Company or Business?

Do you run a company or a business?  I am not talking about legal definitions here.  I am really interested in the meat and potatoes of the patient care entity that you operate.  I was talking with a friend the other day about his business.  Call me crazy, but we got into some interesting discussion about what distinguishes different O&P operations. As we worked around to contextualizing two different camps, we decided one is a “company” and the other is a “business.” Let me explain.

There is a lot of similarity between the two and if you are looking from the outside, you will see a very similar operation.  Patients enter in one condition and they go out in another, hopefully better, condition. There is a staff, there is an exchange of payment and hopefully, the payment exceeds the total cost of the transaction.  All good, right?  But I want to dig a little deeper.  I want to know the details about how that patient’s condition improved. And this is where we start to create a distinction between what we called a “company” and a “business.”

When it comes down to it, we are really talking about value creation.  The question is, how does the O&P entity create value for itself?  When I talk about value here, I really mean what would someone be willing to pay for your business today?  And will it be worth more tomorrow?  It does not matter if your business is for sale…it’s just a tool for measuring.  We all assign value to our own things, but we often include an emotional component that a true purchaser would not consider, so their perspective gives us a more biased value.

A key consideration, and the biggest differentiator we came up with, was how well the entity has incorporated people and processes into its operations.  Essentially, is the organization centered around the practitioner-owner, or is it something that has a defined structure with processes and standards that are scalable, repeatable, and understood through the organization?  We decided that the former is a “company,” and the latter is a “business.”  In the valuation, a key question for the buyer is “what am I buying?” If you can answer that with “my system,” and your “system” is actually identifiable and distinct from you, then you have a “business” (in my little world) and something that can be sustained and continuously developed even with you out of the picture.  There is intrinsic value in that as an ongoing enterprise. The buyer should pay a premium if there is a sustainable system that will transfer with the sale.  A change in ownership should not impact operations.

But if you answer “me,” well, no offense, but that really means the buyer is in for a lot of work.  So they will discount your company significantly to offset the additional costs they will incur.  In this case, a change is ownership will require a new process and new systems.  While not quite starting from scratch, there will be a visible change in the way the business runs with new ownership.  In reality, there are other measures that go into the business valuation, location, contracts, patient volume, patient mix, etc. but the point is that a business, on this scenario, is running because the people, processes and tools are all in sync.  Changing the ownership should not require a change in anything else.

Are you allowing your company to become a business?




Is your staff motivated?

A few weeks ago I wrote about the emerging trend called quiet quitting. And before that, I wrote about the great resignation. Recently the business headlines are focusing on the difficulties businesses are having getting good employees (or any employee, for that matter). Like it or not, COVID, combined with our nation’s response to it, changed everything. If money is what motivates your support staff, my fear is you are in trouble.

The sad reality is that the amount of money it would take to truly have a motivated support staff is not sustainable for the typical O&P Practice. But I think you have an incredible opportunity to attract good people. In a book written in 2014 by Allen Buckley and Jonathan Godbey called “Why Work?,” the two authors look at the economics behind the real distribution of household income. They coined a term they called “the ditch”: an area of income at which lower-income households had a higher standard of living than middle-income households, due to entitlements and refundable tax credits. Back then, a family of four making more than $29,000 was “in the ditch” until their income reached about $50,000. The COVID payments and other money the government has provided has exacerbated the width of the ditch. While there are no reports or analysis of the current income levels that define the ditch, the upper end is significantly higher than in 2014. So using money as the primary motivator is a fool’s errand.

Years ago, when we started leadership training, Paul brought in a world-class business coach John Spence. And John introduced us to a protégé of his, Spencer Penhart. Both of those guys are fantastic and they really embraced the O&P profession. To say that they were instrumental in helping OPIE users grow their businesses would be a massive understatement. One thing each of them said to me was that the O&P business owners have an amazing opportunity in front of them. For most employers, the single most difficult obstacle to overcome when building a team of high performers is an exciting mission. My question to you is, what is your mission? How do you “sell” your company to the people who work there? Are they excited about what you do? And do they feel like they materially contribute to something awesome?

