[ALISON]:
You’re listening to the Grow a Group Practice podcast. Whether you’re thinking of starting a group practice, are in the beginning stages of a group practice, or want to learn how to scale up your already existing group practice, we have lots of great content for you.

Hi. Welcome to the Grow a Group Practice podcast. I’m Alison Pidgeon, your host. Today, I have a recording of the talk that I gave at Killin’It Camp, which just finished up this week. And we have it split up into two parts because the talk was about an hour long. So if you are starting out listening to this one, definitely make sure you listen to part two, that’s going to come out the following week. So I’m talking all about how to scale up your group practice while also reducing your work hours. And there were questions from the audience. And you’re gonna hear Sam, our chief marketing officer, she was the moderator who was reading off the questions to me. So if you hear her voice, that’s who that is. And I thought it went really well. I did have some slides that went along with the talk. So definitely check those out because towards the end of the talk I start talking about different organizational structures for how a practice could look and I made some diagrams to go along with that. So it may not make total sense just from hearing the audio; you may want to go and look at the slides. So definitely check those out. They will be in the show notes. And I hope you enjoy this talk.

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[ALISON]:
So today, we’re talking about scaling up your group practice while reducing your work hours. And I wanted to tell you a little bit first about how this presentation came about. So I was at Killin’It Camp last year and Joe was giving a presentation and just sort of like made this offhanded comment about how I had this big group practice, and I only work five to ten hours a week, and I retired from doing therapy, and everybody’s brains exploded. And then there were people pulling me aside in the hallway, like, what was Joe talking about? How did you do that? I don’t understand. So that’s where this topic came from because it definitely piqued a lot of people’s interest. And it’s kind of counterintuitive, because people think like, oh, the bigger your business gets, the more you’re going to have to work. But that’s actually a myth and we’re going to talk about that.

So let’s jump in here. I have a group practice in Lancaster County, Pennsylvania. If you’re familiar at all with where Philadelphia is, we’re about an hour and a half west of Philadelphia. We specialize in women’s issues, I have an all female staff. And I have… I’m losing track because I’ve been adding therapists so quickly. I think we’re up to, like, seventeen or eighteen therapists now. I have three or four more who are going to be starting this fall. So the pandemic has been actually really great for business, as I’m sure it has been for lots of other people. So client demand has definitely ramped up and I’m trying to hire people as quickly as I can to meet that demand.

So in addition to running the group practice, I have three other businesses. So I own Move Forward Virtual Assistants, and I own a building that is where the counseling practice is housed, so that’s its own separate business. And then I also do business consulting for Practice of the Practice. So I’ve been doing that since 2016 and over the years have developed the specialty of helping people go from a solo practice to a group practice, and now moving more into helping people who are established group practice owners figure out how to continue to scale up. Once you have a handful of conditions, you sort of are met with a new set of challenges. And I get a lot of those clients now where we’re talking about, you know, how do you… exactly what we’re talking about today, a lot of the common questions are, how can I remove myself out of the business as much as possible? How can I not feel like I’m putting out fires all the time? All of these sorts of things.

So a little bit about me personally. I’m married and I have three little boys. They are eight, six and fifteen months, and it’s very busy at my house and loud most of the time. And what’s really important to me is that I have freedom of my time. So me setting up my practice so that I could really pull myself out has been a really big goal of mine. And I’m going to talk a little bit more about how last summer, when I went on maternity leave, I was able to structure the business so that it was totally running without me and I was off work for three months. So if that seems like a pie in the sky dream to you, it is possible. It’s all about how you structure the practice and how you delegate things, and we’re going to talk about that today. So, you know, if that’s a goal of yours, then definitely pay attention and take some notes during the presentation today.

