Hallmarks of an aligned practice

Aligned goals are at the heart of great leadership.

We learn early in life that being aligned with people around us is important. Siblings are expected to get along and follow family rules. Misaligned parents are miserable or divorced. To attract and keep friendships, we align our interests with those of our peers — or risk standing out as odd.

As we mature, we realize it is OK to be original and have unique ideas. But, to work on a team, we still have to mostly align with others — and they with us.

As a practice leader, your understanding of the company mission has to line up with that of your partners, associates, management team and employees. Everyone must work toward the same outcomes. Alignment is crucial.

This is especially important in ophthalmology, where even the smallest practice has more critical, complex moving parts than the average business, such as:

  • An extreme standard of “perfect customer care”
  • Steep, ever-changing regulatory hurdles
  • Reimbursement complexities that oblige 20 minutes of staff time on average just to get paid for a single office visit (compare that to checking out at Starbucks)
  • High capital investments and equipment obsolescence
  • A tight labor market for lay staff and doctors
  • An accelerating pace of new clinical skills to keep up with

All of these moving parts must fit together. Misalignment in just one area cascades into others, affecting patient satisfaction, employee morale and the bottom line.

Alignment comes in many dimensions. Below, we’ve listed seven hallmarks of the better-aligned practices we see in our travels. How many of these are you nailing today?


In the so-called “dyadic leadership model,” the lead doctor and business leader are joined at the hip, like parents in a large family. They speak with one voice. They collaboratively lead upward to the board and downward to the mid-level managers. They meet often to stay informed. And they iron out any differences in private rather than squabbling publicly. They both have a memorized command of the practice’s key performance indicators and agree on the most important weak areas to improve upon.


The owners agree in writing on practice goals, with a planning horizon that may stretch 10 years or longer. The depth of this plan should be in keeping with your aspirations, scale and environment. For the typical $5 million private practice, a thorough strategic plan runs about 15 pages and describes the current and expected health-care delivery environment you work in, your service area and your desired service mix (ie, areas you want to get into or avoid).

Your plan will spell out the desired provider mix (ie, the MD:OD ratio) and growth rate targets. This plan should be updated annually by the board, even in a solo practice, and a summary version should be shared with even the most junior staff so they have a context for understanding their manager’s priority tasks.


The management team, following and aligned with the strategic plan, should list the current year’s chief objectives and action. For example, if the strategic goal is to ramp up clinical and surgical volumes, several actions may be needed: increased outreach efforts, additions to staff, adding an extra exam room or two and the like.

To increase the odds of completion, each tactical priority should have a declared deadline and name the person responsible for it. Strategic plans without an underlying tactical priority list are as ineffective as tactical lists without an underlying strategic plan. Both work together to aid alignment and accountability.


We visit some practices where the staff have no documentation to guide how they do their jobs. Everyone just “wings it.” Operations are different from one office satellite to the next. Each optical branch does their own buying on a whim. Sometimes even the most mundane operations documentation — the personnel manual and job descriptions — are absent.

In the typical private practice, it takes a few hundred pages to spell everything out. Operations manuals, if they are used regularly and updated, align staff at several levels. They are the training document used to assure that new workers learn how YOU want the job done. They are a process auditing tool, so you can check to make sure staff are not drifting or cutting corners. And they are a handy refresher course, valuable for even the most experienced worker.


There are reasonable differences from one doctor to the next in how a given patient’s care should be administered. Some doctors want tests before the exam, while others want tests after the exam. Some prescribe drugs or a surgical maneuver that others avoid.

But, in the best practices we see, the providers compare notes and agree to the greatest extent possible on how patients should be worked up, examined and treated. In a clinically aligned practice, staff training is easier as staff don’t have to learn multiple ways to work up the same patient for different doctors. And, if care pathways are combined with regular quality assurance auditing, patient care and provider skills all improve.


Every new hire should only be undertaken with a clear, written position description. New staff should be on-boarded from a checklist. Personnel policies should be clear and uniformly enforced. Performance reviews should be regularly and fairly applied with enough oversight from the administrator to assure that standards are uniformly imposed from one department to the next.


We are a social species. Most of us enjoy gathering with our practice tribe and comparing notes. But practice meetings at every level (board meetings, management team meetings, department-level meetings) are often dull and inefficient. If this is true of your practice meetings, compare yourself to this checklist:

  • Meetings are held at appropriate intervals (typical: bi-weekly for managers, monthly for the board and quarterly of all-hands).
  • A written agenda is distributed well in advance.
  • Every meeting has something that keeps attendees engaged; examples include a guest speaker, a group exercise, positive announcements and abundant praise and recognition.
  • A strong leader is clearly in charge of the meeting.
  • Issues are “brought in for a landing” ... not just glossed over.
  • Board meetings use Robert’s Rules of Order (especially: motions and formal discussions and votes).
  • Follow-up minutes of appropriate detail are distributed. OM