Episode 42: Scale-Ready Systems w/ Dr Nikki Cottis

Dr. Nikki Kottis, welcome to the podcast.

Thank you for having me.

Absolutely. So you are the owner of Chiropractic Connection, is that correct?

Yes.

In Gulf Shores, Alabama.

Gulf Shores, Alabama. That's right.

Yeah. And the client success manager and a coach in the Wealthy Practitioner with Dr. Stephanie Wigner.

Yes.

And I just learned that you have 3 docs total in your office, a few associates. You just gave a really awesome presentation which I'm sorry for anybody that missed out on that, on systems and building scale-ready systems, which was just phenomenal, the presentation that you gave. So I have a lot of substance to talk through today, but I want to hear first, and I'm sure the audience does too, on kind of what got you to this point, you know, to being, as we'll refer to a few times throughout this episode, the Systems Queen. I know you probably didn't start that way. So just give us some background.

I grew up with the messiest room. It's so crazy that I'm so organized now. Yeah, so I grew up in Pennsylvania, ended up in Alabama only through God, truly would've never chosen to live here, but I've come to love it. Went to Penn State University and then I went to chiropractic school at Life where I dated someone in chiropractic school because that's obviously what you do. And that's how I made my way to the South and stayed. I lived in Tuscaloosa, Alabama for 2 very long years, hated every second of it, and that's where I had my first associate jobs. So 2 really, really, really tough associate jobs, and I can definitely talk more about those if you want me to, and left those jobs, left that boyfriend, not sure if it was Tuscaloosa that was so bad or my ex-boyfriend, and moved to Gulf Shores, which is actually a really beautiful town. On the coast of the Gulf of Mexico or America, depending who you are. And so I'm in this little coastal town and I've been here for the past 12 years. Also have been an associate in this same town for 2 years. I also call myself the accidental entrepreneur. I was very happy, very content being an associate, got let go of a job that just completely blindsided me. And had to pivot. And so that's how I ended up opening my own practice at all. Was never my intention, but truly one of the best things that's ever happened to me.

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Back to the episode.

Hmm.

That's really good. Yeah. I mean, I, I'm glad that you said that you had an associate, a few associate positions that were not great, and then you had one that you really enjoyed, you know, that you thought you were going to be an associate there. Forever, because I think that does kind of showcase or demonstrate the contrast between associate opportunities. You know, I know a lot of people, especially in the entrepreneurial space, which both of us are in, you know, a lot of people talk about being an associate in kind of a condescending way, but like, because we're in the entrepreneurial space, you know, we're more risk-tolerant people and typically visionaries, and that's just our jam. But I know a lot of associates that are extremely content and live incredible lives as associate chiropractors. And that's all they want to do, you know, is, is, is grow the mission and fight for it. So that was really cool to start off that way. But let's talk about the practice that you built. So you kind of got blindsided and pushed over the edge into entrepreneurship, which may have been a great thing, you know, if you wouldn't have had the courage to do that on your own. Um, the fact that you were kind of nudged in that direction is now what led you here. So tell me about how you opened your practice and how you built your practice over the next few years.

So when I was leaving my associate job, I was 4 months away from getting married to someone who lives here, has a job in Gulf Shores. So leaving wasn't really an option, and I just said, I'll just look for another job in a different town. And he looked at me and said, Nikki, are you crazy? Why would you just not open your own practice? And I was like, I just don't think that's what I want to do. So my husband Jonathan was very, very, very supportive, and he said, all we need to do is find a space and make it pretty, and we'll get you started. So I called every single table manufacturer in not just America, also in Canada. Do you have any tables that are available to ship like tomorrow? And Elite Manufacturers in Canada was like, we have a blue table with all the drop pieces, the pregnancy parts, and we can ship it tomorrow. I was like, wow. So everything started falling into place. I had absolutely no budget. I opened my practice on $9,000 that I had in savings, and I made it work. I looked on Craigslist— yes, Craigslist, when that was still cool— for an X-ray machine, and I emailed anyone that had anything available within like a 10-hour drive. And the person who wrote me back was from Atlanta, and he used to be the chiropractor for the Atlanta Falcons. And so he messaged me back, and I said, 'I'm so sorry, I messaged you. I actually can't even afford your machine.' And this man who I had never met said, "I wanna help a new chiropractor. What can you afford?" And so I told him what my budget was. This guy gave me this X-ray machine, but he not only gave me that, when I went to his house, number one, it was incredible. He gave me a pep talk about how this is the greatest profession in the world. And that being surrounded by professional athletes, they have access to every best doctor, every orthopedic, every neurologist, and that all their favorite doctors was him. And so it was just this like super inspiring moment of, God, this guy gave me basically an X-ray machine and he also gave me the pep talk that I really needed. And that machine just broke in November of last year. And I got to recall that of just like, wow, look where I started, where I really couldn't even afford an X-ray machine. And look at me now buying something brand new and really moving up. But yeah, opening my practice almost felt, I hate to say easy, but I was really good at it. And that was what I didn't expect. I opened my office, I got really busy, really fast. I grew in volume. And then about 4 years into practice, my volume was steady and my revenue was completely stagnant. And so I knew that there had to be a different way. And a better way. So then about a year after that, I did have my daughter Hazel, and she's 6 now. And that was really the turning point for me. And I know that sounds so cliché, like once you become a mom, but it's true because you get to this point where you start to miss everything that's happening in your life and you're like, what am I doing it all for? So that's when I made the literal switch of treating my chiropractic practice like a hobby and treating it like a business and knowing that I had the true potential to make a lot of money while still helping a lot of people and staying true to my values of being a great chiropractor without sacrificing my health and my spirit of spending time with my family.

Hmm, that's so good. I'm so intrigued now. First off, that was a great cliffhanger because now I want to know What changed, right? Like, I know you can make that like mental switch of like now your chiropractic practice in chiropractic, the practice of chiropractic being the hobby and then running it like a business, which I love because I'm sure you love being a chiropractor, but that's, that's not always the road to success as a chiropractor, especially a chiropractic business owner. You know, I, I know so many incredible chiropractors and incredible adjusters that have really slow suffocating practices. And I know chiropractors who only treat their, their practice like a business that have a thriving chiropractic practice. So again, there's such a stark contrast there. So I want to know what changed tactically, if you want to kind of get into it from your perspective, when you made that mental switch after having Hazel.

