PTO 163 | PT Partnerships

 

To succeed, we have to know how to build great relationships. But, how do we do that? Is there a specific process or guideline we can follow? Jeff Sallade PT, DPT talks about successful expansion of business through partnerships. Jeff and his partner have expanded to more than five clinics in the 10 years they've been open, all with a partnership business model that's allowed their PTs to grow into new leadership roles. In this episode Jeff shares with us how they've established each partnership as well as some of the details, considerations, and pros and cons to partnerships in general. This episode is a great follow-up to Eric Miller’s discussion just a few episodes earlier, on what to consider when determining if partnerships are right for you.

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Successful Expansion Via Partnerships With Jeff Sallade, PT, DPT

I've got a PT owner from New Jersey, Jeff Sallade, Coowner of 3 Dimensional Physical Therapy, who has been reading the blog for a while and reached out to me via email saying, “I read your blog about partnerships with Eric Miller, some great insight. We've put it in practice and thought it would be cool to share some of the pros and cons of what we're doing.” Jeff, first of all, thanks for reaching out and thanks for joining me on the show.

Thanks a lot, Nathan, for having me on the show. It's great to be here. I’m a big fan of the show.

I've said this before and I tell readers, “Reach out anytime if you have questions, comments or even recommendations for topics or desks.” Thank you first for taking me up on that. First of all, share a little bit about you so people know where you're coming from and then I can start asking you some questions about your partnerships that you're developing.

I've been in practice as a therapist for years. Similar to many private practice owners, I got to a point where I felt like, “I could probably do this better if I did it myself.” There was another therapist that I knew who we two decided, “Let's do this together.” That was years ago. We had an awesome event in our community. We got a bunch of small businesses out. We had a mechanical bull there. It was awesome. We've had our practice for years. When we first started, we were hoping to get enough patients to be able to take up our time during the day.

We didn't want to be sitting in the clinic, looking at each other. After 1 or 2 years, we had a decent amount of growth but we never gave a lot of thoughts of how we want it to grow. We're an orthopedic and sports clinic, what I think is a pretty typical outpatient clinic. The numbers kept growing. We had hired a couple of therapists. The way that the second clinic came about was we had a sports performance coach that we knew. He was about 20 or 25 minutes away. He said, “A vacancy opened up in my plaza. Would you guys ever have interest in opening up here?” I remember my partner and I looked at each other. I was like, “I don't want to be the one to go there.” He was saying the same thing. We were like, “What do we do if we want to open a second office?”

We had a therapist who had only worked for us for about a year but we liked him. We knew he wanted to do some bigger and better things and have more responsibility. He was from the area pretty close to that opportunity. We said, “Let's give him a chance.” At first, he stepped in as a clinic manager. My partner funded a new clinic. It became apparent that he was going to do a good job once he got in there. That's when we started kicking around the partnership model.

How many clinics do you have?

We have five and then we're opening two more locations. We're in the crazy mode of managing the build-outs and the permits of the two offices. It's a little bit crazy but it's a good crazy.

Congratulations. I assume that you've taken this partnership model that you started but then refined over the years and we've expanded that to the other clinics as well.

Once we allowed Ryan, our first partner, to buy into that second office, my partner Ken and I looked at each other and was like, “Ryan's working there. He's benefiting from having ownership in that office.” We have an outstanding employee who's super motivated because of the financial incentive that he has to do a good job. We said, “Maybe this is a good idea. Maybe our retention rate will be good.” We had another guy that was working for us. He wanted to have his own practice but he didn't want to start it from scratch as we did. We gave him an opportunity. This guy’s name is Chuck. He's a total go-getter. He opened his office a year after that second office was open and he is doing phenomenally as well. My partner and I always own at least 50% of the office and then the partner there has percent ownership as well. It's usually based on their comfort level with how much risk they want to take.

Are you also asking them to put in some money to buy into that clinic?

From the beginning with these two locations that we're opening, we identify the location and then the therapist that works with us that is going to go there. All the costs are split according to the percent ownership. Let's say if a total clinic from start to finish costs $100,000, my partner and I are 50% owners and the other person is 50%, we're each putting up $50,000 whether they know it from the beginning and they know what they need to be responsible for financially. We have found that that works best. They own the clinics in the beginning. They feel like they're an owner right away from the first thing that's purchased.

In this situation, I've got a couple of directions that we can go with this but since we're talking about their percentage of ownership, do you agree to a basic salary for that partner to simply be there? What do you do with distributions after? I don't want to get too detailed if you don't want to but how do you establish the financial relationship? Also, consider that you are doing not only management but also providing backend services. How do you account for that? How do you establish this financial relationship going forward?

The therapists that take over the clinic run the day-to-day stuff and they have guaranteed pay. They have a salary for all the work they do related to their clinic. Most of the time, they've been a staff therapist for a couple of years. Their guaranteed pay usually takes a step back. They’re not a drastic step back. They're not eating peanut butter and jelly every meal of the day but we want them to feel like they're not happy with the guaranteed pay that they're getting because if that would be the only way they would get, they wouldn't be happy with that.

You scale back their salary a little bit because they're going to get more on the backend based on performance.

What we do is we calculate profits monthly. We have a way of setting up a bank account. Each of these offices from an accounting standpoint have own separate LLCs and own separate bank accounts. Everything is separate.

For each LLC, you have your own books as well. They always have their own financial.

My wife used to do our accounting. When we got to five clinics, she said, “I'm tapping out.” We have the guy who does our taxes. He has taken over the month-to-month QuickBooks. They have their own books in each clinic. We know on the first of each month how profitable or unprofitable the clinic was. If there are profits, my partner and I take our distribution. We choose how much we're going to put back into the company and then the partner’s free to do with what they want. Potentially, they get a monthly payout of their profits. You can talk to some of the partners. They're all pretty happy with the setup of their deal.

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How do you set it up? If you're 50/50, have you already predetermined the tiebreaker? Do you have the final vote if you can't come to an agreement on something?

Maybe during COVID, there were some crazy votes that we took but normally, on a day-to-day process, there hasn't been a time. Each partner has an operating agreement and it's defined there. If there are ever big decisions, here's how it works. My partner and I get a vote and then the other partner in the office gets a vote too. That's clearly defined. We haven't had to do anything like that but you got to think of everything before it all happens so that you make sure that when you do run into some things, the rules are clearly defined.

I'm sure you establish this with a lawyer ahead of time to walk you through these scenarios and that's a few thousand dollars that's well-spent in order to establish this stuff. I highly recommend that. Not to get too detailed or into the weeds but have you had to agree on set aside accounts for rainy day funds and stuff like that? How much in a line of credit that you have for each LLC? Do you go that far with each partner to figure out some of those things?

When we were first setting this up, we consulted with a bunch of different private practices. Here's what we came up with. Each office has a bank account. In one of the accounts like our checking account that we pay all the bills from, there's a certain threshold that always has to be there. It's like 3 or maybe 2 months of expenses. We know that we can't go below that. There's a buffer built in there. Every once in a while, when payroll falls at the beginning of a month and rent hits, it goes below that but by the end of the month, it has to be back at that threshold.

At the end of the month, if it's not at that threshold then we know that the clinic wasn't profitable that month and everybody has to do an equity call. If it is profitable, everybody gets to take distributions. There are good and bad with being a partner. That's one of the cons. The partner has to get in the mindset of, “If I'm not profitable by X amount of money, I'm responsible for doing an equity call and contributing money back to the office.”

There's a difference between hard equity and soft equity, where soft equity might be you're going to get some bonuses, some profit-sharing model or something like that but hard equity being their name is on the legal paperwork for the LLC. Is that how you've established it? Are these hard equity partners?

Yes. They're on all the paperwork. We have a couple of clinics where there's a partner. For instance, the clinic that I work and treat in, we have a clinic manager. He doesn't have ownership in the office but he has a profitability incentive. He has less risk. If there's a month where we're not profitable, he isn't putting money back up. He hasn't been penalized for that. He isn't getting paid out an incentive for the month. We've done that model as well. People who are as willing to take the jump into ownership. We have another account. We have savings account for each LLC or clinic. Five percent of the profits go into the savings account before anything gets paid out.

To set aside for rainy days or taxes.

If there’s a big piece of equipment somebody wants to buy like a BFR and all the clinics have BFR units, they can use that money to purchase it. We learned during COVID. that we didn't have enough money in our savings account. We make sure that we're not spending that money as readily to have anything that the clinic would want to use.

I'm assuming that you've already established an umbrella company that charges each clinic to do the billing, payroll, accounting and legal services. There's a number of things that the umbrella company has. Do you have something like that in place as well?

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We do our billing in-house, billing authorization. We have 6 or 7 employees that do that. We have a marketing employee and an operations employee. There are certain positions that don't generate revenue that is central to the company. Each office contributes to that. The way that we determine that is by the percent of collections. If we have $100 in collections in a month and one office does $20 of collections, they're paying 20% of the expenses. We call them management expenses.

That's one way to do it the way we did it. Maybe it's similar to yours but we simply charged a flat percentage and we called it the management fee. Based on what I've talked to other PT owners and also other industries that sometimes land between 15% to 20% of collections that will go towards the management fee to cover those types of expenses whether it's marketing payroll, billing and collections, do you think that number sounds about right based on where your collection is at?

The percent collections pay for the salaries of the employees and then there are some other expenses that are sent. We charge a flat percentage to the clinics to account for those things. Those are our expenses for the EMR system and liability insurance. All that stuff falls under a flat percentage. If it benefits all the offices, we pay for that centrally.

Is the lease held by each separate entity for each location?

Each location leases under each of the individual entities.

This partner would still be on the hook for the lease as well.

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We had a lease where we had all of our billing and insurance employees at a separate location. That was all paid for by all the offices individually. They each contributed. What happened was after COVID, everybody worked from home and after that, nobody wanted to come back to the office. We had this sweet office that nobody was going to work in. Each still pays the least. It was a management facility so each office had to contribute a certain percentage to make up for the fact that we were getting out of that week. Everybody's much happier working from home. They do a much better job working from home too. Going forward, we have less expense. One last lead to worry about.

To add these additional locations with separate LLCs, do you have to go through the full credentialing process or do you have relationships with your insurance companies where like, “We're adding another location. It's a separate LLC?” What's that process like?

It's automatic. The person who does our operations knows all the steps to follow. It's like hiring another physical therapist who has credentials. With these two offices that are in the process of being open, she's already on top of the credentialing for those offices. It happens pretty quickly.

It's a whole new process. If you stay under one LLC, you say, “I'm going to add another location.” It's a full-blown credentialing process again.

Each LLC has their own tax ID number but we do all of our billing under that umbrella company. Everything falls under that tax ID so that credentialing is easier.

I see where you're going. The tax ID number of the umbrella company is the one that's adding a location.

This might be good to cover. A question that we get from partners is, “How do I know that the money that my clinic is producing is being distributed to my office if all the money is coming into the central location?” We've made sure that our billing software is able to account any collection that happens at clinic X, Y or Z gets credited to clinic X, Y or Z. Every week, we move money around from our central bank account out to the individual clinics so that every week, they're getting their collections into their bank account.

Your bookkeeper's got to be almost full-time on this stuff.

They're getting more and more hours. We've become known as this biggest headache.

To expand like this, there seem to be two things that are necessary and there could be more but I'm talking off the top of my head. Number one, you've got to have a partner that's in alignment with you, someone that you've known. Not just some PT that you hired off the street and started opening up a clinic but probably has worked in one of your clinics for a period of time. You know they’re value-aligned. You're on the same page but then you also have to have a pretty solid standard policy and procedure manual so that everyone's not running off doing their own different thing. It's six different clinics. Talk to me a little bit about those two things.

In the first part, we were careful from the beginning with everybody that we hired. We've learned that the hiring process is super important. From the first time they meet somebody, we interview them 3 or 4 times. We want to make sure they're a good fit. They come and hang out with us in the clinic before we hire them. It's fair to both of us. We want them to know what the day is like in our clinic as well, if they can see themselves fitting in there. Anybody who potentially becomes a partner has worked for us for at least a couple of years. That way we get to know them as a clinician but also as a person. That is an important part of this whole partnership process.

Even from the beginning, we ask people what their long-term goals are with physical therapy. If somebody mentions that they would like to have some ownership one day then we recognize that person and we'll start to do some things from the get-go with them to maybe help foster those ideas and see if they're serious about it.

Is that something where you advertise?

We don’t advertise. We have seven clinics in Southern New Jersey in between Philadelphia and Jersey Shore. PT is a small world. There's a lot of PTs that don't work for us that know what our model is. I get a ton of resumes because people know that we have at least have the potential to move into some type of partnership profess. It's not super easy to get to that point but we have proof that this is what we do and people like that. It's a good recruitment tool for us as well to get PTs interested in us who are motivated enough to possibly have their own clinic or be a partner down the road.

Are there some people who have expressed interest in that where you said, “That's probably not a good fit?” Have you ever across that?

A lot of it is self-realized by them. A lot of people feel like they want to open their own clinic or want to be a partner but then sometimes when it comes down to it, the realization is there that this is a lot of work and it's not easy. One thing that we're doing is being motivated by us recognizing the need. If we're going to continue to grow, we don't want to grow to be able to say we have 10 or 15 clinics. We want to make sure that any clinic we open has a good chance of being successful.

We're starting what we call a leadership program. We have 25 PTs in practice and this is open to all of them. They have to apply for it. It's a year-long program where we're mentoring them to become clinic managers or partners. We're only going to take 4 or 5 people a year because we want it to be a little bit exclusive but we want the group to be small so we can get a good discussion going. If we took everybody the first year, I don't know what I would do the second year anyway.

That creates a demand. To say that it's exclusive to a certain number of people means you're going to weed out some people but it also inspires some people like, “I want to be part of that group.”

I hope that's what it does. There might be people that are disappointed if they don't get into it the first year but we'll make sure that it's not because we don't think you can’t do it. It's because these are the 4 or 5 people we thought were best for this now but like, “I hope you're still interested when the chance comes again.”

What is their commitment? What are you providing? Do they have to be available certain days of the week or once a month? What is your routine? How much detail can you share with me about the program?

I can still put it together but there's going to be six. Our clinics are all pretty close together. Nobody's more than 40 minutes from another one. Six times a year, we're going to have on-sites where we do probably 3 or 4-hour blocks of on-site learning. We'll have them be shut off from patient treatment for that time. In between each of those six on-site meetings, I'm going to do some one-on-one meetings with each of the people in the program. They're then going to have some readings. We have some required readings.

I got your episode with Stephen Rapposelli where you were talking about books like Who Not How. I immediately got that book. That was a life-changer for me. That is going to be one of the required readings as part of the program. Also The 7 Habits of Highly Effective People. That's the first reading to be read before the whole program starts crashing. We're going to do good books, some TED Talks, podcasts, that kind of stuff.

We had something similar. We had a leadership development program and there was a library of books that were required reading. This is how my partner and I came to have the business beliefs that we have. It's imperative that you read those same books and we discuss what's important about them. They can have their own mindsets as well but it aligns with the mentalities and mindsets. They can see, “That's why you guys do that thing. Now I understand.” They go back and put 2 and 2 together.

We want to create an attitude of lifelong learning. A lot of the people in the program are probably more focused on their clinical learning, which is great because, believe me, we want to have awesome clinicians. We also want people to take the next step like, “How can I further myself as a manager, leader or partner in the company as well?” I'm looking forward to that component for sure.

The hiring process is important. Be careful and make the right decisions. Click To Tweet

That's going to be cool because, honestly, we're physical therapists. We haven't had this kind of training before. For you to share that with your team members like, “This is how to be a leader. This is how we run a business,” to pull back that curtain and give them that training that all your 5 to 7 partners have is something that most people pay money for.

We want to put that as an investment in our employees. I know that it's going to come back to pay us dividends big times.

The second part of the question then is how much effort and what have you done to unify policy and procedures across all those clinics?

I'm the COO of the company. I always joke with my partner. I'm probably the least organized person in the whole business. Somehow that got thrown onto my plate, which is ironic. I have somebody that works with me that’s a total all-star for us. We know that's ever-evolving. We meet every week to make sure that, “Here's the gap here. We have to figure out a way to fill in the gap.” Something as simple as keeping track of our co-pay collection rate or pay to the plan of care get all faxed out. We missed three from last time. It's ever-evolving. We're becoming better at being organized and having some centralized processes and systems. Otherwise, stuff would fall apart.

It sounds like you found your who to help you with that.

I'm not the who for that. I would probably be the worst one. The company would fall apart if I was the who on the operations part.

It's a worthy investment because to pay her to do that with you and coordination is going to be essential for you guys to continue to expand. This is probably something that you might have seen as you took that first location on and the next location. As you started expanding, those holes and weaknesses started to get magnified and exaggerated.