So one of the first things I wanted to talk about is why would you want to scale up your practice? And so these are kind of all of the benefits, or the positives that I see coming out of scaling up a practice. And so I’m talking about… when I say scaling up a practice, once you start going beyond, you know, eight to ten clinicians, you’re starting to build a pretty big practice. And so one of the things that I feel really positive about is that I am able to provide jobs, and I’m able to provide jobs where people feel like they’re treated well, they’re paid well, they have a good work-life balance, they have a positive work culture. And what was really cool was that, you know, when the pandemic first started, and so many people were getting laid off and that kind of thing, I was actually hiring, and I was hiring administrative staff and ended up hiring somebody who had gotten laid off because the business they worked in shutdown. So that was really cool that I was able to do that. And that obviously made a big difference for that person, because they were unemployed, to be able to start working again. So that always makes me feel really good when I meet with my staff, and I’m like, I employ all of you, this is awesome.

The other thing that I feel really strongly about is when you grow your practice, you’re just increasing the quality of mental health services that are available in your community. So I came from community mental health, like, a big agency where, you know, there were some really great clinicians, and there were some clinicians who weren’t so good. And the quality of the service that you received, unfortunately, could really vary, and people could easily kind of fall through the cracks because the system was so big. So I know now how to make sure I’m hiring really quality people who are doing good work. And so I know because we get compliments all the time from clients, what good work my therapists are doing, and how much they’re helping people and making a difference in their life. So that’s another really cool thing as well.

And then the third thing I put down is making more money. So that’s usually one of the big motivators for people is that they realize that, in a solo practice, you’re really tied to how many clients you can see, that is going to be the cap on your income, right? Like, unless you can see a client, you’re not making money and we can only see so many clients in a week, or in a day, because we’re not machines, we need a break, right? So when I am, let’s say, here right now, talking to you all, my staff is working, they’re making money, they’re generating income that goes towards my salary. And so I call it semi passive income. It’s not totally passive, because I’m not just like, sitting back doing nothing, but I’m also not working as much as I used to.

And then the second part of that I call income protection. I made this phrase up. I don’t know if this is the right way of saying it. But essentially, if I can’t work, like last year when I went on maternity leave for three months, most, again, solo providers would just not have any income for three months, but I still did. I was still collecting a salary from the practice, even though I wasn’t working at all. And so if anything were to happen to me, God forbid, in the future, like I ended up in the hospital for a while or something like that, my income is not going to be affected because the practice is still going to be running, my other businesses are still going to be generating money that’s not dependent on me delivering something. So a lot of people might, you know, like, for a while I had a policy through Aflac because I was worried about, like, what happens if something happens to me? I need short term disability or I need some kind of policy just so that I’m protected if I can’t work. And then I realized after I put this structure in place, like, oh, I made my own Aflac policy. I don’t need that anymore because I can not be here and still be making money.

The fourth one is more influence. So I really noticed after you grow to a certain size, it really helps the community to sort of see you as being more legitimate and this can help you in a variety of ways. And so I think this also helps to have more opportunities. And also, the more your reputation grows, the more you attract really good clinicians who want to come work for you, and all that kind of stuff. So there’s definitely lots of different ways that that kind of manifests itself.

And then the last one is about decreasing your work hours. So this is what I was talking about before. Seems a little counterintuitive, right? Like, well, now I have twenty therapists, I must work a hundred hour weeks, right? But that’s not what happens because I can now afford to hire other people to do things I used to do, and still collect a salary. And so I can really pick and choose what I want to keep doing versus what I don’t want to do anymore. And so I have pared down dramatically. And we’ll talk about this a little bit more, we’re going to go into great detail about this, pared down what I do in the practice pretty dramatically. And really, the only thing I still have a hand in is hiring, finances, and anything related to, like, expansion or any sort of new services or things that we want to start. So everything else that happens in the practice is done by other people.

So the next slide is I just wanted to address some of the myths because like I said, a lot of times people will kind of have these preconceived notions about why they don’t want a bigger practice. And so one of the things I commonly hear is, well, I’m gonna have to work more hours, like I said, you have this vision in your mind of, like, you’re going to be doing all the same stuff with twenty clinicians that you’re doing with six clinicians. And that’s not true at all. And so it’s really about how you have the business structured and how you have things delegated, that is going to help you to work less hours. And also, you likely can reduce your clinical hours, because you are going to start drawing a salary from the money that the other clinicians are bringing in. Especially when you’re in the first beginning stages of a group practice, so much of your salary is probably coming from you seeing clients, because you might be putting money back into reinvesting or, like, you only have a small number of clinicians, and they’re just kind of covering the overhead. So all of your money that you’re generating from seeing clients is going towards your salary. And it can be sort of hard to see, well, how am I ever going to get to the point where I don’t have to see as many clients anymore? And we’ll talk about what that structure looks like and how you can get to that point. But you definitely can cut back on your clinical hours if you want to.