Tactically, I had an injury and working really hard using that like foot pedal on the table, kicking it multiple times a day, pushing it down. I developed micro tears in my Achilles. And so when that happened, I went to see an orthopedist and he told me I needed surgery. And being the good chiropractor that I am, I didn't take any of their medical advice and said, I'm not doing that because I said, how long will I be out of work? Of course, it's all I cared about. And they said 6 weeks. And I said, well, that's just not an option. So that was when I really realized, number one, what I'm doing is like physically draining my body, emotionally draining my body, and it is not sustainable. What would happen if I did need surgery and I had no associate doctor, no one to help me, no one to help with this load? My practice would simply fall apart. My practice was 100% dependent on me being there as the person. And I just knew that it wasn't sustainable long term. So I turned 40 this year. My daughter also started kindergarten this year. So when your kids are growing up, it's like at first, yeah, they just like go to daycare and you don't feel like you're missing a lot. Then your kid starts to understand that, like, why isn't my mom ever at any of the events? Or why doesn't my mom ever pick me up from school or drop me off? And that's when it becomes a time of not wanting to make a change, but knowing that you have to make a change or you're gonna look back 20 years in the future and think, what was it all for? And so I knew for me, I wanted it all to be for my daughter. And so in order to do that, it's not worth it to have a practice that just made a lot of money and I didn't get to spend any time with her. I knew that it needed to be both. I knew that I could figure out a way to start to pull myself back while not just maintaining all of this progress we've made, but grow the business with or without me. So it feels really, really good to know that I'm also bringing in associates. You know, you mentioned about me having good and bad experiences as an associate, and I think the number one thing that makes a good associateship is culture. So coming into a practice, feeling like you're valued, feeling like this is the vibe that really fits me is what will keep your associates happy as well as the doctor. Like you have to find these people who understand your mission, who also understand that they can have a super great life being an associate while also starting to provide you some of this freedom that you so desperately need and desire once you've been in practice for 10+ years.

Yeah. Yeah. I mean, I feel, I feel like a lot of that is relevant for me right now because I have a 13-month-old, 14-month-old as of tomorrow or Tuesday, I guess. And yeah, I mean, before it was like I could be self-sacrificing, you know, I could pretty much give myself to the business and, and kind of work myself to physical and emotional and mental exhaustion. And, you know, the cost of that was really just like how I felt in my own body. And so I was really the only person that had to experience the negative effects of that type of hustle, you know, and, and obviously my wife, but we were in it together. So she understood. And then we had Theo, you know, and, and after having Theo, we became so much more purpose-driven. And she came out of the practice. So she trans— transitioned out. And then, you know, not only did I have to be available for the business and for my associates and for my staff members and for my patients, now I needed to be available for my wife who needed support and also my son, you know, and I had to be able to give all of myself in all of these domains, which is seemingly impossible, you know, coming, coming from the prior version of self where like, you know, I gave everything to the practice and everything to the business. So how in the world can we take you know, one person who's giving everything to one domain and then split that everything across 3 vital domains. And so I'm having a similar, um, oh shit moment, as you said, you know, on the, on the last call, uh, over the past 12 months. And so we've been really splitting and, and kind of dividing and conquering on a lot of these things that we're about to go through, hopefully, because I think you have a lot of content that's really great. to build those scale-ready systems. So I guess I, I wanna hear from your perspective before I give you the opportunity to kind of start coaching and teaching, uh, some of the content that you have. Um, what, what, what were the first levers that you pulled on in order to kind of build that profit, profit-making enterprise that worked, uh, in your absence?

Um, so with creating systems, I think that all systems are created from a need. And that most times we don't even have a clue that there are any gaps until something happens. And we're like, how does this keep happening? So once I started really just looking at trends and what's going on inside the practice, and most importantly, what are people constantly coming to me for? How can I create a system around that to help them make their own decisions? So starting with like how we schedule people and then how we make a care plan, how we present a care plan. This is the exact visit that this happens, making a super solid patient journey. So what happens in our office between visit 1 and 12 is not the same as what happens between visit 12 and 24. It's not the same as what happens between 50 and 100. So mapping a really nice patient journey, figuring out what my patient's like, giving them more of that, making sure that we're meeting all of their needs as well. So just really starting with What are the biggest needs? And what are things that my team needs to be empowered to learn how to do that will allow me to start to scale out in my absence? Mm-hmm.

That's good. And at that time, did you hire an associate?

I started my systems well before I had an associate. So I've had in total 4 associates over the past several years and One that was with me before, she was there for about 2 years. And during that time we worked really hard on systems because when she came in, I was like, she doesn't know any of the information that's in my brain. So I hired her before I had the systems and we kind of worked through it together. Learning experience, everything in owning a business really is. Then when I brought on my next associate, I felt like we have a really strong game plan and I had everything recorded and everything in like a really nice document. And I had timelines of between 0 and 30 days, these are the expectations, and 30 to 60 days. And I hope that if I were to ask my associate right now, did you ever feel overwhelmed during the training process, that she would say no. And it's because we got really strategic of what the expectations are, but also breaking things down into super tangible, like, okay, I'm working on this for week 1, and then I have to master that, and then I move on to the next thing. So no, I did not have everything in place before I hired. But I also think you bring up a good point and that, you know, that if you're listening to this, you know, I don't have any systems. Well, it doesn't matter. You just have to pick one thing and start with it and then just extrapolate from there. So the longer that we're in business, the more these things should be tuned in. If you're just starting out, think about like the top 10 things that you're doing that you want somebody else, anybody else on your team to start to do. And I actually had a meeting with my associate yesterday. And I said, these are 4 things on my plate that I need to move to your plate. And so she said, okay, great. And we made a new time for additional training. So I also have everything already recorded in an SOP. So she'll watch those beforehand. We'll meet, I'll say, do you have any questions? And so within 2 weeks, all of those things will be off of my plate again. So that's how we've been able to create that. It also makes me feel very comfortable that when I pull out another shift from my office, that it will be just as seamless as when I started pulling out the first time.

