they need, whether for their good or bad behaviors, and their productivity will improve. Click To Tweet
I love the report aspect. I can't tell you how many times it came down to having to hold someone accountable. I can't remember the specifics of the different scenarios, but I'd have to hold someone accountable. I'd say, “You cannot do that.” They would say, “So-and-so has been saying this and doing this behind your back I don't know how many times, and you do nothing about it.” I'm like, “They did it behind my back and no one told me anything about it. How can you hold me responsible for that?” My fault in that is that I didn't have a way for them to communicate things that I was not seeing. I didn't give them that communication line. I didn't throw them the line to say, “When there's an issue, you can report it to me and this is how you would do it.”
I'd find out after the fact, after I let someone go, they'd say, “So-and-so, when you weren't around, they would take off and get their hair done and show up two hours later. Nothing was going on.” I was like, “When did that happen?” “That happened all the time.” “No one said a word about that. How was I supposed to know?” That happened often because I didn't establish the communication lines to do that. Having a report like that and doing the proper footwork ahead of time to train them in how to use a report. That it's not tattle-taling. We're trying to do what's best for the business. There's a way to do that.
It is getting them comfortable with that idea. When I'm training staff on reporting, one of the drills I’ll do with them as a trainer on that is, I’ll have them right there on the spot. “Everybody, write up a report right now, something you've observed in the last three months that was not cool and didn't follow policy.” That's their completion quiz. I’ve got to see a report.
You can't check off the checklist until they do that.
I give them this example. Let's say if somebody was murdered, someone did something gruesome and horrible, you saw it happen and you said nothing about it. It was proven later in a court of law that you observed the murder and you didn't do something about it. You are liable for part of what happened there. I said the same thing what I would say to that person that you mentioned in your example, and say, “Why didn't you tell me that? You saw it how many times?” I would be this close to disciplining her or him for not telling me that she saw her do it.
A lot of people might talk about having instances in which they were “disciplined” or on probation or written up in their workspace. Did you have write-up policies and steps towards potentially letting somebody go? You get three strikes and you're out. Did you have a stepped program like that?
Yes. You have to have it in that employee manual. Three or four strikes, with the asterisks that this is always case by case. Something severe you're gone tomorrow is at-will employment state. I don't have to tell you why you're going, but then that's the legal side. Definitely, there was a protocol. One thing that's incredibly valuable that many people don't do with HR guys or girls, anyone in between, write the reports but then file them. It will be a bunch of emails they'll send because they don't want to write something, which I understand these days. I get it, but then they're not in a file. When we want to let somebody go, I'm looking for her name and email. Hopefully, I’ll find it or if you remember that was an email. You need that formality. There's got to be a form of policy or procedure or you're in trouble.
I highly recommend my coaching clients. If you're going to write somebody up, one first is usually a verbal warning. The second and third, there are going to be written statements outlining the infractions, the when, the where and why, and both people signing off on that. It's a very simple document so that they understand that they're being reprimanded and that you actually took the time to reprimand them. That goes in a physical file folder. It could be scanned and put in a Google Drive folder if you want, but make sure that's HIPAA compliant. Make sure that's there so that you have your case for why someone, if you need it.
One of the policies in one of my earlier jobs in my career was, you would investigate somebody or some area. A report in an area, the clinical areas are always messy. I want to know that too. It's not just about Joanne who runs the clinical area, but I need to know that the clinical area smells on every Wednesday or something or that the billing team’s lunch room is a mess. I want to know that.
The laundry is not getting done or you name it.
Anything that they observe. I make it very clear and clean that I want that as the boss wants it, when everyone else's opinion cares. In an earlier company, we would investigate based on the fatness of the file. This is when it was papers, but when it was about a thumb thick, half an inch or more thick. That's a lot of stuff in a file. They are not certifications, not your I-9s, but that's quite a personnel file. If you have no time to see somebody's work all day, which you don't, I would audit it once a month or once a quarter, probably for most owners. Let's be realistic. Audit the personnel files.
If you're small, no one in your company is going to have the tension to go and pull all together and interview the girl and fire her. It’s not going to happen. Let’s be honest. If every quarter you go, “I'm going to spend a couple of hours and look through all of my files here, the personnel files. She's had 3 or 4, but then she stopped being late. She was warned twice. She handled it for two months and she was warned again. “Good to know.” That's good and bad for different reasons. The auditing of them and the awareness of what's in those files, the typical owner has no time for that. Putting in the schedule of a quarterly review of these files is valuable. You go, “That happened under my nose?” You didn't know. That's if the report’s in place.
There has to be a process and a procedure, “This is where the reports go. This is how I get them.” I'm sure there's also a follow-up process. After you have received a report, there's probably some communication that needs to go back to the person who wrote it to know that I received it. This is what I'm doing about it. They've gotten to a point where they've followed through the disciplinary process, or they did such an infraction it's time to let them go. What do you recommend we do to let go of dead weight?
Do you mean if that’s confirmed and we're definitely letting him go?
I’ve got many people that I talked to and they're like, “I should've let them go like six months ago.” I never let anyone go too soon, that's for sure. I always wish I had fired them sooner. How do you get rid of them eventually?
Let me tell you one thing is every owner I’ve worked for has a problem with firing. It's not a matter of no time to do it. It's a matter of they're going to get better because you’re a therapist. Ingrained in your being is, “Let's help this person get better, no matter what the struggle is.” Here's an employee and I like him or her and they're great. Maybe I have them for ten years or maybe it's, “She's been at my front desk for twenty years. Whatever the situation is, I can’t let them go,” but you should.
We would always blame ourselves. We haven't trained them enough. Maybe we haven't held them accountable. When we were making excuses, we were dragging our feet. It was good times when we got excited about firing people, because then we knew the replacements were going to be so much better. We’re so much better equipped to bring on somebody who is actually value-aligned at that time.
Let me say this precursor, you have to not be afraid to fire. You have to have the recruitment lines in, so jammed in, so rolling. You have a waiting list or prospect list or whatever you want to call it. You'll get worried, “I can't lose him.” You're in trouble and then you'll keep them on too long. Certainly, protocol states that you can fire them Monday or Friday. Beginning of the week or end of the week. I always like end of week because end of week, day’s over. No one's left and very few staff are there. They know what's coming or they don't. We can talk about that in a second.
