Entrepreneurial Skills for the Nurse Practitioner in Autonomous Practice

1. Entrepreneurial Skills for the Nurse Practitioner in Autonomous Practice Susan E.D. Doughty, MSN, APRN-BC, WHNP Owner and Director, New England WomenCenter South Portland, Maine

2. Objectives • Identify differences between independent and autonomous practice • Describe characteristics of the entrepreneur, the manager, and the technician in all of us • List skills necessary to start and maintain an autonomous practice • List strategies to deal with risk • Identify characteristics of a successful autonomous practice • Describe strategies to prevent burn-out

3. What is Independent NP Practice? • The delivery of nursing services provided by advanced practice nurses over which they have total control: • Financially and legally responsible for all aspects of client services • Define and control nature of services • Determine the nature of the client relationship • Responsible for the actions that occur during that relationship (Aydelotte, Hardy and Hope, Nurses in Private Practice, ANA 1988)

4. Lucille Kinlein, 1977 • Only professional delivering care • Charged a fee for her service • Practiced as a generalist • Gave care within the framework of nursing • Validated the outcomes of her care as far as possible • Differentiated between what she was doing from what physicians do • Hung her shingle

5. Independent • Webster definition: Not influenced or controlled by others in matters of opinion or conduct; not relying on another or others for aid or support • Is any health care provider in 2007 independent?

6. Autonomous • Webster definition: Having the right or power of self-governance, undertaken without outside control • A sense of freedom that is kept in check by a sense of responsibility

7. Collaborative • Webster definition: To work one with another, cooperate • Results from all parties (including the patient) bringing their expertise to the discussion and each party respecting the expertise of the other

8. The Pearson Report • Annually updated compilation of legislation necessary to start an autonomous nursing practice – varies from state to state • www.webnp.net (free)

9. Question: Do We as NPs Communicate Our Expertise? • Remember our authority as nurses within the nursing scope of practice • Equal authority to provide care as any other health care professional • Physician expertise: • Managing unstable patients, complex diagnoses and treatments • NP expertise: • Disease prevention, health promotion, health education, identifying resources and counseling • Expert in assisting patients with adherence and risk management strategies (Mundinger 1994, NEJM, 330: 211-213)

10. What is an Entrepreneur? • A visionary • A dreamer • The energy behind every human activity • The imagination that sparks the fire for the future • The catalyst for change (Gerber 1986, The E-Myth – Why Most Businesses Don’t Work and What To Do About It)

11. The Entrepreneur • Lives in the future, never in the past, rarely in the present • Is happiest: • daydreaming about new markets • dealing with unknowns • probing the future • engineering chaos into harmony • Craves control (Gerber, 1986)

12. The Manager • The part of us • That craves order • That lives in the past • That craves the status quo (if it ain’t broke….) • That sees the problems (Gerber, 1986)

13. Differences: Manager and Entrepreneur • The manager builds a house, then lives in it forever • The entrepreneur builds a house, and the instant it’s done begins planning the next house • The manager runs after the entrepreneur to clean up the mess • Without the entrepreneur, there’d be no mess to clean up • Without the manager, there’d be no business, no society (Gerber, 1986)

14. Differences: Manager and Entrepreneur (cont.) • “It’s the tension between the entrepreneur’s vision and the manager’s pragmatism that creates the synthesis from which great works are born.” (Gerber, 1986)

15. The Technician • The part of us: • That takes action • Would say, “If you want it done right, do it yourself” • Loves to tinker • Lives in the present • Loves the feeling when things get done • Is happiest when in control of the work flow (Gerber, 1986)

16. The Technician (cont.) • The part of us: • That mistrusts the supervisors • Is suspicious of lofty ideas or abstractions • Resents anything getting in the way of their work getting done • Resists imposition of order in a dehumanizing way (Gerber, 1986)

17. Relationships: Manager, Technician and Entrepreneur • To the manager, the technician becomes a problem to be managed • To the technician, the manager becomes a meddler to be avoided • To both, the entrepreneur is the one who got them into this mess in the first place (Gerber, 1986)

