Did you do it yourself, or did you bring somebody in to help facilitate it? So, I've done a number of these, and I've always found it interesting that most groups that you start off with, you think it's going to be strategic planning, which is really about, how am I going to plan for the future? What am I going to go deal with? What do I have to know? And not get caught up in tactical... requires critical thinking, and we all understand those orthopedic surgeons' culture is bone-broke, fixed now. They really don't have a pathway to looking down the road. They want to do something today. I thought they fixed that. You have to, when you do... private equity, that's all about the environment. Probably my head almost came off. Imagine the audience. The other thing in a squat, everybody's probably done it in one way or another, but your strength is quite different. Excellent, don't throw it. Can you raise the mic please for recording this session? Okay, I can't walk now. What your opportunities are, so your opportunities are when you look down at your pathways, you look at what I think I can go do, why not open another office, I want to develop another service line. In our practice over the several years, we've developed a new line of business, it's called OrthoFAST, we've got four, with two more under development, they're just orthopedic walk-in centers, we've plopped them around, within 20 miles of our larger offices, they did about 20,000 visits last year. What we have learned in that, and as part of this analysis is for every dollar of revenue I generate in the OrthoFAST, I get $4 downstream, whether it's to our MRIs, whether it's to surgery, fracture care, whatever it happens to be. So, when you do your analysis, I can capture new patients by putting these in 1,600 square feet and just putting them out in the market a little bit, and they'll feed back into our primary locations. The other thing is threats, what's going on around us, we all know today that we're facing threats from insurance carriers, from merges and acquisitions of other practices, from the retirement of senior physicians to the inability to recruit younger physicians into the geography. We happen to be in Southern New England, and probably one of the most expensive sets of real estate in the country, and it's damn near impossible to get them to want to come. And we always say, you will only get a physician to come to New England if they're from there, or their spouse is from there. And we all understand now that young physicians are the most mobile population. We all know they're gonna stay for two years to get their boards, but then they're now looking. Either they made a bad decision, I tell every young physician as part of this process, there are three things about looking for a job, there's the job itself, kind of environment you're in, the kind of medicine you're gonna practice, the location, is it where you wanna be, is it where your spouse wants to be, and there's the compensation. You'll always get two of the three, focus on the most important thing, and it better not be compensation, because it'll never work out properly. So those are parts of the process when we do our, we have a manpower committee, which is part of our strategic planning process that evaluates what the practice needs, when are guys gonna start retiring, when do I know I have gotta start looking to feed the machine on the backside. We know it takes about five years for an orthopedic surgeon to enter the practice and get to the right place where they're sustaining themselves. And so you have to plan for when my retirements are going, that I have to be able to get them in the back door. And we all have the same thing, oh, I don't need another sports guy, oh, I don't need another foot and ankle guy, oh, I don't need another this guy, well, you do. That's what brings in the opportunity to grow the practice and become diversified. The last part of the process is goals, objectives and tasks. Goals are the big aspect. This is what I wanna go do. And when you do a strategic plan, you should not have more than five or six goals. Otherwise it becomes overwhelming, you never accomplish it. One of my favorite sayings is when you do this process, there's a reason we put erasers on pencils, you can change course. If it doesn't work out, change it, move away from it. The objectives are the five or six things that support the goal. So if I wanna open an office as my goal, then I've gotta go figure out real estate, I've gotta go figure out connectivity issues, I've gotta go figure out staffing issues. Those are all the objectives that I have to look at to satisfy my goal. And then the tasks, what are the little things I have to do to support each of those objectives? And one of the things that you have to be able to go do, and we do it in our practice, is after the strategic planning retreat, I put up those great big Post-it notes in the boardroom and I list out the goal. And then we have a physician champion for each goal. He's gotta report to the board every board meeting, or at least once a quarter on what the status is. So we get some accountability by the physicians in this. One of the things I like to encourage people to do is define the characteristics of a good board member. Because your board is really your directors. So in most practices, a shareholder is also a director, but that's your board of directors, that's who's gonna run your organization, that's who we're relying on to make competent decisions. That's why we have erasers on pencils, we have to undo their decisions, we have to make sure that they're correct. Erasers on pencils, we have to undo their decisions sometimes. But the characteristics are, it works well with others, they use their talents constructively, they bring a different perspective to the developing of the team, so we want them all to