Because at the end of the day, the care provided at O&P facilities is awesome. We help people obtain or regain some autonomy. Some self-sufficiency. Maybe even help them find new purpose or meaning in their lives. I can’t think of anything more rewarding than that. If you are only in it for the money, then I really don’t think what I say will make a difference for you. But if you truly are passionate about the care you provide, you need to rekindle that in yourself and in your company and then make sure everyone understands how vital their role is in achieving patient success. And when you employ people, THAT should be why they come to work for you. And if you can rekindle that excitement and get those people engaged, you will be miles ahead of your competition for staff.

With everything going on in O&P these days, the last thing you need is to struggle with finding good help.

Modern hourglass in running time with copy space on a grey background.


This past weekend my daughter came home from college, and we were talking about the passage of time. She is a sophomore at West Virginia University. WVU offers a summer session called “Adventure West Virginia” to the incoming freshman class that is designed to introduce the new students to each other, the state, and what college life is like. They do team-building things like whitewater rafting, rock climbing and camping. My daughter loved it so much she decided to be a guide this past summer.

As we were talking about her experience with the program, we happened to drive by her high school. She was in the marching band and they were on the field when she remarked at how young they looked. And she started talking about how much you mature in the first year of college. She was reminiscing about some of the incoming freshmen that were in her sessions and how clueless they are about so many things (I almost interrupted her to remind her that cluelessness doesn’t end after the first year of college!). It was fun hearing her stories and her insights.

And she mentioned how quickly her first year of college went by. I said yea…it flew by for your mom and me too! We started to talk about our perception of time and she said a phrase that really caught my attention: “Time is linear, but we experience it exponentially!” I kind of stopped the conversation and asked her if she had just made that up, or if she had heard it somewhere.  She said it just came to her…no one had said that to her.  That  phrase stuck with me and made me think. While neither of us thought time is truly exponential, it hammers home the fact that the older we get, the faster years and days seem to go by. And that drives home to me the thought that if you want to do something, the time is now. Totally unrelated, but certainly connected, was my dad’s reminder to me that I would not learn a new skill or accomplish a task any earlier in my life than that particular moment in time.

The feeling that time goes by faster as we age makes a lot of sense. If you are ten years old, one year is a tenth of your lifespan. At 20, a year is a fifth. The older we get, the smaller percentage of our lifetime a year makes, so it does seem to go by faster. Since we can never claw back time, and since it literally seems to speed up as we age, whatever you are putting off until tomorrow, do it now!

Lady boss in stylish outfit points out to clock, talking about late of her subordinate. Portrait of woman sitting in light office

Quiet Quitting

There is a new trend emerging in the office worker community: they call it “quiet quitting.” It isn’t really about quitting; it started as a movement of people trying to draw more concrete work-life boundaries. Like most trends, there are advocates and there are critics. As you might expect, the critics tend to be career coaches, business leaders and HR professionals and others. On the other hand, some young professionals praise the idea.

Time reports on Maggie Perkins who had been working as a teacher for almost five years when she decided to “quiet quit” her job. In her opinion, she wasn’t quitting, she was merely limiting her work to her contracted hours. Nothing more, nothing less. Time says that “Perkins joins a larger online community of workers who have been sharing their experiences on TikTok, taking a ‘quiet quitting’ mentality—the concept of no longer going above and beyond, and instead doing what their job description requires of them and only that.”

“Quiet quitting isn’t just about quitting on a job, it’s a step toward quitting on life,” writes Arianna Huffington in a LinkedIn post. And Kevin O’Leary (of Shark tank fame) calls it a “horrible approach to building a career.” Others say quiet quitting mind-set fosters laziness and hurts performance, even if baseline job expectations are being met. Some say it fosters a demoralizing workplace.