They go home. They have the weekend to sulk and cry. Call everybody and tell them how bad you are and then whatever. I like Fridays in general. Let me say this too, when I'm going to fire, there are selected few people that I will give a heads up on. That may sound funny. Call them your HR guy, call them your manager. People that were good people and things that are changing in your company. They're aware of it or something's going on. You trust them a lot. You trusted them for years and now you have that talk. There are certain cases where I will say, “I want to give you two weeks’ notice.” This is a grain of salt too because that's probably 10% or less of the people you’re going to let go.
I was going to say that's a very small minority.
There is value in that because you want a turnover, a function, write this up. Even if they are being canned at a Friday, always the version of that in a very small unit of time is, “What were you doing in your area that I should know about?” I would make notes of like, “Check the passcode,” and whatever it is. It’s the same way that onboarding was checklisted. Firing has to be checklisted. Remove passwords.
We had to checklist that because it was the passwords, it was the keys, it was the equipment that they had. Maybe it was a laptop that they could take home occasionally or an iPad. We had to make sure we got all that stuff. Get rid of the access to the EMR and the bank. You have to have a checklist so you don't miss any of those steps.
It’s almost 2 or 1.5 because you need the one in front of the person and the one for after they go. That goes to some of the computer stuff. If you want to be on your ball, when you're calling them up at 5:00, at 4:30, you kill all their access before the hammer comes down. I worked with an employer in Long Island in the New York area. I love that they asked this. There was a question on an exit survey that always had to do with, “Did you ever feel that you were discriminated against?” The person had to initial and sign off. There were many more questions, but that was one of a dozen-ish or something. I love that because no matter how bad that exit interview went, they said, “I have to explain it.” “You're firing me now.”
“I get it. We have our reasons for firing you. We can go over that again, but in your time here, it always needed a two-way communication. Have you ever felt that based on your race, your religion, your sex, or age?” “I guess not.” “Fine.” HR is sensitive to that data. You need the data and if they signed a document that said, “It was on good terms,” or whatever, it’s another notch in your favor. If it ever got ugly, you did something about it. I love that. Definitely a checklist, a protocol. Go over their final paycheck protocol. That's on the checklist. You have to go over that. Is it mailed? Was it handed over to them? If it's a sticky thing, hand it to them. If it's a really sticky thing, give them a few bucks, a week's paid, depending on the situation.
Call the CPA or the payroll company and say, “What check do I need to write to get them off and not have to worry about another one?” Make the call ahead of time for sure. Some of those payroll companies, if you work with a payroll company, they need 24 hours’ notice to get a courier to drop off that check in time. It's important to do that. Some of them are easiest firings in which we could tie their actions back to how they did not observe our values. Our values were professionalism, accountability, growth, and empathy.
If we could ever tie their actions back to, “What you did, I hope you understand, did not exemplify professionalism. You didn't hold yourself accountable appropriately. We can't tolerate that. You broke a value.” We tried to hold it to that more so than any particular action. Some actions were simply intolerant. Even those usually tied back to the breaking of a value in some regards or another. That made things a little bit easier. Correct me if I'm wrong, if you've had the disciplinary procedures in the past, they more than likely know that it's coming. If they're surprised by the firing, then you probably haven't had enough communication with them in the past.
Those are always at stake. When you have them in tears, they didn't see it coming. You're like, “You didn't see it coming?”
It was always so much easier when there was communication. Some of our best firings were opportunities for us to hear their complaints. Share our side of the story and say, “You were productive. You did well with our patients and because of that, we're going to give you a good letter of recommendation as long as everything goes smoothly now. In fact, we're going to help you find your next job.” With some of our PTs, we'd start sending out emails to friends, where we’re like, “We had to let go of a friend. If you've got an opening, we would actually recommend them. They're not a good fit and we recognized that.” When we did that, it made us feel good, but it also turned the tables to help them recognize that we weren't enemies. We have to recognize that it's not a fit.You have to not be afraid to fire. You're in trouble if you keep them on too long. Click To Tweet
You do need to talk to an HR professional or an HR lawyer. That would be probably smart.
With at-will employment, there are some states where it was protocol to give no reason. The human in me wants to let them know why. This was so circumstantial, but the circumstance was that, I never want to get into it and it’s not a good fit. “Your value is great. I love it.” “I was here every day on time.” “You were, but you are not a good fit culturally.” “What do you mean?” “That's all I'm going to say about that.” I’ve had it as intense as the other side as, with a knife in hand, “I demand knowing what you know.” A young lady in marketing, of all places, but she was not having it. She demanded to know, “I have the right to know why.” I got appropriately aggressive with her. It’s not antagonistic, but aggressive. If you want me to pull your personnel file and read you the reports on why, we can do that or we can say, “It's not a good fit and I can write your recommendation letter.” “Okay.”
I do love a recommendation letter saying that in almost any circumstance, “If somebody calls me, I won't say this happened.” To that point you said, it was a short-term firing if they came on even up to a year, I'd say, “It didn't work out and you're having this conversation.” I have said a few times, “For all intents and purposes, on your resume, if you want to put project or you want to put temporary position, we'll back you up.” That way, it doesn't screw them up there. They’re looking for, “What is this, one year and six months at Blah PT?” If they don't put it on there and I'm the employer, “What's this gap of six months?” Instead, “Put us on their PT Blah, six-month project filling in for someone who had maternity.” I don’t care. Say whatever you want, but I’ll make that very clear that, “We got your back.” It's PR. It's the other side of that. “If you're leaving now, still love us as much as you can, please.”
Maybe scrutinize this, if you will, but one of Will's mentors, he said, “If you have a problem employee and they get to a point, you can give them three options. Number one, turn in your resignation now, and I’ll write you a reference letter. Number two, we never have this accountability meeting again. You completely change what you're doing and you are our biggest cheerleader. If something needs to be done and we're asking for a volunteer, you're the first hand that comes up. If that's not the case, we'll immediately let you go. Number three, we give you 2 to 4 weeks to find your next replacement. We're going to train them up. Whenever they're fully trained, then that will also give you time to find your next position. If at any time during that course you cause another infraction, then we're going to let you go immediately. Which of those three options would you like to do?”
It was interesting. We had a couple of those conversations and they actually went well. Some people were like, “I'd like to resign right now. I can see where this is going. If you can get me a check by within 24 hours, I'd be happy.” There were some people who said, “I understand what I did wrong.” This is it's all circumstantial. There were some people that we could do this with. There were some people who simply had to go. There were also some people who, “We're not quite sure. You don't seem like the best fit, but we don't like what you're doing. We're willing to give you another chance if you're willing to take the chance.” That way, it didn't make any surprises come along at all. They were in control of charting their course within our limitations that we provide them.