have some independence, they think strategically. This is the hard part, to get physicians to think strategically and not tactically. Criticizes constructively, and I don't personalize, that's sometimes a challenge, but we have to do that. Shows up and is prepared. I can't tell you the number of board meetings I've had, where we've sent out the agenda, we've sent out the meeting materials, and they come strolling in from somewhere, and they're asking, where are we, what are we doing? They're not prepared, and it just kind of drags everybody backwards a little bit. We all have one of those physicians who shows up late, and he sits down and says, okay, let's start at the beginning, right? They're committed to the mission, vision, values and goals of the organization, they have to be committed to what you're doing. We all understand orthopedic surgeons are very independent, they don't always think about the group. This is the hard part of strategic planning, because it's about the group, it's never about the individual. Has integrity, considers his colleague and community decisions, and values the contributions of other members. Those are the good characteristics that you should put up in your board meeting, or put them in your board packet, so that everybody can see it all the time. So, successful strategy emerges from the decision process in which executives develop a culture, a collective intuition, accelerate constructive conflict, maintain decision pacing and avoid politics. That came out of MIT in 1999, that's the core to what strategic planning is. If you follow that as a rule, as you follow that as kind of how I wanna go do this, it tends to help you bring the process to a successful conclusion. Always remember, your group culture, you need to understand your group culture, because culture will eat strategy every day. We always recognize that if we think we're gonna go do something, then we lose sight of what our group culture is, and it always gets in the way. So, part of the process, the four key things I always look for when I do one of these, is what's happening in our area. It's a good idea to get a good census together of what's going on around you. In our area, there are consolidation of groups, there's been private equity moving in, there's been retirements. I do not know of one orthopedic practice that I've been involved with that's not trying to do something. I just completed two mergers, one in Rhode Island and a friend of mine sitting in the back that helped his group over a couple of years to do one. Everybody's trying to do something. Who are we? As groups age and as groups develop, we kind of lose track of what we are, what we're all about. So, who are we and what are we trying to do? What's ahead of us? This is one of the harder aspects to do, bless you, one of the harder aspects to do is to figure out what's ahead of us. There is no crystal ball, there's no magic, but our occupation requires us to be thinking outside the box a little bit and try to think ahead so we know where we want to go turn, right? And then how will we get there? If you don't plan, any path will do, right? That's one of the key phrases. So, how are we going to get there? How am I going to bring this machine forward to accomplish the tasks and the goals that we want to do to expand the group or keep the group survived, basically. So, leadership versus management. That's a very distinct difference that we need to know about. They function differently. So, your leadership is your board of directors. Management is everybody else. They do different things. Leadership needs to help guide, set the course. Management executes. I don't know how many times we probably run into the, run into the problems of physicians trying to be management at the same time, right? They're down to the blue pencils and green pencils issue. They're trying to tell you how you should go do your job, right? This is one of the only industries in the world where the widget makers own the factory. They hire the lay person to run the factory, then they try and tell them how to do it. So, the board, the leadership, creates the vision and strategy. It communicates the vision and strategy by getting buy-in. It motivates action. That's why we make sure we have a board member responsible for all of our goals so they can champion it. Helps an organization grow and evolve and sets the course. That's their primary objective. That's what we want them to do. That's where they serve us the best. Tactical planning in the C-suite. So, understand and decipher the strategic goals. So, many times after a strategic planning retreat with the physicians, we have a bunch of paper, we have a bunch of things written out. Now we've got to go figure out what they really want. So, we've got to take some time. You've got to get your team together. You've got to sit down and figure out, okay, what are we really trying to get out of this process? Identify the course of action you'll need to achieve those objectives. So, part of the post-planning process is trying to figure out, I've got to get someplace. I need to know what I need to get. I've got to build a team to do it. Tactical planning is developed by those who deal with getting the work done every day. So, as you move down your organization, I'm not sure how large all your organizations are, mine, we've got 300 employees in five locations and 35 physicians. So, I have a relatively flat organization, which sometimes creates a problem. But a CFO and a COO, that's their job, is to figure out how we're going to get there. What they need as a team to go get there. I do the best work by getting the hell out of their way so they can go do what they got to go do. How can the strategic goals be accomplished within the designated limits of resources and the authority we have? We all know we're facing tighter budgets, limited