Executive System

To describe the executive system, we must first define what an executive is. While there are many characterizations of executives, we will focus on one in particular: an executive is “one who gets others to get things done.”

In every practice, there is always at least one executive—the owner. In smaller practices (practices with fewer than five or six staff) there might also be a second executive—the practice manager. Whether or not there is a practice manager depends mainly upon how busy the doctor is, in his/her capacity as a doctor. The busier they are, the less time they have for managing the practice. At a certain point, the owner simply doesn’t have enough time to wear both hats thoroughly. At that time, one of the hats gets neglected. Since the doctor will never ignore his/her clinical duties, the hat that gets the short shrift is the management hat. It is at this critical point in the growth of the practice that the role of the practice manager becomes necessary. It is so crucial that an entire system was designed to ensure this hat gets worn well. I invite you to read up on the practice manager system so that you have a good understanding of what constitutes it.

As the practice continues to grow, there eventually comes a point where the practice manager himself is too busy to get all his duties done. This normally occurs when the number of staff members increases well beyond seven. Why is seven the magic number? That has to do with how many staff an executive can comfortably oversee. While there are rare executives who can manage more, the safe answer for most executives is to have them manage no more than five people. In this case, we have the five staff members, the practice manager and the doctor, for a total staff of seven.

Here’s what happens: As practices grow beyond that point, the practice manager is no longer able to stay on top of all the staff. As an example, the receptionist is suddenly having difficulty filling up the appointment book and, consequently, production begins to suffer. The practice manager needs to quickly debug this problem and get the book filled, even if it means doing the scheduling herself.

Once that is done, once the book is filled, the manager must then find out why the receptionist was faltering suddenly in her duties. Maybe the reception area needs to be reorganized so the staff member can get everything done. On the other hand, maybe the practice has grown to the point where an additional staff member is needed. Or maybe the receptionist was running into some new problem on the job that threw her for a loop.

The point is, there could be many reasons for the receptionist’s difficulties. Whatever the reason, the practice manager needs to discover it and fix it. But sorting out the true reason is time consuming. If, in the middle of solving this crisis, some other problem arises in another area of the practice (let’s say the back office), then the practice manager can never fully sort out the first problem and instead puts a band-aid on it. This band-aid is an attempt to get some solution in place so the manager can rush over to the next disaster.

But since the real problem was never discovered, the band-aid is only a temporary fix and soon the receptionist problem erupts all over again. Now the manager gets pulled from the second problem to go re-fix the first problem. In other words, when the executive is at the point where he no longer has the time to really get to the bottom of any problem and really solve it, he is left with creating improvised solutions that only last so long and eventually blow up again.

In such a case, the manager is simply running from brush fire to brush fire, no longer thoroughly putting out the fire, but instead, just dampening it enough to buy time to move on to the next crisis. Now we have the practice manager stretched too thin to truly manage the practice.

And now we have the need for a third manager, oftentimes called a middle manager.


Middle Management

“Middle management” in a health care practice would consist of someone who oversees the entire front desk area (assuming there is more than one person up front), or a head assistant in the back office, etc. And now we are back to our definition of an executive: one who gets others to get things done. This isn’t because the executive is lazy and doesn’t want to work. Rather it is because, in addition to his own duties, he is in charge of at least one other person.  At this point, he is now, by definition, an executive.

Let’s take a closer look at this role. The main reason the middle manager exists is to buy precious time for the practice manager. Let’s go back to our example above where the practice manager was attempting to debug the receptionist. Whereas before, a problem erupting in the back area pulled the manager away from fixing the receptionist, now with the advent of the head assistant, we have a new outcome. The head assistant solves that back-office problem, giving the practice manager the necessary time to continue working with the receptionist and permanently resolve their problem.

But to do this, the head assistant must be a competent executive. So, now we come to the question, “What is it that the executive does?”

In the main, an executive’s duties are threefold:

  1. Analyze his/her area to correctly identify what needs to be worked on (whether it be to solve the most pressing problem or reinforce something this is working well).
  2. Devise the right plan or solution.
  3. Get that plan implemented.

This is much more difficult and complex than people realize at first. Let’s take these functions apart.


Analyze the Area

In any area, there is no shortage of potential projects on which one could work. Let’s take the front desk, for example. At any point in time, the following issues could be in play: too many cancelations; clients not paying at the time of service, but instead demanding to get billed; swelling accounts-receivable; clients not agreeing to the treatment plan due to not being able to figure out how to pay for the treatment, etc. Any one of these problems, and hosts more, could manifest at any moment in time.