You asked me for my opinion on it. It's dicey. I don't love it because I would challenge that if you're going to have that conversation, they shouldn't be there, generally. If you're going to go that far, what have they done that you’re even having that conversation and giving somebody an out, it puts you a little bit at effect, I feel. If it worked, it worked, but again, circumstances. If it works, that's great.
The way it worked was usually they would opt-out. Rarely did they stay on. They either resigned that day or they said, “Give me a couple of weeks so I can get my affairs in order.” We said, “Okay.” They weren't so bad. We just didn't want them around anymore, but it worked out well when they opted out.
Prior to firing, if you have this evaluation time like you mentioned in the last show about up in Montana, they have these several months or a year checklist of onboarding or whatever. If you have some regimens of ongoing contact training in the everyday communication, then you're going to see this before it gets there and you're going to nip it in the bud. You're going to go, “It didn't look right.” Like I said previously, if I see an indication by a person having a bad day or they're late, any side of not going well, the next day, “What happened?” You don't want it to get to firing the good people, but you have to be willing to fire.
That brings up another point. There should be that regular communication because sometimes PTs will get so busy doing treatment that it's commonplace to do some annual evaluation or employees very much expect some regular evaluation of their performance. They want good feedback. Creating that process for them can be helpful. It shouldn't be a surprise to you and to them that, “Over the past six months, we've had to talk to you about this a few times. Do you feel like that's handled? Do you feel like I got that covered?” All these things preferably have been communicated in the past. It shouldn't be so much a surprise when it does come up and is addressed.
As long as we're not assuming that and we have it documented that we had a discussion or if it was verbal, it was verbal. I like what you said about employee evaluations. As far as the regimen goes, 60 or 90 days after hire, whatever your initial period is, one has to happen there. “How's it going?” “Good.” After hire, an initial, “How's it going?” Definitely annual. Maybe we would do it after the first quarter. We would do it with everybody or I'd have the managers do it. It wasn't like here's a report, read it. What I would do is I'd have the manager fill out their evaluation and then in front of the individual go over their points. “In tardiness, you're great. I love it. Effectiveness at role, remember we had that conversation yesterday, last week, last month, but I gave you a 9 out of 10?”
Open communication. It's on the spot there. They're going to observe. At the end of that sheet, like you said with the reports, the employee now is going to fill out whatever they want. “Here's a paragraph. I don't agree with any of this. This is garbage,” or, “I totally got it. It’s fine.” Sign in the personnel file and you have it there. Also, at the end, that also brings up, “I want a raise. It's been two years.” “Cool.” The manager or the owner or the HR guy, whatever it is, can recommend whatever your protocol is to the owner. “We should look at raise. These are all 9 out of 10s or 4 to the 5s and she's been great.” Cool. I would use it in those two ways as a potential review for raise, but also as an annual thing.
We would have the employees actually fill out those forms themselves and turn them in to us prior to the interview. They would rate themselves on how well they did and how well they exemplified their values, how they added value to our company in the past year? How they've grown? What have they done to improve both themselves and the business over the past year? Those are the things that we would go off of to consider a raise. Is there anything else you want to share about letting go a dead weight? I’ve taken so much of your time. I thank you so much for it. Is there anything else you wanted to dot your i's and cross your t's?
Staying aware of what's going on in the practice as best you can, and that has to happen. Whether that's the reports idea or a version of that, whether it's a firing process, whether it's an annual review process, you have to know what's going on. It's like daily rounds. One last tip. There's a policy about an owner’s, a CEO’s or director’s daily activities. Part of it is walking around all over the place. It's 10 to 30 minutes, depending on how big you are, maybe an hour. Once a week, at least activity is keeping the communication open. That's the big thing. If you don't have the communication. I know what's going on, then you're the complete effect of whatever they want to do.
If people want to get in touch with you, James, how would they do that?
Easiest is email at JamesSavas@Hotmail.com. I don't mind. Anytime.Every owner has a problem with firing. It's not a matter of having no time to do it; it's a matter of thinking they're going to get better. Click To Tweet
I invite everybody to read the first part of the show if they haven't yet. We tried in this to go through the employee's lifecycle from recruiting all the way to letting them go and give you some tips and ideas along the way. You shared a ton of information in the first episode regarding recruiting, hiring and onboarding. There was a huge amount of value in that. I'm glad we got to talk about in this episode how to let people go. I don't know if I’ve talked a lot about it in the show. Hopefully, it gives some people some ideas on what they can do, give them more confidence in how they can go about it the right way. Thanks again, James. I appreciate your time.
Anytime. I appreciate it. Thanks.
I love working with ambitious, driven individuals who have dreams of going big(ger) and just need the right support, backup and capacity to see it accomplished. I help them get that done.
The majority of my professional career has been in the Medical sector with the majority of that time in the Human Capital Management/Recruiting and Business Coaching/Development spaces.
Over 20 years I've strategically planned and executed programs and projects for my partner-businesses' expansion from as few as 4 offices to up to 16 office across 3 states. In my time working directly with various Owners and their staff throughout the boroughs of NYC and down the Rocky Mountains, I've hired well over 500 effective and productive Owners, Executives, Managers and Professionals, as well as created the training regimens for those people and their staff.
In addition to my savviness and acumen as a business expansion professional, I'm a successful soccer director and coach and a very very proud father of 3 amazing beings.
My Mantra is - Keep the create in life and be surprised by nothing!
Additional Points of Interest (some outside PT and some for fun):
* Published article in Impact PPSAPTA magazine (2008) "Hiring & Retention"
* Nationally Licensed Soccer Coach
* Director of Development of several Soccer clubs/groups
* Certified Assistant Teacher
* Co-owner (former) of a small family-owned retail dessert business
* International traveller (school in Italy & worked short-term in Ireland)
* Avid survivalist/camper/outdoorsman
* Humanitarian (as I'm able), directly assisted during 9-11 @ ground zero NYC
* Interned w/ MSNBC out of college (Broadcasting Major)
* Was a celeb-host at the 1996 Grammy's and 1997 ESPN Awards (some good stories not for air)
* Was on HGTV (with my family) in episode of a Montana HouseHunters
* Music composer/Short Story writer (Sci-Fi)
* Best hat I wear - DAD; pays shitty but great rewards!
