Scaling Your Group Practice ft. Maureen Werrbach

Do you feel stuck and uncertain how to grow your practice? This episode is just for you!
Join me, Uriah, and fellow group practice owner, Maureen Werrbach, as we show you how to grow your practice with confidence.

In This Episode, You'll Learn:

  • How to scale at the right speed for you
  • Which struggles can you avoid
  • Which struggles do you need to go through

Resources Mentioned In This Episode:

Group Practice Exchange
Productive Therapist

⬇️ Click for full episode transcript ⬇️

Uriah
Hi, Maureen! Welcome to the podcast!

Maureen
Hi, it's nice to see you again!

Uriah
Yes, it's great to be talking to you. I'm super thrilled, as always. This is actually the first time that you've been on the Productive Therapist podcast. In a proper interview, you did an episode for me, Ten Questions with Maureen Warbeck.

Maureen
Yup, that was a good one. It's been a while.

Uriah
That was 2020, so there you go.

Maureen
There you go. In 2020. I know it's only like three years ago, but it's really like eight years ago.

Uriah
It feels like a decade emotionally.

Maureen
Yes, exactly.

Uriah
One of the highlights for me this year was going to your event and meeting you in person for the first time, which is kind of insane to think about.

Maureen
I remember when I saw you, it was like so nonchalant. It's like, okay. And then you're like, it's nice to meet you in person for the first time. And I was like, what? I didn't even realize because I've talked to you so much, so much that we actually have never met in person.

Uriah
It was definitely 2017 or 2018. So yeah, let's call it four years.

Maureen
Four or five years, yes. That's a long time.

Uriah
That was really cool. Yeah. Well, we're going to get into some fun topics, some things where you and I have definitely have overlap in terms of what we like to think about and talk about, and certainly what the Productive Therapist podcast listeners like to hear about. But I wanted to ask you a fun question first, and I know you won't mind this one. What is left or what is next on your bucket travel list?

Maureen
Folly. I turned 40 next year and that's where I want to go. I was supposed to go there. I had it all like my trip planned and everything paid for, and it was supposed to be for June of the Year COVID hit, and so I canceled it all. So I figured that's what I'm going to do for my forty th.

Uriah
I love it. And what's most attractive or interesting about Bali?

Maureen
I want to go somewhere that is known for its mindfulness, its peacefulness. I tend to be someone that feels like I need to explore everything. So vacations when I go out of the country end up being really tiring because I need to explore all the things. And although I did have a pretty thorough list of things I wanted to do in Bali, I feel like it'll have this air of peacefulness to it.

Uriah
Yeah, that's great. I put together recently a list of all the events that I could find that therapists were putting on four other therapists in 2023, and there's quite a few, and one of them was a trip, sort of a mindfulness retreat, spiritual retreat for therapists to Bali. And I was looking at the pictures and I was like, oh my gosh, it really does look amazing.

Maureen
Yeah, I have a friend who lived there for a little bit and she has nothing but amazing things to say about it.

Uriah
Yeah, I love it. That's cool. So one of the reasons why I wanted to ask you that is because if a therapist starts a group practice and intentionally scales it, grows it and builds a team and then delegates a significant amount, that creates the possibility for them to have a bunch more time freedom and also, fortunately, more money to do fun things with said time. Right. So that's why I'm excited to talk about this because at the end of the day, I really am interested in lifestyle design and like, how good can I make my life while also doing good in the world and taking care of my team? It's a triple win, right?

Maureen
Yep. And I think it's something that feels taboo, like owning a group practice and having time freedom. I know it's something that a lot of therapists feel guilt about. So I appreciate that that's something that you focus on because it does not need to be this taboo thing that if you have time and freedom because you're not working but you're still making money, that's not a bad thing, you know?

Uriah
Couldn't agree more. Yeah, definitely. So the question I want to ask you one of two questions on this topic is in your experience, what are the biggest challenges or mistakes that practice owners make when they're intentionally trying to scale and grow? Maybe they want to get over a million dollars, whatever their income goal is. What do you see people doing that is problematic?

