Dennis Crandall, MD, founder and medical director of Sonoran Spine Center in Mesa, Ariz., originally began practicing as a member of a large group and then struck out on his own to begin a spine specialty practice. "Initially, I left a 15 person general orthopedic surgery practice to start my own spine center," says Dr. Crandall. "That practice had a highly evolved and developed business structure with a very talented practice manager and a talented legal and accounting team in place. I went from a very evolved structure down to me and four employees starting my own spine practice."
Dr. Crandall discusses eight lessons learned from starting his own group.
1. Don't try to do it all yourself. To initially keep his practice lean, Dr. Crandall decided to do all the interviewing, hiring and some of the human resources responsibilities himself. As a result, he spent a good deal of time on the management side of things and employees began coming to him with petty office squabbles.
"These workplace dramas and disputes weren't a good use of my time," says Dr. Crandall. "It was a little more than a year when I decided not to spend my time doing that; I needed a practice manager. What I realize now is that this single hire was the most important hire having to do with the success of my practice."
Since it first opened, the practice has grown to include mid level providers, X-ray and physical therapy services and additional satellite offices.
"All of this takes far more intricate relationships and business strategies that would have been beyond me as a spine surgeon," says Dr. Crandall. "Have the right practice manager with the right background giving you clear, honest, unfiltered advice and helping go through the raw data to see how decisions are made."
2. Settling for a less than perfect practice manager isn't smart. Don't settle for a practice manager who doesn't fit your practice culture or criteria just because the process is rigorous. Even after the business manager is hired, don't keep them around if they don't fit within the practice structure.
"We went through a couple of people before we ended up with the person we've had for the last several years," says Dr. Crandall. "Had I not picked the right person, it would have been a disaster. The single critical most important hire to get right is the business manager."
It's not easy to find the right person for the job because they need experience doing many different things, including managing employees, providing leadership and tackling the budget.
"The office manager needs to be excellent in business practices, personnel management, understand employee benefits, excellent in working with the accountant and analyzing the monthly numbers and projecting the future based on current trends," says Dr. Crandall. "They need to be excellent in problem solving based on the new things their surgeons want to do."
3. Find leaders and partners with thick skin. Spine surgeons are all well-educated and experienced by the time they form a private practice and practice managers must be able to function at their level while also taking criticism when necessary.
"In order to work with a bunch of ego-centric surgeons, this person has to have thick skin and be able to be good politically," says Dr. Crandall. "They have to be able to keep the surgeon shareholders happy. Thankfully for our group, we don't have ego maniacs, but the manager still must have good interpersonal skills."
Dr. Crandall's practice manager is a former chief operating officer for a small hospital and was a good fit because her personality and skill set allowed her to work well with the surgeons.
"She was able to do anything we wanted her to do," says Dr. Crandall. "She had the personality to work with surgeons and have fun and not take any of us too seriously in the meantime."
4. Build an advisory board for objectivity. As the practice grows, having a board of close advisors with different expertise can give you objective information about how to proceed with the practice. An advisory panel should include your healthcare attorney, accountant, practice manager and surgeon shareholders.
"We needed an advisory board or panel in addition to our partners to help us see things objectively or more clearly to give good advice about new practices and keeping the practice healthy," says Dr. Crandall. "They should talk to each other. When we approach our accountant for advice, he'll give us his opinion and then talk to the attorney to make sure there is nothing wrong with his recommendation."
The panel has helped advise on Stark issues related to acquiring and financing an expansion, such as adding additional imaging equipment, and building Sonoran Spine's non-profit research foundation. The panel gives advice on how to treat each move structurally for a tax advantage and make sure everything they do is on the right side of legal requirements.
5. Set goals and bring everyone on board. Spine surgeon shareholders in the practice must have a set of goals so practice managers can clearly understand how to direct the group. Everyone should fully be onboard to make sure these goals are realized.
"Once the business manager has clear directive of what the partners want, the business manager should go about pursuing that and come back with a 'to do' list or 'already done' list as requested," says Dr. Crandall. "If there is a disagreement because the business manager thinks the direction partners want to go isn't healthy for the practice, or risky from a legal standpoint, that's a discussion that needs to be had with the partners so everyone understands the issues."
If there is too much space between the surgeon partners and manager, practice growth will be stunted.
6. Create checks and balances for financial issues. The practice's finances must be handled with care and should include checks and balances to make sure all the numbers come out right. Dr. Crandall has implemented "safety" or "accountability" protocols in how the office staff handles cash, billing and posting.
"Make sure all of the money issues have redundancy in their processes so that you are comfortable the system is going to work," says Dr. Crandall. "Employees should have a sense that they can't be dishonest and not have it noticed. It will be noticed."
You can create a management team to oversee these issues or design the processes so everyone is accountable for their actions.
7. Avoid legally risk business. Take consideration to avoid transactions or other business decisions that are legally risky, if not breaking current regulations. Your advisory board will be able to assess the level of risk for these decisions. Follow their advice and avoid situations that could be troublesome in the future.
"In some cases an idea might seem forward thinking, but it's too risky," says Dr. Crandall. "It might be safe if it is done in another way. The right practice manager should have the skills to work out these issues, such as financing or real estate negotiations, because they are a fact of life for a growing practice."
If the surgeons and practice manager are at odds about a legally risky decision, it could spell trouble for the practice. When the manager takes a firm stand against a risky position, surgeons either decide to back down or proceed without the manager.
"It might make the partners decide to change the management leadership of the practice," says Dr. Crandall. "But the key is a full airing of honest opinions and discussion among stakeholders and advisory team. This is a great time to provide everyone with clarity about the conflict. When these types of conflicts remain, they are often the source of a practice breaking up."
8. Pay attention to the metrics. Prepare for the future by paying attention to your past and present practice metrics. The practice manager, or another person within the leadership structure, should have a strong accounting background to see where the practice is and where it's headed.
"We need to know which metrics to watch the closest and how to project for the future to know when it's the right time to expand," says Dr. Crandall. "They tell us what areas and disciplines are to our advantage to expand and when to hire a midlevel practitioner or how to get the best productivity out of a person. All of these things can be decided once you have good data."
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