We saw and recognized that. We said, “We need an employee that is dedicated to this.” At first, you're like, “Are we going to pay somebody to do something that seems easy?” Once my partner and I didn't have to do it as much anymore, it was like, “How do we even think that this wasn't going to be worth it?”

As you're working with your partners, it's not like, “Here's your clinic, go off and do it. That's great. We'll talk and collect some money.” What kind of communication schedule do you have with them? Do they report things to you? How does that all workout? What is your relationship?

Another thing that's high on our priority list is we want our relationships with our partners to be as good as they can be. One of the tough things that we went through in having partners was my partner and I took some things for granted. We didn't do a great job communicating some things. That led to some frustrations on the partner's side and with my partner and I as well. That's demonstrated to us, “Here's how important it is for everybody to be on the same page.” As a leadership team, my partner and I meet with all the partners once a quarter. We do a three-hour partner meeting.

My partner and I communicate with all the partners on a regular basis one-on-one. Everybody is a little different with how they want to communicate. One guy I talk with every week, another one I talk with every two weeks and one is once a month. As long as we feel that our relationships are good and we're not losing anything, whatever frequency they want, we're happy with it. There's a structure to each call. There are certain things that we talk about and go over. Sometimes it ends up being like half the conversation is talking about non-PTs, talking about life too, to develop the relationships not just the professional component of it but even the personal component.

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You the COO. Are you the one that's also getting the clinical statistics on a routine basis, reviewing them and then also discussing if there are issues out points or decline in stats?

That's on my task list for sure. We've gotten good at defining what metrics are most important to us and getting them in an organized fashion in one centralized spreadsheet. We still have a bunch of spreadsheets and one of the frustrations was, “I got this and that spreadsheet. I don't even know what to look at.” People ended up not looking at anything. There’s a time where we've been like, “Here's what you guys need to look at the most.” It's all on this one spreadsheet and that has made life a lot easier for all of us, for sure.

When you guys are all together, what things are you discussing on those quarterlies?

Stuff that's relevant to the entire company. My partner is a big fan of The Five Dysfunctions of a Team. Probably one hour of the meeting is he’s going to be doing an exercise where I don't even know what's on tap for that. I saw it on the agenda so I'm pretty excited to see what he has in store for us. There's almost like a team bonding component to that meeting but then there's like, “Here's the policy we didn't think of.” We meet collectively to come up with decisions.

Another thing that was hard for me and I would imagine for my partner too was by including other partners with us, all of a sudden, we're not the only ones making the decisions anymore. I could only think of a couple of situations where there was some frustration. Our partners share the same values so it hasn't been as much of a negative as I think it could have been if we weren't careful about choosing who our partners are but you lose some of your decision-making authority.

I am assuming you and Ken still have veto power and hold that to some extent.

Yes on the basis of the individual clinics. In 2020 when we were faced with the proposition of closing or staying open, we put it out to a vote. At the time, there were seven of us. My vote was on the losing end and I had to accept it. I won't say what's inside I was but my vote lost and I had to live with it. That ate at me for a little bit but then eventually, I came to accept it. This is the route I chose.

That says a lot to the relationships that you've established with your other owners in that. It sounds like they were willing to accept it as well if it didn't go their way but once it did then it would be like, “This is what we're doing. In this direction, we're going to do this. Get over yourself. This is what we're doing as a team.”

We accepted it and moved forward. I'll toot our own horn. In 2020, I talked to a lot of other practices and they were down in visits and revenue. 2020 compared to 2019, we were up in visits and revenue. A shout-out to all of our partners and employees that were able to pull that off.

What do you think it was? It's because of this maybe one action or simply one characteristic that you could name as a descriptor for your company. If you look back, what would you think that reason was that things went well?

Sometimes pride gets in the way of a lot of things. Everybody's ability to put away their pride accepts it. There's a lot of different decisions we made and there was disagreement with all the decisions. Once the decision was made, we were able to put away our own personal biases and said, “This is what we decided to do. We're going to move forward and make the best of it.” It’s not just my partner and I but the leadership of all the partners and then the rest of the employees.

We have 65 employees seeing a unified front and it felt like it was a huge factor. With any decisions we made, we were transparent with all of our employees. “Here's what we're doing.” We furloughed people for a while and that was hard to do but we were upfront with them. We told them what was going on. “This is our plan to be able to get your back.”

Congratulations on what you've developed. It's amazing to see the growth of your business overtime. It sounds like you've leaned on the things that you've been reading. You and Ken have put some of these things into practice. You've been intentional about your growth. This opportunity was afforded to you. You weren't necessarily seeking to open that second location but once you did, you recognized here are some of the things that we need to do in order to make this successful.

That took off from there.We said, “This is a good idea.” We like giving people opportunities to be in positions of greater responsibility. We think it's awesome when we tell a partner that they can write a profitability check for their profits for last month. To give them the power to hire the ideal therapist they want at their clinic, they're in charge of all that. We might help out if they want an opinion but we are allowing the ability to put people in a position where they can succeed and do their best. I know that might sound corny but that's a cool thing to be able to do.

We've covered some of the pros and cons. Are there other hiccups that you've had along the way that you want to share?

The hardest thing is the organization of it all. That's getting back to that COO stuff. My partner helps out plenty with the organization because there's the financial and the metric organization. That's the hardest thing. My partner and I still treat but we're treating less than less. We're dedicating more of our time towards some of these centralized things that time needs to be spent on. We want to grow but in an organized and controlled manner. One of the biggest challenges is keeping everything organized as the company gets bigger.

Do you foresee a point where you and Ken won't be treating anymore? To follow up with that, would you be okay as some of those clinic partnerships’ businesses started growing if they started pulling away a little bit more from treating so they could work on the business?

One of the partners is decreasing his treatment a little bit. He's having one of his current PT takeovers managers in his office and he has our full support. We think that's great because he's thinking about, “Maybe I want to have a second office that I'm a partner in.” He'll have somebody that can run the day-to-day of this current office. I like to treat.

I have a bunch of friends. They're runners and athletes. They're all getting banged up. If they call me and they need to be treated, I want to say, “I'll get you on my schedule. No problem.” We have awesome therapists in all of our clinics. It's cool to put them in positions where they're getting the chance to treat maybe the patients that would normally fall in on my schedule. It's good to mentor and help them to see it as a clinician as well.

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Along this way, you've read some books. Did you get any consulting or coaching along the way to guide you guys a little bit on some of these decisions? Did you have a mentor?

We started working with Steve Stalzer and Mike Osler. They’re with 8150 Advisors. They were recommended to us by a couple of people in my peer-to-peer group. Any private practice owner out there who is wondering if it's worth the investment, it's hard. It costs money. It's not free. I've only been doing it for months and I'm not even batting an eye. I don't even know what the cost is but it could be anything. It holds you accountable and spurs you to do things that maybe you wouldn't think of to do on your own. My partner and I sit with them. We do it together every other week.

Do you want to share with us a little bit about what you're doing in New Jersey that you might want to share with other owners across the country?

I have to give credit to my partner for this. We're in New Jersey. In terms of the collections, we have probably one of the lower reimbursement rates from private insurance companies in the country. We want the private practice to survive. All around us, there are private practices that have been selling to corporate and hospital entities. We don't want to do that. Our intention is for our current partners to be the majority owners of the clinic down the road when I decide not to work anymore. We're making a push to form what's called a supergroup where we're getting other private practices to join up with us.

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We're not purchasing them. There's no equity exchange but we have to share certain services in order to be considered a common entity. We're going to take over their billing. They're going to use our EMR. We'll do their payroll and benefits to allow us to gain geographic scope and also to become a bigger company so that insurance companies would maybe listen to us a little bit more readily in terms of negotiating contracts. We're starting that. We've done all the meetings, met with the lawyers and all the paperwork's in place. We're trying to recruit clinics that are interested in joining up with us. That's a big thing on our radar.

You're taking this umbrella company that holds all these major administrative tasks where all of the LLCs underneath that umbrella are the ones that you either own, partners with or partners of your clinics. You're expanding that to include people who you have no financial relationship with. You're going to unify some of the admin-related stuff, whatever it takes to be considered a shared entity.

From experience, we know that there are practices out there that the owners have many headaches and can't focus on the things they want to focus on. We'll take away some of the headaches like billing and payroll and allow them to build their practice. We have some interests and we're confident in the next years that we'll have a bunch of clinics that have signed up with us.

Anything else you want to share in terms of the partnership models, LLCs that you established that you would like to tell?

We've had people who think we're crazy for sharing our equity with partners and the amount of equity that we allow people to have. I wouldn't do it any other way because there are so many benefits to it. I still work a lot of hours but I have a wife and kids. I can spend time with them because I'm not doing every single thing for every single clinic that I own. For private practice owners that are thinking about doing this, I'm happy to be a resource as well. If you want to reach out to me, I'm happy to talk to you about the pros, cons and any of the details that you would want to know about. I'm a big fan of doing it this way.

From my point of view, the people in my network that have multiple practices greater than five, the ones that are the most successful and are expanding the most are those that have established these kind of partnership relationships with value-aligned people on their teams that they've vetted and know they're going to work well. The personalities match and the values aligned. They understand their purpose and their vision. That all align and it's been successful to the scope of some of my friends. I had Blaine Stimac on the show in the past. He's over 30 clinics. A vast majority of those are partnerships and they're across different states. It's the way to go. If people want to ask you or reach out to you, how can they get in touch with you?

My cell number is (508) 259-5481. You could call or text me. My email is JeffSal@Hotmail.com. That's the easiest email to get in touch with me. I'm happy to be a resource for sure.

Thanks for sharing. I appreciate that. We'll have to stay in touch in 2023. We'll come back around.

Keep the good shows coming.

Thanks. I appreciate it.

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About Jeff Sallade

PTO 163 | PT PartnershipsJeff Sallade is co-owner of 3 Dimensional Physical Therapy, with 7 locations throughout southern NJ. Jeff and his business partner, Ken Guzzardo, recently celebrated 3DPT's 10-year anniversary. The one thing that Jeff attributes to lasting 10 years is having the confidence to surround himself with great therapists and partners who are just as motivated as he is to succeed.

As you will hear in the podcast, Jeff feels he chose the best possible path for his business by opting to offer a partnership to PTs at each of his 7 locations. Outside of the clinic, Jeff enjoys reading leadership books, playing soccer with his kids, competing in triathlons (although he has slowed down recently due to having both hips replaced) and traveling with his wife and 2 kids all over the country.

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The importance of the front desk, and the experience that patients have there, can never be overestimated. Stacey Fitzsimmons of Account Matters, Inc. has witnessed this time and again through her work with PT clinics across the country. Considering that the patient's assessment of your clinic (and not the therapy you provide) could hinge on those interactions, you have to make sure that the person at the front desk fits the bill and gets properly trained. Having a natural people-person and problem-solver and someone who is positive, encouraging, and straightforward is essential. Far more than we give them credit for, they have a direct connection to the revenues of your company. Now the question remains, are they more important than the PT's in the back? It's worth considering. Follow today's episode as Stacey sits down with Nathan Shields to tell you.

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Listen to the podcast here:

You Could Be Losing $100k's! Tips For Creating An Amazing Front Desk With Stacey Fitzsimmons

I have Stacey Fitzsimmons of Account Matters. She's been in the physical therapy space for decades. Thanks for coming on and joining us. I appreciate it. We're going to talk about some important stuff.

You're welcome. Thank you for having me. It's a pleasure to be here.

Tell us a little bit about you and Account Matters, what you have done in the physical therapy space here in the last couple of decades and what you're working on. What's gotten you to this point as we're speaking?

Account Matters has been around for a few decades. The original founder of this company is my partner, Diane McCutcheon. She has been in this business for more than two decades. I came on board in 2003 in a consulting manner specific to the PT/OT world. That's what Diane's background was and me coming on board with her, I followed suit. The difference between some other owners out there of billing companies and me personally, is I went into a physical therapy clinic and got hired and I've done every one of the jobs at the front desk, the billing and collecting. The only thing I haven't done myself is the actual treatment because I'm not a physical therapist. Everything that I've learned when I was on the job and then everything I've listened to from people through the years of consulting was how I formed my billing company, Account Matters.

I tried to take all of the complaints of what people hated. I didn't want to do that in my billing company because I keep hearing people complain. That's how we formed ourselves. Going back to the 2003 time, we were forming ourselves of not just a consulting company, but let's open up and give this industry what they need and that's all admin support. Front desk right through your collections getting your money in. That's what we did in this business is we started the billing company. We started adding on, we started training programs and it was all geared towards the front desk and billing department. We offer all of those services here at our company that we can certainly do for people but we took it one step further where if you don't want to outsource your billing and front desk, you don't have to.

We do have trained professionals here that will teach the right person on your side in your practice. For some of those things is I've always tried to set myself a little bit different. There's certainly a ton of billing companies out there. There are a lot of good ones as well as bad. I like to be a little different. I like to try to capture things that I'm not your typical billing company that only knows how to bill, push your payments and collect. I do understand the entire private practice section for physical and occupational therapy.

You initially started off as business consultants and have worked your way over to the billing side a little bit more, from what I remember. When you talk about the billing cycle, you're talking not just about the billing department, but you included the front desk in that. That's a misunderstanding that some physical therapy owners have is not recognizing how much the front desk impacts your collections.

That's where my passion comes in. I was in a lot of pain and couldn't walk. I couldn't work because I was always in pain. I went to a physical therapist. For the reason you become a physical therapist, I didn't become a therapist, but I can appreciate the gift that therapists have to get people pain-free and live their lives. I also understand that you went to school to do that. That's your gift. I don't have that gift. I don't want to touch a human in pain. My gift is business and figuring out how to make sure that what you're doing is going to get reimbursed. A physical therapist by nature, you will do anything for anyone. You love helping people or you wouldn't be in this business.

The only way you're going to continue seeing people is if your doors are open. Click To Tweet

If you have a private practice, it's hard for a therapist to remove the heart. It's hard for them to say, “I'm going to treat Stacey because I know she can't walk and I don't care if I get paid,” which I understand from a therapist. That's your heart. That's you saying, “I need to get Stacey better.” I look at it from you're valued and you won't be able to keep your doors open if you keep doing this for people. I understand it, not from you just have big hearts that you want to help. I'm taking it more like you do, but you should get paid for it because the only way you're going to continue seeing people is if your doors are open.

Is that how you train your front desk people and your billing people? Not to necessarily remove the heart, but training them from a perspective of, “We provide a valuable service and we deserve to get paid as much as possible for the service that we provide. That is your responsibility to ensure that the collections come through at 100% so that we can be reimbursed adequately, if not more so, for the services that we provide,” right?

Absolutely. The part where we're working with the front desk and why I keep bringing your front desk person is because, in my opinion, your front desk person is the most valuable person that you have working in private practice. The reason is they’re the first person to answer the first phone call from a patient. Nathan, you might be the best therapist on the planet. If I'm hurt and I'm calling your clinic, I'm not going to talk to you. I'm going to talk to your front desk person. If she or he is rude, they don't pick up the phone, they give me non-complete answers, I don’t know’s, I will most likely pick up the phone and go to the next person on my list. It makes good sense to bridge the gap between your therapists, therapy owners and the front desk that is typically, “We just need someone to sit in that seat.” It's a lot more than sitting someone in the seat.

If you have the right people, you, as the therapist, with your heart of gold, don't have to answer your patients about their bills and what's going on because you have people to take that hit for you. That’s where it's very important to get the right people at your front desk in your billing department. Those are the people that you, as the therapist, “I don't know what's going on with you. I don't do billing. Go see Stacey in the billing department. She can tell you what you need.” It takes you right out of the equation and it will help your practice to be viable and profitable versus I want to help someone because you are helping them but you should get paid for it.

A good front desk person is like gold. They can set the tone of the clinic. They are the customer service arm of your organization if you will. As you said, you could provide the best therapy on the planet but if they get a bad interaction with that front desk person, either coming in or going out, they're going to remember that more so than the care that you provided. They'll find somewhere else.

Back when we were doing the consulting, we used to travel around the country and we would assess a private practice. What our findings are. We would go through everything down to when I walked through your front door, is it clean? Some places are dirty and messy when you walk in and me as a patient coming in here, “This is dirty. I don't want to be laying on this equipment.” It's very important to think beyond, “I have the absolute best therapist in the world.” It's almost where I can appreciate it if you're going to open a practice, the first thing on your mind is getting therapists in there but it should be getting your admin staff and then adding the therapist. The therapist already knows what they're doing. They need a bench, a table and equipment. It's about your admin staff.

How do you find, recruit or hire the right person for the front desk? What are you looking for? How do you train owners to find the right person?