Maureen
One thing is scaling too quickly, trying to get to the end point and not enjoying the journey. And when practices or any business really scales too quickly, they run the risk of creating potential problems, especially financial problems, not being prepared financially for the size that they're going into, but also not just having the infrastructure and systems in place to support that quick growth. I always say that most of our procedures that we have in our practices are kind of like living documents or living procedures that change as we grow. They evolve as our business gets bigger. And when we scale too quickly, we don't have the time to nurture those systems changes and updates and it ends up causing issues for the practice. In terms of successful scalability, we might be large with a bunch of people, but does that mean it's actually successful financially? Probably not. And also it creates a potential culture issue for staff who feel like things are just changing way too much. Staff like stability. It doesn't mean that we can't grow. But a lot of practices, I'm sure you've had this experience when you grow and people who've been there when you were smaller, they tend to feel anxious or have concerns about that new growth.

Maureen
And so when there's quick growth, there tends to be a lot of turnover and that's really costly for the business. So I'd say that is one and it ties in with I kind of mentioned it. But the second thing is just not having the right systems in place. It's almost like you'll have to build systems and procedures retroactively to catch up with that growth and so it's almost in response to versus a proactive intentional, thought out procedure or process in the business.

Uriah
That makes a lot of sense. Would you say a group practice with five clinicians versus 20 versus 50 versus 100 are probably very different organizations?

Maureen
Yeah, 100% no matter how much we want to say I know I went through this for a long time being like when I was a smaller practice, I loved this family feel and air quoting. Well, not really, but family feel and I remember when we were probably at around 20 staff, I still wanted this atmosphere, family and although we're really large now and we have amazing culture, it is just different and our staff experience might practice differently now than they did when it was five of us. It just is whether we like it or not. So it's about embracing that change and not viewing it as bad. I know a lot of people talk like being corporate is bad and also lumping together that if your practice is large it's automatically corporate or corpority. And I think there's a way to sort of balance all of that. And yes, the feel for staff will probably be more businessy when it's larger because we put more systems in place and metrics and all of that to see where things are falling short. But we can also have the opportunity to still create those close knit personal interactions even when we're large.

Uriah
It just looks different.

Maureen
Yeah, it just looks different.

Uriah
Yeah. Quick question on your point number one, which was a mistake, can be scaling too quickly and some entrepreneurial therapists, group practice owners like, I can name a bunch of people I'm not going to name. I'm thinking about a bunch of people, they move very fast and they're like getting new properties, hiring and they are operating at a high level, moving fast, but that works for them. And then there's people like me. I tend to grow really slowly, methodically, intentionally, sometimes too slow to be honest. So how does the group practice owner kind of figure out what is the ideal pace for them, if that's possible.

Maureen
I think it's possible. Part of it has to do with our risk level and I think to some degree all of us business owners are risk positive because we started businesses that it takes risk all in and of itself. But I think there are definitely people who have the supports to allow them to grow quickly and it doesn't mean it looks great. Again, I don't think that there are many businesses at all who are infrastructurally successful and financially successful in cultural workplace culture, successful if they're growing really quickly, it's probably an anomaly. If you are something, one of those is going to be at least one of those is going to be that that ball is going to be dropped. So I think you can do it. I just think that when you're starting a business and if you grow quickly, you haven't had the time. What we want out of our practices in theory when we first start might not be where it goes. Once we really sit in that business ownership role, we grow as leaders, we become more comfortable with leading with time and our vision and what we really want out of the business might shift a little bit once we truly understand what it feels like to own a business.

Maureen
And so scaling so quickly, I think doesn't give you that opportunity. But yes, there are plenty of people who can scale quickly and luckily maybe don't have any big financial things come up where they've been kind of pushed up against the struggle or the negatives of scaling quickly.

Uriah
Right. Anytime I talk to a therapist with a group practice who's grown to a significant size without really a team that is efficient and working well, without a doubt, they're always stressed and overwhelmed and kind of like at the end of their rope.