18. Balance • “To the extent that we can balance the entrepreneur, the technician, and the manager inside us we can become extremely competent, deriving satisfaction from the challenge of what is demanded of us.” (Gerber, 1986)

19. A Typical Small Business Owner: Entrepreneur Manager Technician (Gerber, 1986)

20. Skills Necessary To Start An Autonomous Practice: Questions • Will I be able to live without a paycheck for a year or more? • Do I have the unflagging support of those closest to me to help me through the hardest times with optimism and determination? • Am I a highly organized person who has the ability to pay attention to even small details?

21. Skills - Questions (cont.) • Do I have well-developed nurse practitioner skills, experience and common sense to make me safe and desirable to potential patients? • Do I know a physician who might be willing to work with me as a consultant and referral source, and to collaborate with me to whatever level I need? • Do I have or can I borrow $80,000 to $100,000 for start-up expenses? (Calmelat, 1993, Nurse Practitioner 18:4, 58-64)

22. Common Sources of Early Failure • Undercapitalization • 22% of working wealthy plan to start a second business, 32% of them would need a loan to pay for it – survey of 504 people with investable assets of at least $1 million (Smith Barney Survey, 2006) • Lack of business competence • Lack of management experience

23. Sources of Capital • Your family and friends • Banks • Government and hybrid nonprofit groups • Vendors and leasing companies • Venture capitalists

24. Why Would I Want to Do This? • Picture yourself in the first car of the roller coaster with your hands in the air • Answer honestly! • To get rich (find another niche) • To help people (there are many other ways without the risk) • Compelling desire to be your own boss and give yourself a better life (this may be for you) • The final decision must be yours and yours alone – do not do it for someone else!

25. Next Step: Homework • Focus, focus, focus • What is your vision? • What is your intention? • Study every aspect • A higher percentage of women than men are successful entrepreneurs because women generally take more time to study the situation before embarking on a venture (Gerber, 1986)

26. Use Your Resources • SCORE • Women’s Business Development Corp. • Other NP owners • Literature: Zaumeyer, C., 2003. How to Start an Independent Practice

27. Resource: The Web

28. Skills for Establishing an Autonomous Practice • Confidence in clinical skills • Ability to articulate the value of your work • Ability to articulate a vision • Ability to write a business plan • Ability to entertain risk • Financial savvy • Ability to establish collaborative relationships

29. Flexibility to function in a variety of additional roles: Business person Researcher Consultant Leader Educator Skills for Establishing an Autonomous Practice (cont.) • Mentor • Maintenance Person • Laundry Person • Public Speaker • Laborer

30. Skills for Establishing an Autonomous Practice (cont.) • Ability to remain current in the nursing field among • Changing technology • Changing standards • Educated patients • Devious insurance practices • Demanding credentialing • Explosion of information

31. Skills for Establishing an Autonomous Practice (cont.) • Ability to document patient records • Ability to document business transactions • Willingness to try to set appropriate boundaries • Still in day job? • Parenting • Aging parents • Spouse • Community obligations

32. The Business Plan • Helps focus • Helps communicate • Evolves with time • Helps avoid pitfalls: • Poor planning • Lack of marketing • Startup timing • Competition • Shortage of Funds • Industry Trends • Inventory Control Krolikowski, N, 2002. OT Practice 7:14

33. Critical Elements of a Business Plan : I • Cover page • Business name (What’s in a name?), address, phone, date, names of principals • Executive summary: major features of the plan • Table of Contents • MISSION STATEMENT • Description of the company including services provided • Survey of the industry: past, present, future • Market research and analysis

34. What’s In A Name? • Memorable and flexible • Allows for adequate growth • Communicates strength and presence of the practice • Trademark search – www.trademarkexpress.com

35. Critical Elements of a Business Plan : II • Marketing plan • Management team • Supporting professional assistance (including accountant, attorney, banker, insurance agent) • Operational plan: discussion of how and where the business will operate • Research and development: improvements planned