I like to find and ask people certain questions about where they came from. I don't care if someone came from the local coffee shop and they're coming in here applying for a job to be my biller. I want to know, at that coffee shop, give me one of your worst days where every time you turned around, there was a problem, and tell me what you did to fix the problems. I want to know what you did at your last job. What was the perfect job you had? Tell me the one thing that you did to make a difference in the company you worked for. I'm usually the one to ask not so much specific questions about the job you're trying to hire them for, but I want to know what you do in your jobs. If you’re a hard-working person, it doesn't matter what your job was. If you're a cashier, be the best cashier out there. If you're a therapist, be the best therapist. I'm always looking for the person to be the best of what they are. Not everybody has the education to be a therapist or a doctor. Some are truck drivers, and they're the best truck drivers out there.

PTO 136 | Front Desk
Front Desk: It makes good sense to bridge the gap between your therapists and therapy owners at the front desk.

 

What you're trying to key in on is to get the best front desk person. When they come into the interview unless it's COVID time and you have a mask on, are they smiling? Do they smile at you? If your patients are coming in, they're not coming in because they feel great. They're coming in because they don't feel good. Is someone going to greet them with a smile? “Hi, Stacey. It’s nice to see you. Hold on. We'll be right with you.” In the interview, how did they dress? They knew they were coming to an interview. Were they sloppy? Because they'll do that at your front desk. Again, we're not looking for models. We're looking for a clean-cut, for someone that can speak clearly, someone that can smile, make people feel happy, warm and welcomed. Typically, what I look for when I'm going for new candidates, it's not so much, “Do you have a degree and what's your experience?” It’s, “What can you bring to us? If we give you the right tools, will you learn and be able to do this job?”

It’s maybe more at the front desk than from physical therapists, but we often talk about soft skills. Skills that have to do with personal interaction, feeling other people out, and becoming a problem solver because we can teach the technical skills like how to call, verify insurance, how to collect the copay, here's the paperwork you need to fill out and here's how you do the EMR. Those are all hard technical skills. We can teach you that stuff, but you want someone who's inherently what we like to call high tone. Someone who is naturally happy and excitable. They don't have to rev themselves up to interact with individuals on a regular basis. They want to interact with people and get to know them.

They ask more questions. They’re involved. They know, just like the therapists know, all about the dog, the kid that's sick, and the husband that's hurting as well. They ask those questions. We like to look for people who are in a high tone. I liked the questions that you brought up about people's past experiences because it sounds like you're trying to figure out, number one, were they high producers in their previous jobs? Were they also problem solvers? There's so much that comes out of nowhere at the front desk that if those people are going to be productive, they've got to be able to solve their own problems with the best knowledge that they have without coming back to talk to the owner every day or every second about, “I've got this. What about that?”

In any private practice that I've been in, they are busy. You've got people coming, do they have a copay? We've got people leaving, do you want to schedule an appointment? We've got referrals and OCS we need to get because this one is coming in tomorrow. “We can't schedule an eval for the first visit because this therapist doesn't like that.” They are answering phones so you don't want to hire someone walking through the door, dragging the feet, and sloppy dressed. You’re like, “What's your five-year plan?” “I just want to have a good job.” You're not looking to better yourself. I always say, “I like the people that don't try to be better than anyone else. I like the people that try to be better than they were the day before.”

You want that energy, but again, you don't want someone coming and telling you their whole life story because that's what they're going to do when your patients come in. You don't like your patients listening to me saying, “I know. I felt awful and this is happening because.” They don't feel good. You want someone at your front desk, “How are you doing? It’s a great day. It's sunny out.” It's really important. You're looking for an ambassador of your company. You're looking for a professional person that you can train on the hard stuff like, “Here's a book. This is how you build. This is how you do that.” You're looking for more than that. You're looking for someone that's going to fit in and make your patients feel like, “I'm so glad I came here. Stacey was so nice when I walked in the door. She couldn't have made it any easier to do my paperwork.” That's what you're looking for.

Many people that are reading might be thinking, “I don't have that person,” or they're thinking, “I've had a lot of turnovers and I can't retain the people that I'm wanting.” What are your recommendations for such a position that can be a high turnover position?

We do have a turnover guide. It's a free download that everyone, if nothing else, get your free Turnover Guide. It's a Bit.ly/turnoverguide. Hopefully, you can read some things that will help you out right off the bat. It's not science. Sometimes, people leave for reasons we can't predict or out of the blue, your best person found the dream job down the street. That's always a tough one to swallow. If you don't give the right person the right tools to succeed, they're going to leave because if you find the right person and you stick them at the front desk to figure it out, they're looking for guidance, a leader, and they will leave you.

Once you do find the right person or if you're reading and you think, “I know that I have the right person. She just doesn't know what she's doing.” It's up to the owners. It's up to you to get out there and find the tools to give to them. We have all kinds of training programs here at Account Matters that we work with a lot of clients on basic data entry. How do you put a person complete into the software? What is it that you're looking for? How do you call and check on benefits? They should be done before you have the patient in for their email. If you hire the right person and they don't know any of this, you're going to lose a lot of money. They're set up to fail. If it's the right person, failure is not an option. They will leave and find a job with a leader that will give them the right tools.

The right people want to know their scorecard and what does a successful front desk person looks like. If you can't tell them, “Your job is to produce blank.” Most front desk it is, “Your job is to fill the schedules.” There might be some other iterations of that, but it’s essentially, “Keep the schedule full.” That's their job. If they can't tell you that, then you haven't trained them on their basic purpose and product. Their job is not necessarily to collect all the copays. That's a vital part of their job but their main job is to keep the schedule full. Number one, they need to know stuff like that. They need to know the statistics that you're going to judge them by. That's what I meant by the scorecard. Are they collecting 100% of the copays on the patients that are coming in? There should be benchmarks.

Your front desk person is the most valuable person that you have working in private practice. Click To Tweet

Right off the bat, “You're coming with us. In your first week, you won't be very fast. The second week, we want you to go from 5 new patients in the system to 10 new patients.” You know your businesses. If no one has a benchmark, they're going to do whatever they want. I've certainly learned my lessons in business as the years go by, “I gave them an open-ended window, how come they didn't do more?” I gave them an open-ended window and they did what they wanted. It's all about setting benchmarks in what is best for the company, not the individual people.

Are there certain benchmarks that you think are more important than others?

I do, especially when it comes to scheduling. The number one benchmark is to make sure that every new patient gets in your schedule within 24 to 48 hours. If they call on a Friday, it will be Monday. Because people are usually leaving a doctor’s office with like, “Go see a PT.” It's top of mind, “I'm hurting. I'm in pain. I can't walk. I'm going to call now.” “I can't get you in for two weeks.” You all know PT places are everywhere. They're going to call someone else. I would say a benchmark is a 24 to 48-hour window for any new patients coming in. They need to make sure they learn the schedule enough to leave those spots open and get your patients in.

The other one that you brought up that I'm very big on is the copay and patient money. I'm huge on that because the minute your patient is discharged, it dropped 60% of you collecting that money. They are out of sight, out of mind, “I'm not going back there again. I don't have the money. I'm not paying it. I wanted to spend it on something else.” It's very important to train your front desk person right away, “These are the reports from your software that you should be running every morning because this will tell you what you should be collecting. At the end of the day, did you meet that? Did you collect all of the money or did you not?”

My goal is always 100%. I almost find no one that can do 100% but if you keep it 100%, you will get the most you can get out of your front desk for collecting. Why aren't they collecting? Is it because they're asking the patients, “Do you want to pay?” If that's what they're saying, you want to train them to say, “How would you like to make your copay? Cash, check, or charge?” Not do you because if you say do you and you have a 21-year-old and it's a Friday, he's going to say, “No, I'll pay next week because I'm going out tonight.”

Have you found a way for owners or front desk people to keep credit cards on file and make that transaction easier for copays?

I would say it's a 50/50 out there with people wanting to do it and people not wanting to. It's all above board and you can. There is a form that does need to be filled out from the patient because the patient needs to give you the okay. I do recommend trying to get the patients to leave a credit card on file. If they know it's on file and they've signed for it, then you should have no problem every time they come in saying, “Hold on, Stacey. Let me finish running your card and give you a receipt.” It's not a question and you're not asking. It's, “You agreed every time you came in, I was going to run your card. When I see you, I'm running the card.” It's little tips like, “Don't ask.” They already gave you their okay so run it when they come out, “I’m running your credit card. Your receipt is coming up in one minute.”

I came across a coaching client who used COVID as a nice excuse to minimize that hand-to-hand transaction contact and transmission or whatnot like, “We're going hands-free as much as possible especially here at the front desk. What we'd like to do is keep your credit card on file. That way, we minimize that hand-to-hand transmission.”

That's perfect because everybody is in the same boat. No matter where you live, you can use that as your excuse. Everybody is dealing with COVID so that’s a good one.

PTO 136 | Front Desk
Front Desk: Not everything is going to be a winner, but you can't let your employee tell you it's going to fail without proving it's going to fail.

 

You could say an excuse. You could say, “According to our new COVID-19 guidelines, this is what we would like to do.” Make that part of simply how things go.

The other benchmark you may want to keep in mind is cancel and no-shows. If your front desk person doesn't know how to track them properly, you might think you have a lot more cancels and no-shows than you do. Make sure that your front desk person knows that if it's not a true cancel, they're deleting appointments rather canceling appointments because that's a benchmark you can set not only for your front desk, you can set that for your therapists. I like to go, “How many? Why are they canceling? What are the reasons?” If you have a cancel no-show policy that has a payment associated with it and if your front desk is collecting, less likely your person will keep canceling and no-show. Those are my top three benchmarks I always give to people.

The cancel and no-show rate seems to be a team attack. If you're below 90% arrival rate, the whole team has to be involved. One of my mentors has said in the past, “The patient will only take their therapy as seriously as the therapist takes it.” If someone cancels and on their follow up visit after that, no one says a thing at the front desk or the therapist about the cancellation, how important it was that missing that appointment sets back their care and the results they're going to get with physical therapy, then the patient is going to think, “I can cancel. It’s no big deal.”

Being a billing company, we've seen mostly every denial, especially in the work comp insurance companies. We've had a few companies come after us for certain clients because they're wondering why it's taking so long to get better. When we send all of the documentation, they know that they've canceled and no-showed so many times that they stopped paying. It’s not only you at the clinic that’s like, “Now I have a therapist that doesn't have an appointment.” You can tell the patient but sometimes, it comes to the insurance companies. If a twelve visit is the norm for whatever part of the body for this insurance company but you're more like the ‘80s going another month that you may get questioned. These insurance companies are going to be mad at you because you're not making it important enough to get the patient in there. You want the patients in there.

The front desk is so vital in that aspect because the therapists aren't answering the cancel call that comes in. They’re not on the phone. It's so important that the front desk understands exactly what we're talking about now and how not coming in for therapy is going to inhibit their progress in care and prolong their care. Also, it's imperative that the front desk also understands the purpose of the clinic and they buy into what physical therapy is all about. If they're casual and laissez-faire about physical therapy and patients coming to physical therapy, that's their attitude on the phone.

That's why people get away with it because they're calling your front desk. “Stacey, can you tell my therapist I can't make it.” “No problem. Goodbye.” If the therapist doesn't say anything, they're like, “I didn't have to talk to the therapist because I see him three days a week.” If you said, as therapists, “Stacey, you missed yesterday. That's the third no-show you've had or the third cancel. We're trying to get you better. I built this plan specifically for you. We want to get you better. If you need to cancel, maybe you could come in at a different time the same day.” If they're not saying anything and your front desk doesn't know, your front desk will keep taking the call, “I'll tell them.”

You need both of them to come together to say, “I took a call from Stacey. She canceled again. Do you want to talk to her? Do you want to say something on the next visit?” They should be working together. Typically in the PT private practice setting, there's always a wall built up in between the therapists and the front desk or your admin staff. I am one consultant that loves to go in with my big wrecking ball and break that wall because it's very important that they communicate for the scheduling and for the no-shows. I can't tell you how many therapists hate their front desk because they always schedule the new people for the last visit of the day. My answers are usually, “Have you told them?” “No, I didn't.”

If you don't talk to them, they don't know. You want to make sure in your practices that there's no wall being built and there's complete communication. That will help your cancel, no-shows and anything else that has to do with your patients because if your front desk doesn't feel that they are going to be undermined or not listen to, anything that comes up, they're going to run to the therapist and say, “I just saw Stacey in the hallway. She said XYZ or whatever.” If there's no bridge between the two sides, you're leaving each one open to not say anything and your patients are doing whatever they want.

For those owners out there that have a front desk person that they're questioning, “I don’t know if this is working out,” or they’re not fully satisfied, do you find that front desk personnel who has been there a long period of time, say a year or more, and then you try to implement this stuff, that it’s hard to teach an old dog new tricks? Is it hard to push in some of these benchmarks, products, and training into people who have been there for a while?

Make sure in your practices that there's no wall being built and there's complete communication. Click To Tweet

Yes sometimes and no sometimes. What I will say is this is where the owner has to be a true leader. I know you've been with me for a year. We're making changes. They're non-negotiable. I am the owner. This is how I want it done. This is how it's going to be done. When you do that, it goes pretty well. Your worker might be a little upset for a few days getting to know the new process.

They can’t control how they're going to respond.

You can't. You have to stick with what you say. What happens sometimes is this is how we're going to do it. The next week you check-in, “It didn't work. I know how to do it this way. I've been doing it this way for years.” If the owner says, “Okay, fine,” and walks away, you've not bettered your company at all. You're staying the same and you're probably missing things. There was a reason why you wanted to change something in the first place. If you stick to your guns and they will not change, they're not the right person. If you stick to your guns and they're like, “This stinks but I'm getting the hang of it.” The next week, “It's a little better. I still don't like it, but it's better.” The third week, “It's not that bad. I’ve figured it out.” That's how you would approach your people that have been there. As an owner, when you make that decision, don't go back on your decision. It's this way. Once you do it correctly, prove to me that it won't work and we'll change it again but I'm not for changing until you prove me wrong.

I liked a couple of things that you said there. Number one, the leader comes in and says, “This is how things are happening. This is the structure that we're going to use. These are the checklists that you're going to follow. In the morning and the evening, you're going to turn them in.” What you said inherently in there without saying it was that you were also following up on a routine basis. It's not like, “This is how we do things. Good luck. Go do it and tell me how it goes.” No. It’s, “This is how we're going to do things.” Follow up on a routine basis and say, “How did that go? Can you show me what you did? Did you follow the process? What did that look like? Here are the checklists that I expected out of you.” If you draw the line in the sand but then don't follow up, then the front desk will go back to the same thing.

I can give you great examples because you're all probably saying, “She just talked about me.” What I see is a front desk person that has had that job for years and they've always done things manual. I'm talking mostly about copays and they're recorded on an Excel spreadsheet and/or a paper form that you have to fill out or a paper receipt. It’s then put into your new updated software that tracks everything for you. It happens to everyone. I'll say, stop the manual systems. You have three systems for a copay. You have software. It's 2021. It works. Use your software, “I don't trust it.” If you do that, you will have discrepancies because you're doing something three times.

If you have a patient asking you a question and you only did 2 of the 3, you'll forget the third one, “How come my three balances don't match up?” The perfect example would be, “Stacey, we're stopping the written process. We don't need the written receipts. They're all on the computer.” If you’ve never checked back in with me and this has happened. I've checked a month later, “How's your front desk doing after the training?” I'll start asking questions. “We still have the written one.” “Why?” It is follow-up. You want to make sure, as the owner, to be a leader. They're going to follow you. “This is how it's done. Do it this way successfully for three months. If you still hate it and it's not working, we'll change it again.” You've got to stick to your guns. If it fails, it fails. Not everything is going to be a winner but you can't let your employee tell you it's going to fail without proving it's going to fail. It's all about the follow-up.

They're not running the ship. They're trying to and they shouldn't be. You need to take the helm. You talked about it and while I have you, I also want to ask you about this. The communication and the relationship between the front desk and the billing department can sometimes have some animosity. How do you help that? Fortunately, we got to a point where the front desk love the billers and the billers love the front desk. They worked very cohesively and they share data. They shared their evening reconciliation forms on a regular basis. They were able to talk back and forth. The billing department could train the front desk on certain items and all that kind of stuff. For people who don't have that type of relationship, where do you start in healing that animosity between front and billing departments?

The first thing is you have to set the company culture as you're a team. I am passionate about communication and being a team. In my company, we all have hybrid schedules. The new people haven't even met half of the other people that work here. I'm big on team-building events. It's important to close your place down periodically to have your entire staff and forcing them to work together. There are a million things on the internet that you can get for, “What should I do for team-building exercises?” Pair people up with people they normally don't work with. They don't like each other because of their positions at their job. If you get that out of the equation, chances are they will like each other.

I also have an army background and anybody that's been in the military, it's one big team. You're not singled out. The goal of the company is to have 100% collections at your front desk and have your cancel and no-show rate at 0%, if possible. It's the company goal. You can set individual goals for people, but you should be bringing your entire company together at least once a month for some type of meeting. More than just lunch to say, “Stacey at the front desk, what are some of your issues you're having when it comes to scheduling with the therapist?” That's the opportunity to get someone to say, “I think this one gets mad at me every day because of the evals but there was nothing available. I'm not sure what to do.”