Maureen
Which is not saying you haven't had all of the experiences of the struggle of group practice ownership in a one year period. If you've gone from zero to 30 people, it's like you're going to have we all go through the same experiences of bad hires, of negative Google reviews, of culture issues. Like there's so many things, all of us experience it at one point or another. But if you scale quickly, you're now at 30 people, let's say in a year, you haven't even had time to process and live through some of these struggles and they're going to be kind of hauled at you all at once. And like you said, they're going to be stressed, overwhelmed and overworked.

Uriah
Those steps are required learning, unfortunately.

Maureen
Yeah. I think they make us stronger business owners and prepare us for the next stage of growth. The more problems that have happened in my business staff issues or unique situations where we've had to work with our attorneys or whatnot those have made me at the end of the day when they're done, more confidence for growth. Because I have now just put another unique experience under my belt that I feel like if this happens again, I can handle it.

Uriah
So true. Yeah. I don't think you're doing this now, but if you want to do this with the Exchange, which anybody listening who has a group practice should sign up and become a member of the Exchange, which is a community for group practice owners. That's pretty much the best out there. But I think you could have a system where people earn badges and maybe they're physical and then they could put them somewhere and fired a friend. Payroll tax audit.

Maureen
Oh my gosh. Well, to that point I'm literally, I've been doing it for about a week now. I'm just so slow at it. But I'm building a bingo card of group practice ownership and all of it is mainly like the hard things. So I wanted to somehow put that out there and be like anyone who gets a bingo means they've dealt with.

Uriah
A lot of things and you win a spa day or something.

Maureen
Yeah, exactly.

Uriah
That's great. I love it. Okay, so hypothetically no, I'm not even hypothetically, can you answer this question for me? So my group practice is ten therapists and we've got a good team. There are some improvements that can be made. Of course I would like to grow it and I would like it to be more profitable and I would like it to require less time of me if that's possible. Because too much if you were coaching me, let's say, and I said, Maureen, maybe not in twelve months, but in some time period I want to double the size of my group practice, I want to get to 20 clinicians, I want to actually make it more profitable and I want to be less involved. What steps would you advise me to take?

Maureen
I would say I would start with creating an accountability chart. And maybe it is that you're accountable to a lot of those things leadership wise. I know. I think you've read the book Traction EOS twice. But I think that is a great foundation not only for business owners to see what things are they truly accountable for because I think we often. And you being kind of the delegation master here. Probably would agree with me that a lot of people think they're delegating when they're truly still like the decision maker on those things. And so it's still taking up mental energy, physical time of the business owner. And to truly delegate means that you are giving out the ownership of the results of the things that someone else is taking over so that if there's something wrong with it, they're creatively coming up with ideas on how to fix it and not having to come back to you like it's truly being done outside of your vision. Right, that's true delegation. And I think creating a true instead of like a roles and responsibilities organizational chart, like an accountabilities chart, will help you see how many things are you still actually accountable for so that you can start to either hire with that in mind, you might notice that you need someone who you're in charge of leading the clinical side of things.

Maureen
Right. If you have clinicians, that obviously means it's always going to take up time to be in charge of clinical. And so maybe you don't have someone on staff that could lead in the clinical sense. So that means that's something that you would have to start looking for in terms of hiring. And we've hired outside for some leadership positions and we've done it internally if we have that, and I think that just takes a long time. So getting to the point of knowing who's accountable for things related to sales and marketing and the operations and finance and the vision work, which obviously would be you, and then someone who can actually hold all those people accountable, like an integrator or whatever, I think that's going to set you up for success to be able to hire. So as an example, we do this whole thing and I have an onboarding coordinator, she's in leadership, she does all the recruiting, all the onboarding, and she has quarterly and yearly goals that she is accountable for when it comes to growth. And we don't have a number like hire ten more people this year because you have to think about people leaving and if you hire ten and five leave, you haven't really grown by ten, you've grown by five.