I got to the point where I just didn’t want to do any clinical hours at all anymore. I have kept my license active, but I don’t see any therapy clients anymore. And actually, that’s been a nice change for me. It was something that I felt like after, you know, thirteen, fourteen years of being a therapist, I was kind of ready for a new challenge and wanted to put more of my time into the business consulting. So that was a choice that I made. And I can always go back and see clients again if I want to, but right now I’m not and it’s working out pretty well.

So the second myth is I don’t have the money to expand. So what happens a lot of times is that you kind of find yourself in this chicken or the egg problem, I call it. You know you need to put money in to grow the business, but you don’t have the money to grow… you know, it’s like which comes first? Like, do I need the money first and then do it, or somehow find the money so the business expands? So I would say if it’s something that you really want to do, you will figure out a way to find the money. I always tell people the story about how I really wanted to buy an office building for the practice. I had no money to buy a building, but I figured out a way to get the money and I have a building now. So it’s all figureoutable and you will find a way and it’s actually probably not as expensive as you think it is.

And then the last myth is that it’ll be too much for me to handle. So I think this goes back to if you’re delegating well, if you’re really relying on your people and entrusting them to get things done and you’re able to, you know, not that you’re going to completely stick your head in the sand and not be paying attention to what’s going on in the practice, but you are going to let go of those tasks as much as possible, so that other people are handling it. So sometimes, we have a customer service issue and my office manager, who is amazing, she will just handle it. And then later, she’ll tell me, oh, this and this happened, and this is how I handled it, and it was fine. She didn’t even have to get me involved, because I empower her to take care of those types of issues. So I would say now, it’s the kind of the higher level stuff that I have to deal with now, which can be a lot, but I look at it like, I have a great support system, I have other professionals that I can lean on if I need something. And again, it’s something that I can figure out.

So, for example, we had a HIPAA breach in the practice, this was like, two weeks ago, and I had to call my lawyer and figure out what to do, [unclear] malpractice lawyer and all of that kind of stuff. And they told me exactly all the steps to take and it was like, okay, this is how we handle this. And it was really unfortunate, and we had to put some structures in place so that it doesn’t happen again. But I didn’t like, crawl into a ball and not come out of hiding. I had people to reach out to who could help me and figured it out. And we dealt with it, and now we can move on. So definitely find those other professionals – and we’re gonna talk about that too towards the end of the presentation – who you can rely on and who can help you, especially if you get into a sticky situation.

[SAM]:
Okay, Alison. We’ve had some questions come through.

[ALISON]:
Okay, great.

[SAM]:
So, are your therapists employees or independent contractors?

[ALISON]:
So in 2015, when I started, they were independent contractors. And then at the beginning of 2020, I switched them over to all W-2 employees.

[SAM]:
Cool. And then, I hear that your hours of work might not increase significantly but how about your stress level?

[ALISON]:
Yeah, if you’d asked me two weeks ago, when we had the HIPAA breach in the practice, yeah, that’s a whole ‘nother story. But no, you know what I think makes such a big difference with the stress level is just being really – and we’ll talk about this too – being really picky about who you hire, and making sure you’re hiring people who are good fits, that you trust to get the job done. And like, I don’t worry at all. When I have a good staff, and right now I have an awesome team, especially my office manager just, like, takes care of things, and like I know if I give her something to do, it’s going to get done. She’s gonna do it right away. I don’t have to check up on her to make sure she did it. So that really helps me to sleep well at night, for sure.

[SAM]:
And then I think this is in reference to the Mythbusters slide, especially the point on I don’t have the money to expand. Someone’s asking, how did you find the money?