resources, be it human capital or financial capital. We've got to figure out how we're going to accomplish what we want to do in those sets of limitations. And you have to factor those in to your process. Management, this is your day-to-day management. They're executing the tasks that they're giving. They're planning in the budgeting side of the house. They organize the staffing. They control and problem solve and then make the organization run efficiently. I call it keeping the trains on time. So we let our management manage. We keep the physicians at the board level of leadership and we stay in the middle kind of like an hourglass to keep everything from colliding. The tenets of a group practice on these things are, so you can focus properly as well, the welfare and success of a medical group is paramount to any individual. This is where the group culture is highly important. The group is the primary objective. Physicians have primary responsibility for overhead, period. We don't make any money. We're often looked at as a drain, but we don't make any money. So the physicians are, their job, cut and stitch, make the money to cover the overhead. That's their primary objective. So the first law of improvement. So when you think about how I want to make a change, every system is perfectly designed to get exactly what results it gets. So you're almost kind of looking at it backwards, right? I want to get a blue pencil, so I got to go out and buy blue pencils. So what you want to do is make sure you understand where you want to get to, and then you figure out the system and the process to get you where you want to go. So a mission statement, I'm sure most people have a mission statement. I'm not sure how many people look at them. I think ours is in a closet somewhere. The who and what our organization stands for. You know, we created a tagline and it's on our letterhead and it's on all of our printed material. You know, excellent care by excellent people. The values, the key factors that guide our organization and improve the framework for developing our goals. This somewhat gets washed, you know, as physicians age and young physicians come in, they all, we have to remind them of what our mission is and what our values are. The external assessment of the group is what's happening in the marketplace, figuring out what's going on around us. So we know that we've got, in our little area of the world, I got two huge health systems, Yale Medicine, Yale University and Hartford HealthCare are just beating the crap out of each other. And it's just standing by watching the bloodbath of who's spending the most money the most ridiculous way, right? So that's what we have to understand is how not to get trapped. What is the competition doing? We do this on a regular basis. We sit down, we have an executive committee because our board is 14. We have an executive committee of three. We meet the second and fourth Monday of every month and we sit down and we look at what other groups are doing in the area. Just so we know, as we look at our plan and we look at our objectives, are we going to run into somebody? Are we going to have a problem with somebody else? Is there going to be, you know, a border war over setting up a location? So we want to know what our competition is doing. We want to know what other organizations are doing, right? We want to know what the hospital systems are doing. We want to know what PHOs are doing. We want to know what private equity is doing. We want to know what other organizations are doing so we can, excuse me, so we can figure out whether we should be part of it or avoid it at all costs. Right, so that's part of your thinking as well. What are the changes in demographics? So we're doing a second CON for a second ambulatory surgery center. And one of the factors that we have found is the demographics have become almost absolute in satisfying the CON requirements. And Connecticut is a state that's losing population. You know, it's like New York and other states. They're losing population. Businesses are pulling out of Connecticut. So we have to keep an eye on what changes in the demographics are because that affects insurance carriers. That affects the ability to provide patients, right? So we can keep getting bigger and better, but if you don't have enough patients, the whole thing doesn't quite work. What's changes in the strategy of insurance carriers, right? We're gonna add more prior authorization. We're gonna demand more peer-to-peer. So we have to know what they're doing and almost kind of out think them, which is hard because they tend to be faster at it and and and more brutal about it. But we have to know what they're doing so we can counter it. So we want we've talked about it before the strength weaknesses and opportunities and the threats I like to. I like to put up what we think we do a little survey before all of our planning retreats. We asked the docs what they think our strength weaknesses are. Of course, they always say the other strength. And they think all the staff is the weakness, right? So we. Predictable so, but you gotta know what those are. So you gotta be able to plan around that. So I, I tend to take my past. Retreats and bring those forward so they can see what they have done previously and what may have changed. Particularly if the physician compliment has has has shifted so that they can kind of go see where we came from where we want to go. What what what may be new or different? So the key questions that we'd like to get answered through some surveys is is the challenges. What strategic issues face the organization versus operational improvements. Remember, as I said earlier, physicians want to retreat to where they're comfortable. And that's the tactical side. We want to get them up into the strategic side. So we always want to find out what