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James Savas is a Senior HR Professional who has worked in the healthcare (and PT-specific) industries for decades, and there is one common issue that he sees PT owners make. It usually looks something like this: the owner hires someone to fill a position, turns around to work on patients and put out other fires, cross their fingers hoping they've made the right hire, leave the new hire to their own devices, and expect them to come up to speed in a week or two. Most of the time, this process doesn't work well for either party, and frustration mounts to the point where the owner throws their arms up in the air and laments, "if only I could find good people." What most owners don't recognize - or take the time to detail - is that there are a number of steps they've missed between recruiting and getting an employee up to full speed. If they take the time to organize the process, the whole system can be a powerful foundation for establishing a rock-star team. In today's episode, James joins Nathan Shields to list a number of simple things that owners can do to create the team of their dreams.
I've got James Savas. He is the Deputy CEO at Hands-On Diagnostics, and that's how I got to know him. James is an expert in many things related to HR, but specifically, he's a senior HR professional with a specialty in Business Development. He's also a certified educator and executive coach. He brings a lot to the table from past experience and PT specific experience. Not just PTs, he worked in other healthcare settings as well. I'm excited to bring him on so we can talk about HR-related issues and depending on our discussion, how these things go, we're looking at making this a two-part episode where we talk about a lot of things related to HR. I want to do that because James has a ton of experience. James, thanks for coming on.
It's good to be here. Thanks for your time.
Share with everybody a little bit. You’ve got a ton of letters behind your name. You've got a ton of good experience. Give us the breakdown. What are some of the professional experience that you have in regards to PT in the healthcare settings and what you've done and brought to the table for PT owners in the past?
I’ve been in the game for many years on some smaller projects. I worked for dentists and chiros a little bit, but mainly the PT sector. Most of my time happens to be with private practice owners and orthopedic clinics generally. What I'll do is depends on what discussion I have. I have to work with an individual that has a good intention to do something with their game that they want to expand either they're too much in the game to expand. They don't have time to think about the administrative side or that HR side or whatever you want to call it. They want to get out of the game and own and let that machine roll.
I am dealing with guys on my track here on those two different sides. I've worked with guys up and down the Rockies, New York, Southern Florida, Central Florida, a little bit in Texas. Mainly the PT side. I'll go in as an HR professional, as a recruiter, depending on the gig. Business development is a big part of what I do because a lot of the owners out there help that can be of service to you guys. They don't have that guy, that ear or that outlet for, “Can I put something on your shoulders? It's all on my shoulders. Can someone else share the burden?”
I generally had been that guy. I'll be the figure out, organize brain, they know that they can do it but they don't have time for it or they don't want to do it. That's a nutshell, but I've seen the chiro practice game overseas in Ireland and all over the parts of the US. I'm dealing with a national company that has a whole bunch of owners all over, I think 26, 27 states. I like what I've done. I worked in Rural Montana and I've worked in the Story of Queens. I've seen both sides of the game pretty much. I can talk to an Alaskan up there if you might have some troubles and the guy in Miami who’s working.
That's good because a lot of owners that I'm supposing are reading, they're like, “I wish I could afford a guy like you to come in.” I know in my situation, people would ask me all the time, “How's the business going? How are things coming along?” Almost to a tee for about ten years, I was like, “I love treating the patients and I enjoy that, but I can't stand the HR stuff.” Having to deal with the employees, the person who gives me no notice and says, “I'm out of here.” Maybe doesn't show up or someone who does give me notice, but they happened to be a PT. I know it's going to be 2 or 3 months before I find another PT even though this PT only gives me two-week notice.
It's like, “Stabbed me in the heart.” Those things kill me and holding people accountable, all those things were hard. Hopefully, we can get into some of that to give some owners some ideas on what they can do to improve that HR side by spending a little bit of time in there. As you worked across the country, we want to talk a little bit about recruiting, hiring, and onboarding. Before we hit those three things, what are some things that you came across in your experiences with PT clinics, in particular, that seems to be an ongoing trend? It’s like you'd come across and say, “This is how you guys think,” or “This is how you guys work.” There's some kind of trend going on here that you need to correct typically when you walk into a PT practice. Anything like that?
I lean into it a little bit before, but what I'll see is that normally the owner has a bunch of ideas for expansion, things he’d like to do, what people he likes to fire, people he or she like to bring on, and he or she got time for not as much evaluation of that data. They have ideas statements all locked in this idea stage. Some of the fixed ideas that they can't afford an employee to do that. Often a debate I get for them is they need to hire, they can’t afford to hire they bring the guy or girl on, they are no good. They have to let them go. They wasted all this time training them.
It is that the attention on those things is not there and their ideas of when they should build up their staffing, how often they should then let go of the dead weight. You have both sides, you have that spot. It's a manager's function that they don't always do that they're busy in treatment or they're busy in other things. That executive manager role where they should be observing the employee going, “That's no good. Why is she still here? Why is he still here?” It's both sides. It's keeping staff that should be there and dumping the dead weight and no time to evaluate that. On the front end, “When do I need staff? Can I afford the staff? How do we get them productive?” Because I'll bring them in and I'll let them go and then I'm busy when they get it done.
I think I know exactly what you're talking about. You've got an idea and you say the solution is to hire blank. Maybe it's to get rid of blank, but you haven't taken the time to work through the process of how to bring that person on and onboard them successfully. I think that's what you're talking about. You were missing steps in between. We've got this idea. We think we see the solution, but there are a lot of steps in between that make that solution successful. We jumped from idea to solution and then go and work on our patients 40 hours a week without lifting our head up to observe, “How are they doing? Did they get any training whatsoever?” I remember many times sitting in interviews saying, “You have this title, but your job is to do whatever needs to get taken care of.”
It was much less delegation and much more of abdication of any responsibility not knowing that the ultimate responsibility always fell on me if they didn't do their job. Poor job at training, onboarding someone, and having some processes in place. It sounds like then as PTs, maybe healthcare practitioners in general that are independent owners failed to take the time to lay out those steps and bring someone on successfully and train them up.
The other side of that went, “They're not doing good. See you later.”
The idea is this person's bad. The solution is to let them go. There might be more steps in between that make that successful that could help us along the way if we do it right. You've been across the country with PT clinics. I'm assuming your role as an HR professional was to do some recruiting. We can never talk enough about how to recruit PTs and get them on board. What were some of your successful actions to recruit PTs and bring them to even some of the rural settings?
The first thing I do when I got to the recruitment part of the HR cycle is to get communication at schools in my zone. In parts of Alaska, there's no PT school maybe around up there. I would get communication with the PTs in the area and what schools are in the area.
