A little more than three years ago, Kaci Monroe realized her dream of opening her own physical therapy private practice. Since then, she’s grown her small, Bigfork, Montana-based clinic into a very successful—and very busy—operation. So busy, in fact, that she decided to open a second location this past year. Oh, and she also remodeled a house, had a baby, and sped her way to a national ranking on the elite Spartan Race circuit (Aroo!). Earlier this month, we sat down with this highly accomplished WebPT Member to pick her brain about all things PT business—from hiring to marketing. Here’s what she had to say (with minor edits for flow and clarity):
When we last talked, you were only a few months into owning your business. Now, you’ve grown it into an incredibly successful independent private practice—and even opened another location. What are some of the biggest—and maybe surprising—lessons you’ve learned along the way?
You can’t do it all yourself.
I think learning how to choose—and then trusting—your employees is a big one. I’ve had to learn how to delegate and let go of some things so I can function as a human. I’m the type that likes to take everything on myself, and as a result, I started to feel some burnout a couple of years into it.
You have to hire the right people—and let them do their jobs.
I have the most amazing staff. That’s one of the best things I’ve done—really vetted who has come through my doors as employees. Trusting their abilities and giving them control has let me be a better practitioner and business owner. That way, I can step back and look at the whole picture instead of trying to control every little thing. I think that was a huge learning point for me—just trying not to micromanage, and instead, looking at the whole picture and having each employee do his or her job.
Your priorities as a practice owner are different than your priorities as a PT.
I’ve learned to navigate the challenge of juggling schedules and priorities. It’s all about setting what you want accomplish first. Sometimes, treating patients is not the thing I put first, which seems crazy, because as a PT I want to treat patients. I love that part of the job. But as a business owner, if all you do is treat patients, things fall through the cracks. You have to remember to put the business first and look at it from that perspective of, “What can I do to help the business most?” Sometimes, that’s being an owner—and being a boss and a mentor. That sometimes comes before treating patients. That’s a big thing—learning to put yourself where you’re needed. And as a boss, that’s different than it is as a PT.
What about business-wise? You don’t learn a lot about business in PT school, so what are some of the things you’ve learned through experience?
You’ll never be able to make everyone happy, and that’s okay.
First, you can’t please everyone. I’m a people-pleaser. I think most PTs are Type-A personalities. We want to please everyone; we want to help; we want to care. But, there are always going to be people who are not super happy, and you’re just going to have to let that go.
You can try to empathize with their problem and situation, but to be a business owner, your goal is to try and make the whole as happy as possible. There are going to be some who disagree with how you practice or what you’re doing. It’s a very small percentage, but it still hits home when you’re a perfectionist.
You don’t have to know how to do everything—if you find the right help.
Also, I can’t emphasize enough how important it is to get the right staff. Get a bookkeeper who can come in and help you balance your books. Get a good accountant. Hire people who know what they’re doing. I remember the first week I was open, I had no idea how to do QuickBooks. I had no idea how to write a paycheck, and I was just going to wing it. And then a patient came in, and she was a QuickBooks expert—so I hired her.
So, sometimes you wing it, and sometimes you hire the appropriate person. I also asked for help with setting up my website, marketing, and taxes. In the long run, I think asking for help when you need it, more than anything, helps you run a successful business.
You can also outsource time-consuming tasks like billing and credentialing.
Some people do in-house billing, and my hats are off to those who struggle through that, but I have no desire to do that, either. So, I outsourced to a billing company. They submit the codes; they resubmit any claims that come back; and they handle communicating with the insurance companies. I also recently handed off my credentialing. I used to do all my credentialing myself, and it was such a nightmare. It’s a lot of paperwork and forms, and if Medicare denies your application because one form wasn’t filled out correctly, you have to go back and rewrite it, and they never tell you which part wasn’t correct. So, sometimes you go back and send in another form, and they deny it again. And every week that you’re not credentialed, you have to hold claims or cosign. When I learned that there were people who could take that over, it was huge. At first, I thought it would be expensive, but it’s not that expensive—and with the time and headache it saves me, it’s worth it.
When you can, outsource the troublesome things that you don’t like. I’m a huge supporter of that. In this case, credentialing was such a stressful, time-consuming thing, and now that I’m freed up, I can treat more or mentor—and not lose sleep about it.
In our first interview, you talked about how tough it was to hire good people. You’ve added quite a few employees to your payroll since then. Do you have any hiring tips you’ve picked up over the years?
You can’t hire for skills only; you also have to consider personality.
With some hires, I’ve personally known the people. I’ve seen their work ethic in the community, or seen them working with another practitioner. Of course, we live in a small community, so it’s easier to find really good people that way. Word-of-mouth is a big one, too. If someone says, “This person’s awesome; you should hire them,” then take note of that, because people notice other people who work hard. Also, it’s important to know which personalities will work well with you and your staff. I think I’m pretty good at judging people, which might sound awful, but it’s important to know a potential employee’s personality type and how it might work with yours.