Yeah, no, that's, that's really good. I think, you know, I, I get to talk to a lot of young chiropractors because I am a young chiropractor. And so I get to hear a lot whenever people are sharing their current experience in practice, whether that be bottlenecks or constraints or just challenges that they're currently going through, because we all go through them. And I think that when you have an opportunity opportunity to talk to somebody who understands, uh, you finally get to uncork it a little bit because nobody else really cares. And, um, so people get to share with me that all the time, and they'll, they'll, you know, just kind of go on these tangents about like not having systems or not having processes or not having scripts or not having whatever. And I'm like, well, that's, that's not true. You just don't have them documented. Yes, all of the things you do. Yeah, you're, you're— if you just, if you just tracked what you did every day for 14 days, you would realize that you're very systematized It's just all in your brain. It just doesn't live in a document.

Yes, you have to start just writing things down, putting them into motion, because that's the thing too. We all have this, just like you said, we do it every day, but then we get frustrated when our team doesn't know what to do. But it's like, we've never actually shown them or told them what to do. We're just like, I thought you could be in my head and understand that. Haven't you seen me doing this for the past 2 weeks? Like, why don't you understand? So yes, getting that information written down, recorded, especially so that you never have to repeat it again. Super, super helpful.

That's good. I mean, you're speaking to me right now, you know, because we're in like this growth phase where, you know, our staff just increased and we kind of multiplied, growth multiplied. And so there's a lot of things that myself and Dr. Mike talk about that we do unconsciously. So we have unconscious competence in a lot of different domains of the business. And now it's time for us to actually get that out of our brains But you have to almost approach it in a weird frame. You have to start to take the observer frame as you start to go through these daily tasks, because I think a lot of times, especially as practitioners, you know, whenever we're going through these, these job roles within the practice, and most of us as chiropractors have multiple, you're going through those roles, you're just being very intentional on what's in front of you. And so in order to actually document it, you have to almost like dissociate from what you're actually doing and observe yourself from a third-party point of view so that you can actually go out and make documentation to teach your, your team and future associates.

So it's so true. And it's also like a lot of times people be like, I don't have time to do that. So if you ever feel like I don't have time to sit down and create it, first you should do a time audit to see where all of your time is actually going. And you'd be surprised how many times during the day you get distracted by emails social media. So if it's like in the middle of patient care, you really shouldn't be stopping to check your emails. You shouldn't be stopping to get on social media. Use that time instead, write down a procedure that you just did and start that process that way. So if you think you don't have time, start with the time audit because it's very eye-opening. And then again, just start to write it down afterwards. This is what I did for that. Make yourself task reminders too. Schedule it in your calendar. For 1 hour on Tuesdays, or whenever, I'm going to sit down and I'm going to record how I make a care plan, how I present a care plan, what my day 1 process looks like, what my report of finding looks like. This is how we do a patient review. This is how I compose an email. Everything that you're doing, just start to set a little bit of time aside every single week to really get that process going.

That's good. And I'm going to get super granular here because I think this might actually be more important for people than, I don't know, that we see sometimes. Where, where are you actually, um, where are you actually taking those notes? Like where, where are you, where are you storing all of that information? And I know you shared, uh, a few hacks on the last call, but can you share with this audience things that you use to kind of speed up that process and make it a little bit easier?

Yes. Number one tool that I use is called ClickUp. ClickUp is a task manager. And so if you find yourself frustrated with especially your team and you're like, they know that on Fridays at this time they're supposed to do X, Y, and Z, but it's continually not happening, ClickUp is great for that. It's also great for eliminating your team coming to you in the middle of shift to be like, hey, so-and-so just called and they need this, or Can you send me this? Can you do that? This makes it so that someone can make you a task reminder, set a due date, and never bother you about it. So I'll get ClickUps made if I'm out of the office for something, like if someone called for me, or if I need to do something, if a patient had a question about something that only I can answer, they'll make me a task reminder. It's also accountability for our team. So every Friday we have a care plan decision and outcome ClickUp. And I'm not in my office on Fridays. And so I can go on ClickUp and I can know the outcome of every single care plan that we presented this week to see, did they sign? Did they take it home? What happened? So that I'm not like, hey, like, whatever happened with Christopher's care plan? Did he sign that? So again, just eliminating— that we want to eliminate all communication with our team, but if we can minimize what we're talking about in office too and just keeping things super streamlined, ClickUp is a great place for that. It's also great for new tasks. So, hey, we need to make sure we're tracking all the leads, make a ClickUp that they have to close after shift. And so if it's a new habit that we're trying to also instill in them, it's like, it's not passive-aggressive, but it's a little bit of a way to just get them on board with doing these tasks that need to be done. So I love ClickUp, huge ClickUp girl. And, um, we also use Loom. We use Loom for nearly everything in, in life. We use it for our practice, we use it for training. Everything that we're doing, we're just recording a video. And so once we record the video, it gets organized. I also have a VA who helps me organize my SOPs and my, um, Loom library. And what she'll do is she'll just take it and put them all into folders. So she organizes my Google Drive too. But we also use Google Drive for any patient documents or like making care plans, procedures for things, etc. And then we use ScribeHow to upload all of the Loom videos for training into this really nice— it uses AI to create a written document. So once you record the video, you upload it, and then AI does the rest. That's probably one of the coolest things that we've implemented within the past 6 months. Because again, once it's recorded, it just needs to be uploaded. And now you have written and visual, because we all know too, some people are visual learners, some people are like, I could watch a video and learn, some people are like, I have to do it. So it really hits all the different aspects of how people learn best and having everything available to those types of people.

That's so good. I think that's going to be so helpful because I think A lot of times you could hear, you know, high, high-level people, high-performing people just talk about what you need, what you need to do. And then you're left thinking, well, how do I do that? Well, that is how you do it. She just gave you what you need to do and then how you actually do it so you can implement. And ClickUp is kind of similar to Notion. So there's a few different project management solutions, I'm sure. And if you already have one, then just see if you can implement it in the way that Dr. Nikki just mentioned. Otherwise, I'm going to start to use Scribe Owl for sure. I'm going to go check that out as soon as we're off this episode.