As I learn about this new trend, several things come to mind. The first and foremost is from the worker’s perspective. It’s something I’ve preached for as long as I can remember: if you are not happy in your job, leave it. If your job feels like work you are not doing anyone, including yourself, any favors. Go out and find a job that excites you. This is less about a work-life balance and more about personal fulfillment. Yes, our families are important. I made the hard decision to leave a great job to spend more time with my family. I am thankful I did!

From an employer’s perspective, we have an obligation to provide clarity of expectation and to foster a collaborative environment, if the work would benefit from collaboration. We have an obligation to screen our potential employees for a culture fit, too. I work for a place that values the work-life balance, but I love what I do and could not imaging “turning it off” after some threshold is met. The work never stops, and we need to be able to focus on what is important at that time.

But if my coworkers need me, or if I am on a meeting that runs past 5:00, I will not leave that meeting just because the clock says it is “quitting time.” If I have a “hard stop,” that is one thing, but I have seen and heard many stories of people who stop when the clock says to. I know for personal experience how frustrating that is when that happens to you.

Let me know what you think of this new trend and if you are seeing it in your practice! Do you think Quiet Quitting is a healthy trend?



There are those who thrive on and in chaos. I have known people who seem to always be involved in one controversy or another and today you do not have to look very far to find controversy. Don’t worry if you are not looking for it…it will find you! I think we need to make every effort to squash controversy as quickly as we can. Controversy is different from disagreement. Disagreement accompanied by respectful dialog can be quite healthy. But controversy is poison. There is little desire to remedy the situation. The goal is to highlight and maintain the chasm between people. Controversy kills relationships and is rooted in bitterness toward one another.

Leading in this current culture of cancellation and controversy can be tough. There is little desire to walk a mile in another’s shoes or to try to see each other’s perspectives. This is not a political issue, but rather a human relations issue. And one person can’t fix the problem. But as a leader, we can influence our little part of the world. I think we have a duty to create a peaceful, respectful work environment where people can come together to do their jobs. A pessimistic view of the role of a leader is to diffuse controversy but I prefer a more positive objective — to pursue peace. If you are a leader, whether formally or informally, ask yourself if your actions, words and attitude foster peace or contribute to controversy. We can’t expect a peaceful culture or effect change in our organizations if we don’t start with ourselves.

You may want to associate what I am saying as “woke,” but I will argue that this is the opposite of “wokeness.” I believe that what is the right thing to do may not be the “fair” thing. I strongly believe that we should seek peace and be kind to one another, but that does not mean we have to stop being effective in our jobs. There are people who depend on us to do what we must do. There are processes in place to ensure that the job is done correctly, so if someone perceives unfairness in the process, we can and should have a respectful discussion about that, but the discussion must remain respectful on both sides, and a decision must be made.

If the “new” perspective brought forth creates a compelling reason for change, then we have an opportunity to broaden our own perspective and see something we didn’t before. At the same time, if the “unfairness perspective” brought forth does not create a compelling reason for change, there is an opportunity for that person to broaden their own perspective. If they choose not to accept the leader’s rationale, then they run the risk of becoming bitter and eventually creating some form of controversy around the perceived unfairness. Mutual respect and tolerance for one another are essential for the leadership role of peacemaker. But so is a conviction to do what is right. Defining what is “right” for your company should be easy because you have given great thought to your corporate Mission, Vision and Value statements, right? Those are your business’ moral compass and the test by which all operational decisions should be weighed.

Whistler Mountain Aug 2022


I am at Whistler Mountain, in British Columbia today at the OPC Annual meeting.  Today’s keynote speaker was a really cool dude named Dr. Brian Goldman. I got to meet him and have a have a drink before I knew he is famous.  He seemed like a really nice guy and as we were chatting, he said the he thinks we (the profession of O&P care) are undervalued in healthcare.  Well there you go…a stranger, and a doctor, no less, getting on MY soapbox!  It was a good and lively discussion with others at the table joining in, but we came around to how we can effectively communicate with a surgeon through our patients and our patient care.

Whistler Mountain Aug 2022

This morning, his presentation was focused on the power of teamwork  and he was talking about how a high performing team can have tremendous impact on whatever it is trying to accomplish.  We are surrounded by teams in everything we do, so my question to you is, how do you (can you) use the teams around you?

