Practice Strategy


The four disciplines of execution in physical therapy private practice.

By David Browder, PT, DPT, OCS

One of the most pervasive challenges that private practice owners face is the need to work, not only in their business, but also on their business. With declining payment, shrinking margins, and a challenging regulatory environment, you have increasingly less room for error on the business side of private practice. Setting goals and planning how to achieve them should be a part of your business routine.

The most difficult part of strategizing is not having great ideas, awareness of our environment, or even knowing how to plan. The challenge private practice owners face is executing the plans they make. The 4 Disciplines of Execution Model (4DX) by Chris McChesney, Sean Covey, and Jim Huling outlines a set of disciplines and practices to ensure that we can execute on our goals. Physical therapy private practice owners can utilize this method so their ideas are translated into actions and these actions yield results.

Our practice began using this model to translate our strategic planning into action at all levels of our practice. Ten of our Texas Physical Therapy Specialists facilities participate in a trial of this execution system. The 4DX system has four disciplines, and the initial results of our trial are described below.

1. Focus on the Wildly Important

“Create a ‘stop doing’ list. Work is infinite; time is finite. If you have more than three priorities, you have none.” —Jim Collins2

The first discipline in this model focuses on the wildly important goals (WIGs). A large number of areas compete for our attention. Clinical outcomes, customer service, growth of referrals, improved word-of-mouth exposure, efficiency of expenses, employee engagement, effectiveness of documentation, and compliance. By focusing on one or two essential goals, we can make a significant impact on a vital area, rather than getting lost in the day-to-day of managing a busy practice.

To identify a WIG, ask yourself, “What one thing would make all the difference for next year?” Usually, this goal impacts everything else in your practice.

Our WIG this year was to achieve same store growth in new patients of 10 percent.

All the other business processes—what the authors of 4DX call “the whirlwind”—have to continue to operate. We focused our attention on this single WIG to the exclusion of other competing interests. We still have ongoing systems that measure and ensure clinical excellence, customer service, compliance, and the quality of connections therapists are building with patients. If 80 percent of our time and energy goes toward these maintenance activities, the rest will go toward our WIG.

2. Act on the Lead Measures

“However beautiful the strategy, you should occasionally look at the results.” – Winston Churchill

Lag measures give us information about things that happened in the past—charges billed, visits seen, wages paid, profits earned, or the number of new patients seen at our facilities. Lag measures often tell us about the goal we are trying to reach, even though the actions that impacted them occurred in the past. The measure might be critically important, but we cannot change it now.

In the 4DX model, acting on the “lead measures” informs us about actions or results that we can influence directly and that predict our performance on the lag measure. In the case of our lag measure of “new patients seen,” each of our team leaders might have different lead measures on which they focus. A few examples of lead measures that might predict the “number of new patients” and also directly influenced by our team leaders are:

  • number of referral source contacts
  • number of handwritten thank you notes
  • number of community events attended
  • number of public relations pieces written
  • number of social media posts
  • arrival rate of referred patients
  • number of days until first available evaluation

We cannot directly impact the number of new evaluations seen in our practices. However, by identifying and taking action on lead measures, we can impact our critical lag measure over time.

3. Keep a Compelling Scoreboard

“The team won’t play at their best unless they are emotionally engaged—and that happens when they can tell if they are winning or losing.” —Chris McChesney2

People work harder when they are keeping score. If you do not believe this statement, just hold a competition around anything—fundraising, customer service survey results, or even completion of compliance items. Your teams will undoubtedly bring more effort and engagement to anything they perceive is part of a game or competition. Search “TexPTS Halloween” on the Internet if you want to see the level of engagement that a contest can produce! Having our team create a scoreboard to track both the WIG (lag measure) and the lead measures on which we are acting has been a phenomenal way to mobilize their efforts. A scoreboard allows the team to demonstrate visible progress (or lack of progress) toward the goal.

This is an example of an amazing scoreboard created by one of our teams to track a contest they held over the course of three months. Staff members (including front desk personnel, therapists, and technicians) formed teams that competed to earn points. Each time a potential referral source was contacted in person (five points), via phone (two points), handwritten note (one point), the team advanced along the racetrack. The goal was for every team to complete the race with a special prize for the highest point earner. This not only became a team building exercise (the competition was intense), but this small team generated more than 400 referral source contacts in a single quarter.

4. Create a Cadence of Accountability

“No action, activity, or process is more central to a healthy organization than the meeting. As dreaded as the “m” word is, as maligned as it has become, there is no better way to have a fundamental impact on an organization than by changing the way it does meetings.” —Patrick Lencioni, author of The Advantage: Why Organizational Health Trumps Everything Else in Business.5

Discipline 4 makes sure that the team’s focus stays on the WIG. The recommended way to do this is to have short (15–20 minute) meetings every week focused exclusively on reaching the WIG goal. These structured meetings have a specific and effective format. Each team member reports on the lead measures they are tracking, the actions they completed the previous week, and the actions they will commit to the following week. This weekly accountability meeting ensures that the most difficult part of reaching goals occurs.

Almost any measureable impact upon key lag measures comes from the compounding effect of multiple small actions:

  • To improve annual profits, you do not have to control expenses for one month, you have to control expenses every month.
  • To improve the number of new referrals to your practice, you do not visit a referral source once, you have to visit many referral sources multiple times.
  • To improve customer service, you do not treat one patient like family, you treat all of your patients like family.

A cadence of accountability, whether ensured by a weekly meeting or by some other method, ensures that our teams stay disciplined. It also ensures that the team is still taking the time out of their busy schedules to act on the lead measures even when their motivation wanes.

With 10 geographically separated facilities, having a weekly in-person meeting was not feasible. Instead, we initiated the separate video conference calls (attended by three or four team leaders) to make sure that each call stayed short and focused. If one of the team leaders cannot be on the call, they are expected to update the group prior to the call. The team leaders then hold short meetings—called huddles—in person at their facilities later in the week. Team huddles typically take 10 minutes or less and help keep every member of the team focused on the WIG. Each team leader reviews the progress on the lag measure and the key lead measures on which he or she is acting, and then delegates tasks to the team.

Surprisingly, these short calls and meetings have quickly become a key way for us to communicate. We keep the meetings short, but it is not unusual to discuss another topic immediately after the meeting. While initially skeptical of adding a meeting to the already busy plates of our team leaders, the feedback on these has been almost universally positive.

While in the early stages of implementation, this model is showing promise. Our scoreboard has us tracking directly toward our WIG and growing at a faster pace than the same period last year. Whether we reach our wildly important goal remains to be seen. Regardless, we have seen that utilizing the 4DX model fosters clear leadership communication about priorities and creates a team environment with clear accountability for results.

David Browder, PT, DPT, OCS, is a PPS member, the program director of Evidence In Motion’s Institute for Managerial Leadership and is on the faculty for the Executive Program in Private Practice Management. He is the regional director for Texas Physical Therapy Specialists in Austin, Texas. He can be reached at


1. Bossidy L, Charan R. Execution: The Discipline of Getting Things Done. New York: Crown; 2002.

2. Chesney C, Covey S, Huling J. The 4 Disciplines of Execution. New York: Simon & Schuster; 2012.

3. Collins J. Good to Great. New York: Harper Collins; 2001.

4. Gerber M. The E-Myth Revisited. New York: Harper Collins; 1995.

5. Lencioni P. The Advantage: Why Organizational Health Trumps Everything Else in Business. San Francisco: Jossey-Bass; 2012.

Copyright © 2018, Private Practice Section of the American Physical Therapy Association. All Rights Reserved.

Are you a PPS Member?
Please sign in to access site.
Enter Site!