Also, do you use Notion?

Yeah, Notion and Monday.

They'll also like link together. So when you're like, I use Loom and ClickUp, I can attach the Looms to the ClickUp with due dates. And then once these things are done too, it will like close the task. So again, that's another way of accountability. I know that someone who's supposed to be watching something has actually watched it. That because they're closing that off. But you can like integrate all of these things too, which is so cool. We're in such a great time of like AI just helping us with all these little things and making it so much easier, for sure.

That's right, it allows you to scale.

Yes.

All right, so you just went through some really cool things inside of the Chiroads Academy, and you talked about the 5 growth codes. Um, do you mind if we kind of unpack a little bit of that on this call?

Sure.

Okay, so you started with scale-ready systems, and you said build once and grow infinitely, which I really liked. And I liked also how you said that not everything in your practice can handle growth. And so I'd love to kind of first start by you just outlining and defining what, what you define scale-ready systems as. And then let's talk about like where most of the bottlenecks are in people's practice, because I think if you can identify a bottleneck in somebody's practice, that gets them a little bit closer to being able to find a solution, you know.

Yes. So with the Scale Ready Systems, it's like when we do it once for exponential growth, we need to think long term. So most times when we are creating systems, we think about what do I need today versus what would I need to do if my practice were to double or triple tomorrow. What are the very first things that would break? And so the first time I sat down and reflected on that years ago, what would break was me. And so I knew again that like the pace wasn't sustainable. I couldn't physically adjust twice the volume that I was doing. Then you start to think about what would happen to my team? What would fall through the cracks? That's another great place when we're thinking of systems is what are the most common things that are already falling through the cracks? Because I need to figure out how to actually fix that. So instead of just thinking short-term, we need to think 5 years, 10 years down the road. So getting super clear on your vision, knowing what is my ideal practice look like? What am I actually working towards with goals? So, and you know, many, when I opened my practice, see, I was in 1,000 square feet. Is that sustainable forever? No, but it was also like I had to open quickly. So, but once you also realize that I want to see X amount of patients make X amount of dollars, I'm gonna need a bigger space, then we need to start looking for a bigger space. So many times we wait until the bottleneck is so tight around our neck that we're trapped instead of noticing it as soon as it happens and starting to create a plan for the future. So when we're thinking about our vision, ask yourself, How many patient visits a week do I want to see? How many rooms would I need? How many staff would I need? How much money am I making? Where am I located? Is this a good place for people to come from different towns? How many hours am I in the office? What shifts am I working? So really getting super specific on what your ideal practice looks like, and then we can reverse engineer that. So if you know that you wanna see 400 patient visits a week and you know that your current office would only allow for 150, then we know that when the time is ready and when time is coming, we need to look for a bigger office space, or else you'll always be trapped by that bottleneck of physical space capacity. We also would know that if I want to see 400 patient visits a week and my physical capacity for adjusting patients is 300, I need an associate doctor. So when would I need to put out an ad for an associate? Where do I even put an ad out for an associate? How do I find them? What do I pay them? So figuring all these things out in advance before we're doing them is also really helpful. But, and then again, how many staff do I need? Is— are there things I can do that I can automate that I wouldn't need a staff? So again, just thinking long-term versus in the moment will be very helpful for creating sustainable systems. And that's what we want. We don't want to make systems today that are working for our 100 patient visits a week. And then in 6 months, we need to redo everything and start from scratch.

Yeah, that's really good. So kind of building the systems with the, with the end goal in mind. And I like, I liked how you actually framed it as like infrastructure, you're kind of building infrastructure ahead of need. So kind of anticipating growth. And I think, especially when it comes back to the Wealthy Practitioner and the way that you guys talk about the abundance mindset and quantum leaps, you know, creating that infrastructure ahead of need is actually calling in the growth that you desire, which— yeah, that's huge, huge unlock there, huge takeaway. So, um, you know, you, you talked about, uh, a few of the, the breaking points, you know, and you said where, where most practices snap, and you kind of talked about front desk overwhelm and documentation backlog and provider burnout, and then you talk about quality. So you can kind of break those down for me just a little bit.

Sure. So with front desk overwhelm, you would really want to think, what would quote break in my systems if we saw 3 times the volume? So would it be the check-in process, the checkout process? How are we collecting payments? So just having everyone's card on file who comes into your office, whether on a care plan or pay-per-visit, that's something that makes your front desk so much more capable of seeing a higher volume. If she's not having to stop someone every time they're coming in, have them get their credit card. We don't want to do that for multiple reasons, but that's one way. The second way is pre-scheduling all of our patients. So me and my associate, we're really good at this and just getting them to schedule with us, the doctor, versus even handing them off to the front desk. But the more you can have your patients pre-scheduled— so top 3 things: having them on any sort of monthly recurring revenue, having their card on file, and having them pre-scheduled. Would allow my front desk right now by herself to see 3 times the amount of volume.

How?

