System to Sustain Practice Growth

By Dr. Russ Rosen | Cornerstone

The conventional wisdom out in the chiropractic business management world is that you can sustain a 20% increase in practice growth each year. If the practice grows faster than that you can expect the classic “roller coaster” in which you grow then crash and repeat… not a fun ride!

Although this is true you can take specific action steps to sustain your growth and not crash your practice. I have seen many of the offices I coach literally double their practices during a year’s time and continue tremendous growth without the roller coaster effect.

The intent of this article is to show you exactly how to sustain growth in your practice without burning out in the process.

The first thing to recognize that this is not by chance or luck but it is absolutely by design.

Follow these simple steps and get off the roller coaster forever!

Make Space

The first thing we need to do is make sure we have space to put the patients.

We need space for New Patients, ROF’s, Re-exams and Re-reports and of course plenty of space to adjust our patients. I continually see docs who do not have special allotted time slots for all of these appointments. I was working with one doc who would bang his head against the glass ceiling of 55 per day. He would hit 60 or so then crash to the 40’s and had been in this cycle for years. I asked him why this occurred and he said there simply was not enough time in the day to handle the load. When we examined his schedule and made space for all of the appointments we found that there were 102 spaces to adjust people and we added a new patient and ROF to his daily schedule! One of my specialties is helping docs see more people in less time and get BETTER results. Personally when I started in practice my visit 1time and visit 2 time was an hour and a half a piece and eventually came down to 6-7 minutes. My close rate, referral rate, and p.v.a. all went through the roof. Clearly it is not the amount of time you spend; it is the focus and quality of that time. I also needed 30 minutes to adjust one patient! Eventually that came down to 2.5 minutes per patient. Let me help you see more people in less time and get BETTER results!

Next we have to make sure there are no capacity blocks clogging up our flow. The first thing to recognize is WE ARE AS STRONG AS OUR WEAKEST LINK! It is not just a trite cliché, it is reality. A classic scenario I run into is the staff feel like they simply cannot see more patients. The doctor pushes for new patients but runs behind. The patients get pissed off and give the CA “stink eye.” The CA’s stop scheduling so tight in the operating system and the practice drops. This is a classic story and has several weak links that need to be addressed. First if the doctor runs late people get pissed. If they get pissed the doctor rarely knows because they take their vengeance out on the staff and the staff stop scheduling so tight. The patients also stop referring new patients. In this scenario we also have staff who feel they cannot handle the load. We need to realize that you can only put one gallon of water in a one gallon container. But the fact of the matter is many offices have a half a gallon in a gallon container and don’t see how to put any more in. Classically I will speak with staff and ask why they are so busy? They are seeing half as many people as other offices I coach but they simply have no more room available. We then examine each and every task and system until we find the weak link. You may not believe this but the most common first problem we deal with is the CA just can’t schedule everyone and write receipts and deal with the rest of the flow. I ask them if they were to have patients prepay and only have to write one receipt every month or two instead of a receipt for each patient each visit and if the patients were to pre-schedule would that make a significant difference? Of course it would they say, BUT THAT WOULD BE IMPOSSIBLE! Of course it is not impossible as it is done in every other office; we just have not taken the time to train our CA’s in this new model. As soon as we clear up their headspace around this issue and then show them the appropriate procedure to accomplish this goal we create a tremendous amount of space. Of course we could go on forever discussing how to create more space but instead I will ask you to read the article entitled “Practice Growth and the Weakest Link” and “Creating the Perfect Life.”

Fill the Space

In other words now that you have the space and capacity to handle practice growth we need to fill that space with warm blooded beings. We need to do “Marketing.” Of course we could spend hours on this subject and won’t but there are a few key points I would like to review. (Please read “New Patients and the Marketing Calendar.”) Many doctors do not like the idea of marketing. They somehow feel they are “above” that. They feel that people should just come to see them because “I am a doctor not a car salesman for crying out loud!” I like to help docs shift their headspace to realize that everything you think, say and do is marketing. What your office looks like, what posters you have what your staff talks about as well as what promotion you run. Literally everything you think, say and do! Also I like to point out that although the end result of marketing is new patients the real reason we market is to tell our story. Because our Mission, Vision and Purpose are so big that we have no choice but to get out and tell our “truth.” I have seen this slight shift in headspace free doctors up to bring in boatloads of needing souls!! My basic formula for marketing is:

External Marketing

Get out in the public and let them know what you do. Make sure all of your marketing is congruent with your mission, vision and purpose! If you are a “Wellness doctor” don’t do “Spinal or back” screenings. I have an entire process but the classics are:

  1. Outside talks
  2. Screenings
  3. Print ads
  4. Social media
  5. Website

Get families in

Now that we have fresh new blood give them an opportunity to get their entire family in to get checked for nerve interference. If you have shifted their consciousness to realize they have a health problem not a back problem AND they really want to get healthy now, prevent problems in the future and have a better quality of life then how could they possibly leave their families at home?? We have an entire process to get families in.