[ALISON]:
Yeah, what I did was I just kept taking the profit that we were making, and reinvesting it. So for example, like, I started out in one office, and then I had three people, including myself working out of that office. And then when we got full, we moved to a two office suite. And then as we started hiring more people and making money there, then I was able to afford to rent another office. So it was like a very slow process of building up, just taking the profits and reinvesting them. I think there’s good parts and bad parts about that. The bad part is you’re going somewhat slowly. I think if I had to do it again, I may have tried to figure out a way to maybe, like, take out a line of credit or something from a bank, just because I could have done it much quicker. But it was all a learning process.

[SAM]:
And then what would you say the benefits are of W-2’s?

[ALISON]:
Yeah, that’s a great question. So for me, what was happening was I got to twelve therapists and then I could never grow beyond that. So as soon as I hired somebody, somebody would leave, usually to go start their own practice. And then I would hire somebody else and somebody else would leave, so I just kept hitting that ceiling of twelve therapists, twelve therapists. And so then I realized that because my area generally has a shortage of mental health therapists that I really needed to offer benefits to be competitive with the larger companies. And I had a lot of people comment to me like, oh, I would love to come work for you but I really need health insurance. So really, retention and recruitment was the main reason we made the switchover. So that was what I actually… I started that process about a year ago, and then we switched over January 1 of 2020. And that was the first thing that I made sure to implement, was health insurance. And so it’s made a huge difference. That’s why I have been expanding so quickly, because a lot of people want a W-2 type job and they see it, you know, I think they see it as somewhat more secure. So that’s kind of why I had made the switch.

[SAM]:
Cool. And then the last two, for the sake of avoiding the same pitfalls, any tips on avoiding HIPAA violations similar to what happened in your practice?

[ALISON]:
Yes. So what had happened was, we have a way… it’s kind of a long story. But anyway, don’t send out mass emails through your email address. It was just like, an inadvertent, like, instead of putting all the clients emails in a blind carbon copy section, she put them in the carbon copy section. It was just a mistake but then there was all this fallout from, you know, essentially, even though it was just email addresses, it was still a HIPAA violation. So there is a way through most EHRs that you can send mass emails and it’s automatically encrypted, like, you can’t see anybody else’s email if you send it that way. So if you have to send a mass email, that’s what I would recommend doing. Don’t send it through regular email.

[SAM]:
Great. And then the last one for now – I think this is in reference to clinicians – how do you know you can fill them up before you have them?

[ALISON]:
Yeah, so that’s another chicken or the egg problem. And I think you sort of have to do it simultaneously. So what was cool was, after the two year mark, I started to see that the practice had sort of gained its own reputation in the community and the therapists started to get clients from word of mouth, specifically for them. So in the beginning, it was me, I was the face of the practice, I was the main clinician, people would call and say, I want to see Alison. And then at the two year mark, they had had enough clients that people would call and start to say, I want to see Whitney, or I want to see this person, and it wasn’t so much me anymore. So I think too, like, we really started to see all of our different marketing efforts really take off. And it became a lot more consistent for me to predict how quickly we could fill up somebody’s caseload.

And so the other piece of that too, is that we would hire folks way ahead of when we actually wanted them to start because we take insurance, so we would want to get them credentialed before they started. So for example, I hired somebody in July, and they just started in September. And during that time frame, we were getting them credentialed. And then four weeks out from them actually starting, we started marketing them. So they’re walking into their first week of work, hopefully having like ten to twelve clients in their schedule because we did all the pre work to make sure they were credentialed, then started marketing them and also made sure to tell people, like, so and so is starting on September 1st, if it was August, just so that they would know, they couldn’t call August 15th and get an appointment. But we found that structure seems to work really well.

So let’s move to the next slide. So you might be asking yourself, what is the secret to scaling up the practice while not working as much? And here’s the answer, it is delegation, and systems and processes. So I wanted to make this really big because I want to share with you everything I know, and I don’t want to hold anything back. And so we’re gonna dive into this in a much more detailed way, what this actually looks like. So before we get into all of that, I want you to think about or even pull out a piece of paper, make a list of all the things you do in your practice. So I wrote some things down that I could think of off the top of my head that I know a lot of practice owners do. So, practice owners do everything from provide therapy to clients, provide clinical supervision, you’re the one running errands, you’re buying drinks and coffee for the waiting room, and you’re running to the bank, and you’re doing all the accounting and reconciling things in QuickBooks, and you’re hiring and doing all the HR stuff, you’re doing all the marketing, the customer service. And then on top of that you’re doing CEO type duties, which is really what you should be spending the majority of your time doing, but you’re not, which is like looking at how you expand the practice, start new services.