PTO 136 | Front Desk
The Administrative Power Center: Front Desk Training Guide And Workbook For Rehab Private Practices

That's the opportunity for the therapist to say, “That's really easy. Whatever the answer is, this is what I would rather you do. Come to see me. I'll move another patient. Whatever the case is.” It's all about forcing them to talk to each other. What we've done in other practices through the years is we would help host that first real meeting and almost force them. I would be bringing up, “When you're scheduling, what do you have trouble with?” It gives the opportunity for everybody like, “Don't take this personally.” We have one company goal in mind and what is the company goal? Everyone should be working toward the company goal.

Your personal feelings are non-existent. This is work. After work, if you don't like someone, fine. If you want to go out with someone, fine, but during work, the company should be all the same vision. Where is the company going and what is the job? Have those meetings. Don't have a meeting just for your admin staff and the therapist. You should at least do one company meeting and make it almost mandatory. Who are your managers? They should be getting other people to talk, “Didn't you say last week you were mad about whatever?” Call people out on what they're saying to get them to talk. You'll find once the mouth starts opening, it all comes out. People are usually, “If you would have said this to me a week ago, I could have given you the answer. I would have told you don't book my schedule XYZ.”

It's all about communication. Communication is the number in any business. Communication is certainly key. To bridge the gap, I would strategically form meetings or events where you're forcing them to work together. As I said, chances are they're going to like each other. If you put them in an environment where they come in and they can see, “The wall is up. These are my people because the therapists are in the back.” That’s how they come on board. Your orientation for your new people whether it's therapists and/or admin staff, you should be taking your new person, “This is Joe. He's the new therapist.” “Hi, Joe. I do all the scheduling. If you don't like what I'm doing, come see me immediately.” That's when you set that. As your new people are coming on, make sure they meet. Everyone they are going to work with and open, “This is my job. If you see any problems, you come to talk to me. I'll help you out.” That will help tremendously to bridge the gap.

Going back and thinking about it, the billing person was a part of the front desk training process. It wasn't some office manager, the therapist training, or the front desk themselves. There was a portion of our onboarding and training where the billing person would get on the line or come in person and train the front desk person as well to know what was wanted and expected on the billing side. There was that clear communication and they understood, “She wants it this way and she likes it filled out that way because of this reason. That's what I'm going to make sure I do.”

It’s funny you say that because I have a billing company. We have billers that come in and that's all they do is billing. We have people that come in, they are payment posters and then we have collectors. They all know what each job is because what was happening early on in the billing company is you'd get complaints from one of them about, “The payment poster this and the biller this.” If you don't know what they're doing, you need to appreciate their position. It's the same thing in an office and this is where your big company meetings come in. The therapist might be like, “This is an easy job. You're sitting at the front desk.” They all think that.

If you said to Joe, the therapist out there, “Since you have a cancel, why don't you come to sit at the front desk for the next hour? Listen to me answer the phone. I'm taking a copay. I'm scheduling. I’m entering new data into the software. I got a call on a referral because this one just left.” If they don't appreciate or know what someone's job is, it's so much room for them to criticize about stuff they don't know. You're a front desk person. They're not going to be a therapist but they should go back and see what they're doing. What is it that Nathan does when he goes back there with the patient? Is he nice? How does he talk to the patient when he comes in?

It should be, “This is what the therapists do. Every time a patient leaves, this is what the documentation is. When they're complaining notes, ‘I hate doing notes,’ this is what they're doing.” Otherwise, a new front desk person can be like, “What's the big deal? Just write a note. Stacey came in and she feels better.” If you don't know what someone's job is, it's very easy to criticize and point the finger until you sit in their seat. Going back to what I first said, I've sat in every one of the admin seats in a PT private practice. I 100% appreciate whoever is at that front desk with ten arms trying to get the job done. I sat in the back and watched therapists. If we're going back decades, there was no documentation. It was all manual. “I can't read your writing. What are you doing? Why do you have to write so fast? You have to do the whole SOAP. There is a lot of notes.” It's all about trying to not teach someone, someone else's job but to let them know what the job is so they can appreciate what each other is doing.

As we're wrapping up here, is there anything else that you'd like to share that you might recommend owners consider as they're looking at their front desk personnel?

Going back on everything we've touched on is look at your benchmarks. Start coming up with what you want to do because when you make the decision to make your changes, stick to your guns. Even if it doesn't work out, prove that it doesn't work out. Don't give up on it. We did write a book and it happens to be all about the front desk to create your own front desk guide. Go to our website AccountMattersMA.com. We have a link on there. There's a book on Amazon and it is tailored specifically for PT and OT private practice front desk.

Communication is the number in any business. Click To Tweet

This will help you write a workbook that you can say to every new person coming in, “This is how we answer the phone. Everybody answers the same way. This is how we schedule and do the cancel and no-shows.” Go to our website and check it out. My biggest thing with owners is appreciating every person that's in your business and getting them to appreciate everyone else's position in your business. It's a ship that needs to move together with nobody jumping off.

What's the name of the book?

The name of the book is The Administrative Power Center because that's what we developed. Under it, it's billing for rehab private practices. It's oddly enough hard to find on Amazon because if you type it in, it comes up with everything that does not say administrative power center. When you find it, we’re the only book called The Administrative Power Center. It's your revenue cycle that we've renamed, we'd beefed up, and we made it a little more fun for people to learn instead of looking at your typical revenue cycle.

I love that you hit on reminding the owners that if they're going to make changes, be certain and clear about it. Also, make sure you verbalize what your expectations are. Our arrival rate is 85%. Successful arrival rates are at 92%. Make sure that's the benchmark. That's what we're expecting. Our over-the-counter collections rate is 75%. I expect it to be 100%. This is what my expectation is. Be clear about those and put it in writing. That's part of the book that you're talking about is to create that workbook, put it in writing and that workbook ends up being, “This is how you get to 100% over-the-counter collections.”

It's your guide on how to run a front desk from A to Z. My partner, Diane, and I wrote it. We have close to 60 years of this particular business. Diane has only worked in PT/OT private practice as well as I. My final thought is to check the book out. It's a great tool for you that you can use for your entire company.

If people wanted to reach out to you or Account Matters, what would you recommend? How do they reach out to you?

There are two different ways. You can go to our website. You'll see a little Ask Dan A Question and you can click on there. There's an info box you can send anything to. If you want to email me, my email is Stacey@AccountMattersMA.com and I will get back to you personally.

Thank you so much for sharing your wisdom and your years of experience in this space. You shared a ton of great value. Thank you so much for taking the time to come on.

You're welcome. Thank you.

Have a great day.

Important links: 

About Stacey Fitzsimmons

PTO 136 | Front DeskStacey Fitzsimmons is the President and COO of Account Matters Inc. Prior to Account Matters Stacey served in the US Army as a paratrooper and a mechanic in the 82nd Airborne Division and then owned and operated a sporting goods retail shop for several years. Stacey has 18 years of experience working with physical/occupational Therapy private practice owners across the country.

Stacey along with her business partner Diane McCutcheon, have recently written and published the book “The Administrative Power Center” to help educate the importance of the front desk position in a private practice setting. Stacey’s mission is to provide the tools and or services of outstanding administrative support to physical therapists nationwide, allowing them to get paid right the first time.

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PTO 44 | PT Clinic Valuations

 

After sharing his professional story, Steve Stalzer, PT is back for the second time to tell us about the valuations of physical therapy clinics and the three factors that can improve our EBITDA. As founder of 8150 Advisors, a PT consulting firm, Steve has guided owners across the country how to calculate and improve the value of their private practices. In doing so, owners have created businesses that not only provide them greater profits but also greater stability, freedom, and a solid platform for growth. Steve breaks down the strategic steps of improving company valuation so you can maximize returns and set yourself up for your eventual exit. Proving how he is a valuable resource to have, Steve shares the tricks of the trade when it comes to creating long-term value.

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Listen to the podcast here:

Calculating And Maximizing The Value Of Your Clinic with Steve Stalzer, PT

My guest is Steve Stalzer of 8150 Advisors out of Colorado. Steve is an experienced physical therapist who bought into and grew a physical therapy company across Colorado in South Carolina a number of years ago and eventually sold it. He is now serving physical therapists as a consultant and advisor through 8150 Advisors which he founded. This was supposed to be part two of a two-part interview that I had with Steve. As you read through this episode, recognize that we referenced part one and talk about this as part two of a two-part episode. To summarize, part one of the interview was about strategic growth and determining the ROIs on your marketing efforts and how that's related. Marketing efforts and strategic growth are dependent upon having a sound foundation in your clinic such as policies and procedures, solid hiring practices, proactively hiring, providing quality care, establishing yourself financially well and establishing yourself in the community.

A number of factors go into the foundation of your clinic, but once you're ready to strategically grow, you want to assess the ROI on your marketing efforts. It will help you accelerate your growth even more and acknowledge those avenues of marketing that are providing you the greatest benefit and especially the greatest profit. All of that was some great information that I failed to obtain on part one of the interview. Should you have questions and need some consulting and advice on growth or even establishing that foundation to your company, please reach out to Steve@8150Advisors.com. That is his email address. His website is www.8150Advisors.com.

Steve graduated from the University of South Dakota in 1997. He also has degrees in Organizational Psychology from the University of South Dakota and an MBA from the University of Colorado. He'll talk about his story with proactive therapy out of Vail, starting in 2001 that he worked closely with four other partners and the renowned surgeons at Steadman Hawkins Clinic. They eventually grew those four clinics into 35 clinics across four states and they pioneered some of the earliest and largest sports and orthopedic residency programs between Colorado and South Carolina. Steve began consulting with practice owners so that he could share his experience and knowledge with others shortly after he and his partner sold Proaxis Therapy in 2015 in which he is the Founder of. He consults clinic owners with growth, efficiency and succession planning. I have to apologize for not having part one. This is part two and if you have some questions about growth, succession planning and improving the efficiency of your company, please reach out to Steve’s email. Let's get to the interview.

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I’ve got Steve Stalzer with 8150 Advisors back with me doing a second episode. Thanks for coming back, Steve.

Thanks for having me on.

We talked a little bit about the ROIs of marketing and how that's related to strategic growth and increasing the valuations of your company. Will you talk to us about how to value your company? How to get better valuations for your business?

When I work without a nurse, the first thing that they should look at is the foundation. Looking and understanding the metrics, how they optimized their metric, do they have a solid team in place so that they can scale the business? Once they start to scale the business, looking objectively at what they're doing for marketing, what's their acquisition costs, go by specific activities and categories and understand the ROI. Looking at what activities are they doing to increase the value of the practice. That was a turning point for us when we started to look at what's driving the value of our practice, not just growth, pitching number, size of staff, number of clinics but truly impacting the value of the practice. There are still a lot of misconceptions. There might be small misunderstandings about what drives practice value but covering some of those is a worthwhile topic.

In the ownership of the business, do you recommend that they start following some of this stuff? A lot of footwork has to be done to hire the right people to get your statistic management in place and get your policy and procedures grooved in and working. Do you recommend they start considering the valuation or even tracking the valuation of their companies early on? Where about in the process do you recommend they start following some of these stats?

Whether you're selling or not, it's important to always consider the stability and the value of your clinics. Click To Tweet

It is valuable to understand what drives value even before you open a business. That is going to change the business that you built. In terms of looking at your actual value, as early as one year in the business, it’s the first thing I look at when I work with an owner. Ongoing whether I'm working with them formally or whether it's a past client that I'm working with. I'll offer to reassess their practice, their statistics and the value of the practice on an annual basis just because I like to see what progress they’re having. Are they getting results from the work we did? I share that knowledge with them so that they can see where they need to work and what they can do to drive valuation to their practice. It's an underutilized tool within the industry. It doesn't have to be super complicated, but it's understanding those drivers of value that I think help owners make smarter decisions.

There's always something to that. I remember doing an interview with John Dearing where we talked about, “Are you ready to sell your practice?” If you're considering what it takes for you to look good to other people and put your practice at the highest valuation possible, even if you're not selling, that just means you're running your company well. That means you're stable. That you've got good marketing in place and you’ve got good policies, procedures and good people. All those things add up to an improved valuation of the company in general. When you talk about valuations of companies, it's not about exactly how much I can get on the market. It can be a reflection of how well your business runs. If it's running well, you always want that because a well-run business is going to be a more profitable business and it's going to be easier for you to manage as the owner.

Even if your goal isn't to sell your practice in the next couple of years, it can still be a collective number that assesses the stability of your practice. It gives you an overall score and things like staff stability, things like diversity of referrals and diversity of payer mix. Those are all things that are healthy for your business and correspond and increase the opportunities that you have to sell that business or give you options when you do choose to exit your business. I'm sure you've heard stories about this as well. One of the worst ways to learn the value of your practice is to go fishing for a number. When you get that call and someone says, “If you’re looking to sell your practice.” I see a lot of owners that want to explore that because they want to see how much it is worth. That can be one of the most cumbersome and painful ways to find out something that's not that complicated. That tends to be where we get a lot of calls. People have someone call expressing interest in their practice and then they call us and they want to find out like, “I'm not sure what it's worth but I'd like to know.”

You mentioned a few of the things that we talked about in that prior episode with John Dearing. It's the diversity of payer mix, it's the diversity of referral sources. What kind of leadership team or what kind of people do you have in place to run the business? Are you personally significantly involved in day-to-day operations or not? All of those things. Am I correct? Is that what you're talking about when you're talking about the value and the valuations of your company?

PTO 44 | PT Clinic Valuations
Good to Great

Let's even back up from there. We worked with John on several acquisitions. We had acquired four practices and we engaged John and Capstone to help facilitate all four of those deals happening. John mentioned that there are a lot of ways to value a practice. He likes to look at future cashflows and the value of future cashflows. The reality in our industry is that most businesses are valued on a multiple adjusted EBITDA. There are three factors in calculating that before we get into risk assessment and how the risk impacts on multiple. EBITDA is straightforward, Earnings Before Interest, Taxes, Depreciation, Amortization. That's very straightforward to calculate. I get a lot of questions on the adjusted part of that equation. To run through some of those, the first one would be normalizing the owner salary. You see some owners underpaid themselves by $50,000 and people overpay themselves in comparison to what a replacement cost would be.

You need to think about your add backs. What would the expenses look like if somebody else bought your practice? On a go forward basis, what does that look like? If you're overseeing two or three clinics and you could replace yourself with a salary of $100,000, then that is very likely to be that normalized owner salary. In a bigger market with twenty clinics, that might be $150,000. The first part is normalizing the owner's salary. You don't get to add 100% of the owner's salary backend. That typically is part of the business and required to run the business. The next part is looking at the owner add expense. That can be anything that's an owner expense that isn't necessarily going to be an expense going forward. If you're doing all your continuing education in Hawaii and they’re week-long courses, that might not be usual and customary continuing to add expense. $2,000 for continuing add might stay in the calculation, but the $20,000 of five-star hotel and travel via that course would be considered an add back.

Your gym memberships, your car and your cell phone, things like that can be add backs.

If they're part of business operations and when you say a cell phone, that might or might not be. A lot of times companies will pay for the cell phone or have a cell phone allowance for the business. That's expected to be a go forward expense. If you add it back, then I wouldn't expect to say, “How come they're not paying for my cell phone after you sell a business.” Your mileage if you're doing marketing runs or meetings between clinics, some of it is above and beyond the normal expenses. First one, normalize the owner salary. The second one, look at the personal expenses as well as one-time expenses.

Let’s say you have a big accounting bill you transitioned from a cash basis to an accrual basis and you had a one-time accounting expense. Something like that would be a typical add back. The work that we do with clients to prepare them for sale, they are one time and they do not go forward expenses. The last one is looking at new clinic costs or startup losses. Let’s say you're calculating the trailing twelve. The trailing twelve, for anyone who doesn't know, when you're looking at the EBITDA number. Let’s say you're selling your practice mid-year rather than use the prior year's financials, you're going to calculate financial periods for the twelve months prior to your sale. That might be July through June. Let’s say you opened up a clinic ten months ago and that clinic lost $50,000 the last year. That is frequently and should be counted as an add back. It’s the normal standardized process. Once you adjust the EBITDA with those variables, now you're looking at, “What multiple do I use?” I know you and John talked a little bit about this and size drives the starting multiple. It's not necessarily revenue, but it's your EBITDA that drives that multiple. Sometimes it corresponds, as long as your company is hitting that 20% range for profit margin. If you're at a 5% profit margin, it’s not going to line up your revenue and your EBITDA out of whack.