Maureen
And so she has her own metrics and account abilities to be proactive around people who are leaving and also growing the business from adding clinicians perspective. And that's something that then you can do when you have these accountabilities is then put someone in charge so that you're not spending more time, who can make sure to bring in the right people that fit your practice and set those goals up so that you get those extra ten people.

Uriah
That's really helpful and I do need to do that. The accountability chart, setting it up properly, like the book Traction Details, we've actually been working on that with the productive therapist leadership team and it's really, really helpful. It seems so simple and straightforward, but when you actually break it down into the appropriate roles and what are they responsible for, and then, like you said, realizing having honest moment with yourself of, oh shoot, I'm actually still doing too much, right? Yeah, that would be really good for me. The two things that are most challenging for me to delegate and outsource are related to marketing and technology because I'm always still the person that does most of those things. But I will say that with some of your support. Actually, I did promote an executive director, clinical supervisor, promoted to executive director and three months since that took place and it's actually going really, really well.

Maureen
That's so good. Yeah, I think the clinical leader is such an important one. Obviously I get that most people are going to say that doesn't seem like new news, but almost more than we think it will help. Everyone knows if I have a clinical director or a supervisor who can help with the clinical stuff, that would give me so much time. But it actually does so much more than that if they know what they're actually accountable for, because it's more than just supervising or making sure that people are reaching their clinical metrics. It can be another sounding board when it comes to diversifying services and whether or not the clinicians you have on your team are people who can do those diversified services for you. Yeah. I think you'll really enjoy long term having that person, and it will take a lot out of your hands, so much of it.

Uriah
It's about the right person, though, because Shauna fills that role and she's amazing. She's like a super networker and actually really enjoys that a lot more than I do. So that's a wonderful thing. But I think as we go from ten to 15, hopefully to 20 clinicians, we do need more and more structure and clear, like you were saying, clear accountability roles and the scorecards are the metrics. Like, what are you responsible for? Like, down to, like, something that's very what's the word I'm looking for? I guess not subjective. Right. It's very objective, and that's not always easy for us to do as a therapist because we're like, how does it feel? Did you meet the goal?

Maureen
I know a lot of people who shift over to EOS have a hard time as therapist because it is so rigid in some ways, but if everyone can acknowledge that and accept it and still get on board, there's so much gross that can happen in the business. But also people feel more successful because it's so objective. They know when they're doing the right work.

Uriah
Definitely. Yeah. And everybody wants that. I used to think in the early days of my group practice that I don't want to be a manager, I don't want to really oversee anybody, and I just want to hire people who are grown adults who are good at their job and then just do the work. And I didn't give them feedback, I didn't give them guidance. I just said, here's an office, good luck.

Maureen
You think that everyone is just intrinsically motivated to do that, right.

Uriah
And you kind of assume that therapist should have good boundaries and know what to do, but that's not always the case. And then I realized at some point through getting some consultation, that I was actually doing them a disservice by not giving them feedback and helping them grow in that role. So many things I've learned over seven years. And I've also realized that I don't love being a manager. I love much more the creative side of things, the visionary side of things, building stuff as you do, I think, right? Yeah.

Maureen
And that's what I should do. Yes. And I have a great integrator who loves holding people accountable, and she has a snack for doing it from such a place of care and love that people embrace feedback from her. Whereas with me, I'm just so literal that it wouldn't come off that way. People would be afraid or they would feel like they're disappointing me, even though they aren't, because I am open to failure. And people making mistakes, and I don't think that people get things right the first time around. And that's okay. I don't either. But Dana, who's my executive director and integrator EOS terminology, she can have conversations with anyone. Hard, hard conversations, and they feel like she really cares about me and my success, which is hard to find, but.

Uriah
To be my skill set, it really is. And somebody can fill that role and sort of go through the motions and say the right things, but there's just an art to it. There is, yeah. Cool. Well, that's so helpful. I mean, we could talk for days about this stuff. But I guess I do want to ask you before we wrap up, how do you see things changing over the next five to ten years in our industry? You're the one person that I listen to and follow in terms of this because I'm not a great prognosticator, but also Ken Clark and some other folks, too, because obviously the plates, the tectonic plates underneath our industry are shifting. Some people are scared, some people are not. I don't know. What would you say? What's your advice? What are you seeing?

