Going Solo: why you need an operational manual

Ray Kroc, the founder of McDonalds, was able to create his enormous franchise empire, in large part, by establishing a uniform process of doing business. Every step in the daily operations of McDonalds restaurants were documented and written down in an operational manual. This is true today and has become a standard in the franchise model. There is predictability and uniformity for customers and employees alike and it is the prime reason why a person’s experience in the McDonalds in Cherry Hill NJ is identical to his experience in Peoria IL or in downtown Chicago. Sipping a Tall Mocha Latte in a Starbucks in Long Island feels and tastes the same as in a Starbucks in Seattle or Cleveland or Timbuktu.

Having an operations manual in your medical practice is important as well, but not because you plan to franchise or because you think you have the business savvy of Ray Kroc. No, writing an operations manual is critical to your start-up because it forces you to develop a mental blueprint for how your practice will operate on a daily basis. It is a dry run; a practice run. Practice runs help other professionals as well, including athletes, actors, firefighters, policemen etc. Good golfers conceptualize putts before actually putting. Downhill ski racers take mental practice runs before the race. Tennis players develop game plans prior to the match. In medicine, surgeons perform surgery mentally, in their mind’s-eye, before doing the actual surgery on the patient. This practice makes the surgery go better. Working on an operational manual is like taking a practice run, only on a grander scale. Writing an operations manual will tell you what you know, but more importantly, what you don’t know and make your start up process go more smoothly and less expensively. You’ll make fewer mistakes. Having an operations manual will make your new practice go better.

Your practice manual should cover everything you can possibly think of, like how your receptionist will answer phones and greet patients, how to autoclave instruments and clean a scope, and how to make up a new patient chart. Your operations manual should detail how you back up your digital records, what you do in case a person collapses in your office, of if there is a fire, and how to forward your phones at the end of the day. Literally you must brainstorm your process for dealing everything from the mundane to the fantastical and put it in writing in your manual.

From a more practical standpoint, the operations manual can assist in training new employees and the manual itself can become a de-facto practice manager, only one that doesn’t cost $50, 000 per year. When employees have questions about, for example, how to autoclave instruments, refer them to the manual. When they want to know how to forward the phones at day’s end, refer them to the manual. Employees like it because they know what is expected of them and you’ll like it because it allows you to focus on other issues.

You do not need to write the manual in one day or even have it completed before you start to see patients. But start writing it. I started to write mine 6 weeks before I opened my doors for new patients and the first entry dealt with the only thing I knew at the time about practice management, which was how I wanted my staff to answer the phone. Adjust, edit, and update the manual as needed. It is a living document that helps you critically evaluate your process of practice management. It will make your practice better.

For legal reasons that are unclear to me but clear to my attorney, your manual will need to make certain disclaimers and statements, such as an At-will policy, a harassment policy, an ADA policy etc. You can get the legal wordings for these sections from your attorney or insurance company.

How to start up a solo medical practice, deNovo!

From my hopefully upcoming book, Going Solo: What to do when you find yourself out on your ass!

The “to do list”—Getting started

In February 2006 I found myself, as I had predicted 5 years earlier, on my own. Solo. No more W2 income. It was the start of my dream! I had been in a larger group of Urologists and was unhappy. Luckily, I had savings, good credit, and a supportive family that enabled me to pursue my dream of going solo. While it has been the best thing I have ever done, professionally, it was not easy. Any young physicians who are considering going solo, as I have done, may benefit from reading on.

I had spent most of my medical career doing medicine; seeing patients, checking labs, rounding, operating etc. I came to work, did my thing, got paid. Period. When I found my self solo, the enormity of what I did not know from a business perspective became painfully apparent and caused for me a great deal of stress. What seemed to be basic issues, like how to go from seeing a patient to actually getting paid, how to collect co-pays, how to submit a claim, how to get a phone system, do payroll, FICA, and on and on now seemed impossibly complex. To make things worse, I had very few places to turn for advice on medical practice start up and management and what advice I did come across often was not practical for my situation. I was overwhelmed and panicked. You don’t have to be.

Medical practice is a small business just like any other. We may have issues that are unique to us, but the essence, obstacles, and, often, the solutions are the same for doctors, dry cleaners, pizza men, gardeners, chiropractors, dentists etc. In fact, a business entrepreneur friend gave me the best advice—the key to start up. What is key? The key is to define your ultimate goal, identify obstacles between you and your goal, and then to brainstorm solutions. List, actually list--on paper--obstacles on the left, goals on the right, and solutions in the middle. Do this, because it really, really works. Brainstorming relieves stress and enables you to focus, accomplish goals, and feel pride over reaching milestones. It is the first step in start-up.

Obstacles include everything that stands between you and your goal. My obstacles in February 2006 included lack of office space, little practice management knowledge, not enough money, no patients, no hospital staff privileges, no referring doctors, etc. Your obstacles may be similar to mine, but might be different, but you will have obstacles. Identifying them will help you to overcome them. It is essential that you list all--I mean all---of your obstacles. Slowly but surely, in a systematic fashion, you’ll overcome them.

Solutions encompass everything you are going to do to overcome the obstacles. My solutions in February 2006 included taking a loan, finding a real-estate broker, personally picking up an application for staff privileges at the local hospital, etc. I had a list of solutions on paper that corresponded to an each obstacle. As goals were accomplished and obstacles overcome, I would feel pride and relief. Make the list. You’ll feel better!

Finally, you must have goal. And not something like “to make a lot of money.” You’ll never have enough money. I mean to set a professional goal. What you want from your practice, profession, life, etc. My goal was my ideal practice—my dream practice. The practice I always wanted, but never thought I could have. If you don’t have a goal, get one. If your goal is nebulous, focus it, on paper. As you progress through the start up process, and beyond, the obstacles change and you must find new solutions, but the goal remains the same. Your goal is your rock. Your goal practice is your beacon of light that guides you through a very turbulent process—starting up, growing, and maintaining a modern medical practice. Without a clearly stated and written out goal, you will drift. Referring back to your goal will enable you to get back on course, complete the task at hand, and find happiness.
After making your list, you can start ticking off solutions. The list method is nothing new. In fact, my mother-in-law uses it quite frequently. And it may seem simplistic and juvenile, but it is not. Opening up a practice from scratch is an enormous undertaking and is best accomplished by breaking the process up into many smaller steps. The list method is a mental exercise and practical way to do this. You will find that with this method, you can be up and running, in business, seeing patients in 6-8 weeks, start to finish. Every day will have a goal directed purpose and you will make measurable progress with minimal stress.