Your practice is underperforming. You get to starting multiple based upon where your EBITDA is at. Is it $500,000? Is it $1 million? From there, you have to think about, “What makes my practice more attractive and what presents risk for a new owner?” This gets into your question about, “What are some of these risks?” What I tell owners is, “On a positive side, the best thing you can do to make your practice more attractive and drive in multiple is to have positive growth trends.” If you think about a business that you would like to buy now, nobody wants to buy a business that's going downhill. The line is going down and patient visits are flat. People want to buy businesses that are representing growth. That ties back to the strategies we talked about around strategic growth. The rest of it is mitigating risk. How do you grow your practice in a way that mitigates risk? How can you be aware of those factors as you work on your strategic plan? You're continuing to mitigate risk associated with a lack of referral diversity of transitional risk around not having a strong team. Building your practice in a way that makes your practice run better, but also increases the value of it over time.

Showing a positive growth trend is one of the best things you can do to attract buyers. Click To Tweet

If someone is looking to buy your practice, that's what they're looking for. They want to say, “If I'm going to put my money here, how safe is it?” If they recognize that this is a safe investment that's going to continue to grow, I'll pay more for that than for somebody who's relatively static, the leadership is questionable, policy and procedures aren't quite in place and their net profit margin is less than 10%. What they're going to pay for is the people who are maybe in the upper echelon of profit margins greater than fifteen at least and maybe closer to 20% profit margins. There is strong leadership in place that's not dependent on a single individual and diversification of payers and referral sources. Those can all be strong links that people are willing to invest in. That goes back to making your business better for you as well as an owner. Just focusing on those things can take you a long way whether you're ready to sell or not.

It's no different than if you and I were looking at analyzing the stock. Something that is very stable is going to make a moderate return. Something that has a high risk to offset that risk, people are looking for a high return. The way that investors do that is to pay less for your company knowing that it has high risk associated with it. By paying less, you give them the potential for a higher ROI and it’s not necessarily good for you. Some of the things, you hit a lot of those. There are things that people can do to think about mitigating risk factors. I'll just go down a checklist that I often run through when we're doing a practice assessment.

The first one that I talked to owners about is, “As long as you're willing to stay on for two years, buyers like to see that.” If somebody is looking to sell business and exit, that's a big red flag. It might scare some buyers away entirely because they associate that practice, that stability and some of those relationships with you being central to that. You've built that business into what it is. A lot of buyers get scared away if you're planning to sell it and walk out the door the next day. We talked about growth trends being one of the best things you can do to increase the value of your practice.

Overall, the industry has been growing an average of 7% for the past several years. This is market specific. If your growth rate is even 2% or 3%, you might be losing market share within your market. Often, I'll use 7% as an ideal growth rate for the owners. It's going to be market specific. Showing a positive growth trend is one of the best things you can do to attract buyers. You mentioned the profit margin. Anything that's below 15% is going to raise a red flag in terms of how a higher risk is associated with it. Being in that 20% range is ideal and being below 10% is going to be a little bit of a red flag in terms of risk. In referral diversity and payer diversity, you'll often hear that 25% of your referrals are coming from any one group or any one provider. There's a risk associated with that. If you step back and think about it the present medical model where a lot of Orthopods are opening their own therapy practices. If 30% or 40% of your referrals come from one group and they decided to bring therapy in-house, that's a big hit to your business.

We've seen that happen with owners where they might lose 30% of their volume because of something like that. Payer diversity is an interesting one. A lot of owners have a hard time understanding this one. If you go back to the days of Balanced Budget Act and NPPR and things like that, Medicare cut rates relatively quickly across a large volume of patients. You'll often see buyers look at Medicare paramedics about 25% also being a risk factor. You had clinics in Arizona. I'm guessing you average 40% to 50% Medicare and that's the reality of doing business there. It’s something to be aware of that buyers might see that as risks. You mentioned team and I know you and John talked about having a process for developing leaders within your team and having a succession plan in place. If you were to walk away from the clinic for a month, would it continue to run effectively and efficiently without you there? You have a right-hand person that can step into your role.

PTO 44 | PT Clinic Valuations
PT Clinic Valuations: Something that is very stable is going to make a moderate return.

 

We invested a lot in training our clinic directors and wanting leadership development. What you see over time is that becomes your biggest variable to growth. Once you get recruiting down and once you get marketing down, then it becomes developing that middle management. That's not unique to our industry. It’s a very common barrier that you need to overcome for future growth. With that team, your most buyers love to see if you have HR laws, if you have your clinic directors and even your staff under noncompete, then it’s reasonable, compliant and versatile. As a buyer, one of the scariest things is thinking, “What if the staff leaves?” I bought six buildings that are sitting empty and referrals are following us therapists. Back to your question about when you start thinking about value, just knowing that that drives value. That's something to think about early on and understanding what the HR laws in your state allow and what's a reasonable noncompete to put in place.

I love that you brought all those up because they're extremely valuable and we can't go over those enough. We're talking about valuations and that contend towards the conversation about sales. Where do you see the market is? As we’re talking, we’re in March 2019. Where do you see the trend for PT clinic sales and acquisitions?

Consolidation in healthcare has been undeniable over the last few years. There's a great blog post that Ryan Buckley has from Livingstone capitol. He does a lot of big MNA work within the PT industry. He graphed out the number on your add on acquisitions that have taken place over the past as well as the value of platform companies. When he's talking about platform company, he's talking about a company with 100 finance with private equity back company, maybe down to the 50 clinics or $50 million range. He's talking about bigger companies that are a “platform.” If you look at the value of those companies, they were selling for about 7x to 8x many years ago. In the last few years, that's been an average of 11.8%. Those companies have gone up by almost 50%. There are a lot of factors and I know you've had different people on who have talked about what's driving consolidation in our industry and some writing acquisitions multiples.

I attribute a lot of that to outside investors looking at healthcare. When you go back to the financial crisis a few years ago, private equity groups had to look at what industries weather that storm well. Healthcare is one of those industries that weather that well with aging demographics. There are a lot of factors that make physical therapy an attractive industry. Like it or not, that outside investment by private equity groups has driven the value of practices. We get a call once or twice a month from a private equity group who says, “We're looking for the next platform company who has $5 to $10 million in EBITDA. We'll even look at combining a couple of groups that have $2 million or $3 million EBITDA to make an investment.” The point is there are a lot more buyers out there than there are sellers now.

How long has that trend continued? I never tried to answer that question and I don't have a crystal ball. Often you hear people say, “The next 12 to 24 months is a great time to sell.” I've been hearing that for the past few years. Sometimes you have to look at who’s making that statement and who has a motive behind it. That being said, the multiples are at an all-time high. If you look at those platform companies, if your company is valued at an 11x or 12x by somebody for a 5x, you've immediately doubled the value of that company by tucking it under your umbrella. That goes back to make the point about size matters. You start to add together 50 to 100 clinics in different markets with different referral sources. There's a lot less risk of losing 30% of it and you see multiples go up accordingly. We're still seeing 30 to 40 acquisitions taking place most years. At the same time, you still see a lot of clinics that are coming out. The industry has a relatively low barrier to entry. Even though you're seeing some consolidation, there are still a lot of independent clinics out there that are doing well. It's been a seller's market for quite a while now. You need a crystal ball to predict when that will turn around.

There are a lot more buyers out there than there are sellers today. Click To Tweet

You talked to some people and a lot of it is tied to interest rates. If these people are going to buy a clinic, they're going to finance it more than likely. As interest rates go up and get a little bit tighter than their willingness to get loans and take money out, it's going to go down. That might be one indicator if you're wondering where the market is going at any given time.

You can find a lot of information on will private equity become less aggressive as interest rates go up? That is a huge piece of the puzzle for private equity groups. That is something to keep an eye on.

A lot of the guys that might be reading this blog aren't necessarily in that position to sell. Maybe they are, but what is your advice to them? You said you go down this checklist with the people that you consult with. Is there a particular area that some of these newer or smaller PT clinics aren't putting their focus on that they should be? Do you see a trend amongst the things that you're working on?

It varies. Have a solid strategic planning process where you assess your practice, look at your current value, look at your risk factors and look at what's preventing you from the next big milestone for your practice. If you think about it, what would it take for you to double the value of your practice? Is that managing your metrics better? Is that having a more efficient recruiting process or is it a more effective marketing process? Stepping back once a year is ideal to assess your practice. In going through a thorough assessment of what's trending up and real opportunities. Which of those opportunities are going to have the greatest impact on owner practices? It all starts with having a solid foundation, a solid team and solid metric management. From there, a lot of our value creation came from things like partnerships with health systems and creating joint ventures. In some markets, that's an unrealized opportunity for owners. With others, it might not be. Sometimes we don't look at that bigger picture to say what would that opportunity in owner practice do for our value?

Even if that's not your goal, but if you were to sit down in the strategy session and say, “What's keeping us from doubling the value of our company? What would it take to double the value of the company?” That's a good starting point to maybe start brainstorming what some of our obstacles are. What are some of our barriers that are bigger than what we're dealing with right now in the current time? Maybe it is what you're dealing with right now. To start from that question and go forward, it could be powerful.

PTO 44 | PT Clinic Valuations
PT Clinic Valuations: Stepping back once a year is ideal to assess your practice.

 

Two of the things that I look for when I'm working with an owner, we’re doing an assessment and we’re doing annual plan, is fixing significant weaknesses. Sometimes you have to step back your business to say, "What's our biggest weakness that's holding us back? Is it a solid clinic director development program? Is it our AR? Is it metric management? Is it marketing? What's a significant weakness that if we fixed it, it would stabilize their practice and it would have an impact?” It would allow us to accelerate our growth. That's a way of turning your weaknesses into opportunities. The other one is, what are your competitive advantages? How do you leverage your competitive advantages for growth?

We had a strong practice liaison team and a couple of individuals. We leveraged them to diversify our referrals and grow referrals from family practitioners and internal medicine doctors. That was a way that we leverage the strength to fix a weakness. If you look at it from that perspective, it starts to turn your SWOT analysis from an exercise that you go through emotions, but then you're not sure what to do with it, into how do we quantify these in terms of what value does that bring to our practice from an analytical side. It's easier as an outside person looking at practice and saying, “Did you know that changing this number from here to here or putting this in place can increase the value of your practice by 10%?”

We try to quantify those things. When we started doing that within our own practice is when we started to get clarity on where we should focus time and energy as well as what is not worth doing. There are a lot of things that feel good and look good, but when you quantify it like, “Is it adding to the value of our practices? Is it stabilizing practice? Is it growing our practice?” That can help provide a lot of clarity. Sometimes, as an owner, it's just as important to understand what you're not going to do as it is to understand your top priorities.

We talked a little bit about the valuations of some of the larger platforms. If you're looking at a guy who's got maybe one, two, three clinics and they are considering going on in the market for one reason or another or some exit strategy. Those valuations are quite a bit lower than the seven to eleven or eleven to fifteen that the larger platforms are getting. What would be a reasonable multiple for those guys who might be looking to sell?

They're not in the same category. I hesitate a little bit to put a number out there because there are many variables that come into it. If somebody has let's say $500,000 or less of adjusted EBITDA, those are in the three to five range as a general rule. Less than $500,000 is a pretty big bucket. That's everybody from $100,000 less than $1 million of revenue. Somebody that seemed that $500,000 adjusted EBITDA range, if they've got a solid practice, there are not a lot of risks. That's the starting end. As the profit goes up, multiples go up. It's not uncommon to see private practices in the 9x range if you've got $4 million or $5 million. You can start to see as you increase in size, it gets closer towards that range. That's a general number that you can put out with a few caveats.

Simple, though not easy, ways to increase the multiple of your EBIDTA: Positive Growth trends >7% and Mitigate Risk (develop a strong team, diversify payors and referral sources) Click To Tweet

To get the higher ends, you're going to have to follow exactly your list for mitigating risk when it comes to positive trends and a diverse payer mix or diverse referral source mix. That's when you're going to get the higher multiples. When you say three to five, I can remember getting proposals a few years ago and they were closer to two range. They've gone up and that's a benefit to those people who are looking to get out and a boon to the practice or to the profession in general. When we're talking about valuations, is there anything else that you’d like to think about or you'd like to stress with owners?

A couple of other things that are good to keep in mind. Any owner that has let’s say an MSA with a hospital or physician group where they're providing therapy but it's under a service contract. Those often have a 90-day out or 120-day out or either side can terminate the contract every three years or so. It's important to understand the language in those contracts. You might not be able to shift the language in those contracts. Those are going to have an asterisk next to them when you're looking at the value of that practice. They're not going to command the same multiple that your general business carries just because of that out. They might be valued closer to 1x.

I've seen examples and then part of examples where those who run for a long time, but eventually get terminated and therefore represented a high risk and their multiples are not the same. Overall, having a mechanism or understanding how to calculate your adjusted EBITDA and where you're at now, understanding your goals and what your exit options are. It's that classic starting with the end in mind. There's a lot of value in that even if your eventual exit is not in the next few years. Understanding how all these things are going to impact your profit now and your future value and your future exit options. Understanding that there are risk factors.

The more you can chip away at knocking those risk factors down, it's not just going to be good for eventual transaction and transition. It's going to increase the stability of your practice. It's going to prevent any incidents from hurting so much if something happens. It's a good way to organize if you've got an ownership team with several owners. It's a good way to align the team and saying, “Let's look at priorities.” When you start to look at value, it focuses on that conversation. It could be great for having that common goal within your ownership team.

If people want to reach out to you personally, Steve or with your group, how would they do that?

Our website is www.8150Advisors.com or they can email me at Steve@8150Advisors.com. If people have follow up questions, I'm happy to help. Our whole team got into consulting as a way to pay for what we learned from others along the way. We enjoy helping business owners grow the value of their practice and hopefully, learn from some of the mistakes we made and learn from some of the things that we did well. That was why we started 8150. That's our goal.

You've already added a ton of value to whoever is reading this. I appreciate it. By all means, if people need or want more information about what Steve was talking about or about getting some coaching consulting in general, I highly recommend you reach out. Thanks for your time, Steve.

Thank you, Nathan. I appreciate it.

Important Links:

About Steve Stalzer, PT

PTO 44 | PT Clinic ValuationsSteve graduated from PT school at the University of South Dakota with a masters in physical therapy in 1997. After working in several leadership roles, he joined Proaxis Therapy in Vail, CO in 2001 where he was one of four partners in an outpatient practice that focused on sports medicine working closely with world renown surgeons at the Steadman Hawkins Clinic.

Over the next 15 years, they grew the practice from 4 clinics and 12 therapists to 35 clinics across 4 states with a staff of more than 200. Steve and his partners grew the practice through a combination of acquisitions, opening freestanding clinics as well as forming several health system partnerships including both joint ventures and management agreements.

They pioneered one of the earliest and largest sports and orthopedic residency programs taking 10 residents each year between their CO and SC operations. They also collaborated with Blue Cross of South Carolina and Greenville Health System on a “Therapy First” initiative for the treatment of low back pain and placed therapists in several ski town emergency rooms in Vail, Beaver Creek, Breckenridge and Keystone.

Steve attributes their success to having built a great leadership team and investing in that team by working with leading consultants both in and outside the therapy industry. Steve began consulting with practice owners to share his experience and knowledge with others shortly after he and his partners sold Proaxis Therapy in 2015. Steve is the founder of 8150 Advisors, a physical therapy consulting team that helps clinic owners with growth, efficiency, and succession planning.

Steve has degrees in Organizational Psychology and Physical Therapy from the University of South Dakota, and an MBA from the University of Colorado.

In 2018, he was the lead presenter on “Strategic Growth: Big Data, Cash Cows, and Mangy Dogs” at PPS along with John Dearing from Capstone Advisors and Emily Bagby, a Practice Liaison Consultant with 8150 Advisors. Steve has written several articles for Impact Magazine on Strategic Growth, Practice Valuation, and Succession Planning.

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PTO 33 | Clinics

Starting your own clinic can already feel like going over a mountain, how much more when you have more than twenty clinics on hand? Someone who knows just how that feels is co-owner and co-founder of HealthQuest Physical Therapy in Michigan, Bill Knight. We pick his brain as he narrates his experiences of owning twenty plus clinics which continue to grow and expand. He talks about the elements that made them successful while giving great tips for aspiring owners out there on their role in the business, whether as businesspeople or clinicians. Bill also shares about the importance of partnerships to business success and implementing programs that really help a lot towards the productivity among the staff.

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Listen to the podcast here:

Your Only Competition Is Yourself

Picking The Brain Of Bill Knight - Owner Of 20+ Clinics

I've got a friend from my network by the name of Bill Knight. Bill is the Co-owner, Cofounder of HealthQuest Physical Therapy in Michigan. They have over twenty clinics out there. He's been successful. They do things right. I wanted to pick his brain. I don't have a path to go down on this podcast because we cover a number of topics. I simply wanted to pick Bill's brain on his experience and what he does successfully at his clinics to continue to grow and expand because I believe they were planning on opening up a few more clinics. The projections are great for their company overall. In general, I wanted to see what they've done right, what they've found to be successful and allow them to continue to grow.

