1. Alexander, Susan DNP, ANP-BC, ADM-BC

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If I had asked people what they wanted, they would have said faster horses.


-Henry Ford


More and more nurses are beginning businesses for many reasons: wound care, family therapy, in-home respite services, and acute/chronic patient management. Owning a business can be a fulfilling and flexible way to build a career, or it can be a professional nightmare. According to the US Department of Labor Statistics, half of all small businesses will fail within 5 years, and only a third survive 10 years or more.1 For nurses who want to start their own businesses, taking the time to plan a strategy of business design, implementation, and ownership can contribute to long-term success.


Use your head. The first key investment is the time needed to create a solid business plan, which should begin as much as a year before the doors of a new company are ready to open. Think carefully about realistic short-, mid-, and long-term goals. The bottom line for any business is revenue generation, and this entails more complexity in the world of healthcare. For example, how many patients will need to be seen daily to create the cash flow needed to sustain daily operations, while building capital for other projects? Lending agencies will likely want to review this business plan as they work with potential borrowers to design the best financial strategies for new companies.


In the beginning, an attorney, preferably with a specialty in business law, will be needed to assist with creating the articles of incorporation for the company and obtaining tax identification numbers and to offer expertise on the intricacies of state and local business permits and licensing. To prepare the physical site of the business, the negotiation of building leases or purchases, repair and/or renovations contracts that may be necessary, and follow-up inspections to ensure that local building codes are met is needed. For many health-related businesses, having a location near the local hospital maximizes visibility for those patients who may be unattached to providers and in need of care. An attractive building, with easy-to-access entrances, bright lighting, and lots of parking, may be especially appealing to patient populations such as older adults or families with small children.


Manage the bottom line. The cycle of revenue generation is vitally important to a business; in healthcare, this begins with providers' ability to produce cash flow. To bill third-party reimbursers, healthcare providers must be credentialed with each insurer. The process of credentialing can be lengthy, taking 3 to 6 months or more with some reimbursers. Once the physical and mailing addresses of the business are established, the process of credentialing can begin. Retaining a billing agency that can comprehensively manage the credentialing process simultaneously for multiple insurers is a strategy that has been suggested by practice owners as a method to both initiate and maintain cash flow from day 1 of operations (C. Landrum, personal communication, October 8, 2015). Creating financial policies for the business, with review by legal counsel, is also needed before the business opens so that key steps in the revenue cycle can be established before clients are seen. These policies also need to be supported by the practice management systems. Building payment fee schedules into billing systems can eliminate errors as patient volume grows.


In the 21st century, efficient management of a healthcare practice necessitates the use of electronic health records (EHRs) for management of patient visits, scheduling, and billing. Many (EHR) systems contain all 3 of these functionalities. It is important that you take the time to investigate these systems and how you will integrate them into your daily work flow. Consider goals for productivity, ease of system use, adherence to clinical guidelines, and how the system will handle the data produced by the software application. Common choices are installation of a client-based server, which houses data within the clinic, versus use of software as a service, in which users access the EHR application via the Internet while data are stored off-site at a remote vendor location. Software as a service options are increasingly chosen because of the lower costs and inherent scalability of the products. Regional Extension Centers (RECs), created and sponsored by the US Department of Health and Human Services Office of the National Coordinator for Health Information Technology, offer support to healthcare providers in the selection and implementation of EHR systems through their RECs.2 RECs can help to prepare providers for Meaningful Use programs that directly impact reimbursement. Selection and installation of the practice's EHR system should take place a minimum of 3 months in advance so that scheduling of the practice's opening days can occur, work flow processes can be established, and training of employees can take place as they are hired before the office opens.


Find the team. After spending several months in preparing and securing funding for your business plan; identifying, securing, and preparing securing the physical location; and getting the physical office prepared, it is time to consider the hiring of the employees for the business. Consider the specialization of the practice and the type of medical training needed by the first employee. Generally speaking, staff with more extensive medical or nursing training, or licensures, warrant higher salaries. What is most needed for a new healthcare business is an employee with flexibility and the potential to be cross-trained to work in multiple tasks as the business grows. An important consideration is to ensure consistent payment of the employee(s), despite the variances in cash flow.


Get the telephones ringing. Sitting in an empty office on your opening day, waiting for the telephone to ring, is not a comfortable situation for a new business owner. Including a line item for marketing expenses in the business plan may help to prevent this, along with strategies such as marketing the opening of your new business 60 to 90 days prior to its opening day. In addition to traditional print-based media such as newspapers, telephone books, and magazines, many low- and no-cost marketing opportunities exist for new business owners. For example, many cities have Chambers of Commerce that can assist small business owners in establishing relationships, improving visibility, and gaining access to needed resources. Promotion of "grand opening" activities is an example of how a local chamber of commerce might help a small business in improving its local visibility. Investigate ideas for low-cost marketing strategies, and maximize the use of social media to promote your business. Sites such as have simple, sound ideas that can be helpful for the new business owner who is marketing on a budget. Use every free social media site that you can find-in this day and time, many clients find new business via social media such as Facebook and Twitter. Mailchimp is an e-mail marketing software application that offers great way for business owners to manage mailing lists, store newsletters, and other mailings, while submitting these across multiple social media platforms. Analytics functionality, allowing the owner to track client responses, is also included in the application. As an additional marketing strategy, many business owners are using professionally designed Web sites for marketing. Although slightly more costly in the short-term, Web sites offer ongoing accessibility to a wider target market, while allowing the business owner a mechanism to showcase their work in a manner that is always accessible to potential clients.