Internal promotion

Now that we have new families under care let’s give them an opportunity to get their friends in. Remember people want to refer! Do you ever tell friends about the new great block buster movie you just saw? Of course you do. Were you paid to do that? Were you coerced? Of course not, it is in our nature to share good things with our friends. In Robert Cialdini’s book “Influence: The Psychology of Persuasion” he helps us realize that there are “windows of time” where people not only will refer to us but they actually WANT to refer to us. In fact, if they do have the opportunity to refer to us THEY WILL HAVE A BETTER EXPERIENCE AND LIKE US EVEN MORE!!! All new patients come from one thing. And that is ENERGY! If you and your team get psyched up and it is part of your mission to “help save lives” vs. “get some people out of pain” you will see amazing results with your internal promotions. Remember to let me help you and your team with some killer internal promotions.

Piggyback internal promotion

Usually right after a great internal promotion we can do another one. Because it was such a great success and we have a bunch of new patients in from that event we can now give them an opportunity to do the same. There is a science to this Make sure we discuss it in detail.


Now that we have given our active patients an opportunity to refer in their family and friends it is time to go and do our external community outreach program.


Now that we have filled our practice it is time to reorganize. The classic blunder that most offices make is they continue to fill the practice till it bursts!! Remember, a one gallon container can only hold one gallon of water. So it is time to rest, recover and REORGANIZE!! As soon as our practice has growth we have to ask our entire team these questions:

  1. What worked?– Get very clear about what worked and then do more of it. By design, not by chance. So clarify what has worked in each position and make it part of your system. Make sure it becomes part of your training manual and continue to do more of it! (Michael Gerber’s “The E-Myth Revisited” is a must read!)
  2. Challenges– Were there any challenges? Remember you are only as strong as your weakest link. I ask my offices to look for the challenge. The question is not “Is there any challenges?” The question is “Can we find them before they become a problem?” So as part of the Performance Appraisal System every person on our team must review every “behavior” and “task” (See Performance Appraisal System in the “Dream Team” workbook.) We all need to see if any of our “A” performances have dropped to a “B”. Remember classically we will have capacity issues but we will not see the effects of those problems for 60 to 90 days. We then have the classic downturn of the practice and we have no way of figuring out why it happened. We always look for the problem in the last 30 days… but of course it is not there. So each person must clarify where their capacity blocks or challenges are. We recommend asking each person on your team. “Are you bored, stressed or in the zone?” If they are bored then carry on. If they are in the zone then ask them would they still be in the zone if you got to your next goal. If so then REORGANIZE. If they are stressed then of course you must make space and reorganize. You cannot sustain growth and be in defense at the same time.
  3. Fix challenges– Now that we know where the challenges are we need to fix them. This is what the performance appraisal system is all about. The offices who use this each and every week thrive. Please be one of them! Remember this phase may take several weeks. WE DO NOT WANT TO DRIVE A BOAT LOAD OF NEW PATIENTS TO OUR OFFICE DURING THIS REORGANIZATION PHASE!! It is time to rest, regenerate and reorganize!
  4. Set new goals– Now that we have successfully cleared up any challenges and recovered from the filling phase we want to set new goals. Please read the article called “Goal Setting.” Be clear, be specific, make sure the goals are agreed upon by the entire team and make sure they are exciting.
  5. Action plan– As part of the goal setting process we need to have in writing what each person on the team is going to do by when to help reach the goals. Without this step goal setting is simply WISHING!



Now that we made space, filled it and reorganized we are ready to repeat the entire process again. Figure out ways to make more space. Again please review “Practice Growth and the Weakest Link.” Also realize the only way to make more space are to add more staff/associate, space, equipment or speed.

I realize this was quite a bit of information and in reality we can spend hours on each step. My wish is that you not only gained a few pearls of wisdom from this discussion but more importantly that you implement those pearls, plant those seeds and experience the joy of Sustained Practice Growth.

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