A strong leader leverages the power of teams to multiply effectiveness and to achieve a better outcome than is possible without the power of the team. Step back and think about what teams you can tap into: If you are a clinician, and the most intimate level, there is a team of two, you and your patient.  You can add parents or significant others to expand the team.  At this level, you can collaborate on determining desired and reasonable goals, setting expectations, and creating a strategy for the plan of care.

In your office, you have technicians, admin staff and other clinicians who can all collaborate and answer other questions, like what is the best wat to deliver the care we intend to deliver in the most effective way.  What challenges do they see and why do they see them as challenges?  Do others see something different?  Once everyone has expressed their thoughts, the team can decide on the best course of action.

Outside of your office you have physical therapists,  doctors of physical medicine, primary care physicians and more.  How do you think you can bring those teams together and go through the same exercise (including the patient) to determine the desired outcome and the best way to achieve that outcome?

One of the concepts Dr. Goldman introduced us to is a teaching methodology known as “Visual Thinking Strategy” (VTS). VTS is an inquiry-based teaching method that improves a student’s ability to describe, analyze, and interpret imagery and information through observing and discussing visual art.  What does this have to do with O&P?  The strategy used here is actually quite effective at fostering a strong team.  In art, there is no right or wrong answer.  What you see is what you see.  The really cool part of this is that we move from observation and feeling into critical thinking when we delve into why you think what you think.  Again, it is safe here to express the rationale for your thoughts.  In VTS, as the team looks at the art, there are three sequential questions asked: The main aspects of VTS teaching practice include three key inquiries:

  1. What’s going on in this picture?
  2. What do you see what makes you say that?
  3. What more can we find?

As you work though those questions together, there is opportunity to others to express their views on the same work.  Again, here there is no right or wrong, but we are all given the benefit of another’s perspective and we may see the picture a little differently as the discussion evolves.

Think about how you can apply these same concepts in your practice with the different teams you have access to.  Imagine the possibilities when all the stakeholders can express their views and then bring them together into a cohesive plan! Now expand those stakeholders to include the vascular or orthopedic surgeons who are about to try a limb salvage or an amputation.

Who’s the Boss?

Recently a friend at work shared a meme that said “Build a team so strong that anyone who sees it doesn’t know who the boss is.” That same day, in the Wall Street Journal, there was a cartoon depicting a person seated behind a desk wearing a crown. Across the desk was another person saying “don’t be silly, everyone knows you’re the boss!”  Same day, two takes on a similar message…it had to be a sign!

In the first meme, to an outsider, the boss is indistinguishable from the team.  In the cartoon, the boss is wondering if the team knows his role.  How is this relevant to managing an O&P practice? It’s leadership!  I wish I could share the images with you, but I don’t think the copyright police would appreciate it.  In the cartoon, the boss is pictured a little sheepish (no offence to any sheep intended).  You get the distinct impression that he is weak and probably ineffective.  In the meme, the boss and the team are all pictured in a strong way.  It is clear that they are a force to be reckoned with. They present a united front, so the implication is that if you ask any one of them a question, you are going to get the same response.  If you asked random people at your company what a policy is on something, or how you handle an issue, would you get the same response from multiple people?

In the cartoon, I see a system where people have an idea of what they are supposed to do, but there is, perhaps, not a lot of clarity.  So they “figure it out” on their own.  Fantastic, you say!  I have created a team of problem solvers! In this situation though, there is not a lot of clarity. The staff may have tried to get that clarity, but the boss has been unwilling or unable to provide it.  The boss has ceded the leadership role and one or more informal leaders have emerged in the company. The job will get done, but there will be a lot of floundering and messiness. This becomes apparent when we look at workflow consistency.