we think of the strategic issues. They want to have addressed. We want to know what the barriers are. What would prevent the organization from developing strategic goals versus operational improvement? So once we understand what we're trying to do, what we think is important, what do we know are our barriers? Is it not enough staff? Not enough money? sure that we have the best value for the organization, and we want to make sure that we have the best value for the organization, and we want to make sure that we have the best value for the organization, and we want to make sure that we have the best value for the organization, and we want to make sure that we have the best value for the organization, and we want to make sure that we have the best value for the organization, and we want to make sure that we have the best value for the organization, and we want to make sure that we have the best value for the organization, and we want to make sure that we have the best value for the organization, and we want to make sure that we have the best value for the organization, and we want to make sure that we have the best value for the organization, and we want to make sure that we have the best value for the organization, and we want to make sure that we have the best value for the organization, and we want to make sure that we have the So, what would be the most important initiative for the organization? They wanted to enhance their executive leadership. They wanted to raise the bar of who was running the organization. You know, we see through a lot of the mergers and acquisitions and consolidation that some very good, talented people have left the industry. And as opportunities change, trying to get replacements into some of these practices is a challenge. So, finding the right talent, finding the right leadership, finding the right skill set is absolutely paramount to the group's future. Basically, building relationships with the insurance and healthcare systems. You know, for the first time, we've gone down a pathway of looking at some relationships that actually are a PSA, you know, tying ourselves to one of the systems. Is that the better way to go? Is there more ability for us to do that versus making a super group? When we talked about a super group, groups coming together, we thought that was a five-year process and just trying to blend cultures alone, you know, physician cultures of different groups is very challenging. We talked to one group as part of this process, and they had consolidated. And their response was, well, you just come in under us. And we said, well, why would we do that? Why wouldn't we form an MSO and we both be, you know, we're equally of size, got a lot of locations. Why wouldn't we do something different to make it work? Oh, no, no. We've done a lot of marketing. You need to come in under us. And that ended that conversation. So, we knew what one of our barriers was. One of the things that I always hear from the doctors is, we got to trim. We got to cut expenses. And I look at them and I go, tell me where. Here's the P&L. Walk around. Tell me where. Well, we should change the shredded boxes. I said, yeah, that'll help. That'll help. Maybe if you showed up on time and saw two patients, we'd be better off. That's never their fault. So one of the docs said at the beginning of the year when we were, you know, you come out of the end of one fiscal year, you start the next fiscal year, and you've got high deductibles and you've got all the things you got to face. And one of the docs said, well, we might have to hold the doctor's salaries. And I said, well, we do that every year, because you get your bonuses at the end of the year, which is not an uncommon thing. He goes, well, you might need to take less, too. And I said, I can retire. So he just looked at me, stood in the door, and he said, well, that's not a good answer. And he left. So, you know, again, what's most important, I got to get data collection, right? We don't do very well at some of this stuff. And we don't, we talk a lot. We think we know what we're doing, but we've got to get better data. We've got to get better information for us to help make decisions, make the practice a significant player. You know, one of the things that we did was open these orthofasts around the market because it kept us the ability to get our name out a little bit further. We can reach out a little bit further with not a huge investment, 1,600 square feet, you know, an x-ray table, three or four exam rooms, and you can make a play. You can make your business grow a little bit faster. We determine the footprint we want, new offices, you know, is it worth pursuing to push harder and all these things. You know, it takes a little bit of money, and we can talk about some of the solutions that we've done with that, you know. So when we look at financing, I may have did it on one of the listservs, rather than go commercial financing for a lot of the projects you don't want to go do. We form leasing companies. I form a simple LLC, and the physicians or senior management can put in the money. You then lease it back to the practice, so the practice has an operating expense, a deduction, and money goes back into the leasing company. We use a 10% rate of return, then the members of the leasing company, they get a deduction on their 1040 for the depreciation, and they get a higher rate of return on their money. Works great. I've got four or five of them going. I got about $10 or $12 million worth of projects. Every time we have a project, one of the docs goes, we're going to do a leasing company, we're going to do a leasing company, because they apparently got money burning in their hole, so. So here's some of the answers we got when we talked about what was your contribution. Changing the answering service, that was his contribution, you made us