Identify opportunities for growth. Operating a healthcare business is unarguably different from businesses in other fields. Regulatory guidelines permeate the environment of healthcare, payment for services most often comes from a source other than the patient who receives those services, and it is difficult, if not impossible, for healthcare providers to negotiate payment for services rendered. Despite these obstacles, opportunities for success remain for the business owner who is aware of trends and opportunities in the healthcare arena.


The Vaccines for Children (VFC) program was created by the Omnibus Budget Reconciliation Act of 1993 and first implemented in 1994.3 The VFC program has proved to be an effective tool for improving the health of children in the United States, maintaining immunization rates for preventable childhood diseases at or above 90% and preventing 21 million hospitalizations and 732 000 deaths.4 Choosing to participate in this valuable program can improve the health of patients and practices that care for pediatric patients. The VFC program provides free vaccines to participating practices that are used for eligible patients. Providers are allowed to charge an administration fee per immunization injection or oral dose, which helps to offset the healthcare practice's costs for accepting Medicaid and uninsured patients. Adhering to the recommended schedule for childhood immunizations has additional benefits for patients and providers, by building rapport between parents and the practice, providing a chance for healthcare providers to offer anticipatory guidance, and improving management of chronic conditions, which can result in preventing unnecessary emergency department visits and hospitalizations. The VFC program has been key to building a pediatric practice and offering quality care for children in a rural, underserved state: "The VFC program is essential for pediatric patient care in Alabama. My practice is 75% Medicaid and our goal is 100% vaccination for all of our VFC eligible children. This program allows us to vaccinate even our most underprivileged children" (C. Landrum, personal communication, October 8, 2015).


Despite the continued reactive versus proactive focus of the present healthcare system upon disease management, efforts to increase population wellness are key in reducing costs and improving overall health outcomes; this is particularly true for vulnerable populations such as pediatric patients who may visit healthcare providers multiple times throughout childhood. Pediatric wellness visits offer opportunities for children to have evaluation of height, weight, and blood pressure; testing of hearing and vision; and to receive physical examinations and scheduled immunizations. Parents have excellent chances to interact with healthcare providers, asking questions regarding growth and development questions, along with other areas of concern. A wellness visit to a healthcare provider's office should not become an opportunity for exposure to disease, necessitating a subsequent sick visit. Whereas many healthcare providers have attempted to prevent the transmission of disease in their office patients by segregating patient waiting rooms into "sick" and "well" spaces, 1 healthcare provider and practice owner, Chase Thomas, CRNP, has taken this concept a step further by constructing a separate building designated exclusively for pediatric wellness examinations. He plans to have the wellness portion of his practice staffed separately so that there will be no mingling of staff caring for sick and well patients throughout the day. Both office staff and the triage nurse in the wellness building will receive specialized training that will allow them to identify signs and symptoms of disease in patients, who would then be escorted to a separate "sick" building for treatment. Although the training process for staff and patients represents significant challenges, Thomas estimates that his investment will result in revenue increases of 30% or more as a result of to increased wait times in both the wellness and sick management buildings. Mingling sick patients with those who visit an office for a physical examination is less than ideal, states Thomas, "[horizontal ellipsis]you're not promoting health that way[horizontal ellipsis]you're coming to the office for one thing and picking up something else."5


Follow your heart. Healthcare is an expanding market. Growing numbers of older adults, changes caused by healthcare reform, and the incorporation of technology present challenges and opportunities for nurses who are willing to consider how their skills and knowledge can be used in the new environment of healthcare. The willingness to embrace change, to understand and address issues related to revenue, and to be flexible in responding to the daily needs of any healthcare business is necessary for both business owners and employees. With their excellent communication and patient care skills, nurses are in a unique position to start successful healthcare businesses that will address a variety of patient care needs.




1. Frequently asked questions about small business [press release]. September 2012. Accessed November 15, 2015. [Context Link]


2. Regional Extension Centers (RECs): advising providers in all phases of electronic health record implementation [press release]. US Department of Health and Human Services. 2015. [Context Link]


3. Omnibus Budget Reconciliation Act of 1993. Government Printing Office 1993:326-324. [Context Link]


4. Whitney CG, Zhou F, Singleton J, Schuchat A. Benefits from immunization during the Vaccines for Children program era-United States, 1994-2013. Morbid Mortal Weekly Rep. 2014; 63(16): 352-355. [Context Link]


5. McCreless P. Anniston pediatric clinics to open wellness building. Anniston Star. 2015. [Context Link]