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Episode 22

Solving Staffing Issues in Therapy

Nancy Mura, President of Survival Strategies, talks with our host Allison about her journey into the Pediatrics industry. Other topics discussed in this episode include: • Best practices in Private Practice • Solving staffing issues • Positioning your ‘A’ team within your practice
Published on 02/08/2024
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Episode Transcript

Allison Jones

Good morning, good afternoon, and good evening, and welcome to the Therapy Matters podcast, your one-stop resource for expert insights and advice on everything therapy and rehab. I’m your host, Allison Jones, and today I’m joined by Nancy Mura, the founder of Peds-A-Palooza.

Nancy, thank you for joining me today.

 

Nancy Mura

Allison, thank you so much for having me. I love being here.

 

Allison Jones

It’s great to have you. Nancy, you wear a lot of hats. You are the founder of Peds-A-Palooza, as I mentioned, which is how we became acquainted. But you are also the president of Survival Strategies, Inc. Before we dive into today’s topic, let’s unpack that for the audience and tell us a little bit about yourself, your background, and what you’re focused on in the therapy space today.

 

Nancy Mura

That’s fantastic. Let’s hope I get all of that. You might have to re-give me some of those.

 

Allison Jones

Yeah, no problem.

 

Nancy Mura

I think my favorite thing about my whole journey into private practice is that I am not credentialed in anything. Not that I want to belittle myself; I think I’ve had a nice impact in this profession, so I don’t want to belittle myself. But I will say this: I don’t have any fancy letters. I’m not a clinician. I’m not a therapist. I’m not a practice owner. I am a serial entrepreneur, and I build businesses and help businesses. I love to tell stories, Allison, that relate to people; someone out there can relate and go, Oh my gosh, that was me. I like to make sure that I emphasize whatever you believe in: God, Juju, the universe, somebody closes a door and they open two windows, and that’s my mother’s Italian voice coming through as well.

Here I was in this great real estate career, flipping houses, having a great time of it. I got very sick with an autoimmune disease, and I didn’t know what I thought. It was really bad. I just really could not get any help on it. Doctors left and right, nobody could diagnose me. I wound up just needing to be in bed for about a year. If you get anything for my energy in five minutes, because you and I have talked a lot, being in bed for a year is not an option. That was not a good time. But when I got myself well, and I say got myself because it took me controlling the medical field, but that’s another story for another time, another podcast. But I needed a job. I need a job that doesn’t have a pipeline. I need a job that does not rely on sales in the future.

I wound up with Survival Strategies, with this very low entry position. The CEO, God bless him, Craig Ferreira, he’s amazing. He saw who I was at a time when I didn’t recognize myself. I was this ball of energy. I was this entrepreneur. I was kickstarting a million things. Now, I’m this very tired human being that is just like, go slow, go easy on me. I was Adele. I was like, go easy on me. I had this very low-level position in a great company.

What Survival Strategies does is they’re a training and consulting company for private practice. They’ve been in business for 35 years, and that’s all they do—only private practice. What they teach on how you grow a business, how you stabilize a business, and how you get it ready for expansion—I would say the word scale, but I hate the word scale. I’m like, scale what? You don’t even have a foundation. People, please get a foundation, and then we can talk about scaling. But how you scale after you’ve stabilized—that’s what they do. They could do that in the automotive industry. They could do that in the restaurant industry, but they love private practice—very specific private practice, I must say. They really like PT, OT, speech, anything that rehabs people from a whole-person perspective. They love that. I love that as well, because even looking at my own recovery, I needed to be looked at as a whole person, so that resonated. 

Anyway, I love the company, and I love the clients because private practice owners are one of a kind. Nobody is waking up in this industry going, how many patients before I have the beach house? Nobody. This is a purpose-driven field, and that resonated with me. Wouldn’t you agree? Completely purpose-driven. I loved the clients, loved the company, and loved what we were doing, but it wasn’t enough for me, so I left. I ran an outpatient orthopedic PT clinic that services the adult and senior communities. I did that, and I loved that as well. 

It was very funny. I think the guy needed the business to lose money because I came in and I quickly saw from my training, wow, you’re never going to make it, mister. You have two $90,000 USC graduates, and you’re doing 40 visits a week. Wait, I can help. This is what my company does. I told him he had to put me through a program. He put me through a referral development program through Survival Strategies, and I boomed the business. The more I boomed it, the more he yelled at me. Isn’t that weird? All my stats are going up. My graphs are looking amazing, and he’s screaming at me every time the stats go up. What I figured out is that he bought these limping practices all throughout the United States. He needed that company to lose money, and I was now making it make money, which is what our company teaches you how to do. So, long story short, he just came in one day, Allison, and he just shut it down. It was the highest number we’d ever reached. He came in on a Friday, and he said, we’re closing down.