Because she's not scheduling, she's not checking in and out, and she ain't running payments every time someone leaves. So we're running payments 4 times a month. She's got to run the occasional pay-per-visits and everything else is happening automated. So those 4 times a month when care plans run, payments are posted, we don't have to do anything for that. So we have a very sustainable system for front desk, if patients are calling the office a lot and they're like, I can't keep up with the volume of calls, then we want to figure out how can I entice or motivate my patients to text instead of call. So it's part of our new patient script. When the doctors are with the patients, when we're reviewing the schedule, we also say, did you get a text reminder for this appointment? And they'll say, yes. I'm like, great. That is actually two-way texting. Our office also prefers that you text versus call if you need to make a schedule change. They're like, oh yeah, like my ideal client, they like to text anyway. They don't want to be on their phone. So it's a win-win, but we just put that in their brain that, hey, we actually prefer if you text. And they're like, oh yeah, it's easier for me too. So just setting the patient up for number one, your expectations of how your office runs, If your office runs on time, you need to tell them that, hey, our office runs on time. We run by appointment only. We have a 15-minute door-to-door guarantee as long as you show up for your appointment time. Then they're like, dang, I better be on time for my appointment. Oh, and I'll be in and out in 15 minutes if I do so. If I don't, I might not be. So just setting the expectations with your patients. Documentation backlog. This is a big one. Documentation is hard. And so if you're seeing a high volume of patients, we need to have some sort of strategy or system around that, whether it's macros. I have a scribe, like I have a scribe who takes my notes and inputs them into EHR. So there are ways you can get creative without you physically having to do every single piece of a SOAP note. So just using AI again, there's some AI things we can do for that. There's assistants that we can use for that. And just getting— that's also a good point. Like if you got an EHR when you first opened, that was good for like 100 visits a week, but it's not great for 500. At some point you're going to have to change your EHR. So just keeping these things in mind, that if it's not sustainable in the future, we probably want to look for the better option straight from the get-go because it's a pain in the butt to change EHR when you're 5, 10 years into practice. Provider burnout. So that really happens with extended hours. So when we're seeing a higher volume of patients, if we feel like we really can't give people the quality care they deserve, then we'll just add more hours. And that's really never the right answer. So a couple different things that we can think about. Number 1, if your office is at capacity, you have a waitlist for new patients, you should consider pre-qualifying your new patients. So really only letting people come to your office who are committed to your care, who are a great fit, and who are gonna, quote, do what you say and they'll get great results. And number 2, raising your fees. So if you're constantly at capacity, it's a good time to reevaluate doing a fee increase as well. And number 3, getting really solid on creating like IP around what your strategy is around how you take care of patients. So I like to use Webster Technique for this. You go to a Webster seminar, someone teaches you what to do, and it's a true protocol. So you're going through a protocol A through Z, you're learning all the steps. And once I check the— this, and then I check the round ligament, and then I check pubic bone You're going through a protocol which makes it fast because you know what the next best steps are. And so we all know that we're much faster adjusters 2 years into practice than we were the day we graduated. We're even faster when we're 10 years, 15 years, 20 years. That also isn't helpful if you hire a brand new doctor. So how can I teach a new doctor to get, quote, faster at adjusting? Well, I need to teach her what my IP is. I need to teach her This is the system. This is the flow of what you would do for a baby with colic. This is what you would do for a baby with a latch issue. This is what you do for every pregnant woman. This is what you do for someone with headaches. So creating these intellectual properties around how you actually create protocols around taking care of patients will speed you up without diminishing quality, and that will help eliminate provider burnout. And then patient experience. So we never want the patient experience to suffer. At a higher volume because number one, you never want patients to feel rushed. So even if your office does run very quickly, even if it doesn't, you don't want them to feel the squeeze of becoming a busier office. No one should ever step foot in my office and it feel different than if there was 500 people on the schedule that week, or if there was 100 people on the schedule that week. Their experience should never falter. And so that's where you really start to figure out what would I miss or what would I screw up if our practice volume tripled tomorrow. And so if it was, I don't know if I would know everyone's names, okay, well, what's a great system for remembering everyone's names, learning those things, maintaining office flow? Where are we creating these bottlenecks so that we can eliminate it before it even starts? Hmm.

So many good nuggets there. So many good nuggets. One thing that, that you mentioned in the last call was the Netflix principle. I keep referencing that. Sorry, but the Netflix principle, I really like that. First off, like, I love, I love that, that Netflix principle idea where you're trying to collect as much data as possible and you're making them feel known. And this just takes me back to How to Win Friends and Influence People, you know, and, and knowing people by their name, but also knowing small little details about them. And that helps make them feel connected to and valued as a member of your community. Can you tell me a little bit more about the Netflix principle and how you use it?

Yeah, of course. So the Netflix principle is, so if you have a Netflix account, you have different profiles and like in my house, it's Nikki, John, my husband, and Hazel, my daughter. What I like to watch is very different than what John or Hazel likes to watch. And so for me, it's like Emily in Paris, Love is Blind, really bad reality TV shows. Jonathan's is like Vikings, documentaries, really weird things about like World War II, stuff I do not want to watch. And so he'll always be like, Nikki, don't accidentally watch your girly shows on my profile because it will—

Emily in Paris.

Yes, it will screw up his algorithm, right? And so when we're doing that, Netflix is taking all of this information about me. And if I watch Emily in Paris, it will give me a suggestion of what I should watch first. So the more information I give Netflix, the better information it spits out. And it's constantly saying— and you know, they have that like recommended by what you've watched before. 99% match. They're getting all this information because of the information I'm putting in. So how we can take this principle and utilize it in our offices— we need to learn as much about our patients before they even step foot into our office, as much as we can. So most everyone has some sort of social media too. You can look at their Facebook ahead of time, know what they look like. You can look at their Instagram. That way, when the patient is coming in, you know, without a shadow of a doubt, oh, this is my new patient. Like, this must be Travis. We've been expecting you. Just being prepared. We also provide all of our new patients with a new patient drink. So when they come into our new patient room, their name is on the board. Again, we're ready for their appointment. They can feel that. They know that. So having their name on the board, having their favorite drink, drink. How we get the information for their favorite drink, it's simply part of our new patient script. At the end of the phone call, um, we'll say, we have 2 more questions for you, and one of them is, is super random, but what is your favorite thing to drink? And they'll tell us their drink, and then we'll say, oh, okay, great. Um, and then the last one is, do you know where our office is located? Just to get the call back on track. And so when they arrive, we have their favorite drink in a cup, and it costs like most times free because the majority of people say water. But even if it's something else, coffee, latte, whatever it is— well, we do have a latte maker too, just for that reason. But like, we can provide that. So just providing what they want, what they like, and also going above and beyond because they've never gone anywhere else that if they said they wanted a latte, that someone would actually give it to them. So again, making the experience better. And then we also survey our patients. So anytime you guys are going to make a change in practice, you shouldn't do it based on emotion or what you want alone. You should survey your patients. So think about your top 10 most favorite, most ideal clients and invite them to a dinner. Ask them that you want their feedback. Doctor doesn't go because you want it to be Very, very honest. And so you have someone go on your behalf and you're surveying them. Do you like the hours? Do you like the smell of the office? Do you like open adjusting? All of these things that you want to know. What would make you refer to us more? What could we do better? So surveying your patients is a huge way to increase and use this Netflix principle. Um, on visit 6, we'll send a survey out to our patients. It's like a quick check-in. That's half how are we doing and half how can you start to help us. So gathering information again, do you like our office hours? Um, are you happy with your care so far? Are the results what you thought they would be, etc.? Do you own a business or know somewhere that one of our doctors can be a presenter at? So I asked like 4 questions about them, and then I'm also going to ask them if they would like us to do anything for them, which inadvertently also helps build our business. So what will really set you guys apart as chiropractors in towns with as many other chiropractors as there is, is truly the experience that you provide. And so if you look at your Google reviews, look at your top 3 most common words and take that and 10x it. So for us, it was friendly team, knows my name, goes above and beyond. So we're like, how can we take these 3 words and make this what our true brand is. So that includes training on when we respond in text, use an exclamation point or an emoji. These are little things that help set the culture of your office apart so they know that whoever they're texting with, they can't tell the difference. They don't know who it is. If they said that you always know their name, we say their name every time they come in. So just looking at your reviews thinking of what are the top 3 words and how can I take those things and literally 10x it to help make our patient experience that much better.