Even if there aren’t any local schools, those PTs can reach out to their alumni or their alma maters.
Getting that line is the first thing I'll do because I want to be well thought of by those schools. I want them to see my name, PT, and go, “We had an intern over there.” “I've heard that.” “He graduated from this school.” I want that PR is done well. As a comment, there's this element of the recruitment side. It is a marketing PR action in bulk, especially the recruitment side of it. The PR value of letting the schools know who you are is one of the first things.
Looking at the current good staff you have, who's been there 5, 10 years, or 2, 3 years, the owner's included. Even the front desk girl, the marketing individual or whatever it is. “Who do you know?” One of the biggest successes I've had in recruitment. I ran it as a pilot for myself to see to test myself years ago when I said, “I'm going to put no recruitment ads out.” I'm not recommending this. We had about a hundred staff, some satellite clinics. It was a big company. I said, “I'm going to only promote to my staff. I'm going to send out a weekly email to my staff, a few bucks ahead for a referral bonus internally for other staff. I'm going to bang it out and I'm going to run it like a campaign.”
Every week, there was a newsletter or a promotion from recruitment HR guy going, “Who do you know?” I get at least a name a week, if not 5 or 10. At one point, I had an 87% retention rate, only dealing with strictly my staff's referrals. That's how I got a guy from the UPS man. His daughter, his friend was in school for PT and we got her. The value of those lines and people never think of those things. They don't think of their staff, the mailman, or even the schools, but those two routes, they keep the new students come in and beat you on this side and they keep your current active good people that you’ve got in your business thinking. Those are two of them.
I love what you said about recruiting through your current team. If they're A-players, they're more than likely going to hang out with other A-players and bring you on. It’s the same thing with the students. If you can get a few of those students from certain classes who are in alignment with your company, and they toot your horn, then they're going to bring on their other awesome PT friends. They're not going to bring on a friend who's no good and more than likely they're not hanging out with those types of people. They're going to recruit for you and tout the benefits of working at your company and bring you on. I know that those are huge successful actions. I know, especially in rural communities.
I've had Dr. Sabrina Starling. She lived in Rural Wyoming and would help people recruit simply by using your network. Go to Christmas parties, “How's the business going?” “The business is going great.” During the course of conversation with anybody, maximize your network and say, “We're looking for someone like you. You're an awesome person. You're productive. You're a rock star. You've achieved many goals. Is there anybody like you that would want to work for me?” Take advantage of your network and leverage it.
To add to what you're saying is generally, they’ll refer people like themselves to some degree. They roll with that crowd, but also, they're not going to refer other people because they don't want to be felt bad of themselves.
It's great to leverage your local schools and alma mater. I know my business partner leveraged local PT schools down in Phoenix. To the point where we had PTs who said, “At any given time, if you have an opening in your clinics, let us know.” We had people “on the bench” and that was our goal. It took about 2 to 3 years to get to that point. He did an amazing job recruiting to the local schools, such that if any PT were to leave at any time, no fears, we would call up people and say, “Put in your four weeks’ notice, we're ready to go whenever you are.” We had 2 or 3 people that we could call at any given time to come on. It puts you in a different position altogether, minimizes the fear and puts you in a power position for sure.Most small PT practice owners hire to fill a position without taking the time to considering what a new hire needs to be successful. Taking a little time on that process would save both parties many headaches. Click To Tweet
The big thing is constantly promoting. Most owners I've seen goes, “The law's leaving. We're expanding. We need only one PT.” They’ll recruit for one PT or they'll lose one and get one back. They'll sit on their laurels and go, “We're good because I have the number of equivalents working for me now.” It's got to be constant action. Owners that are single-handing the business are not going to spend 5, 8, 10 hours a day recruiting. Any constant flowing and constant thought about it. Maybe an Ad, an email to your staff, that takes minutes and email to the school, “How is it going director?” It’s been a while. It's little effort, but it keeps that PR communications live. It's in there. It’s got to be constant. If you guys built it up where you had a waiting list, that's what you’ve got to do. We used to interview for the heck of it when we didn't need an interview 1 or 2 a day. “We don't need anybody yet, but we're here. They can shake, hug, love what you got here. I'll be back.” If they don't come back, I gave them a call and said, “Who do you know?” “You're not looking.”
I tell my coaching clients because we got to a point where we always have the ad out whether we were hiring or not for any position on our team. We were doing interviews for the tech positions, the front desk positions that were a little higher turnover. We were doing monthly group interviews for that and sometimes we were able to pull some gems out of that. Sometimes we didn't. We always had a PT ad out. Never let that strap off. We always had it going, always collecting resumes because you never know, especially where we were in Arizona. It's notoriously hard to recruit, but you were in a similar situation in Rural Montana. Just a little bit of time each week, it shouldn't take too much. If you can set aside 30 minutes to an hour, send out some emails, send out a text, promote, make a phone call. That's all you need to do. We get to that point where then as we are hiring, what are some of the things you recommend that owners establish as a “hiring process?” We had certain phases that we would take potential candidates through or potential employees through, but what do you recommend?
What’s completely underplayed by most is what’s next? We can talk about Rural Montana when I was up working for a client, a handshake, look them in the eyes, and maybe a pump on the back. That was your application. “I like you. You're a stand-up guy or girl, let's do this together.” There's something to that. That should happen appropriately every time again. I look at the recruitment onboarding that part is a bit off, where it stops and starts its own thing. It can be a technical subject because evaluating an employee both current inside but also coming in. I find that tantamount to you seeing a patient and seeing what's wrong with them.
You're going to evaluate them all over the place every which way you can to get to the bottom of what the problem is. I evaluate the heck out of these people coming in. There is the interview process. I have a testing regimen. We always would do. There’s a resume review, application review, a testing regimen. I have a couple that I've used a lot and then interview questions and then reference calls too. After all, that, when they're coming in, if that's what you're talking about, what does day one look like? Employee manual review policy, but let me know what piece we're talking about.
Let's talk initially about the hiring phase prior to offering the job or the day one of being on the team. Our steps taken were, collect the resumes. We do a phone call, but that wasn't much of an interview we wanted to screen for. What was their phone voice like? What was their tone level? Were they an excited person or they sound down? If they could simply pass a couple of those things and as I said, we also did some group interviews, but if we could get to a one-on-one interview, then we were doing some intelligence test. We would focus heavily on values. Make sure we were talking about our values and what those mean to people.