change the answering service. Directly responsible for recruitment. Ran a history of the group. Athletics. Expanded neurosurgery. So that's what they felt, that's what their answer is. And all those things were not necessarily for the group, but for them more or less individually. So some of the things that we did in our strategic planning was real estate. You know, we built two buildings over 110,000 square feet of space, two MRIs, surgery center. We built the buildings. We had them for a relatively short period of time, three, four years. And we found a way to finance them through a medical company called Montecito. Came in and bought both buildings. And the physicians who got their money back out was able to reinvest back into the trust. So they're making, not only did they get the building sold, they got, and I'm not a huge proponent of physicians owning real estate because of all the crap that goes with that. But it got them out of the real estate. It got them an investment and they got their money back. So it worked out pretty well for them. We got second MRI. So we did second CON to do a second MRI, which is awfully hard in the state. We thought we were going to get it faster. We finally got it. We had to, you know, relocate some buildings, do some things. But that was one of the initiatives that was in our strategic plan was developing additional services. And we felt the second MRI to service our population was the way to go. And it has worked out very well. Future opportunities that we talked about. Recruitment. Complimentary related services. You know, we've always talked about doing rheumatology. I know a couple practices in there have rheumatology and it's been successful. We're expanding our interventional pain. We've got two interventional pain guys. We're looking to bring a third one on because we can put those in smaller locations. You know, it's a CRM. It's a couple of exam rooms. You don't have to tie up a lot of big square footage. So it works out real well. Other opportunities. Merger discussions. Groups without walls. Geography. All the things that you have to go down. I know a number of groups that have gone through mergers and executives have been the odd person out. Good, talented people. You know, in one of the groups that we talked to, their new CEO said, well, I'm going to be the CEO. And I said, okay. But you don't know anybody in our group. So I'm not sure how that's going to go over. But that's the position they wanted to be in charge. Other opportunities we've looked at. You know, one of the things we've wrestled with as a group trying to evaluate options, whether you merge, you look at private equity, was at some point the physicians are going to be employed in a different place, in a different format. So what's the least controversial for them to go do? We all understand in some of the earlier private equity deals, it's the second bite of the apple. But what's the structure? Who's going to be the ultimate buyer? Who's going to be running the organization? As I said, when we talk about goals, the major initiative should be no more than five or six in order to manage the process. I think that's important. You can get overwhelmed. And it's part of when you're doing this and defining what those goals are. You need to kind of back up the group a little bit to make sure that what they're looking to go do makes sense. Every one of them reads an article. Every one of them reads the Wall Street Journal. The best is they go to the locker room at the hospital. They come back with all these ideas. Oh, you know, his overhead's at 10%. I don't know how he does it. So you've got to put some reality in this. You've got to have some real reality checks as you're trying to develop this so you don't go down a pathway that you know you can't. You don't want to go down it if you know you can't be successful. It just won't help the organization. No more than five or six initiatives. You can have as many people on the process as you need. And, quite frankly, when you look at what the goal is, you go pull the talent to support it. It might be finance. It might be technical. It might be clinical. Whatever it happens to be, you've got to pull the team in to go do that. So, as I said, the objectives, these are the key elements of the goal. You can have a number of objectives to create the goal. Objectives are very quantifiable and measurable. You need to have a timeline. So, as I said, when I put up those big sheets of what our goal is and we start looking at the objectives, we have a timeline. We know when we want it to be. And one of the things, as we talked about before, is what position is going to be the champion that he can shepherd this to ensure that there's position buy-in. It's hard keeping them on task. It really is hard keeping them engaged, too, because some of this stuff takes a while. And a lot of them don't want to give up their time. And this is what we're talking about, tasks. This is how you want to get each of these. Who's going to do what? What supports it? Not complicated. Easy to develop. You want to have your successes. You want to measure your successes. Part of the whole process is the timeline. You want to be able to publish your successes, that you've accomplished something that's going to get you where you want to go. One of my phrases, just don't rearrange the deck chairs, right? This strategic planning process is an opportunity for you to take the group, lead them forward, not just rearrange the deck chairs. That's what happens. I'm just going to shuffle this around. It'll be better. It looks different. I'm going to put some lipstick on it. I'm going to change the paint color. You want to really have something that's substantial. I always suggest that you try to use an outside facilitator because there are some political issues that arise. One of the phrases I