P2what-attourney accountants and practice managers DON't tell you about practice ownership

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P epcid

R eglan

A lcohol

C rying

T axes

I buprofen

C omputer Crap

E nergy (or lack thereof)

PRACTICE• P rimary concerns• R egulatory concerns and

government • A dvertising• C ash• T ime for Family and Friends• I nventory• C ulture of your practice• E mployees

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The eight things attorneys, accountants and practice managers

don’t tell you about practice ownership

Part 2

Raymond J Ramirez DVM

University of Illinois 1986

[email protected]

Ramirezdvm.com

Slideshare.net/rayjramirez

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PRACTICE

• P rimary concerns• R egulatory concerns and government • A dvertising• C ash• T ime for Family and Friends• I nventory• C ulture of your practice• E mployees

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PRACTICE


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Time for family and friends

– Repeat after me:

–Staff are not your friends

– You are held together by a paycheck, and caring for each other not saying bad,

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• Maslo Hierarchy

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• Remember George Bailey?– Always Building and loan– Erupted in GBS

We don’t have Frank Capra

Or Clarence or…

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• This thing all things devours: Birds, beasts, trees, flowers; Gnaws iron, bites steel; Grinds hard stones to meal; Slays king, ruins town And beats high mountain down. nizations

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• Find friends outside of work.– Civic organizations– Church– Children’s school friends parents– Colleague from neighboring town (outside of

competitive area)

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• Friends will keep you grounded.

• Things like this (convention) are great…– Need ongoing – more than every 12 months.– Maybe Skype/ Google Hangout sessions– Some significant time should be talking face to

face

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• When friends are from civic world after ownership– Cautionary tale

• They do not always distinguish between problems with staff/ issues you have and how good of a Doctor you are.

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Time for family

• Set aside time with husband / wife

• Schedule it – if not on schedule, will not happen.– Guard it like a dog guarding a bone

• What to schedule?– Carefree timelessness

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Time with family and friends

• They don’t care how much you know, until they know how much you care…

• What would your family say you care about by proof of ‘wasted time’?

• Set boundries– Even if home for only 30 min

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Time with Family

• Ideas: go to children events, even if you don’t like– Dad-daughter dance– Bowling– Driving to, from practice – even if middle of

day

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Time for family and friends • Questions?

Avoiding…

Pepcid

Reglan

Alcohol

Crying

Taxes

Ibuprofen

Computer Crap

Energy (or lack thereof)

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PRACTICE


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Inventory

• Two basic concepts:– Just in time– Bulk buy

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Inventory

• Do nothing because I said so

• Look at Fortune 500 companies..

• How do they manage inventory?

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Inventory

• 95% of those companies manage the highest cost inventory with ‘just in time’– Dell pioneered in computers– McDonalds in food– FedEx makes it’s living helping manage JIT

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Inventory

• Just in time• How looks in practice:• Instead of ordering minimum of Frontline in 2010,

we ordered 70% from a special in February.• Market was saturated with ads in Menards, many

other places, and despite our proof of ‘just as low’ price, clients purchased elsewhere, and still had inventory 18 months later.

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Inventory

• Not saying there may not be some things that would be wise to order.

• But bought practice in Dec 2007,

• In June 2013 purchased first order of medication vials!

• Money sitting on shelf, not in your bank account

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Inventory

• Get online pharmacy partner

• Many out there – to me, no reason to have to pay a fee.– USE them. Our solo doctor practice averages

3-5 approvals through our pharmacy / week.– We do not stock Vetmedin (3 patients on) or

Soloxine,

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Inventory

• What we do stock– 1 NSAID – others are scripted– 1 Heartworm preventative – choose favorite– 1 flea preventative - we switched in 2012– 1 flouroquinolone – 1 ‘penicillin’ tablet

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Inventory • Questions?

Avoiding…

Pepcid

Reglan

Alcohol

Crying

Taxes

Ibuprofen

Computer Crap


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PRACTICE


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Culture of your practice

• Establish a culture is critical to your enjoyment of practice.

• Word association – Two different industries

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There is no right or wrong..

Just make sure you are not out of place for your niche

Could do same with restaurants

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What do you want yours to be like in the following scenario:

An annual exam

Sick pet outpatient

Surgery

bring in ‘drop off’

going home

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We need to know what culture we want

Need to talk about daily, and model.

Need to correct when not doing

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Culture of practice

• If person not do procedure correctly– 1st time wrong, assume I (trainer) did not give

directions clearly – Second time, start to think did not hire correct

person– Not everyone is fit for every practice, and

culture.– How many think the Ritz Carlton would hire a

Motel 6 employee?

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• This is not an OHE process: set up and done.

• More like riding a bicycle: always correcting and balance

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Culture of practice

• The 1,000,000 question with no lifelines

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A: No - valuable

C: No- know everyone

B: Yes

D: No only computer person

50:50

151413121110987654321

$1 Million$500,000$250,000$125,000$64,000$32,000$16,000$8,000$4,000$2,000$1,000$500$300$200$100

Are you willing to ask people to leave,

even if they were with the practice a

long time?

X X X

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• Changing culture is difficult, and takes time, and must watch with EVERY hire.

• Practice purchased in 07. From colleague thought was mid level price.

• Turns out was low cost, high volume

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Culture of practice

• Staff said wanted to change

• But no enthusiasm for phone, new clients.

• At recent staff meeting, current staff went out of way to mention first staff WERE NOT friendly.

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Culture of Practice

• Have friends borrow a pet and mystery shop your clinic.