That was a great 6-minute segment there. I have so much. So we just got back from the scaling workshop with the Hormozes. And one of the things that we took away, maybe the biggest thing that we took away, we were obviously there for like higher level strategy.

And finding the constraint of our business and then getting really tactical and granular on the action items and priorities that we can come back and execute on for the next 3 to 6 months. And we did that. But like, still, when somebody asked me like, what's the biggest thing that you took away? The answer that I give is that every single one of their staff members knew our names. They knew our business. They knew our top line. They knew our bottom line. They knew our, the potential constraint that we had in our business. They knew where our business was located. They knew when the business was started. Like, they knew so much about us before we ever walked into that room. And not only did they know that information, but they were able to actually, like, convey this feeling of, like, importance to us because they had prepared, essentially. And, and so much so, this was demonstrated at the highest level because Alex came in and did a Q&A.

And so there was, I think, like 9 of us that actually got to ask questions and every one of us that went up there to ask a question, it started with, hi, my name is, and as soon as the name came out, he was like, Daisy Jacobson, you own the AI whatever, your top line is this, your bottom line is this, this is what you're struggling with, you're located here and you're looking to do this, what's your question? And everybody was just like, whoa, this is like, this is like the, you know, like, I don't know, one of the greatest entrepreneurs of our era that spent time preparing 40 companies in this room, and he knew every single person that came up there, and it was a random selection process. So there's no way he could have just studied 9 people that— yeah, the 9 people that were asking the question. And so that right there was like mind-blowing for me. I was like, okay, just a little bit of preparation goes so far.

Yeah. And on the flip side of that, have you ever been somewhere else where they were like, oh, who are you? And You feel like unimportant, right?

Sure.

Think about too what that did for retention of you wanting to go back to a Hormozy event, right? They made you feel like they actually care. We do this in the Wealthy Practitioners. So when we had the Profit and Purpose event in Nashville in May, we had a team meeting ahead of time with a list of every single person who was coming that wasn't a current or a past client, a.k.a. they probably didn't know anyone in the room. So part of like, me and Gabrielle's job, the other coach in the Wealthy Practitioner, is like, find these people, say hello by first name, make them feel super duper welcome because nobody wants to go to an event where it was like everyone was snobby, nobody talked to me, I didn't like the vibe. What we want them to do instead is be like, dang, these people knew my name, they made me feel welcome. They asked me to go to lunch. So we literally had a full meeting about like going through putting a name to a face so that when we saw them, we could at very minimum go up and be like, hey, my name is Nikki, I'm on the Wealthy Practitioner team. We're so glad you're here. Like, tell me a little bit about you, Alicia, like just so that they know that we were expecting them at this event. And so when you do that to your patients, You know, when you walk into like a medical doctor's office and they have like the windows closed and Beth at the front desk, she doesn't even want to look at you in the, in the face. And you're like, where's the bathroom? And she's like pointing around the corner and you're like, well, there's 17 doors around the corner. So the best way you can make your patient experience great is think about the worst experience you had in a medical doctor's office and do the exact fricking opposite. So giving an office tour, anytime someone asks where the bathroom is in our office, We don't ever point no matter how long they've been coming. Let me show you where it is. Even though it's like one door and they can't miss it, it doesn't matter. Let me show you where it is. Someone on our team will get up and take them to the bathroom. And so that's just another part of like going above and beyond, making sure that we are prepared for their visit, because if we're not, it like it would really show. So we want them to come in, feel so welcome, know that we're expecting them, know that we're ready for them. And again, if you look at our reviews, that's all it talks about. Like, my new patient experience was like 10 out of 10, this and that, and how that goes for retention. Like, people go where they feel a community and where they feel welcome. Sometimes too, these people are coming to you, they are in pain, they're miserable, and we just have to remember that we may be the only person that's being kind to them. In their entire life. We may be the first touch that they've had in a long time. And so just making them feel so comfortable in our presence will literally triple your internal referrals. People ask us all the time, how do I get new— more new patients? Let's love more and take care of the ones who are there, and then they'll start to refer. I've never asked for patient referrals ever, and we average 40 to 50 new patients a month. And so if you just take care of the people who are coming, they're going to naturally refer to you. You also want consistency. So if you refer someone and they didn't get their favorite drink, well, then they're gonna be like, well, why didn't I get a coffee? So you have to create consistency too, which is why the system matters. So it's part of the script, ask for the drink. And if it wasn't in the script, then they probably forget. So again, it all comes back to what is the system around scheduling a new patient? ABC schedule.

Yeah, and I think that's the project. You know, the project is figuring out how can we take this system that exudes like excellence across the board for the entire client journey and take that in a 100-visit practice and scale it into a 500-visit practice, you know, where now there's like multiple new patients that are coming in every single day. Like what type of preparation, where, where are the pockets of time where that preparation can happen? What is the process where you can actually have that team-based preparation? And then how do you execute on it consistently? And so that's where my mind's going. It's like all of the things that you're saying right now is, um, just another demonstration of like unreasonable hospitality across the board. And how do you do that at scale? And I think that's where like the best businesses in the world have figured out how to do that, you know, and, and that's our job right now.