I've had a few discussions with other physical therapists, as they're looking to expand and grow and open other locations, those owners that I've talked to not only on the podcast but outside of the podcast, have been successful with expansion when they've brought on partners in those other clinics. If you're looking to expand and open up another location, consider what you can do to make that person, that clinic director, a partner and have a vested interest in their success. I'm seeing that pattern both from my own experience and the guys that I talked to. That partnership is a way to go if you're looking to expand but even outside of that, Bill has a ton of stuff that he can share. Thanks for joining me, Bill.

Nathan, I appreciate the opportunity to get on here to speak to you and to other professionals alike regarding my experience and what has allowed me to move into a situation where I can not only help others in this incredible profession both patients and other employees alike. Also, to take the profession and optimize the opportunities for my family as well.

You've got a ton of experience. I don't have a particular path to go down. I know there are certain things about the business that I want to know and talk to you about. Before we get into that, do you mind sharing with everybody about your story, where you can from as a business owner and whatnot?

I have been a therapist for years. The first ten years of my career, I've worked in private practice for another practice owner who, at the time, was planning to bring the key staff members onboard as partners. I and my co-founding partner, Stuart Siegner, were two of those employees. At an all-staff meeting instead of discussing that any further, he told us that he had sold the company out from underneath us. We had put a good amount of our early professional career into that and planning that to be our future. When that happened, Stuart and I decided to go ahead out on our own and venture into this private practice thing and take that risk.

PTO 33 | Clinics
Clinics: The way to grow is to realize that you don't know anything about business at all in the first place.

 

That was how long ago?

That was years ago. We started in 1998. At the time when we discussed that, we had also come to a mutual agreement that if we had the opportunity to help others, we would help others along their journey to ownership as well and not do what was done to us. Our model has gradually developed from that perspective and from that view.

It's been a rosy scenario ever since?

Our first clinic did exceptionally well. I knew a ton of orthopedic surgeons in the area. At that time, nobody was doing their own PT in doctors' offices, so we had more business than we could ever have wanted. We didn't understand how to run a business. We didn't understand anything about marketing. We were overflowing with patients. We opened two additional clinics at that point to handle the expansion. The bottom starts to fall out when all the groups of orthopedic surgeons in this area started opening their own practice, which then caused our model to crash. We were essentially in a state of panic and not knowing what to do. How do we save what we had created, which now at this point, created a new lifestyle for us?

It forced us to look at what we were doing and to come to the realization that we don't know anything about business at all. We were trained to be physical therapists, to be clinicians and we were great at that. That's why we had the business we had. Other than the people who are already loyal to us, we were getting far less from a referral source than ever before. When things were coming in, we did not know how to economize, hunker down and make it through that tough times. What we did was we looked at do we want to take the time to go back to school and get MBAs to figure out how to run a business or do we want to look at something more specific? We found a group within the profession that trains exclusively physical therapists and the whole business model side of running a practice. We started that in 2003. We were a little slow initially implementing the things that were recommended. Once we did, things started to take off.

If you are developing a practice, you need to understand and own how much you don't know. Click To Tweet

I remember from talking to you in the past, you got to a point while you're at three clinics and with all the changes that came on, did you have to scale back the number of clinics that you had at the time?

We never scaled the clinics back. We were close to closing one of the three. We were able to work through that. We were able to implement a lot of the strategies that we learned. What happened and what would happen with any profession is things are heading in the other direction and things started to turn around for us.

If I remember correctly, your specific numbers were such that you'd gotten down to a hundred and something visits a week?

At one point, our busiest clinic, we were seeing about 350 visits a week. The other two clinics were around 200. We were seeing about 750 visits. When it got to the point where it was bad, we got to one week where we were at 158 visits between three clinics. At that point, we were panic-stricken. That's what drove us in the direction we did. Things turned around pretty rapidly when we started to learn and implement some of the strategies again that we had learned through the training.

What would you say was one of the most important things that helped turn you around? Was there one particular action or thing that you did that you can look back on and say, "When we started doing this, things started to improve?"

PTO 33 | Clinics
Clinics: When you get the structure, the processes, and the systems in place, then it makes it so much easier to duplicate that over and over to your business.

 

The number one thing was putting the focus on active marketing, developing and understanding what marketing is, and all the different areas and elements of marketing that are there. Implementing that, understanding that people aren't going to come to you that you have to develop relationships. You have to network with physician groups and with the community at large. That was a big thing that helped to drive business to us, to understand that we needed to know what was going on. That concept of tracking everything, statistically analyzing things and then planning accordingly on what steps need to be taken to improve.

Prior to the decline, you weren't tracking statistics as closely as you started doing after the fact?

We were not tracking much anything before the decline started. We were seeing patients as much as we could. We tracked a few things but not that much. I had a person who worked with us early on that had some accounting backgrounds which helped. She helped us a bit from that perspective. Relative to understanding all the things that you need to track to know what's going on, we weren't doing a whole lot of that early on.

As you started implementing that program to track statistics so you could act accordingly to help those statistics improve and that helped out a lot.

When you put a statistic on and track anything and put the focus on it, if you're taking ownership of it, it's going to improve. We identified what objectively needs to be tracked on each position in the organization and started to do those things. As we did that, people started having a clearer picture of what they needed to do, what should be occurring. Lo and behold, things started to turn around for us.

Don't let go of the fact that you're a strong clinician. Click To Tweet

I want to come back to your program on what you do to ensure productivity amongst your staff in regards to the marketing that you did at the time. A lot of effort back in those 2000s could be spent focusing on physicians and physician networks. What we're seeing in the APTA statistics is the number of physician referrals has declined significantly over the past few years, some 50% or something like that. Have your marketing efforts changed in the last few years whether it's social media or direct to consumer?

It's changed. We still market our physician groups very aggressively. We have three full-time physician marketers. A physician still accounts for about 34% of our total referral source. We learn the difference between internal and external marketing. We've put a focus on internal marketing and got the employees to understand, to buy into the fact that it's everybody's responsibility to market and to draw business into the clinic.

You say 34% is physician referrals. Have you been able to track how many repeat clients?

The other big thing is we track the two together as far as repeat patients, previous patients as we call them, and referrals from family and friends from those patients. That accounts for the greatest number. That's probably still about 42% of the business that we have and that stays strong. The remainder of that is outside community marketing and efforts through the school systems. As time has gone on, our marketing program has matured and become much more sophisticated. We brought on a social media expert that has handled and taken care of all of the social media marketing that occurs basically taking over our web page, our website and do tremendous things with that. We worked with the staff on doing videos and encouraging them to get out into the community and market and promote. That's been huge for us. She's done a fantastic job.

Have you been able to track your ROI on someone like that, your social media expense and web page work and stuff like that? Have you been able to track what your ROI is on that?

PTO 33 | Clinics
Clinics: If things are working, continue to work them. If they're not, don't be afraid to make changes.

 

We have not isolated exclusively to that. We're doing more and more of that. I don't have a number to say this is exactly what our return on investment for that is. I can tell you that it is significant. Our growth continues to increase year after year. We started developing strategic plans. Initially what happens is you develop a strategic plan. You're not sure what that is. You develop it. It doesn't become anything. We're to the point now where we develop it and we go back to it on a quarterly basis. The strategic plan has been a huge aspect of the entire plan. Focusing on that, understanding where we're at in regard to that and addressing accordingly, I can tell you that all of the partners' expectations on the social media site have been exceeded from what we've received on that. I can't give you a number, but I can definitely tell you it's an important aspect of your marketing program. If people aren't doing it, they’ve got to get on the ball with that.

Who's involved in your strategic planning out of curiosity?

The way our business model is set up, so we have a management company, which is the core of the umbrella. That management company has majority ownership shares in each one of the clinics that we have. We have partners that are part of the umbrella company, the management company. Those partners also act as consultants. The consultants or one of the partners will meet with the director owner at each of the clinics and together will develop a strategic plan for that clinic. We also have a strategic plan for our umbrella company that's put together by the owners and our VPs within the organization.

You've been so successful. How many clinics do you have now?

Legal entities, currently we have twenty. Within those entities, we have outside what we call satellite facilities. If you take the satellite facilities into account, we have 24-ish. Things are going well from that perspective. It's a model we've put together that when you get the structure, the processes, and the systems in place, it makes it so much easier to duplicate that process over and over.

People nowadays are so much more knowledgeable than they ever were. Click To Tweet

What would you tell someone who's starting off as a clinic owner, maybe they're in their first year of ownership? What advice would you give them in this environment about developing a practice in getting started off? Any words of advice?

We are all trained as a physical therapist to be clinicians. We take great pride in being good clinicians. Most people who are ready to go out into private practice they understand at this point that they're pretty good. They've pretty much mastered this whole clinical treatment side of the game. They have a strong affinity to that. They are drawn to that and want to continue to do that. If you are developing a practice, you need to understand and own how much you don't know. Learn as much as you can and then get the infrastructure in place. The sooner you get the good infrastructure in place, the quicker your business is going to expand and grow to the point where it's stable. Your life is going to get back to some form of balance. What I've seen in a lot of practice owners, and I know what I did for so long, was that 60 to 80-hour work week was a regular drag in every week after week after week. You're in a mode of coping with what you're doing. Oftentimes, it’s very disheveled. When you get a structure in place and systems and processes in place that goes away. That's what I would stress with somebody is don't let go of the fact that you're a strong clinician. Don't lean on that as your strength and not do all the things you need to do to get the foundation in place for your business to take off.

You need to become a business owner at that point. Not necessarily a master clinician, but if you want some stability in what you're providing and what you're doing. You feel confident in the service that you're providing to patients that you need to take ownership as the owner and as the leader. Get some business acumen in place. What would you tell those same owners that might have a ton of competition around? Whether it's a hospital-based network coming in, what would you tell maybe even yourself back in the day when you had all that competition come?

It's what we talk to our junior partners and people who are coming on to partner with us on a regular basis is you're not in competition with everybody else. It doesn't matter how many people are in the area and how competitive that area is. If you have the infrastructure in place and you're doing the things you need to do, your business is going to grow. That's the great thing about this profession. We are scratching the surface on the number of people who take advantage of this profession and moving forward that's going to grow more and more and more. I know early on people worry so much about somebody opened up across the street or down the street, "What am I going to do?" the hospital system. They're so suppressive with their physicians and not allowing physicians to refer out. You need to have a plan. You need to understand that plan, be consistent with that plan, and continue to work it. If you do that, everything is going to fall into place for you.

One of the benefits that I see from people who are starting out in ownership is that there's a capability of moving off of something that's not working out. When you have a clinic or two and a number of physical therapists, changing the direction of that bigger ship can be difficult. When you're small, you can be a little bit more flexible. You can accommodate the needs of the community a little bit better. You can make changes to the policy and procedures, take feedback and immediately implement them and stuff like that. There's an advantage there when you're young that allows you to make changes on the fly almost.

PTO 33 | Clinics
Clinics: You can get a staff to stand with you for three years, then there's an 80% chance that employee will still be with you after ten years.

 

You make a great point there. You need to have the time to be able to analyze and look at what programs that you've developed and you've got implemented. If they're working, continue to work them. If they're not, don't be afraid to make changes. I'll give you an example. Years ago, things were grooving well for us. I looked at and idealistically thought I want this organization to be part of the solution to the epidemic that's occurring in this country with obesity and the lack of movement that's progressively worsening. Those are the biggest timebombs as I see them. We focused and put a lot of money and attention into these programs not to say that it's not something that's not important. The reality over time was that while it's good, it's a great distraction to where you need to be. It wasn't paying the dividends for us from that perspective. We were a little bit slower than we needed to be to pull the plug on those programs. Having done that, you get refocused on what you need to be and you grow and build on the cash cow that's gotten you where you are. From a business perspective, that's the one thing I would recommend to everybody is stay flexible and don't be afraid to make changes if you're not seeing the outcomes that you're looking for. To see those outcomes, you’ve got to be tracking. You've got to understand what's occurring.

The important thing about your story is that you followed that. This feeling you had a little bit of a passion to do something good. You have the capability of doing it. You implemented it, but you also recognized that at some point, it wasn't fulfilling its purpose or might have taken your eyes off of the catch down and what's keeping you alive. Pulling the plug on it was an equally courageous move.

What we've done on top of that is starting to look at people in the communities where we're at, they're doing a great job with that already and partnering with them to assist back and forth. What that's created is a flexible partnership where there are referrals back and forth, which has helped our business in the long run on the PT side. We're helping not only the people we’re referring to but the people who are being referred to experts that have developed a program. From that perspective partnering with other people and networking as we have talked about is a good idea.

The cool thing about that is you've found people who are the experts in that. You guys were trying to become some of that, but it distracted you from where your core business was. Now you're able to partner with experts and support them in what they're doing. I don't want to be judgmental, but they're probably doing it better than you were or at least you like to focus on that.

What you run into is not only the networking with that particular group that does a better job producing a better product than we were able to. The collateral networking that occurs within those groups is significant because instead of now doing this all ourselves, the collateral networking to all the businesses that they're working with has expanded and allowed us to expand with them. To become a viable force against the physicians and against the hospitals within the communities. We are well-known and well-ingrained into the community. That networking model has paid off.

Understand that you're taking a risk now so that the outcome can be multiplied significantly later on. Click To Tweet

Impressive how your goal to make that part of your clinic eventually became a goal for you to support the experts in it and have now that's paid off in networking and referrals. It's most definitely a bigger having a greater influence on the community. I want to go back a little bit to the productivity of your company because to get as big as you are, and people need to be productive. I know you shared with me in the past a little bit about your productivity expectations out of physical therapists. Could you share with me a little bit about the program that you use to ensure and have an agreement with your physical therapists as to their productivity?

There's a two-part response to that. From a marketing perspective on the model that we use, we essentially look for therapists who are more entrepreneurially driven that understand what that requires. We have transparent communication with them on all levels such that they understand your performance could dictate opportunity in the future to have your own clinic and to partner with us. That in itself has been a significant recruiting tool for us. The other side of the picture is what does full transparency, communication and expectation mean? It allows us to identify those people that are not afraid of performance and helps to weed people out. We have this program called The Fair Exchange Program. When we bring a physical therapist or a PT on, we explain to them their entire cost to the organization which will be their salary, payroll taxes, benefits, vacation, personal time coverage, professional development, and educational development costs.

What we do then is we look at that and expect to get 3.8 times that number in production or in visits. We have a formula that we use for that. If they get more benefits if their cost on that overall package rises a bit. They have to work a little bit harder to see their minimum required the number to have a fair exchange. Once the fair exchange is met, let's say your weekly number is 60 visits that you need to see to get a fair exchange. If you're averaging 65 visits a week, your five visits per week above what you needed to be. At the end of each quarter, we look at how many visits above the number that you need to see are you. We pay them 25% of the total dollars of that are brought in on those visits. It's not a bonus system. We call it a flexible pay program. They have a guaranteed base salary. They have a flexible pay program where they can earn more money based on their productivity.

They'll have a smaller salary but based on their productivity, that other portion of their "salary" could vary depending on the productivity.

We're competitive in our area on how we pay people based on a starting salary when people come in. The difference between what we do and what a lot of companies do where companies give regular raises that have nothing to do with productivity. That increased income that they earn is truly earned income. What it does is it weeds out those people who don't want to work hard. They don't understand that the private practice entrepreneurial model. It also identifies those people who can thrive in this environment. Those are the best people to partner with because they understand and know what it takes to develop a practice that's going to thrive and represent the brand of, in this case, HealthQuest the way we want it to be represented.

PTO 33 | Clinics
Clinics: The more mistakes you make early on, the better things are going to be for you.

 

You found that sets you apart as one of the employers in the area. Do you find that that physical therapist now gravitates towards you? Is it like a recruiting tool?

It's a definite recruiting tool because now what happens is we hire people on and people from one class talk to the next class and they talk to their friends. We're blessed in this area to have three universities that have PT programs so we do not ever have a shortage of students between PTA and PT programs. We have multiple students that run through the organization. They learn about the organization. They go back and talk to their classmates about it. It's become a destination location both for the clinical internships but also for people who are interested in private practice. They now understand this is an opportunity. It's much easier to recruit and to hire.

I'd assume your retention is probably better as well because you're getting those people who are a little bit more motivated and understand the model already.

It's funny you bring that up. I try to look at research and a lot of different areas. There were some studies that came out years ago that indicated that if you can find a way to maintain interest and attention in an employee. You can get him to stand with you for three years. There's an 80% chance that employee will still be with you after ten years. The question is what do you need to do to maintain their interest that first three years so they've dissolved that habitual pattern working with you? What we did was we started to look at different things and we developed a professional development program within the organization. The professional program is a three-year program. Once they have several the courses they need to take and they go through a lot of different specific learning and many internships within the organization. When they finish, they receive a $5,000 bonus. They're motivated. They're going to learn and develop as a clinician with the $5,000 tag at the end that will benefit them. We benefit knowing that if we can get them to stay on for three years, they're much more likely to stay with us. Do we get people who jump ship and move around as everybody does? Yes, we get some of that but I don't think we get nearly as much as a lot of people do.