The point of the first meme is that effective leadership builds a team of people who all understand what the goals are, what the rules of the game are, and what the boundaries are.  You can bet your bottom dollar that everyone in that company knows exactly who the boss is.  But because there is so much clarity around the mission, vision and values of the company, there is no question about what we are doing and what the acceptable parameters are.  When that culture is fostered and developed, and the boss has successfully transferred that knowledge to the staff, it is much easier to allow the staff the freedom to do their jobs.  The boss can be confident that the job will get done and the outcome will be as expected.

And please don’t read what I am not writing…I am not advocating for micro-management.  Far from it.  I am advocating for a hand’s off approach to leading.  Micromanagement is about as inefficient as you can be.  There is no way one person can be the expert in all things related to running a successful business.  But you cannot have a “free range farm” either.  It is imperative that structure is in place to allow the freedom to perform. Sounds incongruent, right? Reach out.  Let’s talk about it.

Graph of CFO Optimism

Cautiously Optimistic

This week, I want to further my prognostication about the US economy, but back up my prior assertions with data.  Two different, well-established surveys of business leaders in the US regularly assess their thoughts about the direction of the overall US business climate and their thoughts about their own company’s business projections for the next six months.  Some interesting data has emerged from these two reports.

The CFO Survey was started in 1996 by Duke University’s Fuqua School of Business. It is now a quarterly survey conducted by Duke in partnership with the Federal Reserve Banks of Richmond and Atlanta. In this survey, CFOs at America’s leading companies are asked about their “optimism about the US economy.”  It also asks about their optimism for their own company’s performance.  Looking at the data, there was a divergence in 2015 where corporate optimism was relatively stable but US optimism fell.  In 2015 we had terrorist strikes on three continents, the Trans-Pacific Partnership was accomplished, Russia intervened in Syria, and the US signed the Paris Climate Accord. (Council on Foreign Relations)

Starting with the third quarter report of 2021 optimism about both the US economy and the company outlook have dropped.  But the corporate optimism has dropped much less than the national optimism. The chasm between the two is the largest in the 20-year history of the survey.

Graph of CFO Optimism

John Graham, a Duke finance professor who helps direct the survey, thinks the CFOs’ optimism about their own companies reflects a belief that they will be able to manage any challenges the economy throws at them. “Things aren’t great, but we have a plan,” is how he categorizes the mind-set.

Now I want to introduce you to the Business Roundtable, an association whose members are the chief executive officers (CEOs) of America’s leading companies. These CEO members lead companies with 20 million employees and more than $9 trillion in annual revenues.  They just finished up their quarterly “Economic Outlook” survey of their members. In it, they ask for the CEO’s corporate expectations over the next six months regarding Hiring, Capital Investment, and Sales.  In general, the report indicates that the CEO expectation for their own companies is still higher than the historical average, though their expectations for the next six months dropped from the previous quarter, producing the sixth largest quarterly decline in the history of the index.

If we look at the data from these two surveys together, we might see that corporate leaders are losing confidence in the US economy overall, but they believe their own companies will weather the storm better than others.  In the near term, that might translate into “cautious optimism.”  But is that optimism misplaced? Do you share their optimism about your own company?

If the economy really does enter a recession, many of us will find out exactly how prepared we are.  And the chances are we are not as well prepared as we think. What are you doing now, to prepare your company for a sustained economic downturn?  Are there opportunities to improve efficiency? To use the resources at your disposal to improve your bottom line or to streamline your processes? Let us know below!

Clock on a pile of dollar bills

What are you doing to prepare?

If you have read the news lately, you may have seen headlines that say things like the Fed has successfully tamed the inflation monster through tightening.  Or that the strong labor market and consumer fundamentals point to a mild recession. You may have even noticed that some of your raw materials costs are coming down.  But beware.  The numbers they are using don’t necessarily tell the full story. As in most things these days, there is a flip side…while things may look relatively rosy on the surface, there is underlying data that says the worst is yet to come. So what can you do to help ensure your company weathers the storm?