• If not test, can not improve.

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• Want to find folks who naturally want this type of service, not where it is a ‘stretch’.

• One receptionist interview mentioned would have client come in for Exam if not ‘too expensive’… when asked what is proper fee, said: “I don’t know not been a receptionist for while, maybe $30”

• Point is not if receptionist is right or wrong, may not be right fit for your practice, if your OV is $55, or maybe great fit if yours is $25.

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• Questions? Avoiding…

Pepcid

Reglan

Alcohol

Crying

Taxes

Ibuprofen

Computer Crap


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PRACTICE• P rimary concerns• R egulatory concerns and government • A dvertising• C ash• T ime for Family and Friends• I nventory• C ulture of your practice• E mployees

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Employees

• Management expert Glenn Shepard recently shared an experience of second worse day of veterinarian in MN life was day came in and fired everyone.

• He asked what was the worse?– Every day of the 3 months leading up to that

day.

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Employees

• Some of this may sound like some things we hear from management consultants

• But with new owner, we will focus on 3 that are critical

• Changes from previous protocols – Training staff to handle correctly

• Training and reviews• Hiring

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Employees

If not purchased clinic yet:Make sure of following legal protocol:All staff are fired as of last day of previous

legal entity that is XYZ Animal Clinic…And rehired by “new improved XYZ Animal

Clinic”• Restarts clock• No one has seniority

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Employees

Changes from previous protocols – Training staff to handle correctly

– All your protocols should be written down.• If some you did not think ‘needed’ to be written down, have a

staff member be your scribe, and start a Word document and tell them “type this up for me, and have it printed before end of day”.

• Do NOT let go on for more than 24 hr.

• Ask if understand protocol, ask them to repeat it back.

• “See one, do one, teach one”

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EmployeesChanges from previous protocols

• Never correct in front of co-workers – always in private – either office or exam room.

• Always use the ‘sandwich’ method of – Praise one thing they are doing– Correct protocol we need to correct– Ask them to repeat back so they understand– Praise a second thing you are appreciative of.

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• You have to read body language like you would a patient– Is this person really telling me the truth about

this?– If you ave a key person who is not on board,

they can do a lot of sabotage of your changes– Finding out if they are not ‘on board’ is much

harder when you are the boss, vs when you are a fellow employee.

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• Habitforge.com– Motivated person takes 3 weeks to make a

change– Unmotivated person…. Unsure if ever will

change.

• May look at you with blank stares, or nodding

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• What happens if your ‘favorite’ staff member, when you correct them about protocol for the third time, says “I forgot”?

• Get over your fear of ‘I can not do this without them’!

• No one is indispensable.

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Employees

• Training and reviews

• Not common in Veterinary medicine, to have a phase training schedule – and need to do with your ‘existing’ new employees.

• Weekly review of how week went,(for new trainee) things they were supposed to learn, remember, memorize for job.

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Employees

• We started with a Wendy Myer’s training list and added/ subtracted to it. – Don’t’ take time to reinvent the wheel – use

others wheel and tweak it – saves time and money in long run because not making all the same mistakes.

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Employees

Training and reviewsReview of job doneHow many here have had a review in their life?I had never had a review prior to my giving reviews

to my staffSome places I had worked 5-7 years As an associate, worked 1 yr, and 2.5 yr – no reviewDoing relief work, called every clinic to get review of how I could do better next time.

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EmployeeReviews

• How often is recommended?

• Glenn Shepard says annual are on way out– NONE are related to ‘raise’

• At least q 6 months

• One manager to reduce turnover, instituted monthly reviews

• Turnover went from 150% to 20%

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Employee Reviews

• Why reduction?

• Know what is expected.

• Know how to improve

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Employee Review

• One note on reviews:

• Do not give a 1-5 review– Why?– How many give perfect score?– How many give lowest score?– Just made a 3 point scale out of 5 point

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Employee Review

• Use a 1-10 scale

• Several online to look at things you want to address:

• Punctuality, doing things not want, follow directions, do weekly, biweekly, monthly cleaning list, prep for sx next day…

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Employee

Hiring

It is not a badge of honor to never have to hire, or never have fired someone.

• From business ‘best practices’ model:

• Get as many people as you can involved in decision

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Employee: hiring

• Create a process to start – you may tweak

• We have 3 step process

• Phone interview

• Onsite Interview– Reference and previous employer check

• Extended ‘job shadow’ interview

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Employee: Hiring

• Know your standards – back to Culture• Don’t compromise.

– If won’t follow to try to get job, they will not follow when on the job

• Example: If you have a policy of only 2 stud type earrings, we mention during phone interview: “We have a policy of only stud earrings, no hoop earrings, or hoop necklaces for your safety with excited dogs” and they come to interview with 7 hoop earrings….

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Employee: hiring

• Common best practices axiom:

• Hire slowly, fire quickly.

• People can fake it for a while to ‘get’ a job.

• We do it all the time, with our clients!

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Employees• Now you can sit on top of world!

Questions? Avoiding…

Pepcid

Reglan

Alcohol

Crying

Taxes

Ibuprofen

Computer Crap


66

Practice

Avoiding…

Pepcid

Reglan

Alcohol

Crying

Taxes

Ibuprofen

Computer Crap


P rimary concerns

R egulatory concerns and government

A dvertising

C ash

T ime for Family and Friends

I nventory

C ulture of your practice

E mployees

Health & Medicine

P2what-attourney accountants and practice managers DON't tell you about practice ownership