That program is not only professional development in terms of continuing education, but it's also leadership development?

There are two tracks to it. The initial track is clinical. In the clinical development program has several different markers that they need to hit. Within our organization, we have a lot of very experienced, well-trained clinicians, some that do continuing education courses on their own. They teach ongoing continuing education and they do weekend continuing training where people can come in and practice developing their skills. We have that side of the program. Once they finish that aspect of it, they move on to more of the business side, the executive training that goes along with that program. It helps some people who aren't sure if they want to be an entrepreneur. It helps them identify, "Am I interested in this or am I not?" It also helps us identify people who are going to be big players and people we want to partner with moving forward.

I want to make sure we shared an experience that you have that you shared with me. I thought I want to share your experience with the audience here because you were having some issues at the front desk and you wanted to get a handle on it with your front desk personnel. You did one thing, in particular, using a secret shopper. I wanted to get to your story on that.

Early on, we had focused so much of our attention constantly on what was occurring clinically, what was happening in the clinical area. It somewhat ignored the most important aspect of your business and that's that first impression where people are being greeted, met, and drawing their first impression. We started to look more and more into this from some communication I've had with other practice owners, etc. I started to look and I came up with the idea of identifying how good are our front desk people at greeting people at the front door, answering phones, and identifying potential patients. How are they at capturing that?

Everybody who is in practice and every facility has people that call in. They're calling in with curiosity, shopping, thinking and searing. There are so many of those people who get called in. Those are what we call missed opportunities. Every time somebody escapes with getting signed up. I always thought that our practice was pretty good at this. I thought we do a pretty good job teaching people their requirements, what they need to do. I had a company that I was talking to that offered to play a shopper for us. She called while myself and two of my partners sat and listened to the phone call. We ended up calling eight different clinics. The results clinic after clinic were simply abysmal and every call occurred and the worse it got, the more anxious I developed. I found myself walking around. I was having a difficult time listening to it.

It reached the pinnacle when one of the clinics was called and the actual partner owner, who was the director at the clinic answered that phone and how he answered the phone and how he handled that phone call was disappointing and shocking, let's say. We realized at that point we have a bigger problem at the front desk than we ever believed and knew that we need to do something about fixing this moving forward. I would recommend that everybody take a real good look at what's occurring at your front desk. How much are you respecting what they're doing at that front desk and who they are and how trained are they. Statistically, are you tracking what they're doing at the front? Are you being brutally honest in not letting people get reasonable with you? Are you providing the training necessary as needed?

The biggest question is what are your training procedures like? Are they trained or did you hand them the keys after sitting with them for a couple of days?

Initially what we have been doing in the past is we have a central administrative building where everybody essentially handles all the HR, the billing, and the finance. People would come here. They would do all their paperwork in their onboarding. We do a small orientation training process. We'd send them out to the clinics and expect the clinics to train them where they're running short staffed. That's what they were put out were these people who are insufficiently trained. The first thing we did was develop a task force of other front office managers from all the clinics and we started to identify all the different areas where work needs to be done. From there, we developed a certified training program. Everybody has to go through the training and they have to get certified, which means they have to pass written exams and practical exams. They have to be able to perform in front of us to show that they understand how to do that. We have several different areas where we do different things.

The last thing that we did at the front desk that's made a huge difference for us was recognized the number of people that call in or come in that is simply shopping. The fact that their front desk is expected to do a lot to essentially hook those people and get them in so that they're a patient. They're a big part of the sales process and we never recognize that and did anything to assist them. We've developed a program that essentially says, "You hook and bring people on, you'll get a significant incentive." We pay the incentive out quarterly, but it's pretty significant. The front desk staff all understand and know when someone's calling, they're looking for shoppers and those people that they can flip because they know each time they flip, there's another additional $50 or $100 that goes to their bonus that gets paid out quarterly. It's been a big difference.

I like the terms that you use because number one you're calling these patients shoppers and they are. If they've gotten to the point where they're calling you, they've already looked at your webpage more than likely. They might have looked on social media. They looked on Yelp, the Google reviews and at the comments. They're calling you and they're not just asking when you're open.

People nowadays are so much more knowledgeable than they ever were and that is because they explore a lot more. Everybody is looking for Google reviews, testimonials. Everybody is looking at do you have a sophisticated, well-developed, informative and creative so that it's an interesting website. If you don't have those two things, you're going to miss out on a good chunk of people because they're a good move on to the next one they find. That's phase one. Phase two on getting them is when they contact you, they're now asking informed questions. They know a lot more about physical therapy than ever before. You need a front desk staff member that is trained and can answer those questions, sound intelligent and interested in caring that can draw them in.

That might be the most important part. Are they interested in caring because if these people are calling and saying, "What times are you guys open and how many therapists do you have on staff and do you guys treat this malady?" If they simply answer those questions and hang up then that's a failed opportunity. They need to be interested in caring and say, "Tell me about what's going on. This is our experience and this is what we provide here." That gets into the salesman part of it. That's training that many clinicians bypass when they are considering their front office staff.

If you're a great clinician and you're thinking you want to go into private practice, it's everything at this point is second nature. Back then it wasn't. It was overwhelming. There was so much to know and understand. What you need to do is have some plan to understand how do I start to get the infrastructure in place? I highly recommend that you understand the value of that front desk especially early on because every call could potentially be a patient and you need to see it as such. You have someone that you have confidence that they're going to draw those people in for you. That's where it all starts.

Thanks for letting me pick your brain, Bill. You've got a ton of experience and you're successful. Things that you've done have turned into gold.

The last thing I would say is we've made tremendous mistakes along the way. We've wasted a lot of money. The heart of what an entrepreneur is somebody who's willing to take risks and understands that you're taking a risk now so that the outcome can be multiplied significantly later on. Understand that moving forward so don't be afraid to make mistakes and to lose a little bit here or there because you're going to learn on the way. Later on down the line, the more mistakes you make early on, the better things are going to be for you later on. Develop that infrastructure and that plan and then take the jump. It's well worth it.

You could definitely consider it tuition. You didn't get an MBA. You might as well invest in some of the programs that you need to whether it's a consultant or your infrastructure or the training that you do and consider that your tuition.

There's no question that comes back so much greater than you will ever expect. I know it did for us.

Thanks for your time, Bill. I appreciate it.

Nathan, no problem. I appreciate you giving me the opportunity to share with everybody.

If anybody wanted to check out HealthQuest Physical Therapy, what's your website? How do they get in touch?

They can go to HQPT.com and check out our website. If they have any questions, feel free to contact us.

Thanks, Bill.

Thanks, Nathan.

Important Links:

About Bill Knight

PTO 33 | Clinics

I grew up in an active, health-conscious family environment and I have spent my adult life passionately believing, living and attempting to exemplify the value of healthy lifestyle choices.  It is my belief that optimal quality of life is found thru conscious choices that nurture our physical, emotional, and spiritual self.

Shortly after high school, I was introduced to the profession of Physical Therapy and quickly realized this was how I wanted to leave my mark …assisting others.  I practiced honing my craft for ten years and then with the help and support of my family and founding partner, I came to see the opportunity to assist others beyond those that I could personally care for.  HealthQuest started from this realization and continues to grow and evolve today.  It started and continues with personalized hands-on care based on cutting-edge, evidence-based science and continues thru education, support and ongoing personal reactions with everyone we are privileged to assist.  Along the way, we have built an elite team that shares in this passion and philosophy of caregiving.

I am grateful for the opportunities I have been given, to develop and lead this organization and assist in its expansion as it seeks to touch and influence even more individuals along the way.  Thank you for taking the time to learn more about us and myself personally.  It is my hope and belief that the passion that this company was founded on, continues today and will always be as we expand into the future.

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PTO 27 | Powerful Team

 

Jeff Lee, co-founder and CEO of Measurable Solutions, knows what it takes for an owner to achieve greater revenues, profits, stability, freedom, and growth. What does it take? A team. An owner can never do it by himself. An owner has to have a POWERFUL team around him to carry out his vision. With a powerful team, an owner can expect to, in Jeff's words, run a company from any distance which continues to grow and run on its own and provide the owner the freedom to do what he/she wants to do. Is that not every owner's dream? Jeff and I break it down into some of the simple things necessary to do just that. We say its simple, but it takes the discipline and effort to groove these teachings in. Measurable Solutions is around to help you out.

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Listen to the podcast here:

How To Build A Powerful Team with Jeff Lee: The Key To Stability And Freedom

I have Jeff Lee, the Cofounder and CEO of Measurable Solutions based out of Clearwater, Florida, Seattle and Vancouver. It has been around since 1999. It has made its mark on the physical therapy profession. In that, it's been on the Entrepreneur Magazine's Hot 100 list and has set an industry standard for its type of executive training in the physical therapy field for executives and owners. Many of Measurable Solutions clients are Inc. 500 award winners in the past and several have gone on to win Practice of the Year in Physical Therapy. Jeff’s objective is mainly with his clients to get them to be able to run their businesses at any distance, creating the freedom to do what they want. He's achieved that with hundreds of clients over the years.

In full disclosure, me and my partner, Will Humphreys, have trained and used Measurable Solutions’ teachings for a number of years and have significantly grown our businesses to the point where we sold our clinics in the last few months. Thanks to the teachings, training, help, support, whatever you want to call it, from Measurable Solutions and their consultants. A huge kudos goes to Measurable Solutions for their help with our companies. Jeff and I are going to talk a little bit about what it takes to build a powerful team around you, whether that's staff or executive team members. We have a little bit of a conversation going back and forth. He lays down some of the laws that are necessary to get those staff members and those team members up to speed rather quickly, but also how to develop your internal staff into greater leaders. I think you'd get a lot out of it.

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We've got Jeff Lee from Measurable Solutions with me. Jeff's got a ton of physical therapy experience working with physical therapists and clinics, working through and with Measurable Solutions. Me and my partner, Will Humphreys, worked with Jeff through Measurable Solutions for a number of years to get to where we're at. Jeff, thanks for coming on with me.

You're welcome. It’s my pleasure to be here.

I've been anxious to have you on. We want to talk a little bit about building powerful teams, specifically executive teams for clinic owners in the physical therapy space. Do you mind sharing a little bit about where you came from? What got you to this point and led you to Measurable Solutions and working with physical therapists?

I've been working in this industry in terms of training executives and private practice for about 38 years now. I started Measurable Solutions back in my carriage house in Clearwater, Florida with my partner and that was back in 1999. My partner is a physical therapist and I said, “Why don't we promote to physical therapists?” He had a fairly big practice in Cincinnati, Ohio and he said, “I already tried that and nobody responded.” I said, “That was because you probably had the biggest practice in town and everybody hated you.” We started promoting to about 5,000 names. At that time there was probably about 24,000 to 25,000 private practices in the US. We started on the East Coast with 5,000 names. My partner put together a brilliant newsletter that went out to those 5,000 names and the phone started ringing off the hook.

Did you see immediate responses to your newsletter or did it take a few trials?

We were sending out postcards with very little results. There were few leads that came in. People were interested in doing our new patient course. We sent out the newsletter and on the very first week, we got 75 calls. Then there were about 45 calls the next week. We had this off of that one mailing. It was a huge return. At that point in time, we knew we hit the mother lode.

Is there something that you learned from that that you can share with physical therapist nowadays? Whether it's your approach or switching from postcards to newsletters or the content within them.

Postcards are great. It's a nice little reminder of who you are. It's more like an advertisement. Whereas the newsletters are more PR because before somebody can make a decision, they have to understand who we are. With the newsletter, you have a lot more to say. You can talk to them on their reality level and increase the reach and understanding. As a result of that, we sent out the newsletter and the postcards. That was the combination. One newsletter a month and postcards every week. Eventually, we got into the Midwest and then on the West Coast as well. We are mailing to the entire list every week.

A true owner is someone who can run their company from any distance, which continues to grow and run on its own, and provide him/her the freedom to do what they want to do. Click To Tweet

Now you're working in Clearwater in Seattle, right?

Clearwater, Seattle and Vancouver, British Columbia.

My podcast is all about helping physical therapists recognize or achieve stability and freedom as owners in their practice. You've been helpful in helping hundreds of people do exactly that. Building up their clinics to the point where the owner can not only wear their executive hat to become executives instead of just physical therapists, but also to get to a point where there are true stability and freedom in their practice as an owner. A lot of it has to do with building up that team around you.

That's very much it. We've worked with thousands of practices that have come to our office and they come in all shapes and sizes in all different locations. Everybody that comes in feels that their practice is unique and their circumstances are unique in their area. That's minorly true but not majorly. The information that we give our clients would work if your practice was on Mars. It didn't matter. Everybody would say “You don't understand, in my area, we have more ignorance per capita than the United States.” It's not true. You have to improve your hiring techniques. Your job as an executive is to continually work yourself out of a job as a practice owner. Number one, you're a PT but more senior to that is that you're a business owner and you're an executive. You're the CEO of that practice. Even if you only have two other staff. At that point, you have to start building it up.

We've come up with a goal for our clients, which many of our clients have achieved. It goes like this, “An owner who can run the practice at any distance and have it expand on its own, creating more freedom to do what you want.” I've read that and asked hundreds of practice owners if they'd like that. There's nobody who wouldn't want that. We feel it's a very worthwhile goal, which gives ultimately people more freedom. It's probably why they got into being in private practice and then they realize “What did I do? It probably would be easier for me to be just an employee somewhere.” If they have the proper tools it's a piece of cake. I say it is a piece of cake, you have to roll up your sleeves and learn a lot of basic things about business and how to run a team. How to manage it and what's the correct way of managing. There are about a billion ways to do it wrong and there is one way that is majorly correct. We've searched high and low to come up with that technology and we found it. It works like gangbusters. It works 100% of the time.

If you truly implement it.

We always give a guarantee it works but you've got to guarantee you're going to apply it.

That's the case with anything. The beauty about your system and what you guys train people on is organizing your business, organizing the structure and delegating the necessary aspects of business ownership to the property executives so that you aren't doing it all on your own as an owner.

That's where hats come in and play. The term hat has caught a lot of usages. I hear a lot of people saying it now. That came from the railroad industry where the brakemen wear a different kind of hat than the engineer and so on. In your business, you have several hats and they have to be defined precisely. The most important part about a hat and knowing this and building a team is everybody knowing what their product is. It's important for the business owner to know what the product is too. I've been in hundreds of practices throughout my career and I always ask the owner, “What's the product of your practice?” They look at me sometimes with a dumb look or sometimes they'll give me an idea of what their product is but it's not a product. It's something that they do.

Like providing physical therapy.

What's the end result of that? The definition of a product is a finished or completed thing that has exchange value. Unfortunately, on the job force now when you're out there and you're interviewing new prospective staff, whether they be physical therapists, as PTAs or admin staff, 75% of them don't know what a product is, which is amazing how they even get by. I always ask a person, “What kind of products have you produced in your last job?” You take a look at the sports industry. They're very much in tune with that. They're only going to hire players that have stats. Whereas most business owners will hire people if they can fog up a mirror.

That's true especially for those of us who are looking for physical therapists. We’re just looking for a warm body.

A lot of times it's in desperation. There was an emergency created because there wasn't anybody looking for PTs when they should have been. They put it up to the last minute, “We got to hire somebody because we are getting a flood of new patients in.” It's always too late. It's horrible. Many times, you're better off not hiring somebody if they're the wrong egg.

That could take months, if not a year or more sometimes to overcome someone that isn't a good fit that can poison your team. I've experienced that myself.

It has devastating effects especially when you have a smaller group. The effects can be very not as devastating but they still can have the potential to be super devastating for a bigger group. You get one bad egg and you get a wrong guy in there whose intentions aren't very good. They can taint a group.

PTO 27 | Powerful Team
Powerful Team: Your job as an executive is to continually work yourself out of a job as a practice owner.

 

How do you find those people? How do you develop then a powerful team? It's a matter of planning and hiring the right people but what is your instruction for us? How do we create a powerful team around us so that we can become that owner that can run the company at any distance that grows on its own and get the freedom to do what we want?

One of the things is, “Can they produce a product?” When a person comes in, I give them something that is not too hard, not too difficult to produce or it is something that's needed. Let's say you're hiring somebody at the front desk or in your front office. You need somebody who has some skills with people. I’ll give them a list of people that you need to reschedule or get reactivate. See if they can fill that book up and have people come in.

As part of the interview process, you'll have them do an on-the-job interview.

I give them a little trial for a couple of days, sometimes three to really tell you. I got that from Nordstrom. When Nordstrom hire people, before they bring them on, they have to go around to each manager in the store of each department. That person has to give them a thumbs up. It has to be 100% thumbs up from every department head before they bring that person onboard.