Now, this is an interesting thing. This is another thing I like people to think about. Usually, when you get fired, you’re like, how do I contract? This is the entrepreneurial mindset. I just got a check with all my PTO for all of my vacation. You know what I’m going to do, even though I don’t have a job? I’m going to go buy a new car. I’m going to go spend money and buy a bigger thing and believe in myself more, so I went and did that. Then I went back to Survival Strategies, and I had this idea in a hot yoga class, believe it or not. Hot yoga, shavasana, I’m laying there in a pool of sweat, and I said, you know, nobody is helping these peds guys, this pediatric field, this pediatric profession. Everyone is lumping them in with what we call adult PT.

Allison Jones

It’s very different.

 

Nancy Mura

It’s very different, and nobody was helping them. You know what? I think we can go in there and be specific. My slogan is that private practice is its own animal, and pediatrics is its own species. Now we have a few other species: home health and ABA. There are things that we delve into that are also their own species. We now design our curriculum, so to speak, or our programs, and we train our consultants around those things that are inherent.

I just worked my way up. I blew up this peds thing, and we started Peds-A-Palooza, which started as a Facebook group with me and Diane Crecelius, who’s the owner of ABC Pediatric Therapy. She’s like my co-conspirator and co-creator, and she was one of our earlier clients. She started as a mom and pop, little tiny fish, and she now has ten locations and does, I don’t even know, 3330, 3400 visits a week. That’s what we do. We grew this Peds-A-Palooza idea, and the Facebook group now has a couple of thousand owners in it. Then we started recognizing other areas: people who wanted to open a private practice, going back to outpatient orthopedics. Because I brought this really great idea to the table, I quickly rose up in the company and was made president. That’s really nice. That’s new. I’ve been president for about two years of a company that’s been around for 35 years, so I feel pretty good about that. With the impact we have on this industry, I think we’re leaving a footprint for sure, and we just love helping this industry. It’s just that simple.

 

Allison Jones

Excellent. Well, thank you. Thank you for that background. Thank you for that insight. When we were preparing for this podcast today, we threw out a whole bunch of topics. We talked about: should we talk about reimbursement challenges? Should we talk about technology issues and economic burdens? There were a bunch of different things that we talked about, but we kept returning to the same theme. We kept coming back to staffing and hiring. That’s what we’re going to focus on, and that’s where we need to dig into today, overcoming those staffing challenges, and specifically, we’re going to aim to provide some tips and tricks on how to deal with those challenges and come out on the other side successfully.

 

Nancy Mura

Awesome, love it.

 

Allison Jones

That’s our goal today. First up, and you talked a little bit about it earlier, there’s been a shift. There’s been a little bit of a shift. You talked about this being a purpose-driven market, but there’s been a little bit of a shift in hiring in this market. Tell me a little bit about what’s changed recently.

Nancy Mura

There’s a couple of things that have changed. One is when a couple of the bigger fish got out there. I just spoke to a lovely owner today that has 17 locations, and she’s privately owned. She has 478 staff. When she started, the playing field was very different. People not only didn’t know their own kids, nobody knew that kids needed the amount of help they did, the developmental issues that they had and that they needed. Everybody thought they could go through the schools, and the school offered services. It was this very no man’s land of pediatric. That’s pediatric. 

Adult PT, outpatient ortho, they had a PR problem in the beginning, going way back. When you have a little car accident and your attorney or insurance company says you should get a PT, I remember thinking, I don’t want to waste my time with PT; go there and throw a ball and get a little heat pack. I don’t have time for that. I had no idea what physical therapy actually did, and neither did the world. There was a PR problem in a lot of fields. Chiropractors were considered quacks back in the day. Now, people have a chiro on speed dial. They go three times a week. There was a PR issue in the beginning.

It was very simple to get into business—simple to get into, but not easy to grow in because people didn’t recognize the demand. Now, with certain fields like peds, it’s like gas stations; there is a practice on every corner. What does that mean? That means they all need to be staffed. Then an interesting thing happened, especially since I’m going to speak mostly in the pediatric sphere because I’m knee deep in that on a daily basis. The other thing that happened besides the fact that there was this growing need for more therapists was that therapists started coming out of school with a different idea of how much they needed to make. That’s a little bit interesting. There’s a little bit of push on the end of how much because there’s student loans.