Making sure people were attentive when we talked about values and not swung back in their chairs and not caring any body language, assessing that stuff. There’s time to also talk about the job description and what your productivity expectations would be and what you're required to do. After the one-on-one was then a job shadow, preferably not with the interviewer, but with somebody else. After everyone agreed and they'd gone through all the processes, then we offer them the job. That was ours. What do you recommend on top of some of those things or different from some of those things?
A phone screening and a reference check. There’s like the normal systematic things you do. You do reference checks. If I got only one of the three, I got at least one, but try to get at least two.
Something successful for us in regards to the reference checks in which email was always the easiest. I don't know what it was. If I tried to get them on the phone, inevitably, they didn't have “time” to call me back. If I could say, “I'm interviewing this person. They put you down as a reference. Could you either give me a call or email me back your thoughts about them?” That made my reference checks much more successful and timelier.
For time, that’s a great idea. I liked the opposite of myself. I had time to do this. I had to speak to the person on the phone because I wanted to ask some questions. I wanted to hear what they said. I wanted to hear them go, “Lag, do you have an answer?” I did do that because if I'm doing a reference check, then the applicant knows there are some interests. I'm even going to that point. After the phone call with the candidate and I liked them, I'm probably going to have you come in. What I'm going to do is I schedule them to come in and before they would come in, I do the reference check. If I liked them enough after the testing, “I'll see you tomorrow at 2:00,” but I didn’t hire them yet. When I could do that, I could leverage the applicant. I could say, “I called three people. I couldn't get through to Cindy, Joanne, or Mark because they're hot.”
That's been successful. After the initial little phone thing and then the reference checks and now they're coming in for the interview, what you asked them to interview? You could strip that thing out 50 pages. I think the role and the expectations, the bonus structure, what all of that needs to go. I generally do that at the end. I like to start it off personal, “Tell me about yourself. What do you do?” I love the question along the lines of, “What do you do on your time off?” I don't want someone who’s good at watching television.
They have a whole lot of favorites, no offense, a bunch of favorite podcasts, TV, and that's all they know, all they do or that's a lot of what they do. I'm out there, I'm hiking, especially for the rural parts. I want to be out there. I want someone who skis in the winter and likes the summer. That's a big part of it. Once you get to know them and it's a fluid or it's garbage because you'll know that quick. I want someone to interview me in the interview. I want someone to go, “Let me ask you.” They either go, “I have questions for you.” They have a pen and that’s fine. It’s formal. They’re going to be organized. They interview me, “Why are you here? How long have you been here? Why did the owner do this?” I love those questions.
I look for a great personal character and they're involved in life outside of my business. We looked at PTs in one of my practices, I worked for who wanted to own. It might be off-putting to an undergoing. I don't want someone that wants to take over, kick me out, or open next door. At the same time, I don't fully agree with that because as long as they were qualified, good applicants and everything that you do qualify them under. Once you get them in, if their purpose is like, “Down the road, 5, 10 years, I want to have my place, move back to where I come from.” Why not facilitate that? I think that's a misstep too sometimes. I don’t want someone that's, “I’m just going to live here in two years, at least so I can pay for it.” Think bigger.
There were some things over time that I got used to asking. I started steering away from, “What are some of your strengths? What are some of your weaknesses?” It was surprisingly common. I'd ask them what their weaknesses are and they'd say, “I care too much.” I steered away from that and started asking more like, “What books have you read recently?” I want these people who are intrigued. If they're honest, they're like, “I don't read books.” “What do you do? How are you growing?” Maybe they could be listening to a self-improvement podcast instead of an entertaining one.
Secondly, “What is your five-year plan?” Even with texts, with the front desk and older people who I would interview for positions, I want to know that they've got some goals in place. “I'm not sure.” I enjoyed asking some of those more specific, deeper questions. I enjoy talking about values. A friend of mine who I interviewed a couple of times, Sturdy McKee out of San Francisco, wouldn't hire anybody that hadn't played a team sport in the past. You can understand why, because you are working much like a team in a PT clinic that people maybe they're doing individual sports might not be used to the team concept much. That was one of their filters. I love those kinds of things that filter people out and you find a certain candidate when you start narrowing things down.
I love that idea and you reminded me that we used them at one point. You can be the passive indeed goer where you put an ad and that's all you do, or you can pay a month, which was reasonable at the time and see resumes. What was nice about that is you can search for keywords like NCAA or soccer, football. There’s a word bully in searching a certain criteria. I worked for an agency for a while too. I have a recruitment agency side. I've seen both universities. They're different universities. To be able to search, you're talking about a tool. I can search for football, Montana, and hiking.
What was your experience in the past? We've had some good experiences with on the job interviews. We'd tell them, “We expect you to come in for two hours.” Sometimes we'd pay, sometimes we didn't. I don't remember if we had a policy in regards to it, but either way, there was an expectation that they would come for two hours and sit with the person in that position. Even maybe come in and do some of the work but there was a definite expectation that they would be engaged. You want to see how they interact with patients, how they interact with other employees. Even though they're new to space. If it was a front desk or a tech person, two gold stars if they brought a notebook and took notes. What are your thoughts on the job shadow?
I love that. That's what we call it, a job shadow or a working interview. We didn't use them frequently. I would say it wasn't for every employee equal working interview, but there were somewhere I was especially questioning the fit or their background. What do they know? If I had a billing person come in, I'm going to want to a little bit more, “Sit next to Joanne. Let's see you talk to Joanne about your job. I want to see you at the desk with her. Look at some claims, tell me what these fixes mean.” I want a little more live stuff. For certain technical positions, I loved it. Certain receptionists, what we wanted to see, like we had a girl who was in there for years. She was the boss, a reception manager. We stick girls next to her and let her feel them out for half a day, 4 or 5 hours.
On the PT side too, I had one of my first employee way back was a chiro. She had PTs and she'd hire a massage therapist. She asked him to treat her in the interview. “Can you go back here?” “I'm not a clinician.” “X, Y and Z aren't feeling too good. Can you get back there?” She judged them on their ability to do it and understand your language and stuff. I love the hands-on idea. Every PT we hired, we would have them shadow our clinical director or our lead PT. Any technical clinical position, I'd have her do a little walk around. I do a little intro to the space but then I go, “This is what we do.” She looked for indicators like eye contact stuff. Are they involved? Are they asking questions? I would tell her what I wanted her to do and she does it. That was invaluable. I can work half day or something.