That means the department heads worked with them in order to get to that point.

They worked in there. They worked side by side. They saw how fast they could pick up the job. They saw how their people skills were. Were they polite, did they have good manners or were they rude? Did they have good manners while they're carrying a dagger behind their back?

I've had applicants come through the process. They've been on the phone, they've done a group interview and they’ve done a one-on-one interview, and I put them in the on-the-job interview. I'm thinking the entire time this person is going to fly on through. What happens is when they get amongst your peers and not trying to impress somebody, they let their guard down a little bit and show who they really are. The things they talk about, even their language sometimes and more importantly, how they interact with the patients and fellow employees and attempt to get their product is huge. It's very revealing.

Those are the two main factors in selecting the right person for your team. Number one, can I produce a product? Number two, what are they like when the mask comes off? When we were dating in high school, you go out for the first couple of days and you think you've got your dream person. Then after sometime, you start finding out who they really are. That's what you want to get stripped off as soon as possible before you commit to hiring a person.

Would you use the same protocol for say you've had somebody that's worked with you as a staff therapist for a number of years and you think they're going to be a great manager or clinic director or maybe even a marketing director? Would you utilize the same process to test those people internally who are already with you?

I see a lot of guys make mistakes along that area. They get a good person who can produce and they are a production machine. Then they put them on an executive position and they fail miserably. What you have there is a worker orientated type of executive. An executive is somebody who knows how to get the job done but doesn't do the work. He gets others to get the work done. You've got to see how good are people at getting others to get jobs done. That's your measuring factor whether the guy's going to be a good executive or not. You don't want somebody who's going to piss everybody off either. Some people's management skills are like that of Adolf Hitler’s or something like that. That's not the way to do it. You're trying to increase the affinity. You're trying to increase everybody's participation. You're not going to get that by yelling at them. You’ve got to have somebody who's persuasive but is right in most of their decision-making process and has some leadership skills that people want to follow.

How would you measure that? Have you recommended certain tactics or techniques to use to measure some of your internal staff's capability of moving up the ranks?

I do stuff like leaving them in-charge for a couple of weeks. Somebody goes out of town or somebody goes on vacation or whatever and then that person steps in. You can see what they're made of before you committed like, “We are now officially posting you as the Grand Poobah over this area.”

Especially with the expectation that so and so is gone for a couple of weeks but your job is to not let anything fall through the cracks. We're going to act like that person’s never left. Would you be upfront with them saying, “This is a trial,” or not so much?

Not so much. The other thing is you're going to know and especially I like to do things with my staff. We go and do outings and different stuff like that. You start to see people who are the ringleaders. You start to see who the Alpha people are. That's who you want. You want somebody who's not rubbing people the wrong way but they can bring the group's morale up. That's important that you have somebody, then the rest of it can be trained in. That's the other thing in terms of income. One of the definitions of lost income is the amount of money that you could have made but you didn't. Where I find that money going out the door is basically not training their staff. You take a look at where the income comes from. There are two laws. Hatting equals control, hatting is another word for being trained on one's job, and control equals income. If you want to increase income, you have to increase control.

There are about a billion ways to manage a business wrong and there is one way that is majorly correct. Click To Tweet

How do you increase control? By training and getting more skilled at the job. Your front desk, if they know how to keep that appointment book full and get 98% of them coming in at the scheduled time, it takes some skills, that takes some practice and that takes some training. The other thing is that you have to drive in on what the purpose is of the practice so that people can get behind what you're doing and it makes more sense. Not only do they know the practice’s purpose but they also know the purpose of their job and how it fits in.

Would you say if those people are properly trained on the purpose of the company, their job and they know in detail the product they are to produce in their job to the point where they have control, that's going to increase your income, based on the laws that you just laid out? The training doesn't have to be severe. It's making sure they understand the purpose. They understand the product and then the step-by-step parts of it start falling into place when you have the right person. The training is important but if they're the right person, they're going to follow those training and find even better ways to make things happen.

Especially if they have the purpose. Do you know what the formula for living is? It’s having and following a purpose. To what degree are people living? How strong is their purpose? It has to be super strong plus they have to demonstrate it in life and on their job. Somebody who has a strong purpose is dedicated and who is aligned. They get up in the morning. They're excited about coming to work on the effects that they're going to create because they have such a strong purpose. Their degree of professionalism is going to be a lot higher than most. They're not going to settle for being an expert, they're going to be a super expert.

PTO 27 | Powerful Team
Good to Great: Why Some Companies Make the Leap...And Others Don't

It goes back to what you hear some consultants talk about. I know in a popular book, Good to Great by Jim Collins. He always says, “First who, then what.” Once you find the right person, and maybe you can share your experience with this, when you have that right person that's already in your company and you recognize that they're rock stars. It's almost like you can drop them into other departments and know that they will continue to succeed.

I have a couple of key execs who are like that. I can pretty much put them anywhere. The reason for that is they've been trained on this technology more than most.

Your training isn’t just one-day things. You're spending, would you say months?

It's equivalent to getting an MBA. An MBA where you have to get results and they have to prove it. It shows up in their stats. It’s like a good ballplayer. As a coach, you're going to invest more training into that individual because you know you're going to get more mileage out of it. I come up with another law here is I always flow power to the direction that I depend on power. If somebody is proving themselves to be very good. They're getting results and very competent individuals, I will flow them power. Like more money, more time, more training, more assistance and more everything. I want them to have longevity on the job. I'm going to give them assistance. I'm going to have somebody go get their lunch for them if needed and all those kinds of things. You flow power to power, that's basically it. That comes from a law from Aaron Hubbard. That's how you can grow a group is you flow power.

One of my consultants used the term like, “Feed your tigers and shoot your dogs.”

I was looking at the Seahawks playing the Rams and it was a tight game. If you do something wrong, you get penalized. If you do something right, you get a bonus. These guys were following one of the main rules in business, which is you get what you reward. When you reward an up-stat or somebody who's a high producer, you’re going to get more. If you reward a down-stat or somebody who doesn't produce very well, you're going to get more of that too. You penalize down stats and you reward up stats. If the government did that, we wouldn't be in the pickle we are.

That goes back to when you have what you might consider B and C players around a bunch of A players, the A players are going to leave. They could go two ways, they either become B and C players themselves but if they've got a strong purpose, they're going to find some other place where they can succeed.

That's where good leadership comes in. If you have your A players and you have some B and C players, the way you manage those B and C players is how you're going to keep the A players in the game. There again, you flow power to the direction where you depend.

What is your recommendation when a group comes to you and they figured out that they've got a ton of B and C players? Maybe they have one or two A players. Yes, reward them, help them out as much as possible, but what do you recommend to the Bs and Cs?

It's like you have to fish or cut bait at some point in time. If you based off of statistics, if a staff member is costing more money than they're making you, that's a curtain call but you’ve got to know how do you measure that? How do you know when somebody is viable or worth their weight? What production level? For instance, you had a guy where you were getting 25 new patients a week. Then you hire this person who's a PR and marketing guy to drive in more patients and now you only have 20 new patients. He's gone. He's costing money. If he comes in and now you've got 50 new patients. He has to do more than 25 in order to be worth anything. That's how you measure something like that.

If he does well, then flow more power to him. With those Bs and Cs, it's going to be important to have those one-on-one conversations and be upfront with them. You've got to make sure they all understand what their purpose and their product is and then have an accountability meeting that says, “What's your purpose and your product? What’s your key stat? What's one way to measure if you're doing well for me or not?” Whatever the owner decides that number is and has agreed to with that employee, then they need to look at it objectively and it's not an emotional conversation at that point. Are you pulling your weight or not?

They either are or they’re not. In some cases, you get a guy and he can get some products but they're far inferior between and they're not such good quality. You can turn that guy around that has some potential or at least an inkling by getting them in on what their real purpose is. Getting them to understand what their product is and all the sequence of steps in order to get it and then pump up the volume.

Many times, you're better off not hiring somebody if they're the wrong egg. Click To Tweet

Sometimes that clears things up. Once they're clear on that and you invite them, “We want you to stick around. There's a reason we hired you. Can we agree that if you start doing these things and start producing, we're going to be together for a long time?”

If you do all that and you still have goose eggs, then you’ve got to push the eject button.

I've never fired someone too quickly. I’ve never looked back and thought, “I should have kept those people around a little bit longer.”

I err in that direction of keeping somebody on too long just like everybody else. The reason for that is because you try to give people chances. The reason why you hired them is that you thought they'd worked out. When it becomes plain, you have to cut bait quickly and not waste around on it and not hesitate. The other thing is some people only hire when they need staff. You should continually be taking applications as a business. Always, never stop hiring.

Never take the ad off. You always want to keep that inbox full of résumés. It helps so much. It lessens the fears of what might happen in the future. If it allows you to cut bait and do some tuck greeting. Just to have some of those résumés onboard at all times. We've used that principle in the past and it's allowed us to turn people over quickly when you get that sudden leave. Someone suddenly drops their notice and doesn't even give you two or four weeks as might be a professional etiquette and say “We're going to hire somebody here by next week. We won't miss a beat.”

Following that practice has been huge for us in our practice in the past. That's been very comforting and maintains the stability of the practice as you do that. That can be a little bit harder with physical therapists but once you get the pipeline rolling, you can have two or three people who are on the bench per set ready. Maybe they've already had on-the-job interviews. Maybe you’ve kept in constant contact with them so that even when your physical therapists go down, you can return to some of those people and see if they're ready to take on a job with you.

I have known practices that did just that. They had all kinds of applicants ready to come in and they had a mass exodus. They had a bad egg in the group, which is like a white mutiny. Within one week they were right back to slugging. The guy lost about 50% of the staff. I can't stress that enough in terms of being a good executive is having a personnel pool or staff ready to standby. It is like having your national reserves.

We've been straight up with those people who are waiting in the wings like, “We don't have a position for you right now, but we'd like to stay in contact with you in the future. If you move positions or if you're looking for something, you're ready to move away from your company or a position that you're at, will you please stay in touch with us?” We developed relationships with these people. When tides turn and they typically do, then we'll find a position for them. Sometimes even if we don't have a position for them, we'll bring them on anyways. If we think so highly of them, we'll find a place for them somewhere.

PTO 27 | Powerful Team
Powerful Team: An executive is somebody who knows how to get the job done but doesn't do the work.

 

Sometimes a person can get caught in the rut in terms of hiring people for certain positions. They hire one person, they don't work out. They hire the next one, they don't work out. The third one finally comes along and it works out. They wasted six, sometimes nine months of production in that area. Why not hire them all three at once and then the best man wins? That creates some healthy competition amongst the three people there because they know if they don't cut it, it’s curtains for them. Sometimes they'll see that they're not going to be able to compete with the people who are there. They'll self-eliminate. Let's say you’ve got some potential. You can see that the person can produce products. There are three different kinds of hats that people should have on getting somebody onboard. The first hat that they should have is an instant hat, which is usually like one page.

You do these things to cover the basics of your position.

Something that can be grooved in on a guy in fifteen minutes or maybe half an hour. We call that an instant hat. They do the instant hat and they get more productive and go, “That's awesome.” Now you give them a mini-hat. The mini-hat is a little bit lengthier. It might take a couple of days full-time to get through it. You feed it to them over a period of time. They eventually get their mini-hats on. It gets them a little bit more in detail of what their duties are and how to handle this and that. How to handle an irate caller or different things like that. Once they've got that and they're doing pretty good, then you give them a full hat. It will take some time to get through but it's every part of the hat, soup to nuts.

Every possible scenario, every possible situation and your approach for all of them.

Let's say you have somebody who's doing great there. They start doing other hats of their neighboring positions in the clinic. Pretty soon, they do all these four hats and they know every hat in the organization. Now, you've got somebody who has the makings of an executive.

The higher the willingness of staff member has, the better staff member you have. Click To Tweet

Then they start training the next person to come up there take over their hat. That's essentially what you do.

The ideal scene is every staff member in the practice knows how to do everything top notch. They know every hat in the organization. How flexible could that be? You're going to have each of those individuals who have specific responsibilities like over the admin, the hiring or over the production or somebody to do the marketing and PR. If you have everyone trained to do marketing and PR, then they can all shift over there and help out in marketing and PR and drive the public in. Drive all the new patients in and then you've got everybody who can deliver in there and everybody’s in there is pitching in on the delivery.

I'm not alone in this but I've had plenty of techs who would cross train to the front desk. When you lost that front desk person it would be huge to have a tech that could cover the front desk. I even had some of my PTA do some tech duties but they'd also do front desk duties and know how to call insurances and whatnot. In times of trouble, they would more than happily jump in and made for some huge flexibility.

That would be an ideal scene they have to get. That gives you the importance of these hats and putting those hats together is usually a big task but it's a very worthwhile task if the hats are done fully.

The instant hat, mini-hat, full hat, those are things that can be compiled over time not just by the owner. The people who are performing those jobs well, if you could ask them to take fifteen minutes to start writing down some of the things that you do. Maybe they start doing that on a weekly basis and over the course of a few months, you're going to have a solid hat.

You give that only to your rock stars.

The only ones who are producing. Not the people who you're going to fire next week.

You give your competition that hat.

PTO 27 | Powerful Team
Powerful Team: Being a good executive is having a personnel pool or staff ready to standby.

 

Is there anything else you want to share with us about building a power team?

There are three factors. There are three classes of staff. The one that you keep around is your willing staff member. You’ve got to take a look at it. Are they willing to do whatever? You don't want somebody who is, “I'm sorry, I don't do windows.” That's not a willing staff member. You want somebody who is willing to do anything. If they can't, they're eager to learn how. That's a willing staff member. Then you have the other two, which you want to get rid of. That's the defiant negative and the wholly shiftless. Which means wholly is entirely and totally all together. Shiftless is lacking resourcefulness or inefficient or lazy. Your person who is not quite there, lazy, wholly shiftless, you don't want those guys. Your negative defiant guys are you go black and they go white, you go fast and they go slow. They're always opposing everything.

Those guys are pretty obvious. It's the wholly shiftless where you're giving them another chance, “Let's move them to this position. Let's give them more training. Maybe we weren't clear the first time. Maybe there's something going on at home.” There's always an excuse or you always want to give them a second chance, third chance or fourth chance. Those tend to be the wholly shiftless. They're not as easy to spot sometimes as the negative defiant.

What it is, is if you've got somebody who is saying yes to you and they actually mean no. It's the individual what we call non-compliant. You give them an order, you give them a task to do and they never get it done. Not right off the bat is that a wholly shiftless person, sometimes they have too many things to do. They're doing them all and they can't get that thing done. If you give it to somebody, an individual who is not overwhelmed, who needs more work to do and you give them a task to do and they don't do it and they say, “I'm all over it. I'm behind it 100%,” and they never get it done.

They'll come back with lots of excuses.

I found it better to just push the eject button. As an executive, you're there to cultivate willingness. The higher willingness staff member you have, the better staff member you have. I treat them good, pat them on the back, buy them candy, get flowers or whatever.

Thanks for your time, Jeff. It was nice talking to you again.

It’s my pleasure.

Thanks for your insight on helping people develop that power team to get the owner where they want to be. I love what you said, the owners that can run a company at any distance continues to grow and run its own and freedom to do what you want. I love that definition of an owner. Thanks for your time, Jeff. I appreciate it.

You're welcome. Thank you.

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About Jeff Lee

PTO 27 | Powerful Team

Jeff F. Lee is Co-Founder & CEO of Fortis Business Solutions, an international business training and consulting firm engaged in the areas of business management, product de-bugging, ethics, PR, marketing, sales training, succession planning exit strategies, helping companies in turnaround situations. Fortis is an umbrella company that owns the brand “Measurable Solutions” and “Veterinary Practice Solutions” Measurable Solutions made it on the Entrepreneur Magazine “Hot 100 List” and has set an industry standard for its type of executive training company for being the fastest growing company internationally for 5 years in a row. Many of Measurable Solutions clients are Inc. 500 award winners and several have won practice of the year in their respective areas. The “Veterinary Practice Solutions” brand has helped hundreds of veterinary practices expand their practices several times over and has helped the practice owners into owner independent practices.

Mr. Lee’s objective with his clients is to get them to be able to run their business at any distance creating the freedom to do what they want. And has achieved this with 100’s of clients. He’s clients have achieved many Inc. 500 awards as well as won PT Clinics of the Year.

Since 1979 Mr. Lee has been involved in business management and consulting for entrepreneurs, Financial Advisors, and health professionals, as well as international finance and estate planning.

He holds Certificates of graduation and MBA from the Hubbard College of Administration has been interned in Executive Management, Organization Executive Course, Strategic Planning, Financial Planning, Organizational Communications, Ethics & Justice, Management by Statistics, Public Relations, Marketing, Sales, Data Evaluation, Product De-bug, Quality Control and Business Development.

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