You have a bigger hiring network than you might realize.
When I go looking for a PT, I shoot out little feelers to my friends who might be like-minded or have worked in similar settings, and say, “Hey, do you know anyone who’s looking for a PT position? I have an awesome opening. Who would you recommend?” I’ve had people come to me, too. One of our new PTs came to me seeking a job, because he knew our reputation was great.
I’ve tried using recruiting services—the APTA has one. I got a great person using that, but I think word-of-mouth is the better route. I’ve even gone to other clinics and said, “Hey, we’re looking for a PT. Do you know of anyone who has applied to your clinic that maybe you can’t hire right now, but thought would be a good hire?”
You often have to rely on your gut.
For me, hiring is more about meeting in a comfortable setting, getting to know the person, and seeing if you interact well. Usually I can tell within the first 10 minutes of the interview whether or not I’m going to mesh with this person. Looking at their references can help, too; if you know any of their references, talk to them. Ultimately, you can’t really judge a person until they start working for you full time, but I think you can listen to your gut. You can also bring them into the clinic and let them meet and interact with other staff. And again, being in a small community, most of my staff members know the person I’m bringing in, and they can usually give me tips on the person. In some cases, I have either hired or not hired based on just that. There have been other times that I’ve liked people and wanted to hire them, but they didn’t want the job. Don’t get disheartened if the person doesn’t take your job offer, either. Keep trying.
Do you have good relationships with other PT clinics in the area? Do you see them more as colleagues or peers than as competitors?
You have to put competition aside in order to provide patient-centered care.
I don’t have any riffs with anyone. I think we work well together. Other clinics shoot us clients all the time to get in the pool or the gym, so I feel like we have a good reputation that way. I think working together is the best, especially for the patient. Maybe you don’t have the skills for a certain person. For example, I refer to vestibular specialists or to therapists who have something specific in their gym. It’s really about the client. I think if you can look above the competition, you can form better relationships.
Communicating is great. I have other local PTs asking me, “What are you doing about this billing problem?” And I’ll tell them. If you hoard information, you’re not helping anyone. So, I share. And then, when I’m trying to hire someone and I go back and ask if they know anyone who is looking to get hired, they might say, “Oh yeah, this person is looking for a job.”
You also mentioned that it’s tough for small independent practices to compete with the compensation and benefits packages offered by larger systems. How have you combatted that to get good talent into your clinic?
You should pay people what they’re worth—and get creative about the rest.
I’m a big believer in paying people what they’re worth. I gave up trying to offer lower wages, because I didn’t feel like it was fair. Maybe I can’t offer all the benefits the bigger facilities can, but I can give my employees a wage that makes living possible. If you pay employees what they’re worth, then they’ll want to stick around. I also try to compete in other areas, like with paid time off. Additionally, I give my team bonuses they can use that for whatever they want. If it goes toward their healthcare premium, awesome. If it goes toward a gym membership, cool. If it goes toward paying bills, great. I don’t care what they do with that extra money every month; that’s their decision. But it’s my way of contributing to their health care. That way, I’m not dictating which plan they have, and I’m giving them some money they can throw at it—or at wherever they want.
You can attract talent with your stellar culture, too.
I’ve also gotten big enough now that I can pay into an IRA. So, I can compete a little bit there. And then, I can offer people a different work atmosphere, which is competitive in itself. It’s a bonus—having a good environment to work in. It’s something different than they’d get in big corporations or chains.
Has your marketing evolved as you’ve grown, or is it still mainly word-of-mouth?
You can get a lot of traction with local advertising.
We are hugely word-of-mouth. But now I do advertise—more as part of giving to some sort of cause [where you get advertising as part of your donation]. And then, like for the Montana Women Magazine, I like to run an ad in there to support and reach women in the community. I have advertised more, especially in the paper when we opened our second location to let people know that we’re out there. That’s a great way to advertise, just in the local paper.
You need an online presence.
I’m on social media now, and although I’m maybe not as active as I should be, our presence is there. And that’s important, just to have an online presence. But, with our changing society, I might have to get more active in that.
You should build relationships with physicians—not “buy” their referrals.
By and large, though, we have people coming in and not saying they saw an advertisement, but maybe saying their friend Joe came in and got better and recommend them to us. That’s mostly how we still get people. And doctors know our presence now. We’ve been here long enough that they know where we are and who our therapists are. And I think it helps to go into those physicians’ offices once in a while—maybe not bribing the doctor, though. I don’t believe that’s a good relationship; we should be seen as an equal. But if they’ve been referring a lot, I’ll give an updated list of who works here and what our services are, along with a little thank-you basket.