I always tell people that as a CEO, I’m always thinking at least three to six months in advance. Because you need to have a future plan and you as the CEO are going to be the only one thinking of the future plan. Your staff is just going to be in the present moment, making sure they see their clients and get their paperwork done. But I’m always thinking three to six months ahead. So I’m actually right now planning out January, like, who’s going to start working in January? Are we going to have enough staff just to manage all of the administrative pieces by the time we get to that point, and we’re another size and all of that kind of stuff?

So just take a minute and think about all the things that you do in your practice, maybe jot some things down, if you want to share it in the chat that would be cool. I had a consulting client who was running a million dollar practice and she was still answering the phone; she was the administrative assistant answering the phone for her million dollar practice. And so then when we started working together, I said, the first thing you’re going to do is get an assistant to answer the phone for you. Because there’s no reason why you should be answering the phone if you’re grossing a million dollars.

So Christy is saying, all the things, yes. I was there too. And Jen is saying, payroll, email scheduling, [unclear] for clients, seeing clients, referring clients to clinicians, networking, relationship maintenance. Someone said, in addition to all the stuff I already have on this list, she’s also training new administrators, creating training manuals and standards for the practice. Somebody commented, I did outsource the phone situation and it’s been awesome. Yeah, that was one of the first things I outsourced and it was just like, a total game changer with my stress level and… taking care of the physical office. Yeah. Oh, someone’s saying I still clean the office. You know how long it took me to give up cleaning the office? Because it was hard for me to trust somebody because there’s like [unclear] sitting around. So I cleaned the office for way longer than I should have.

Yeah, what’s great, now that I have… somebody mentioned about taking care of the physical office, because I own that building, so I can’t just call the landlord if something breaks. But I have my office manager in charge of facilities. So if she notices the plumbing is not working or whatever, like, she’ll call the plumber and get all of that taken care of. I just told her, like, if something like that needs to be done, just do it. You don’t need to ask me for permission. And so that’s been nice because now it’s off my plate.

Okay, yeah. So lots of people are doing lots of things. So I’m going to tell you right now, we could probably have a whole ‘nother presentation on this. But if you are still doing these things that you could probably hire somebody for $15 to $20 an hour to do then you are not using your time effectively. You definitely need to be hiring somebody to do that for you.

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[ALISON]:
Well make sure you check out part two of the talk that is coming out next week. And like I said in the intro, definitely check out the show notes because there are some visuals in there that will make the talk make much more sense. And I know many of you had asked me about my family’s trip to the Outer Banks in North Carolina. So we have made it here and we’ve been here for almost two weeks now and it’s going really well. We’re living in an AirBnb, in a house that’s about a five minute walk to the beach. And we brought our babysitter along and bought my podcast mic and all my work supplies and we’ve been working, and going to school, and every day after school is over, we go to the beach and just been having a lot of fun being here and it’s easy to socially distance with people because the beach isn’t very crowded. So yeah, so it’s been going really well so far and we will be here for a whole month so I will keep you posted on how it’s going. So thanks so much for taking the time to listen to this episode, and we’ll see you next time for part two.

Grow a Group Practice is part of the Practice of the Practice Podcast Network, a network of podcasts seeking to help you grow your group practice. To hear other podcasts like the Imperfect Thriving podcast, Bomb Mom podcast, Beta Male Revolution, or Empowered and Unapologetic, go to practiceofthepractice.com/network. If you love this podcast, will you please rate and review on iTunes or your favorite podcast player.

This podcast is designed to provide accurate and authoritative information in regards to the subject matter covered. This is given with the understanding that neither the host, Practice of the Practice, or the guests are providing legal, mental health, or other professional information. If you need a professional, you should find one.