Conversely, perhaps the projects that need to be undertaken are those that will reinforce what is already doing well. For example, there is a sudden increase in the conversion of shoppers to actual clients; or suddenly more money is collected at the front desk than expected; or a greater percentage of clients are returning for their recall exams. Observing any one of these improvements, an effective practice manager would want to investigate the affected area to discover what changed and then work out how to reinforce what caused the improvement, so that later on that change doesn’t inadvertently drop out.

The reality is that, at any point in time, a number of projects could be in play simultaneously. In such an instance, the executive’s job is not only to figure out what items to work on, but also in what order to do them.

So, in analyzing an area, the executing is seeking to find:

  1. What projects need to be undertaken and
  2. In what sequence the projects should be done.

The common mistake that nearly every executive makes in conducting this type of analysis is that he relies upon intuition or perception, rather than statistics and other objective data, to help him identify what to address. If a doctor were to diagnose in this fashion, using his ‘gut’ to tell him what’s wrong, rather than turning to objective data like blood analyses, x-rays, MRIs, etc., that doctor would soon have a lot of unhealthy patients.

So, this tells us that to properly manage the area, the executive would need to have a dashboard of statistics that clearly indicate how the area is functioning.

Once the dashboard has been created, the next step on the analysis is to know how to interpret the stats to determine which area(s) to focus on. So, if there are four situations that are hurting the area (e.g., too many cancelations, the book not ever getting filled up, money not being collected at the front desk and clients waiting too long) and two areas that have improved (shopper conversion having gotten better and more clients accepting their treatment plans), the executive must know how to read and compare the various stats to figure out which ones to focus on first.

There is an actual methodology for doing a statistical analysis; any executive who wants to do a good job needs to be trained to take that approach.


Come Up with a Plan

Once the analysis has been completed and the project identified (whether it’s a problem that needs fixing or an improvement that needs to be reinforced), the next step is to work out the concrete solution. For example, which specific actions need to be taken to resolve a cancelation problem? Or, if there had been an action that improved something, like a change in how the receptionist talked to shoppers that improved the shopper conversion rate, what specifically needs to be done to keep this new action stably in place?

It is not enough, then, for the middle manager to discover the problem; she needs to know how to solve any problem that crops up. This necessitates that the middle manager be trained to identify the various common problems that one will encounter in a practice and to know how to determine solutions.


Implement the Solution

Now that the plan has been devised, the middle manager must get the staff to implement the solutions in their respective areas. This step is deceptive, in that it is much more difficult than it seems. It has been the downfall of many a manager.

The reality is that even good staff will resist doing new things asked of them. This pushback can happen for a lot of reasons: they don’t think there is a problem in the first place; they might admit there is a problem, but they think the proposed solution is worse than what is currently being done; they feel so overloaded that asking them to do something different sends them over the edge; or maybe it’s as simple as, “Change is difficult for people.”

The point is, every executive has to be comfortable dealing with resistance to orders given. How one handles that resistance is what spells success or failure for the executive. Being a bully and shoving back on the resistance doesn’t work; neither does implementing the solution oneself, just so he doesn’t have to deal with the resistance.

This problem can be further exacerbated by the desire to maintain friendships. Most middle managers were, on one day, a staff member with prized relationships with the other staff, and the next day they became a manager with the need to give orders to their friends. If you want that manager to succeed as an executive, you must teach him/her how to navigate this predicament.

When navigating the transition from staff member to manager, there is a falsehood that needs to be exposed. Some people believe that to be a good executive, one can’t possibly be friends with his/her staff. So, does this mean that you have to curtail your friendliness and put on airs? No. That is patently ridiculous. The key is how to maintain friendly relations with the staff while still being effective as a leader. This can be done, but it is a skill that must be learned.



This article was intended to demonstrate that, as a practice grows, executives will inevitably get stretched thin. Ask them to manage too many staff and you’ve simply inhibited their effectiveness. The solution is to start putting middle managers in place. But, when you do this, you simply must give them the tools to succeed.

The following are some of the most indispensable tools that are necessary for any kind of executive system:

  1. Development of statistics by which middle managers can run their areas and their personnel.
  2. An understanding of how to conduct statistical evaluations.
  3. The ability to solve problems that a manager will invariably experience.
  4. The ability to issue orders and gain compliance.

Failure to train the middle manager on these skills will result in having a middle manager in name only. This, in turn, means that the practice manager will become too overloaded to be effective.

The moral of this little story is, “When you put an executive on the job, whether it be to manage the whole practice or a fraction of it, take the time to train that person well.”

If you have any questions about how to be a better executive, feel free to give us a call at 1(877)386-0388 or fill out the form on this webpage, and we would be happy to assist you.

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