Maureen
Oh, my gosh.

Uriah
I know. Huge question.

Maureen
Sorry. There's so much that's like a whole episode, really quick overview, and I guess anyone who's listening, who hasn't been doing this research might be alarmed or confused. You can Google half of the things I'm going to say and find some literature on it, so do that. I think there's going to be a shift when it comes to insurance reimbursements. One shifting away from the fee for service model to the values based reimbursement model I envision. The way that works is that everyone's going to be paid a lot less initially at the gate and based off of assessments that insurance companies are going to want. They will then provide additional income for assessments that you send over to them. So you could potentially make the same amount that you're making, but you won't right off the bat without showing that you're providing assessments value according to them, which sucks because they're going to dictate what value means versus us. And so I think that's going to have a huge effect financially on businesses, especially if you're salary based. I think there is a potential for therapists who are even hourly or commissioned. We have to make that shift when the initial reimbursements are much lower, that it might create the space where staff leaves because they obviously only see what's in front of them and they will likely blame the insurance companies or likely blame the group practices over the insurance companies.

Maureen
But there are things we can do to be proactive, like looking into how you can start to do within your value system some type of assessments or feedback that show that you're asking clients if they feel like they're getting better or doing better or growing or whatever their goal is. And there's things like Blueprint and I know EHRs are now starting to add assessments to their EHR, so there's ways to do it. I also think insurance companies are likely going to be harder to get in with our panel with in the future because I'm seeing them start to purchase companies like CVS is owned by Aetna and now CVS has therapist offices inside there. Which means that insurance companies can just direct clients to their own therapist. Which means that they're essentially paying themselves versus having to pay out to private practitioner. That will be, I think, an interesting thing and it'll also make it harder for private insurance companies or private practices to get in with insurance companies. And I think we'll see probably not in the next five years, but in the next ten years slowly. It getting to this place where people start getting out of insurance to do private pay and it being an overload of private pay practices who don't have enough clients who want to pay out of pocket.

Maureen
And those practices that will survive through that or survive through it are ones that have diversified services outside of oneonone or insurance facing things. Even if you're an out of pocket, like even if you don't take insurance, if you allow clients to submit claims or user out of network benefits, that's all going to affect them too. But I think being proactive and looking at how you can service your clients outside of the traditional therapy model could be really helpful in kind of weathering through that. I also think diversifying services in terms of making your practice a wrap around is going to be helpful. So having met management or any other wellness related that kind of helps the whole body in a sense is going to be something that people are looking for, as you can tell, since COVID I think all of us are wanting the easiest, right? We are okay with teleported. US are okay with telehealth. I see my own therapist through telehealth. I don't want to drive anymore. I'm like I can just go in. So people are going to want, you know, are more likely to gravitate towards practices that can meet all of their health needs versus going here for one thing and here for another thing.

Maureen
And so anything we can do to make our practices more well rounded like that is also going to help us kind of weather that.

Uriah
Yeah, that's helpful.

Maureen
I mean, I'm just going very mildly.

Uriah
I know it's like touching on those things. I would tell people though, if you're interested in sort of keeping up with changes and staying on top of those things because that's what we're going to need to do to survive and thrive in this whatever is coming, that's the.

Maureen
Visionary work we should be doing for sure.

Uriah
Yeah, I think they should check out the exchange honestly and take advantage of all the resources that you have and that you continually add I think that's probably one of the best ways to stay up with things. Also, your free Facebook group, the Group Practice Exchange, is a wealth of information. I'm not sure how to wrap this up. I was going to try to ask you one last question, but this is really helpful. Thank you so much for being on the show. And we'll have to do a round two some time to to dig into some other things.

Maureen
Would love to.

Uriah
Yeah.

Maureen
Well, it's good to see you again.

Uriah
You too. Bye!

Maureen
Bye!

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