Never dreamed you’d be doing this?
I’d venture a guess that for most people working for someone else was not a part of the dream of becoming an acupuncturist. If it were, the acupuncture profession, meaning the schools and the alphabet organizations, would have been working to this end for the past 30 years. There might have actually been for jobs for acupuncturists by now. Instead most acupuncturists are self-employed. Those with busy practices contract out other jobs like accounting, bookkeeping, cleaning, laundry, etc. A really busy practice might have some part time office help, but mostly acupuncturists work for themselves, and they work alone. With the birth of the community acupuncture movement ‘punks began to recognize that working with others was much better for the stability and sustainability of our practices, and that we could provide many more treatments if we worked as a group. And it was less lonely.
For many reasons, growing a CA clinic to be big is a really good idea. One reason is that no one wants to, or can, work all the time, but our do need acupuncture all the time. More specifically, we have seen that affordable acupuncture is so needed by so many, that a well-built CA clinic will attract more people than one practitioner can treat. That is to say, all of the busy clinics started by a lone practitioner eventually end up looking for help. The fear of making the leap from self-employment to employing others can be eased with a general understanding of all of the parts. It can take time to get a handle on these parts, but often the growth of our clinics keeps in step with the development of our abilities to manage them. Or in the case of rapid growth, the learning curve is just steeper. Fortunately by becoming an employer, you are recruiting help, and as we have seen time and time again, accepting the calling to do community acupuncture brings with it a certain amount of grace in the form of help from our communities, our patients, and our patients’ communities.
While there is no exact science to figure out the optimum size for a CA clinic, we have a firm hunch that for each practitioner working 4 to 5 shifts per week, they should be doing around 100 treatments. Seeing 100 patients per week simply cannot happen if you are working totally alone. At the very minimum you will need someone to be answering the phone, returning calls, scheduling, re-scheduling patients, and receiving money. A lot of clinics have started out with help from excited patients or friends, retired family members, or local high-school interns. For the sole practitioner starting a CAP front desk help is usually the first step towards being an employer.
Data from CAN’s LOC Survey over the past four years shows that clinics with multiple owners, and thereby punks, tend to have larger incomes and see more patients. Bigger isn’t always better, but the data also suggests that the bigger clinics are able to pay their workers living wages sooner, and given the nature of the business, having a larger base of patients who come for treatment regularly, and work as a referral network, are two more reasons to get the clinic as big as you can, as fast as you can. This means that many CA clinics will be started by multiple practitioners. This is great news as it means more energy directed from the start towards the goal of having a successful clinic. However, the conundrums of a sole practitioner now thrust into employer-hood are now multiplied. With a common ideology bringing us together, we still may need to develop a common business sense, and by necessity the different parts of running a business need to be split up between partners. There will be natural affinities that draw us to particular aspects of running a business, but it can be tricky too, as splitting the bottom line infers splitting the work it takes to get there. Sometimes it is hard to quantify the work we do for our own businesses.
Some what determines how fast and big a clinic grows is beyond our control. External factors like location, square footage, signage, rent, working solo or with others, will interact to produce a successful clinic or not. Some of the choices we make around external factors will be chance, or just guessing. But what we can exert more influence over are the internal factors, the systems and invisible structures like how we communicate with patients, and each other. Understanding what it will take financially, in tangible measures, to break even or profit will allow you to relax when things are on course, and should motivate changes when not. An example of this is knowing how many patients it takes per shift, or per hour, to reach your break-even point; that is to meet all of your operating expenses, including payroll. Budgets, talking-points and “scripts” are examples of ways to exert what control you do have. Training materials and employee handbooks are another example. When you know where you need to be, it is easier to move in that direction.
If you consistently fall short of your goal, you know that you need to take a look at the factors that are exerting their effects. For example, are treatment plans being consistently communicated to patients? Are hours of operation sufficient for patients to comply with treatment plans for multiple visits per week? Are there enough chairs, good signage, or a way for patients to easily spread the word for you? With the CAN forums we have been able to share answers to these questions; though I suspect that for each clinic and its unique circumstances the answers vary. The point is that we don’t need to be reinventing the wheel; we may need help in mounting the tire on the wheel, filling it to the proper pressure, and making sure it stays in balance. And this requires that there be systems in place, and then some oversight to see that these are functioning as they should.
These clearly defined systems and policies communicate expectations to employees and help to channel their energy productively. Systems and policies will also help temper the emotional charge for the “boss.” For many of us our clinics are our passions manifest; they are our livelihoods, and a resource that our patients and communities rely on. Without our personal commitment our clinics would not be as vital as they are; but we have to balance pouring our hearts and souls into our work, with “not taking it personally” when things go in an unexpected direction, or when we come up against a challenge. Management systems and skills are a way to keep on course, they delineate boundaries that bind together what is needed, and exclude what is not.