How did you come to the decision to open another clinic location?
You’re best off starting small and growing naturally.
I had an employee who was interested in having some ownership in a clinic eventually, and we worked out a deal. I told him, “I don’t have the time or the desire to spend more hours at another clinic, but I do have the time one day a week to throw some hours at it to help start it.” And he’s thrown more hours at it. So, we opened that second location. Now, we’re starting to get busy, so we’re looking to hire another employee—probably two employees, because we’ll need front-desk staff. So, we grew it kind of naturally. We started small, and we’ve just been adding hours as it’s been getting recognized around the valley.
You don’t need to reinvent the wheel with your second location.
In addition to starting small, we started in a gym. We had such great success with our first location, which is in a gym, that we wanted another one. And a new gym was opening in the next town, and they had a few rooms to lease, so we got that as our starting point. We may outgrow that location, but when you’re first getting started, a good place to be is inside a gym or another health facility.
What were your biggest to-dos as you prepared to open your second location?
You might not need as much as you think—but you do need to be able to get paid.
First and foremost, we focused on getting credentialed with insurances—making sure we could get paid by the payers. That meant getting my billing company on board to start that process. Then, we had to fix up the space and make it look presentable, not only for the employees, but for anyone walking by. You want a clinic that looks like a clinic, not just a couple of rooms inside of a gym. We bought a couple of treatment tables and a few safety items—a mat table for people to stretch on and parallel bars. But when you’re in a gym, there are already weights there. We’ll grow and put in more equipment and whatnot as we see what kind of clientele we get. It wasn’t terribly expensive to start up, so that’s why I pick gyms. It’s just a little easier.
We also had to make sure people knew we were there, so we put that ad in the paper and visited some doctor’s offices to let them know about our second location.
Personally, what has been your biggest challenge as a multi-location practice owner?
You can’t always say yes.
Learning to say no was the biggest challenge. I have a bad habit: when someone asks me to do something, I’ll do it. Learning to juggle and balance being a business owner, a mom, an athlete, and a treating therapist has been tough. I’m scheduling patients in wherever I can, and sometimes that’s not the best idea, because I get worn out and tired. It’s still a balancing act of trying to delegate and say no when I’m stretched a little thin. But, that’s my personality; I’m going to go as hard as I can until I break, and then maybe I’ll learn how to back off a little. You have to learn what’s healthy for you, and I’m learning my breaking points.
It’s also about knowing when to hire. When we’re getting busy enough that I’m just shoving people into my break times before I pick my daughter up at daycare, that’s when I know it might be time.
Even as you’ve expanded your business—and your family—you’ve still found time to compete on a national level as a Spartan racer and give back to your community as a volunteer cross-country coach. How on Earth do you balance it all?
You take it one day at a time.
I don’t know. I go day-to-day sometimes. As we get into the cross-country season, I’m going to really have to work my schedule—just moving some treatment hours. It’s all about trying to find my priorities. That’s huge, because everything right now seems like a priority, so I try numbering which ones are the top priorities. Being a mom is definitely number one—taking care of my daughter. That even ranks above the business.
You have to trust your team.
Then, keeping a healthy business comes next. And keeping everything running smoothly means that maybe I don’t treat as much. That’s the hardest thing for me, is letting go of some of those treatment hours. I just have to trust that the therapists I hired are just as good as—if not better than—me, and I have to really promote those people. But it’s hard for me, because I like to take patients on. I like to know that people trust my skills. Learning to delegate and give up some of my tasks is huge. It’s hard for me, but that’s how I’ll have to juggle it if I want to keep doing everything I’m doing. Being a coach has definitely been a dream of mine, to help the community in that way, so I’m going to try it this fall and see if I can coach, treat, run the business, compete, and be a mom. We’ll see. There might be some breakdowns.
If you could go back and do it all again, is there anything you would have done differently?
I would have started sooner. There’s just that fear of starting your own business. I probably would have started a second location sooner, too. Even though it’s scary to think about opening a business or another business location, once you do it, it’s so wonderful and so much fun. And I live such a wonderful life. Being able to be a boss and a business owner has been great, and I’m like, “Why didn’t I do this sooner?” It’s not that much more work, it’s just different. You have to grow as a person to adapt to that lifestyle. Oh, and I would make our facility bigger. We’re now adding on to our main facility, because I didn’t ever believe that I could fill this huge space that we’re in. I never foresaw us needing more treatment rooms. And now we do.
Big thanks to Kaci for sharing her PT business wisdom with us and our readers. In the spirit of keeping the information exchange going, we invite you to share your own tips or stories in the comment section below. And for a complete guide to starting a physical therapy practice, check out this resource.