It's even like with new patients, for example, we did have a bottleneck where it was like, why are we not— I was like, why are we not registering these people for their scans and posture ahead of time? And they're like, well, we don't know their height and weight. I'm like, okay, so we added to the new patient paperwork, right? So asking your team for feedback too. Like, what are you guys seeing? What's the issue with— like, why are we not making this in advance? Why are we not— if you take insurance, why are you not verifying insurance in advance? Okay, well, we just need to ask for it in advance. So adding height and weight and putting like necessary for your thermal scans, they're going to give you their height and weight. And now we can pre-register all new patients before we even start shift. For the name board, getting all the names pulled and ready, set into a certain spot. Having the drinks ready, knowing what's like next, and then being able to turn over the room really quickly too. So having everything prepared is so helpful. Paperwork printed, folders ready, everything that we can do in advance needs to be done at least before shift, if not the day before. Hmm.

Okay. So let's talk through a few other things that I have here, um, which is the 3 tests of scalability. So I loved, I loved the scale-ready systems. And now let's talk about the 3 tests of scalability. Okay. So I loved how you broke this down, which was the value test, the resource test, and the quality test. So you want to start with the value test?

Sure. Value test would be what is something that becomes more valuable as it grows? So that could be team. If as we grow, this team is more valuable. This could be your EHR. So like I mentioned, if you have a crappy EHR. So having a good EHR, anything that is worth more because it does more as the practice grows passes the value test. Resource test is expands without proportional resources. So I have 3 doctors and I have 1.5 staff. A lot of times with 3 doctors, we'll talk to people who have 7 staff and it's like, why? There's really no reason for that. So with the volume that we are seeing now, we were able to do that with 1.5 people. And it's 1.5 because we have 3 doctors, we need 2 people. If we have 2, we just need 1. So how many people can each employee take care of? And it's really up to like 250 should be 1 employee. And then after that, we start to think about more. But we want to again, make sure that as we're adding on, it doesn't make sense to grow and then have our overhead grow just as much. So if you don't know what your profit is, that's somewhere you should really start too. But we don't need to add resources that aren't necessary.

Great level of awareness. So can you, um, can you tell me just very quickly, uh, what, what an average profit margin is across the industry that you see? And maybe, maybe if you see like practices that are struggling profit-wise where they typically are versus practices that are really excelling where they are profit-wise.

Excelling would be in that like 40 to 50% range.

Okay.

And struggling would be we've seen like 2% profit margins. So, and you know what it all comes down to? Overleveraged on team. So whether it's how you pay your associates, if people have them on like a, just a, um, like a percentage base, that's a big no-no, and that will never help you pull yourself out of practice. But solid profit margins would be 40 to 50%, and then the people who are below that, it's always, always, always coming down to overleveraged on team, whether it's doctors, whether it's staff, etc. That's the number one thing that we see.

Okay. Do you have a thought thread that you were following there before I interrupted?

Uh, quality tests. I never got to that. Sorry. Um, our quality tests for maintaining quality at scale. So I think that I did touch on this, but how things improve quality at scale. And for us, it's patient education. So we do have open style adjusting, and with the open adjusting, it's— that's really where patients can hear and see other things that they might not have seen if they were in the office by themselves. So watching you adjust the baby, people are like, oh, I didn't know so many babies got adjusted. Or pregnant women, people like, oh, I didn't know you could get adjusted if you're pregnant. My sister's pregnant. Um, on the flip side of that, adjusting a knee or an ankle or a jaw. I didn't know you guys could adjust extremities. So being able to use that improvement of patient education while we're serving more patients as well. And when we were on the call before, someone said, well, I don't have Open Adjusting, how can I also use this for scale? So improving our quality would be if you don't have an email list, starting an email list and starting to take the conversations that you're having with your patients behind closed doors and making those email series. So helping someone with their jaw, hey, this is Bob, and this is how I helped him with his jaw. And then putting that into ChatGPT, making like a 3 to 5 email sequence and sending that to your patients so that they're like, oh, I also didn't know that, and let me forward that to my mom who's been struggling with TMJ for the past 5 years. So all of these things that the more people we see, the more education opportunities we have, whether it's in person, social media, or through our email marketing as well.

Yeah, I mean, I love that. I love that example that you gave, which was, you know, people, people may ask like, why, why would I need to send out education on things that I can help with to my existing patient list? And I think that's a great point. You know, like, you hear just in through casual conversation with people all the time what they're going through in their life. and typically, you know, you've probably heard what physical ailments they're also being challenged by. And so if you can send something about migraine headaches or if you could send something about sciatica or whatever, whatever it is, like it could be nervous system dysregulation, it doesn't matter, and then that person can immediately have a hit, "Oh, so-and-so just told me about their migraine headaches and, you know, how debilitating they are, forward them that email," and then give them an option or an opportunity to then find their way into your new patient funnel. I love what you said, which is like you're decreasing friction to transaction for somebody to become a new patient in your office. Yeah, so there's several different ways of doing that, and going through your existing patient is first one of the most low-cost ways that you can.

Yeah, email is basically free, right? You can have like a $10 a month thing, but Mailchimp. Yeah. Yeah, exactly.

Yeah, that's awesome. So let's just, um, let's finish this off because we've been through this entire episode and we've really, we've talked about growing the business and we haven't even really talked about like revenue or financials. So, you know, I think asking that question about profit margins, really like whenever, whenever I talk to chiropractors that are strained, it's really because they're strained in profit. Well, they're typically strained in two ways. They're either strapped for time or they're strapped for money, one of the two. They're either making a lot of money and generating high profits, but it's because they're chained to the business and they're doing a lot of the labor, or it's the inverse where, you know, they just have— they have no money. And sometimes it's both, right? Where like they have no profit, they— and they have no time. So now they're in a really tough position because they don't even know how to pull themselves out of either hole. So can you just kind of give me a high-level overview of things that you guys see in the wealthy practitioner and how you help them out of that?