Practice Management or Management Practice?
The only way to really do acupuncture is to practice on patients in the same way that the only way to manage others to practice on them (with them?). There is a lot to managing a practice, but to simplify things I break it down in my mind into 2 parts: the stuff I can get someone else to do, and the stuff I have to do. Here is an example: I hire payroll service, they take care of paying everyone, taking out the right amount of SS, SUTA/FUTA, updating tax rate changes, filing quarterly taxes with the state (since my state requires this), and sending end of the year tax forms out to all of us. Should they make a mistake in paying the payroll taxes, they are 100% responsible. The payroll company has to pay penalties and fees on my payroll if they make a mistake. That to me is totally worth the money they charge. What I have to do is make sure everyone tracks their hours, or set-up a salaried positions, or track patient payments if I am paying a percentage. I have to determine what people will be paid, when they get a raise, what they need to accomplish to get a raise, etc.
Paying everyone is only one aspect of running a business. But you can see that there are a lot of steps to doing it, and there are resources available to help you cover all the steps. That type of management practice, where someone else does an essential job that isn’t of the acupuncture variety and all I have to do is pay them, is a “best practice.” There are many other good and best practices, and many opportunities to practice these practices. Practice implies gaining a skill. There are many skills associated with running a business; we won’t be drawn to all of them, nor will we be adept at all of them. Don’t make yourself unhappy trying to do things you hate. Recognize this in yourself and get help when you need it. See the chart below that outlines the most basic tasks required to run a clinic. Look it over and see which things you can imagine doing and which things make you cringe. Are you already doing everything on this list yourself? Fantastic, but then surely you will need to recruit help in order to maintain momentum and growth. You are on your way to being an employer.
Structure and Flow
The amount of paperwork connected to being an employer is tremendous and can be as overwhelming as the amount of information behind all this required paperwork. There are personnel files, I-9 files, time sheets for payroll, vacation and sick time to be tracked. There are quarterly tax-rate changes, filing estimated taxes, accounting for and putting aside funds for self-employment taxes for some, or knowing that you need to budget a cushion into your payroll figures because the business will be responsible to pay an additional 12% or so of the total payroll (wages) figure in Social Security and unemployment taxes. Tracking payments, income, herb sales, herb orders, the weekly schedule, coverage for time off, weekly patient numbers, average patient fee, thoughts of expanding hours, adding punks, moving, marketing, web design, ahahhah…. so much to do… it is hard to prioritize sometimes. Sometimes the chaos seems at its least when we’re in the treatment room seeing 4, 5 or 6 an hour for a few hours. That’s where the calm is… because that is where we are most in the flow of the energy that is connected to what we do.
All that other stuff, while it can make you crazy or at least agitated, must be in place on some level in order to allow for the flow of the treatment room to happen. Unless you love it, the tendency is to work on the business/structure stuff in spurts. It’s often when problems arise that solutions are sought. Luckily our collective employer experience is available via the CAN forum, formal and informal mentoring, and the POCA employer materials. The force and momentum that has emerged and amplified around community acupuncture is something we have all been called to harness and direct. Being good employers and “good corporate citizens” is part of the structure we need to direct our collective energies for the greater good that they are meant to serve. Now let’s get to work!
Here is a handout from the Being Bossy breakout session at the CANference today:
WHAT IT TAKES TO MAKE THIS THING WORK (besides our job duties):
PHYSICAL PLANT Maintaining, cleaning, managing the physical structures and place, and equipment PR and
MARKETING Printed and written materials, contact with media, networking, website, newsletter, merchandise
ACUPUNCTURE Supplies, competitive pricing for supplies, sharps containers and disposal
HERBS Maintaining pharmacy, monitoring financial of pharmacy
FORMS Developing and editing, printing
FINANCIAL Payroll, taxes, bookkeeping, Loans, budgets, accounting, bills,
SAFETY OHSA, needlestick, universal precations, first-aid, emergency plans,
TEAM BUILDING Birthdays gatherings Appreciations Group activities STAFF Hiring/Firing, training, training manuals, meetings, job-descriptions, feedback, evaluation, salaried duties
CLINICAL SKILLS AND DEVELOPMENT In-house materials, case review, training exercises
OFFICE SUPPLIES Maintaining and purchasing, researching competitive pricing for supplies
MISSION and PURPOSE Building strong community, out reach locally and with CAN,
LEGAL Malpractice insurance and risk management, liability insurance, incorporation,
CLEANING All surfaces, bathroom, all sinks, rugs, laundry, cups,
OFFICE EQUIPMENT Obtaining needed items at good prices-chairs, blankets, lighting, computer, desk, file shelving, etc.
GROWTH and PLANNING expansion New/2nd location Trainings