36. Critical Elements of a Business Plan : III • Overall schedule: timeline for major events- starting and developing a business • Critical risks and problems • Financial plan: revenue and budget projections for the first three years • Proposed financing: listing of resources • Legal structure: type of corporation • Appendices and supporting documents including curriculum vitae and other background data

37. Budget: Estimated Income • Projected monthly charges: • Visits • number of visits per month times profit per visit • Special procedures • Laboratory income • Injections • Other income Zaumeyer, C., 2004, Advance for NPs, 14

38. Monthly expenses: Salaries for all staff Office space including taxes Utilities including trash removal Hazardous waste disposal Telephone Office equipment Office maintenance and cleaning Outdoor signage Medical equipment Building and business insurance Security system Office supplies Medical supplies Licenses Physician consulting fee Bank fees Advertising marketing Budget: Estimated Overhead

39. Printing Laboratory fees Payroll Payroll taxes Sales taxes Professional fees Health insurance Liability insurance Life insurance Disability insurance Continuing education Certification fees Entertainment and promotion Travel Association dues Subscriptions Property tax Budget: Estimated Overhead

40. Budget: Advice • Hire an accountant and an attorney • With whom you are compatible Who get along with each other • Licenses, legal form of business, tax ID number, state and federal requirements • Work with an experienced insurance broker • personal malpractice • business liability • disability • employee benefits

41. The Next Step: To Do List • Find collaborating practitioners to: • share call • provide peer review • Work with commercial realtor • have your attorney and one other person examine the lease • Apply to 3rd-party insurers for credentialing • Can take up to 3 months to complete • Set a start date (you’ll never feel ready)

42. Plan Ahead: Market Your Practice • Brochure • Answer the question ‘What is an NP?’ • Tell about the practice • Include bio and photograph • Open House • Press release • Speaking engagements • Service clubs, library

43. Plan Ahead: Market Your Practice (cont.) • Flyers • Media interviews • Advertising • Yellow pages (include website address) • Newspaper (run 6 weeks, stop 6 weeks – include photo) • Condition-specific draws better than general • Carry your business cards everywhere • Get involved in community groups

44. Computers/Software • Consider using a consultant • Decide whether to outsource certain telecommunications • Billing • Website • Electronic Medical Records

45. Organize the Office • Start small with room to build (1100 to 1200 square feet) • Make it fun: feng shui, smudging • Create • Privacy, safety • Unimpeded flow of patients • Adequate rest rooms, storage • Break room/kitchen

46. Interview and Hire Staff • This is the biggest chunk of your overhead • All staff need to: • commit to your vision • support marketing efforts and business growth • be willing to grow with the inevitable changes of practice evolution • Hire the right people, pay a fair salary • Build a community – circle concept • Provide staff with regular performance appraisals • It takes months to find a customer and seconds to lose one

47. Open!!!! • Use down time to market the practice • Remember the ebb and flow of activity – don’t panic when business is slow

48. Skills to Maintain an Autonomous Practice • Remember the mission statement • use it in decision-making • Track marketing • Ask patients how they found the practice • Examine all records, watch the checkbook • Beware of little expenses: ‘a small leak will sink a great ship’ • Allow yourself adequate time to work ON the business • Distance yourself for perspective • Network • Renew your energy

49. Skills to Maintain an Autonomous Practice (cont.) • Keep overhead down and income up • Fine line: penny wise, pound foolish v. do we really need it? • Systematically pay off debt load • Avoid credit cards • Use home equity to deduct interest • Lease with option to buy • Monitor your line of credit carefully

50. Strategies to Deal With Risk • Lighten your load • Take small bites! • Get support when you need it • Ask for help • Protect your relationships • Get clear on your goals and perspective • Plan in phases • Set daily, weekly, bi-weekly or monthly goals • Negotiate for what you want • Don’t be afraid to ask for the impossible • Have a contingency plan • Sometimes just knowing there’s a Plan B can make all the difference Rist, N. 2002. Small Business Savvy: A Woman’s Guide to Building A Business