Yeah, I would start with reading Dan Martell's book, Buy Back Your Time, and then also figuring out what your cost per hour is. So a lot of times we're stuck doing all these things. Like, I would have never thought to hire a VA until someone was like, why are you doing high-level tasks that someone could do for $10 an hour? And I was like, interesting. So if you figure out your, like, what your hourly rate is, so what your revenue was for the month divided by how many hours you worked. That's your hourly rate. And you can take your overhead out of this. So if your hourly rate is $200, you can buy back your time for anything less than $200. So that could be hiring someone. I don't do my own laundry. Like, I pay someone. She comes to my house twice a week. She is like a house manager. She does my laundry. She cleans my house. She organizes my 6-year-old's atrocious room. Like she comes in and she does these things for $25 an hour. So I bought back my time, I bought back 5 hours a week by paying someone, whatever, 8 hours a week for someone to come and do that. And then same thing as a VA, I can pay someone to do these tasks because my hourly rate is higher. Then once you have an associate, so thinking about in an office setting, bringing in an associate, my hourly rate is worth more than an associate. So what can I offload from my plate that is higher level and even pay someone like an associate to take over these tasks? What can my front desk do? What can an office manager do? So you have to start with knowing what your overhead is. If you don't track your overhead, you should be tracking that. If you don't know what your profit margins are, you should also be tracking that. And then you figure out your hourly rate. And then we figure out what are tasks that I'm doing that are worth well less than this that I can pay someone else to do. To buy me back some of my time. That's even— I got a promotion at The Wealthy Practitioner and I have to dedicate more time to that. And so I run a full-time chiropractic office and I thought, well, how can I create more hours in my week? Well, I need to offload X, Y, and Z tasks from what I'm doing for my office. So I gave my associate a raise, gave her more tasks to do. Now I just freed up 8 more hours of my time per week to go work on something else. So we have to get creative sometimes and also know what our hourly rate is worth and what I can give to someone else to help me get there. If you're also like, well, I have more time than money right now, then you're, you're honestly still in the hustle season and that is just part of it. And I know you mentioned like being— your child is very young and he's 14 months old. There are different seasons that we all go through and I've owned my business for 10 years and been a chiropractor for 14 years, and the amount of work that it took to get my practice to the point it is now didn't happen overnight. I do wish that I had all the resources available that I know there are now to help cut that timeline down. And so that's where people are at such a unique, like, place in 2025, is it doesn't have to take you 5 years to figure out that your practice is killing you. There are shortcuts and you can pay people to literally help you find the shortcuts. So just learning honestly from Stephanie how to start to buy back my time, how to start to pull out of practice, has been invaluable to finding that quote balance of work-life, mom, all of the things, and how I can run a business, be a successful chiropractor, have two doctors, and work full-time for a coaching company too and have all the time in the world to make it happen.

Yeah, I mean, I think, you know, just talking about like the have more time than you have money, that's a, that's a, it's an interesting dichotomy because like when you're in that place, you typically, you're just riddled with a scarcity mentality, you know, but that's actually the time, the time where you need to switch or transition into an abundance mentality. And you need to, as challenging as it may be, become very resourceful in order to invest in the strategies or people that can help you strategize. Because typically the people that have more time than they have money, it's A, they haven't let time time. So they started, you know, 12 months ago and they just haven't seen the fruits of their labor. They're still in the labor, which is okay. Sometimes there's not an accelerated path out of that. You just have to do the work over a consistent amount of time until eventually you will be on the other side of that. And in retrospect, you will see that. However, there, there are also other situations where, you know, they've been in that same, that same situation for years, you know, and the only reason that they're still in that same situation is because they're still acting the same behaviors. And they haven't invested in an outside resource that can help them strategize. And, and, you know, one of the things that I took from this weekend is that strategy is essentially just learning what to prioritize, and that essentially is just learning what not to do. So a lot of, a lot of times as entrepreneurs, you know, we have all of these things that we have to do, but if we actually looked at the revenue drivers or what moved the needle forward, that could actually give us more money for our time, we would see that there's probably 3. And if we consolidated that down a little bit, we would probably see that there's one big one, or at least one big one that we should be attacking right now. And so if you don't have the skills to be able to zoom out from your practice and be able to identify any of those areas in your business that can help you pull a profit lever to give you an outsized return right now, there are people in this industry that are doing that at a really freaking high level. And you're a part of one of those groups. You know, I mean, I— it like, I, I just got like goosebumps whenever you said if you don't know your profit margins. Like, I just can't imagine being in a place in practice and in business where you don't have enough of a grasp on your business to know if you're leaking resources. And if that's you right now, just know that that's okay and there's a way out.

Yes. Yeah, it's like, yeah, start— you need to start figuring it out. It's never too late to What am I not doing? And then how do I fix that? For sure. Yeah.

Okay. Well, I think, I think we're at a good stopping point here. This was, this was awesome, Dr. Nikki. I got to sit back and just listen for the last hour. And I'm gonna go, I'm gonna go re-listen to this because I think you gave a lot of really good takeaways and things that, that we should be focusing on inside our practice from a client experience standpoint, for sure. That was the biggest takeaway that I had from this episode because it was the most relevant to where I am right now. But I'm sure that there are other listeners that took away other things in other domains, and I'm sure this is going to help a lot of people.

Well, thank you so much, and thank you for having me.

Absolutely. Well, where can— where can people find you, and do you have any resources that you might— could share with the audience?

Yes, we have a 52-week marketing document that gives you guys one idea for every week of how to get new patients so how to drive people into the practice. I'd be happy to share with you guys. You can find me on Instagram. It's my name, Dr. Nikki Cottis, D-R-N-I-K-K-I C-O-T-T-I-S. And I also have a scalable systems document too that I'll be happy to share with you. You can just message me on Instagram and I'll send that to y'all. I'll send you that for your show notes.

That'd be great. Yeah, if you could send me the link for the show notes for the first one and then for the second, they can shoot you a message on Instagram.

Awesome.

All right, awesome. Thanks for being here.

Thank you.