Opening a Successful Ophthalmology Practice: Concentrate on Culture

Despite recent trends in healthcare consolidation and daunting factors, such as adopting electronic health records (EHRs), increased equipment and facility costs, reduced reimbursements, ever-changing billing and coding rules and regulations, there are still a great many reasons to pursue private practice ownership.

The perks of private practice include maintaining the freedom to create a culture, workflow, and schedule that allows you to fulfill both personal and professional goals, greater earnings,¹ and providing care that garners greater satisfaction.²

The last of these is perhaps the most important reason to opt for private practice, despite the challenges. According to a 2023 survey, patients overwhelmingly preferred private practice, with 57% reporting they felt the quality of care was higher than that obtained at corporate-owned practices.

Additionally, and to some degree surprisingly, 58% of respondents said they were aware of who owned the practice where they were being treated.²

Twenty years ago, my partner (at the time) and I started with a blank piece of paper. We put a picture of a patient in the middle and said, “What can we do to best treat this person and feel good about doing that?”

And from that jumping off point, SkyVision Centers came into being and has grown into a thriving practice. Private practice is viable…and desirable…because you get to determine how you practice and what your lifestyle is going to be.

Our culture is built around letting everybody reach their peak within a tribe of adults that's geared toward giving the patient the best experience that they can have. In our inward culture, we call ourselves a tribe of adults.

There's no upper or middle management in my practice; we don't have a practice manager, business manager, front desk manager, or lead technician. Our culture is basically built upon the fact that everyone is responsible for their relationships with everybody else.

We don't have a management person who's going to referee interpersonal relationships within the office; it's each person’s responsibility to play well in the sandbox with everybody else that's in the sandbox. To help with that, our organizational structure is built on something called the “pond theory” of management.

When you look at most medical organizations, they're very hierarchical and look very much like a pyramid. You've got the doctor at the top and the individuals who are actually doing the work from the base of the pyramid and, actually, hold the whole thing in place. This organizational chart is very familiar.

Our organizational chart looks very, very different. From the side, it looks like there's a thick line on the bottom and one stem with a single flower shooting up in the middle, representing the leadership/practice owner.

However, if you look down on the pond, you see overlapping lily pads. Each lily pad represents someone who's working in the office. And where those lily pads overlap, there is something that needs to be done that any one of those lily pads is capable of accomplishing.

The person responsible for that particular task is chosen by affirmation from the other people in that overlap. Once that person is chosen and agrees to accept the job, it is the responsibility of everyone else in the overlap to do their part to ensure the assigned person is successful.

So whether it's a new instrument being implemented, scheduling patients, seamlessly moving their chart along, or insurance confirmations, there are several people—several lily pads—that will overlap, but one person will have the responsibility for bringing that task home, while the rest are responsible for ensuring a positive outcome is achievable.

I, personally, think as a practice owner, you need to be the servant leader. Establish a practice where people work with you, not for you.

We have a hiring philosophy that is very different, but very simple. We hire bright, happy, and kind people. Of course, there is a minimum level of intelligence that's necessary to work in healthcare.

Whether you're doing the technical things or even just answering the phone, you really, really have to be able to think on your feet; there's no strict script. However, we have learned that almost all the skills that are necessary to do the jobs within our practice can be taught.

And so we hire for personality. If you hire that personality, your internal culture is off to a great start.

As a practice owner, you want to create a culture where patients expect to have a good experience, and where everyone around you works to make the patients feel like it was you that gave them that great experience.

Essentially, there are two cultures: the inward-facing, discussed earlier, and outward-facing. The most relevant way a private practice can set itself apart from the big, consolidated systems is to have a very particular outward-facing culture that is its own. Externally, our culture is constructed to provide the best eyecare experience available.

Remember, if you're in private practice, you don't have an established brand like the big players—think Cleveland Clinic, the Mayo Clinic, Baylor, or Bascom Palmer. We create our presence in the marketplace and set ourselves apart from the big consolidated organization by how we make people feel. That is dependent on the outward-facing culture you're consciously creating and actively cultivating.

Recognize that patients don't have the ability to acquire the knowledge to let them truly tell the difference in quality and outcomes between two doctors or two practices. How are they going to tell the difference between my 99.9% lack of complication rate and somebody else's 99.85%; there's no way to do that.

You can't even compare my 99.9% with somebody else's 98.3%. So, patients judge a practice by how they feel—such as when they entered the office, were greeted by the staff, underwent the exam, or went into the operating room. This is facilitated by a positive internal culture.

If you plan on opening a practice, prior to choosing a name, finding a location, buying equipment, or investing in an EHR, decide on the culture you want patients to experience when they enter your office. Ask yourself, are you going to be a high volume, high throughput, super efficient practice where it's all about high volume, low margin?

Or are you going to have a high touch, high added value practice where you're really trying to give patients a superior experience? This answer will inform the size of your suite, how that suite is designed, the procedures that will be offered, and your staffing needs.

For example, with the second option, you may be a little heavier on the staff side and have some extra diagnostic equipment that enables you to really get down into some of the nuances that a high volume, high throughput practice isn't particularly interested in delving into.

Once you have established this you can begin the process of budgeting, seeking financing, locating an office space, and the multitude of other tasks that precede a practice opening.

If I see 50 patients a day, 40 of them ask when I’m going to retire. But, because of the culture I'm surrounded by—the culture that my good, great friend, Scott Schlegel and I created so many years ago—I'm happy to come to work and I'm not in much of a hurry to retire.

In 2025, private practice shouldn't be dead, despite the fact that we have massive consolidating forces against us. You can make a very, very nice living being in private practice while creating a culture that makes you eager to come to work every day and provides your patients with stellar confidence and care.