Everything is connected to everything else. Now you’ve got practices on every corner; you’ve got that, and you’ve now got this huge demand because now they’re diagnosing better. There are more people recognizing it, and so the demand is just huge. People need more therapists. But I think the biggest change is in how many practices have opened up. Once everybody got past the PR and insurance and all these things, that happened. It’s like real estate. It goes from being a buyer’s market to a seller’s market. Well, right now, it’s a staff-driven universe. It’s employee-driven, meaning that, in essence, the clinicians don’t need the owners as much as the owners need the clinician.

Now, the reason I say that’s an apparency is because that’s not the way the universe works. That’s the way it looks on paper. The same is true in real estate; it’s a buyer’s market. But guess what? If nobody buys—oh, we’re buyers, we’re up here—nobody buys, it switches and becomes a seller’s market. Right now, everybody is like, hi, I’m a therapist. I’m needed and wanted, and that’s all great and groovy unless schools start releasing a lot more people or a lot more people enter the work field or practices get swallowed up by other practices that can go out there with a really big need to acquire personnel and very heavily hit the industry and get everybody, and they can do things that a mom and pop can’t. They can fly to colleges. They can fly to a job fair. I’m here in Michigan. I’m not going to fly to Florida where there’s a great school. I mean, you could, but the chances are small.

Those are the kinds of things that have changed the most: the demand is not meeting the supply, and then the student loans crush on the people that want to be hired. They come in wanting a higher salary. All of that just adds to the shortage. The shortage is nationwide. I’m sure anybody who’s listening to this will agree. It’s nationwide.

Allison Jones

Absolutely. Then the question becomes, how can practices adapt to these changes and overcome these challenges? What do they need to do?

 

Nancy Mura

Well, I’m going to tell you, and I always say this, and I said this when I was in real estate. People were like, but you could list my house. The guy down the street said he could list my house for $100,000 more. I’m glad he said that. I am never going to tell you what you want to hear. I’m going to tell you what you need to know. This may be a bitter pill for your listeners to swallow. I’m apologizing in advance, and I’m from New York, so I’m very straight. I’m not Willy Wonka. I can’t sugarcoat stuff. 

Look, someone is going to get hired somewhere. It’s like dating. It’s like there’s no good man, and there’s no good woman. Someone’s got a good man. Somebody’s got a good woman. How did they get them? I don’t believe in luck. Luck is not a word in my vocabulary unless you want to have luck defined as where perseverance and opportunity meet. It’s a crossroads. If you persevere and increase your opportunities, you’ll have what I call luck. But in my world, that’s a real dirty four-letter word. Luck means you can’t be a cause; it means you’re going to be the bug and not the windshield.

Here’s the dirty truth that I would want listeners to know. They are going to go to work where they want to work. There are people who need to work somewhere. Why not 123 PT or 123 Pediatric? Why not this facility? Why? Because they can choose. The number one thing is that you better have your ducks in a row. You better run a fine-tuned, well-oiled machine. Your culture should be very well defined. To attract the right people, which aids in your stability, which then aids in your expansion, you have to have a system in place so that you are efficiently well-managed with expectations and people want to know the good ones.

First of all, you can hire, but do you want to hire an A team or a C-plus team? I’m going to assume anybody listening to this is looking to improve themselves. You want an A team. I’ve seen what A teams do for a practice. It takes a village. It’s not some owner waving a magic wand. It takes that team, that support, that compliance, that foresight, and that vision of others to make the dream come true. I hate to be cliche, but teamwork does make the dream work. But that owner better know what the dream is. That owner better be well-defined, have a mission statement, and have policies and procedures in place. If I’m an A-plus person and I come interview at your practice and there’s nowhere for me to go—I can’t go up; I can basically be lateral—that’s going to be a problem.

I had a lady tell me today. A gal came in and told her three patients that a day is all I can do in an eight-hour day. She didn’t hire her. She’ll go across the street and go to work. Somebody will hire that girl and give her that because they’re not organized enough to be able to discern or be able to reject. They can’t reject. They’re in a position where I need you. Come work for me. I’ll take anyone. You don’t want to take anyone. That’s number one. Your culture and your expectations need to be well defined. Your practice needs to be incredibly well run. Not everybody becomes an entrepreneur. It is not the easiest thing. You’re taking on a lot of responsibility and a lot of liability, and sometimes staff will make more money than the owner.

