Scale up to recover: Economic considerations for practices in a reset

It doesn’t matter if you fall or stumble nine times in your career as long as you get back up nine times.

At the beginning, you start with nothing and then you build a patient base, staff, equipment and office space. This holds true whether you are getting a job in a practice or starting your own.

Most successful practices and businesses agree that failures and setbacks are opportunities to learn and improve. These experiences become the building blocks to grow as a person, provider and business owner. Being battle-tested creates the confidence needed to grow your practice. However, the complete shutdown across the country last March brought widespread fear and panic.

The pandemic had a sudden and significant impact on all practices. Many were unprepared to have almost no revenue for months, along with having to lay off nearly all staff. The COVID shutdown has been an unprecedented setback, requiring providers and administrators to dig deep in their tool kit to rebuild the practice and find ways to survive.

Here’s how my practice has accomplished our COVID comeback.

THE DISTINCTION: GROWTH VS. SCALE UP

Growth becomes steady and linear by adding resources, such as providers, equipment or facilities; revenue will show a linear increase as a result, but it requires spending on your part. Scaling your practice increases its revenue significantly without incurring substantial cost — an especially attractive prospect right now. A typical definition of scaling in any business is accelerated growth, often a 20% or more increase in the annual revenue, for 3 consecutive years.

Well, starting at near zero revenue after a two-month shutdown requires scaling up to a target goal of an 80% increase in revenue, relative to the 100% before the shut-down. How to do that?

Sun Tzu said it best back in the 5th century BC in “The Art of War”: “To act with speed involves not frenzied activity but rather careful preparation matched by a sense of urgency.” Rapid change involves risks that could stress the infrastructure and processes — thus the implementation requires several considerations that I will address below.

COMMUNICATION

Information is changing quickly as patients continue to walk through our doors again. Establishing protocols is dependent upon external groups such as the AAO or the CDC.

The next critical step is setting up communication links to spread current information. Any plan to scale up the business must include communicating goals to staff. Otherwise, providers or practices within the group risk either missing out when the group begins to recover or not feeling included in the process, which impacts buy-in.

For example, at first our practice was hesitant to communicate often; information was changing rapidly, so it was difficult to formulate clear policy or guidance. However, we quickly learned that silence led to the staff creating their own narrative. For instance, we furloughed some employees with the full intention of asking them back to work once the office reopened. However, after a few weeks with no contact to guide them, some staff decided their unemployment benefits would be lost and they would not still have a job. So, our practice created group emails and implemented apps such as SLACK to form chat rooms to ease dissemination of information — and pre-empt rumors. We updated every Monday, even if we had no new information.

Another real-life illustration of the importance of timely communication: One of our locations did not realize our group was allowing more patients into the building and so could see two additional patients per hour. After seeing only four patients an hour in a large office, a 50% increase in the effort to scale up was a big deal. Fortunately, this communication failure lasted only 3 weeks, until two doctors within the group but at different locations were discussing a patient and also happened to discuss patient volume. Two more patients an hour for three doctors working a 40-hour week over 3 weeks is 720 exams — and precious revenue.

Neglecting to formulate and implement an information plan will impede any strategy for accelerated growth.

TRIM THE FAT

It is unthinkable to have a practice reset to almost nothing: no patients, no staff, no revenue. However, it creates an opportunity to make changes for when the lights come back on. Scaling any business requires a diligent analysis of staffing and work-flow efficiency. A critical look at each staff member’s role and at prior processes enables you to rebuild and come back stronger, leaner and more efficient. Warning: Some staff positions may be eliminated and others consolidated instead of falling back to the status quo.

Due to the challenge of operating with limited staff and social distancing-caused space constraints, we initially had patients register by phone so they could skip the waiting room. However, the clinical team took this a step further and spoke to patients over the phone to update their histories and document the chief complaint. This shortened patient time in the office even more, allowing us to see additional patients.

BREAK THE RULES

Stress stimulates new ideas that probably wouldn’t have been implemented under normal conditions. Insurance companies broke the rules of the old normal first, easing requirements and allowing for reimbursement of telehealth visits. Most providers and patients had little to no experience with this type of interaction; now both parties would like to find a permanent place for this type of care.

As a physician, it seemed to me that showing videos to patients, such as during a cataract consult, was impersonal. However, the difficulty of communicating through a mask became the impetus for creating two 2-minutes-long videos: one about the expectations and risks of cataract surgery and the other about technology considerations for cataract surgery. Patients appreciated the chance to digest the information before my dilated exam as well as the opportunity to see and hear me without a mask on in the video. I enjoyed not having to recite the same spiel several times a day.

The success of these videos has led my practice to make a postop instruction video and text it to patients 6 hours after cataract surgery. In the past, I would not have considered texting a patient any information, but given the reception it is now here to stay. I am currently working on a questionnaire to text to new cataract consults that will build the history of present illness before they come to their first appointment.

As you scale your practice to seek accelerated growth under the “new normal,” keep in mind that success requires a communication plan, analysis of staff and workflow and the confidence to upset the apple cart and implement novel ideas.

There are few opportunities in your career to scale your business. Remember that the changes you can make in a crisis can positively and permanently impact your practice. OM

Scott LaBorwit, MD, is a principal at Select Eye Care, with locations in Towson and Elkridge, Md., and is an assistant professor, part-time faculty, at Wilmer Eye Clinic of Johns Hopkins Hospital, Baltimore. His e-mail is Sel104@me.com.

Disclosures: Dr. LaBorwit is a consultant to and speaker for Alcon.