always live by is that there are three things that will get a practice administrator into a career-altering event. Build a building. Change a company. I've done those. I live in a hotel a lot, but I think those are the things that are huge initiatives, and that's why sometimes having an outside facilitator just to manage the process, just to take you out of the crosshairs. That's an important part, and sometimes when I do them, we'll ask the docs, do you want the executive in or out? And sometimes they want them out from the first part so they can talk about them, and then they want them in the second part so they can participate. Everybody's a little bit different. Every group's got a little different approach to it, but that tells you a lot of what you're going to face. Okay. That's it. Thank you. when you're acquiring the assets? I'd answer it a little bit differently. What's the purpose of the acquisition? Yeah. And I would argue wrong, right? So if we understand where the culture is going, so if they're successful and they're viable, then their quality really is not an issue. That's a perception, right? I'm the best. Well, I am the best. My mother told me I was perfect, so it's okay. So that's the problem, right? So they're already there. They're already seeing patients. They're already making a presence. So you got to kind of take the perception away and say, this is a business decision. This is a strategic business decision. Tell me why I shouldn't. Let me start with that one first, right? So I use those characteristics, we put them up so they can see them. I think I mentioned, you know, my for the first time in my career, I had to go deal with a father-in-law on our onboarding of a young guy. Now he's been a board member for a year. He has yet to say we. And we've had to sit him down numerous times to say, they call you toddler in the OR. Because he's a whiny little, which, which, which, which. So he has yet to figure out it's a we. And when we do our board agendas, it's about the we, the group, what's best for the group. What are the things we wanna talk about that makes it for the group? And anytime one of the guys goes down the pathway of a me, the senior executive committee will just, the senior executive committee will just stamp on him and say, that's not what we're talking about. So I think it's repetitive, right? As I said before, orthopedic surgeons are trained from a very early age to fix things, but they don't know how to build things. And that's part of it. And that's part of what I think our job is, is education. To remind them, this is about the group, this is not about you. I had one guy recently come to me and say, well, I'm gonna go to the other hospital, they're gonna pay me a director fee to do my robots, blah, blah, blah. And I said, well, you can, but that check doesn't go to you, that check comes to me. And he goes, well, why? I says, because your employment contract says you can't work on the outside. So we created a single member LLC, it's called OSG Trauma. So all the money that comes from medical directorships, clinic, call, all this stuff goes into this. And then I have a big slush fund that I can do different things with it. I can either pay them out as a 1099, or I can cover some other expenses, but I don't run it through the overhead of the practice and I don't tie it to the practice because they share in it differently. But that's a we. That's a we. Did I answer your question? Okay. So I think it's the same thing. I think, you know, I'm not 100% convinced I know what our culture is any longer because the physician population has changed. I know what we think we stand for. I think we understand that we wanna all do good work, but I think every physician does good work. I think the question comes down to, is our culture organization driven? You know, and I think we have some physicians that tend to look at it as they're here to serve me versus I'm here to participate. I always tell the physician, you're worth about 25% of the patient's access. Everybody else doesn't. They're responsible for everything. And I said, so it's about the we. So you have to keep driving it. And it gets tiresome. That's why I drink. A lot. Well, the best thought about one of the buildings we built, we put a wet bar in my office. You think I'm kidding. The goals themselves might not be a 24-month timeline, they may be longer. So ones that we know have a longer horizon, we bring them forward to the next one. But part of the reason I do the strategic planning retreat is to get them together, to focus on the organization. And I think because we have a physician's age, some guys are thinking about retirement, some young, you've got to get them into the process. Now we've made a point. I won't do them on a weekend. I won't do them in the office. So I make them give me an afternoon during the week. Then we go to an outside place. If I left it up to them, about an hour, but I think no more than five, you know, depending. Again, I've had them go longer. I think, I always think about doing them where there's a social event at the backend. So we've done them, you know, on a Wednesday, for example, and it goes noon to six, noon to five, and then there's a dinner. Sometimes there you can bring a spouse or whatever. Sometimes it's just them. But I think you lose them. About 70%. You know, some of the senior guys who understand it better will help with getting the young guys to come forward. Because we do it a lot for the young guys to understand this organization has to be built. And I think as we find champions for the goals, we sometimes don't let them volunteer. We volunteer them. And it helps them get into the process and helps them learn a little bit. You know, one of our newest interventional pain guys, we have an in-house dispensary from Freedom Link for Workers' Comp. It took a little bit