There’s plenty of owners out there not taking a paycheck. It drives me crazy. I can help you with that, but just know that’s not the right scenario. They know it’s not the right scenario. But sometimes, the staff make equal to or more than an owner, and you have to have all your expectations written out so they know that. But your A team wants to know that there is a lifeguard at the deep end of the pool. Somebody is running the show because they did not sign up to be the owner. They did not sign up for that amount of liability or that amount of responsibility. I would say there’s three people. There’s three types of staff or people in a practice. On this far side here, you’ve got the owner, and they bring all that responsibility and all that liability. I have a dream; I have an idea. I have an ideal scene. This is what it’s going to look like. People start practices for so many reasons. Rehab saved my dad’s life. I have special needs kids, and I wanted them to come to my facility, all kinds of reasons.

Then you have people on the other side, and they just want to punch clock. Maybe I’m an entrepreneur, and I’m starting a dog food company in my garage at night. I don’t want to think about your job on the weekend. That’s great, and they come in and do a great job. That’s them. But then there’s this person in the middle. They’re the A-plus. They are the people who don’t want all the responsibility. I don’t want all the liability. I don’t want all the things I can’t figure out because it is a ball of wax to figure out private practice. But I want to go somewhere, and I want to help you grow, so you go somewhere. For you to get those people, you have to have a mapped-out plan.

We have something that we’re actually doing this weekend, which is a ladders program that one of our presenters developed so that her staff could just go up, and they knew they started here and, in five years, they could be here. This is how much money you can make, and it’s pretty nice. Efficiency, lifeguard at the deep end of the pool, somewhere for them to go, the culture has to be right, and then you cannot hire under fire. That’s where a lot of people go wrong.

You’ve probably seen it. You hire under fire. You’ve got a clinic with 18 women in it. You’ve got 33 staff, and 18 of them are women. If somebody is going out on maternity leave, somebody is moving, or you’re in a facility that’s near a military base, and that’s why you got a lot of referrals from this military base, well, guess what? Somebody in there has a spouse that’s going to get shipped out somewhere else. They’re going to go from Point Mugu to Cape Canaveral. People are going, so why do you wait till the end? You need to be collecting those resumes all the time.

We have a webinar called the Lemonade webinar, and it is peds, but I’m telling you, it really is just administrative know-how, and we have a ton of other industries listening to it. You go to pedsapalooza.com. You go to the knowledge center, you get a password, and then you can see almost four years of twice-a-month administrative know-how stuff. We talk a lot about hiring. One of them is to collect resumes. Get good people and meet them anyway. Have someone that you know can read people. You yourself meet them if their resume is spectacular.

We just had this happen the other day. Right now, we have a little bit of a hiring freeze in certain areas. A gal came in, and the people that usually do the hiring and interviewing met with her, and they weren’t that impressed by her. To be honest, they just weren’t. They just thought she was okay, and they thought she asked for too much money. I heard something else. I met with her anyway. First of all, I was right. The way it read was that we came across a little bit like we disregarded her. We didn’t really duplicate what she had to offer the industry. Just by meeting with her, she fessed up, like, you know what? I can see why. I’m really in flux myself. I don’t know if I want to live in Chicago, and then I couldn’t be here where you are in Florida.

It might not work anyway, but I really just wanted to meet you. Why? She was one of those people who got completely rehabbed, and she wanted to be in a field. What a purpose! You’re just going to put someone’s resume aside like that? No. Let’s think about what we can do. Can we do a podcast? Can we start some kind of thing that honors these great therapists? Maybe we can invent something that isn’t there yet. No, I can’t hire you right now. But I met with her, and I have her resume, her purpose, and her whole beingness absorbed into my memory.

I always have a motto. Great people deserve great people. It’s terrible when an awesome, amazing staff person has a tyrant, horrible, disorganized employer, and it’s horrible when an amazing, generous, purpose-driven owner has just a cruddy staff person that really doesn’t care and is just there to collect a paycheck. You have to constantly be looking for and collecting resumes. If you get a person who is amazing, hire them.