Whether you believe the economic conditions are improving now and the Fed has been successful or you think the Fed is still screwing things up, your company will benefit from a plan. The Dallas Fed has a measure called the “trimmed-mean consumption inflation index.” It is considered by many economists to be a very good measure of inflation because it excludes the most volatile prices.  In May of 2022, the index was at 4%.  For reference, the Fed target is 2%.  Today’s Wall Street Journal says consumer inflation surged to 9.1% in June. By any measure, it is fair to say that uncertainty is high!

As a leader, what do we do in times of uncertainty? The Harvard Business Review and many others have lots of great advice for executives.  Rebecca Zucker and Darin Rowell published “6 Strategies for Leading through Uncertainty” in HBR on April 26, 2021.  They say we need to:

  1. “Embrace the Discomfort of Not Knowing,”
  2. “Distinguish between complicated and complex,”
  3. “Let go of Perfectionism,”
  4. “Resist Oversimplifications and Quick Conclusions,”
  5. “Don’t Go It Alone,” and
  6. “Zoom out.”

Cool…How do we do that? First, says Satya Nadella, CEO of Microsoft, leaders must shift from a “know it all” to a “learn it all” mindset. This is hard to do but it takes a strong person to admit that the team is smarter than any one individual. Once we admit that we don’t (can’t) know everything, then we allow ourselves to learn. Complicated things are typically highly technical and hard to understand (like tax law) . We can typically break down complicated things and create a known solution.  Complex things often contain several interdependent elements which may change unpredictably or may even be unknown to us at first. Contrary to a complicated problem, the solution to a complex problem usually comes from trial and error.

Managing through the uncertainty we are facing today creates a complex problem.  If we are expecting to perfectly execute our business plan through the current challenge, we will not be successful.  We have to know that by its nature, trial and error will result in failure.  The challenge is to fail small and learn from it. Most high achievers have a desire to solve problems quickly, but we need to learn to balance our need for action with a disciplined approach to understanding the core problem. We can not “distill” the challenge down and solve the problem quickly because there are too many interdependencies.  Disregarding them could lead to a massive failure.

Engaging your peers, especially those whose opinions you value but whose experience is different than yours is a great way to get an “out of the box” perspective on possible actions you can take to navigate the environment. Finally, allow yourself to step back.  If you are deeply engaged in the situation, you can easily get lost in the details. It is essential that you take a high-level view at regular intervals to make sure one of those unknown or unpredictable elements hasn’t gone off on a tangent on you.  Get a feel for the environment, confirm your objective and then get back to work once you have a good understanding of the environment.

Mid Year Check-in

Wow!  Time seems to fly.  It’s already July. It’s time for the mid-year check-in.  How is the company doing?  When you look at your goals for the year, are you on target?  How are those referral sources panning out for you?  Have you met your intended target for the number of new patients in your practice this year?

If you have not looked at your dashboards for a while, now’s a good time to crack them open and see what the data is telling you. Start with the Executive Dashboard and click on the Referrals tab.  (Make sure you select the current year!) There are three options in the “metric Toggle” that let you slice the information in different ways.  Look at last year’s numbers and ranking as compared to this year’s.  Are there any referral sources that are down from last year?  Any new sources?  Is there anyone who hasn’t sent a patient your way this year?

Are there any relationships you need to manage?

Flip over to the Overview tab.  What is that data telling you?  What percent of your clinical visits are unique patients?  How does this change if you change the category (on the left) to be only O or only P?  Are you efficiently managing your patients?  What percentage of your clinical visits are deliveries? And how many new patients have you entered into OPIE this year?  How many would you like to have?  Would referral management help here, too?

Jump over to the “Ins Verif Auth” tool and click on the timeline tab. Look at the graph displaying the “Average Time to Completion (in days) to see where there may be opportunities to improve patient throughput.  Now click on the Financial Responsibility tab.  How many patients owe you money?  Click on the column to see who they are and how much they owe.  Have you already delivered them?  Should you have?

On the WIP:Aim For Success, is your WIP Clean? How many patients do you have on hold?  And how many do you have on there that have already been delivered and billed?

Every month we offer an overview of these tools to help you save time and money in your practice. Check out the offerings here.