of a downturn. He's taken on this objective to rebuild it, redo the formulary and manage it. So he's taken a personal interest in fixing our dispensary. Well, that's part of the challenge, right? So we have part of our compensation plan, which is an equal share. We also have this slush fund from the OHD trauma. And sometimes we'll bring money down to reward them for doing something. But we try not to impact them terribly in their productiveness. So if we have a meeting for them, it might be at 7 o'clock in the morning before they start office hours. Or it might be at 5 o'clock in the evening for an hour, not long, so they can participate. I try not to take, other than the strategic planning retreat itself, I try not to take them out of the OR, I try not to take them out of the office. Cuz then all I hear about is whining and complaining. Then you have to shoot them. I think private practices have a three to four, maybe a five-year horizon. For all the things we talked about. We're battling insurance carriers. We got crap we can't fix. I got institutions wanna control stuff. You know, I did a talk with one of our CPA people who's probably one of the smartest individuals I know. He's a lawyer, MBA, CPA. And he sees stuff on a national basis. And he says that his comment was maybe four. Private practice. I think that's our single biggest challenge. How do we sustain ourselves? We all know reimbursements come down, expenses are going up, right? So that curve is, I'm not sure how I'm gonna fix it. I have to get rid of the shredded boxes probably, but I don't know how I'm gonna fix it. We have a couple of aquariums in one of our offices and one of the guys said, we should get rid of the fish. I go, yeah, that's gonna help. So they all love to have their lunch brought to them, right? They all love to have their, send their people out to get lunch. So rather than having me to run around with petty cash, I got them all debit cards. And I said, here's a debit card for your person and go get your lunch. He said, it's coming right out of your paycheck. And he said, well, I don't need lunch that bad. I think part of it's this process, part of it is at every board meeting bringing up issues in advance so we can plan, if we see and we know something's going to not be right, then I got to get it on the table sooner, not at the time it breaks. So I got to be better at forecasting. Now, they break a lot of the stuff, so that's part of the problem. But I have a saying all the time is a lot of our guys like to fix things. They'll put their red cape on, they'll run around the office and they'll try to fix everything and then they go back and put the cape in the locker and say, well, I fixed that. I go, yep, now I got to go undo that. So we want to keep them on task. We want to keep them on mission. So we have to be better at predicting what we see is going to be a problem. Whether it's space, whether I know the only way I'm going to be able to fix my group is to expand it, I got to have space. Investing in new buildings is costly. Do I want to do something in a different location? So I think those kinds of forecasting, one of the things I do is I calculate my revenue per patient. So it's number of visits, dollars, I get a revenue per patient. It's all in. So call it $400 a patient. If I want to expand a service and I know I'm going to generate another 10,000 visits, I have a model that says, oh, I'm going to generate this kind of revenue. And I can get a better outcome of predictability by using some of our information to guide them into a decision. So I think a lot of it's got to be us forecasting and seeing it. But it's kind of hard when you're up to your tail on alligators, right? And your job was to drain the damn swamp, but you're up to your tail on alligators. We work, and I don't mean to be offensive, doctor. We work with some unrealistic individuals with irrational expectations. The management team or the physicians? You got to take that, you got to take it away from them. You know, and it's sometimes, and I'm a little callous with this sometimes, I'm older than every one of the guys in the group. So I get away with things I probably would not normally get away with. I always say, our job is to manage and be right, not manage to not get fired. Those are very different tacks. Our job is to be right. That's the only purpose we serve. So if you know it's not right, don't want to punt it. So no, this is what we're going to go do. Do some of the homework, get it on the table. We're not punting this, we're going to go deal with this. Then when your tail feather's gone on fire, we'll fix that. You know, again, I'm not trying to be terribly callous, but we got to tell them what they want. They don't know what they want. We got to tell them, this is a business. This is the only industry in the world where you've become a shareholder and you've done nothing to get there other than two years of being in practice. They're now a multimillion dollar entity owner who doesn't know what a P&L is. So we've got to take some of that out of their hands. Hopefully I didn't bore you, thank you very much. Thank you, Steve, we appreciate that. We have a little bit of a gift here for you. Thank you for the information. Oh, thank you. You're very welcome. It's not a bottle of Scotch. No, no. So let's just cover a couple of numbers or codes for you guys before you get out of here today. So if you're applying for AAPC credit, please be sure to write down this code, 835830J, as in John, U as in umbrella. Again, the code for this session is 217806. Please make sure you enter that into your mobile app. 217806 is the code for this session. Can I? There it is. Perfect, thank you. Goodbye to the freshmen.

strategic planning

orthopedic practices

organization goals

private practices

forecasting

leadership

management

organizational success