If you’re an owner, you have to live up to the risk. When you’re an owner, you’re a trapeze artist. There was a time when, when you’re on that trapeze to get to the other side, you have to let go of the rings. It’s just inherent to get to the other side. You have to be willing to get to the other side. What does that mean? That means you hire that person, and you build a caseload. That’s where the efficiency is. Everything is connected to everything else, Allison, because if you’re efficient enough, you’re not sitting there going, oh, shoot, it’s Sunday at 4:00. I got to go to Costco and get the toilet paper for tomorrow. I got the cupcakes because we’re celebrating four staff birthdays. No, that’s not you, because you’re organized and efficient.

You can say I have a vision. I got this gal or guy. They’re phenomenal. Their track record is unbelievable. The only reason they left their practice is because the practice shut down, got absorbed, or blew up, and they are available. I don’t want to let them go. Build it, and they will come. But that’s why you have to have that level of efficiency. The culture, the efficiency, the culture, the risk, not hiring under fire, and giving them a place to go are, I would say, the five top things. Don’t be afraid of new graduates. There’s a plus side to new graduates. You get to break them of any habit before they have it. Those would be my things. That’s what I would say.

 

Allison Jones

That’s excellent. That’s amazing advice. Any final thoughts that you want to leave the audience with?

 

Nancy Mura

Yes. I think this is a very difficult time out there. There’s been a lot of change. I don’t want to be a doomsdayer, but I saw it with the outpatient ortho. When the conglomerates come in and buy up everybody, it makes it very hard for mom and pops to survive. Now is the time to put your stake with a little white flag into the ground, call it yours, and stabilize. Get efficient, stabilize, and expand so that you make a name for yourself so that when someone comes in and opens up ten locations in 18 months in your area, you can survive through that. Secondly, anything that you can conceive of can be done. I’ve got a ton of people talking about diminishing reimbursements. Hiring and diminishing reimbursements—there’s ways around that. If you’re willing to be the windshield and not the bug, there is a solution to every problem that you have in private practice.

You need to talk to people. Look, I drank the Kool-Aid. I’m with Survival Strategies. But go out there and seek a mentor, seek guidance, get with someone, a company, or a group that is doing better than you are, and surround yourself with them. Bring something to the table to give them in reciprocity, but be willing to engage and keep an open mind, and you can always learn. This lady with 17 locations and 478 staff asked, why are you talking to me? She said, because you’re never too good to learn. That’s what I would leave people with.

 

Allison Jones

Yeah, always be learning.

 

Nancy Mura

Always be learning, ABL.

 

Allison Jones

You mentioned pedsapalooza.com. Where can people learn more about Survival Strategies?

 

Nancy Mura

Great. You can go to survivalstrategies.com. There’s tons of testimonial videos of our clients, both pediatric and adult. That’s pretty much what we do: OT, PT, speech, whether you’re pediatric or adult, and we do audiology. We love audiologists. We love helping that profession as well. But those are the professions right now that we feel we can give the most help to. You can go there. If you are pediatric and you’re over 100 visits, you want to go to pedsapalooza.com or billable hours with 100 or more. If you’re under and you’re a newer practice, there’s a group for you called POPPEE. These are Facebook groups. POPPEE is for peds opening up new private practices. There’s the Private Practice Network & Conferences. That’s a Facebook group for your traditional outpatient ortho that treats adults, so vestibular people, audiologists that do adults. Otherwise, you’re in the Peds-A-Palooza. We direct you. You do find one of our groups, and we direct you. We ask you a bunch of questions, and then we tell you where to go. That’s what we do. That’s what we’re good at.

 

Allison Jones

You’ll find the right spot. Find one of them, and you’ll get directed to the right spot.

 

Nancy Mura

That’s exactly right.

Allison Jones

Excellent. All right. Well, Nancy, we are out of time, but I want to thank you so much for joining us today. There’s so much great information in this podcast, so we’re excited to share it with our community and share those five great tips for handling the staffing challenge out there. Thank you so much for joining us. I want to thank our audience for tuning in to the Therapy Matters podcast, your one-stop resource for expert insights and advice on everything therapy and rehab. We look forward to seeing you in the next episode.

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Thanks for listening to Therapy Matters. Do you like the podcast? Give us a five-star rating, subscribe, and tell all your friends about the show. Want to be a guest or know someone who would be a great guest speaker? Contact me at allison.jones@raintreeinc.com. That’s A-L-L-I-S-O-N.jones@raintreeinc.com. Therapy Matters is brought to you by Raintree, therapy and rehab’s favorite EMR. Raintree is the only all-in-one therapy EMR, delivering a complete and seamless end-to-end patient journey from first contact to payment to patient retention. To learn more about Raintree, visit us online at raintreeinc.com.