A lot of these people, for 30 minutes to 60 minutes, they can snow you over. They can talk a good game, they can show some personality, but when you get them with peers and not with the “boss” or the head guy, and maybe they'll let their guard down a little bit more. For two hours, they start showing their true colors. How often are they bringing up their phones and checking their text messages? How often are they off to the side? I had a coaching client who was interviewing a PT and she had been working in the home health setting for some time and she said, “You've been working in the home health setting for long, how would you help somebody? How would you screen if they came in for low back pain?” She says, “I would do this and that.” “Why don't you show me?” She's like, “I would do this, that and the other.” “No. Imagine I'm the patient and tell me what you want me to do.” She couldn't do it.Most good applicants that wind up being hires want to know that someone's going to be watching out for them. Click To Tweet
Imagine if she had gone off of the interview, the face-to-face talking portion, and not asked her for some specifics and hired her on. Those kinds of screens are important. They were talking game talk. Maybe they were able to go through that portion, but then they would do a job shadow with a PT in the clinic and you wouldn't see any engagement between the candidate, the PT and the patient. They weren't asking questions. They were simply standing there against the wall, watching what they were doing and I'm like, “You don't have any soft skills. I understand you can technically do what you need to do, but you don't know how to talk to people.” That would simply write them off. Otherwise, we were ready to bring that person on that desperate, but I'm thankful we didn't.
One of the clinics they worked for not too long ago, they had a home health piece and then the clinic and brick and mortar in-clinic services. What was nice is even to some PTs and you didn't want them in the clinic. You want a clinic PT to be a certain individual. You want high communication. You want the comradery there and you want the ability to handle a bit busy-ness. You're wasting 18, 20 plus a day to be productive. In the home, they're saying 2, 4, 6, 8 hours a day, maybe different games. They were even different hires there. I liked them, but he's not a go-getter. Stick him in the home.
That made sense for that guy, because maybe he can on his own terms. Let him take his time with six patients to enjoy, but he's not going to work in my clinic and mess me up in there. One thing to add to what you said too. I wasn't sure about the person's honesty level and I wasn't sure about their real intentions. I would give my clinical director or the other manager questions. I would give them things to say in front of us. It’s almost like a private investigator. Have them talk about their last job or the last employer. The face I get in 60 minutes is handshakes, big smiles, hugs. When they're in front of this peer, not their boss, they could have a different conversation. I'll say it's their scenario, but I definitely will use that too. Even once or twice a patient who I knew was in the clinic, “I'm getting the new PT coming in for their shadow. With legal restraints, give them a hard time.” They roll with it or not. I'll play that side too.
I can't overstate the importance of those job shadows, because like I said, there were plenty of times where people pass through the interview phases with flying colors. They got to the job shadow and we're like, “Red flags done.” It's important to have those. The next step is important because we don't know how to onboard people. I wonder if business schools teach that at all. How do you onboard somebody day one? You would think that it takes much hand-holding and much time and effort. I know that there's a difference between the PTs and PTA and the rest of the team. What are your recommendations to establish an onboarding process for those two different groups?
Behind that, you need general policy stuff. State by state if you have to legally have a handbook or not. I know that depends, but you need to have something to provide. I think most good applicants that wind up being hires want a regimen of some kind. They want to know that someone's going to be on them, not micromanaging. All the people I've hired over the years, they want someone that's going to be watching out for them. They want to be disciplined when they need to be. These are the good people that you hire. I think if you have a regimen of, “Here's the checklist we're going to do here. I’m open with my communication and direct. We're going to do this checklist of steps here.” I always included in my onboarding day one is some kind of orientation. You can look at that from the viewpoint of, “This is where the front desk is and go meet your boss.” That's what a lot of people will do. Shake your hand, “I’m your boss, come to me with problems, I’ll see you later.”
Having the formality there, the regimen, I like to have almost like a scavenger hunt. That’s what I create because I want them to come in for any position. It’s a PT, a trained professional, a little more sideways by that or an administrative person. I literally will have them find out where you're going to work. “Go and see what your cubicle is. Go meet your boss. Go shake the owner's hand. Count the number of chairs at the lunch table. Find out if we have a microwave.” It sounds completely goofy maybe what that does is it orients the person in the environment. I'll have to go out the front door and come back. “Do we have a signup?” “You don't have.” “What does it say?” “It's an old business.” It works as an investigation for me because then, “We have no computers. I forgot that.”
It gets them out of their comfort zone. It throws them a little bit off, gets them comfortable. I have to meet five people at least that first day. “I'm doing this weird checklist thing that HR guy said. Let me shake your hands.” That's a big part of it because it gets them a little comfier. People know who the heck they are to some degree and then I'll give them a buddy. I’ll say, “This receptionist is your buddy. Questions about where the lunchroom is, ask her.” “Betty, here’s your buddy,” shake hands and I'll leave him alone.
They're all for about 30 minutes-plus digging around the office. People are seeing them interact and they're doing whatever and I'm getting the packet ready. I'm getting the onboarding process. There's your checklist. You have to review the purpose of the company. The owner wants everyone to know this, because like you said before, even going through the interview stage. If your purpose and theirs don't align, they should not be there. I had noticed this part, I had an owner that would meet with every PT two weeks every month and go over, “How's it going in life?” The owner would meet directly, 30 minutes to an hour, and go over there like, “What do you want to achieve with 5, 10-year plan? How does it align with us and does it align with us?” I think the formality of a checklist, I like that orientation thing.
An employee handbook, review, simple policies, the dress code, the piercings and tattoo code, and voting policy. If you want to take days off, this is the form that you use. We use an HR professional, it was a onetime shot to develop that employee handbook for us and they are out there. I don't know how I found her, but she sat down with me 2 or 3 times and we'd go back and forth on email. She'd give me the standardized stuff that was required by our state. The policies that we had to provide and federally had to provide. She said, “What is your time off policy? Let's put that in there and what do you want?” She would guide me through the creation of that employee handbook and there are independent people out there that can do that for you.
I think even companies like Paychex also have an element that they can do that too. I fully agree that that needs to be there, whether your state legally needed to have it there or not because you don't know how many times an employee who leaves under unfortunately bad circumstances. “I want my last paycheck. I want my bonuses. I want my unused paid time off.” “You signed this. It said we don't do that.” How many times does it save your butt? Fifteen to thirty policies about functionality in the clinic written down. One thing I would say is that the owner needs to spend the time to know them, that's the thing too. Having an HR company do it. It can't just be in your email and you went, “Did I?” Many times not for bad reasons, but you have to know them because if you don't know those and you're going to be the effect of what you don't know.
