Before You Hire a COO, Read This

Here's a conversation that happens more than you'd think. A physician-owner is frustrated. Billing is a mess, staff keeps turning over, every decision still somehow lands on their desk. They don't have a clear picture of what's wrong. They just know something is.

So they start thinking: I need to hire a COO.

Or — just as common — they think: I can't afford a COO. I'll just hire a few good people and piece it together.

Both instincts are understandable. Both usually miss the mark.

More people is not the same as the right expertise.

The "build-a-COO" approach has real appeal. Spread the cost, cover the bases, avoid the big salary commitment. In theory it sounds reasonable. In practice, what you end up with is several people who are each partially responsible for things none of them fully understand — and no single person with the operational experience to see how it all connects.

Revenue cycle is its own discipline. So is healthcare finance. So are operations, compliance, and IT infrastructure. Hiring a capable office manager, a billing coordinator, and a part-time bookkeeper doesn't add up to someone who can diagnose why the practice is underperforming and build a system to fix it. It just adds payroll.

And a COO, for all the cost that comes with that hire, is still one person. Asked to be fluent in all of those domains simultaneously, inside an organization they don't know yet — that's a significant ask. It usually shows.

What we actually see.

The practices that struggle most are often ones where the physician-owner has been running everything by instinct — and it worked, until it didn't.

Volume isn't always the trigger. Sometimes the practice is small and stuck. Staff is thin, turnover is high, and the owner is making every call not because they want to, but because there's no structure that makes the answer obvious without them. So they hire more people hoping the problem dilutes. It doesn't.

That's not a staffing gap. That's not a leadership gap either. That's an infrastructure gap — and neither headcount nor a single executive hire fixes it on their own.

What has to exist before any of that works.

A practice that's ready for operational leadership — whether that's a COO or a capable team — can answer a few basic questions cleanly: Where is revenue leaking and why? Which workflows are documented, and which ones exist only in someone's head? What decisions genuinely require the physician-owner, and which ones land there because nothing else is set up to catch them?

If those questions don't have clear answers, it doesn't matter who you hire. They'll spend their first several months — sometimes years — finding out. That's a long, costly runway before anything actually improves.

Why Practice Now first.

Our engagements are fixed-term. We come in with the right expertise for what your practice actually needs — revenue cycle, operations, finance, IT, whatever the real pressure points are. Not generalists. Not a patchwork. People who have done this work inside real practices and know what functional looks like.

We examine what's happening, diagnose where the dysfunction is concentrated, and build the infrastructure that makes the practice run without the owner at the center of everything. Documented workflows. Clean financials. Defined roles with real decision authority.

When we're done, we're done. The systems stay, the practice runs, and whatever your next hire looks like — a COO, a strong operations lead, a built-out team — they're walking into something they can actually work with.

We're not the alternative to getting the right people in place. We're what makes those people effective when they get there.

If you're already having this conversation.

Whether you're eyeing a COO hire or thinking about piecing together a team — have a different conversation first. Not because those aren't valid paths. For a lot of practices, they're exactly right. But without the foundation, neither one works the way you need it to.

Let's look at what you actually have, and what it would take to make the next step land.