I know the APTA can help. I think Rick Gawenda was promoting some policy and procedure manuals that can help you with compliance. That's a different thing, separate from the employee handbook, but you’ve got to make sure that's on your checklist. What's your HIPAA policy? Are they going to do some video training? There's a lot of video training on HIPAA that qualify. Maybe your state requires some OSHA training and Medicare Fraud & Abuse. Making sure you check these boxes, not waiting for the next team meeting, that's maybe scheduled in the next eight months to do those compliance things, doing them at the front end. That's why I like some YouTube videos that can support you in that regard. MedBridge has some of those compliance videos. Sit them down here, “Watch this for the next 30 minutes. If you have any questions or concerns, let me know. Scan over our written policy so we can sign you off on the compliance portion of that onboarding.” I think a lot of people miss that, especially as small clinicians, we don't even think about it.
I think you hit something too. When we have a robust onboarding, I’ll put that in an ad. I'll tell you the truth because we've talked much about the recruitment, the ad side of things, which we can do separately or whatever. When you're advertising for a PT and all that stuff, when I put a robust onboarding process or rigorous, they get the idea that, “They don't mess around.” You're this much more apt to get an employee that, “They have a robust whatever.”
Someone professional or looking for an organized structure. That makes the difference between a mom-and-pop shop and an enterprise. I think that's where a lot of PT owners want to get to. A mom-and-pop shop are at the front of the store. They're greeting every customer. They're taking a reorder and that's what a lot of individual clinic owners are when it's them and maybe one other PT. If they want to truly get some freedom, they want to move over to an enterprise. An enterprise has the structure of a hiring process and an onboarding process to ensure the success of those people that come on board and that they're fully “trained.” I know you can take that to many levels. Our onboarding process was towards the end, there was offsite.
They would have almost likely a full day of onboarding training at a different place. I know even in Blaine Stimac’s case in Montana, I interviewed him. I think his onboarding process was spread out over the course of six months or even a year. They'd have a few days and then they meet up again 30 days later and again, 60 days later, 90 days later. Meet up again at the six-month mark and review some of those principles as they needed to and hold them accountable. You can go crazy with it, but at least having some structure for that onboarding can establish a foundation for the team.
I know Blaine is a basic structure. That is a lot to be said about. You can call it ongoing training. You can call whatever you want to call it. There’s this onboarding element where week one is a whole different game plan than month six, I think you should. There needs to be a 60, 90-day, whatever your terms on your employee manual. Review how they're doing in 3 months, 6 months. It has to be there for sure. That's part of that thing at the beginning, I mentioned where you need to know what this person is doing in your clinic. How has it been going? Spend the time to build out the policies, the regimen, and build out the basics. Spend time now so it’s done. Because once it's done, it's done. Once you have the manuals, it’s done.
Once you get that signature, if they have a question regarding the paid time off policy, go check the handbook, “You don't have to ask me anymore, you know where the handbook is. Go look for it.” That helps the trainer. Initially, it's probably the owner but in the future, hopefully it's not, but if you have an organized checklist, that's something that you can hand over to someone else. That's where you start gaining some freedom is when someone else, not the boss starts espousing the purpose and the values. “This is what we do.” When that goes peer-to-peer, that means a lot more than from the boss talking down. It helps out a lot and it also ingrains in the trainer, those same values and expectations, and helps them along the course of it. If something is written out if there's a “curriculum” to it.If your purpose and your prospective hire’s purpose don't align, they should not be there. Click To Tweet
Even in a small clinic, where you have an owner and a couple of staff, letting a peer having one person. I had a receptionist do it. I've had the lead PT do it but having somebody else responsible for that basic administration. Make sure that this new employee does this and this and report back to me that they've done this. It's off your plate as an owner a little bit. Maybe you give them a little money on the side appropriately for doing that. Maybe they have a little bonus, but you have to give up some of those hats.
I'm going to cut off our discussion here because I want to transition into how to get people out the other end of the business. That is getting rid of dead weight, disciplinary procedures, developing that HR. Not just from the beginning like we talked about, but through the course of the life cycle of an employee. It might be going out the door in good or bad circumstances. Before we move on to that, if people wanted to get in touch with you, James, how would they do that? Are you willing to share?
(917) 312-4294 is my phone number. I love helping people. I worked for the company because I'm helping multiple owners in multiple states at the same time. I couldn't do that years ago. My email is JamesSavas@Hotmail.com.
If people have some questions, they can reach out to you at JamesSavas@Hotmail.com, that makes it easy. Readers, watch out for the second part of our conversation. If you won’t, just move on to the next part and we'll start talking more about the life cycle of an employee.
I love working with ambitious, driven individuals who have dreams of going big(ger) and just need the right support, backup and capacity to see it accomplished. I help them get that done.
The majority of my professional career has been in the Medical sector with the majority of that time in the Human Capital Management/Recruiting and Business Coaching/Development spaces.
Over 20 years I've strategically planned and executed programs and projects for my partner-businesses' expansion from as few as 4 offices to up to 16 office across 3 states. In my time working directly with various Owners and their staff throughout the boroughs of NYC and down the Rocky Mountains, I've hired well over 500 effective and productive Owners, Executives, Managers and Professionals, as well as created the training regimens for those people and their staff.
In addition to my savviness and acumen as a business expansion professional, I'm a successful soccer director and coach and a very very proud father of 3 amazing beings.
My Mantra is - Keep the create in life and be surprised by nothing!
Additional Points of Interest (some outside PT and some for fun):
* Published article in Impact PPSAPTA magazine (2008) "Hiring & Retention"
* Nationally Licensed Soccer Coach
* Director of Development of several Soccer clubs/groups
* Certified Assistant Teacher
* Co-owner (former) of a small family-owned retail dessert business
* International traveller (school in Italy & worked short-term in Ireland)
* Avid survivalist/camper/outdoorsman
* Humanitarian (as I'm able), directly assisted during 9-11 @ ground zero NYC
* Interned w/ MSNBC out of college (Broadcasting Major)
* Was a celeb-host at the 1996 Grammy's and 1997 ESPN Awards (some good stories not for air)
* Was on HGTV (with my family) in episode of a Montana HouseHunters
* Music composer/Short Story writer (Sci-Fi)
* Best hat I wear - DAD; pays shitty but great rewards!
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