Lonely at the Top? You Don't Have to Be

Engage key team members for more effective strategic planning

Originally published in Impact Magazine, the Magazine of the Private Practice Section of the APTA, October 2026.

Practice owners often carry more than responsibility. They carry context.

They remember why a referral relationship changed, why a previous hire failed, why a payer decision still matters, why one clinician needs a different kind of support, and why a certain growth idea sounds good but doesn’t fit the practice. Much of this judgment is earned through years of risk, repetition, and recovery. That experience is valuable, but it’s also a heavy burden.

Owners are seldom short on ideas. What they are short on is sharing strategic context. The owner can see the path, but the team sees only the assignments. The owner understands why the priorities matter, but the people asked to execute them may not have been part of the thinking that produced them.

Sometimes owners try to tighten control: If I want it done right, I have to plan it myself. But control is not the same as alignment. Telling your team the plan is not the same as letting them help build it. There is a critical difference between informing and including, and most of us have spent years perfecting the former while avoiding the latter. That is one reason ownership can feel lonely at the top.

The solution is not to turn strategy into a committee exercise. The owner still owns the vision, the risk, the financial reality, and the final decisions. But if the team is expected to carry meaningful priorities, key people should be included before—not after—the strategic plan is finalized.

Including your team in formulating the plan means inviting them into the diagnosis, not just the prescription. It means letting them see and contribute to the sometimes brutal facts¹ before they’ve been sanitized. It means trusting that the people who answer the phones, treat the patients, and manage the schedule might see something about your business that you’ve missed. That is the purpose of establishing a quarterly strategy day, which we’ll explore further later in this article.

Start Before the SWOTT

Many strategic planning conversations begin with a SWOTT: strengths, weaknesses, opportunities, threats, and trends. That can be useful, but only if the team knows what the SWOTT is testing against.

Without context, a SWOTT can become a complaint list, a brainstorming session, or a collection of disconnected observations. Context is critical. We don’t say a fish’s weakness is its inability to ride a bicycle or climb a tree. These are not relevant in its context.

In the planning process I use, we begin with five pieces of strategic context before completing the SWOTT:

1. Vision of Meaning. This includes the practice’s higher purpose, core values, and long-range destination.² Why does this practice exist beyond profit? How do we do things around here? Where are we headed over the next eight to ten years?
2. Value Discipline. There are three options: Operational Excellence, Product Leadership, and Customer Intimacy.³ Pick one. Strategic clarity requires choice.
3. Target Customer. Who is our ideal patient? It’s not everyone with pain and insurance. It’s the patient for whom you create distinctive value.
4. Three-Year Goals. Where do we want to be in three years on our way to the BHAG? (BHAG stands for “Big Hairy Audacious Goal,” a term coined in the notable business book Built to Last.²) This gives direction without pretending the future can be predicted in detail.
5. One-Year Goals. What must be true by the end of this year for the three-year picture to remain credible?

Once those pieces are clear, the SWOTT has a job. It is no longer a generic business exercise; it becomes a reality check against the chosen direction. It changes and evolves as we make progress.

Use SWOTT as a Reality Check

The most important question in a SWOTT is not “What do we notice?” but “What does this mean for where we said we are going?”

• A strength matters if it can help advance the strategy.
• A weakness matters if it will limit the strategy.
• An opportunity matters if it fits the target customer and value discipline.
• A threat matters if it could slow or derail the one-year goals.
• A trend matters if it changes what patients, referral sources, staff, payers, or competitors will expect next.

This keeps the conversation grounded. For example, a practice may identify strong clinical outcomes as a strength. That is helpful, but the next question is strategic: Are we using that strength to attract the right patients, support the right referral relationships, develop the team, or justify our value?

Another practice may identify poor plan-of-care completion as a weakness. Again, the issue is not only operational. If the practice’s value discipline is customer intimacy,¹ and it is a business built around trusted relationships and caring for people, poor completion is not a metrics problem. It is a strategy problem. The SWOTT process should reveal the few issues that matter most right now.

Turn the SWOTT Into QSPs

After the SWOTT, the work is to select the quarterly strategic priorities, or QSPs. A QSP is not a task list but a strategic project for the next 90 days. It should be aligned to the one-year goals, clear enough to explain in plain language, and specific and measurable so that the team can see what successful completion looks like. A good plan has one to three QSPs; more than that often means the owner has created a wish list instead of a plan.

Each QSP has a What, Who, and When.

• What does success look like?
• Who will champion it and ensure it crosses the finish line?
• And when will this be completed?

The champion—the “Who”—is critical. The champion doesn’t need to do all the work; in fact, they shouldn’t. Rather, the champion coordinates the work, clarifies next steps, removes friction, and ensures that the priority crosses the finish line. This is how the plan leaves the owner’s head and enters the practice’s operating rhythm.

Bring the Right People Into the Room: The Quarterly Strategy Day

You don’t need the whole company to attend the quarterly strategy day. In many practices, that would be impractical and unproductive. A smaller group is fine. For example, at one PT practice I work with frequently, the owner brings three key people to the quarterly strategy day, and I facilitate the process. We start with the strategic frame: Vision of Meaning, Value Discipline, Target Customer, three-year goals, and one-year goals. They complete the SWOTT through that lens. From there, they choose the QSPs for the next quarter and identify champions.

The value is not only in the final list of priorities, but in the shared thinking that produces them and the shared execution that follows. The team hears the owner’s reasoning. The owner hears operational truths from people closer to the work. Assumptions are tested before the plan is rolled out. Potential obstacles surface earlier. People begin to understand not only what the priorities are, but why they matter.

The Owner Still Leads

Including key team members in strategy doesn’t reduce your authority. It strengthens your ability to lead.

As the owner, you still set direction, decide what risks are acceptable, hold financial responsibility, and make the final call when tradeoffs are required. But when your key people help formulate the priorities, they are more likely to champion them. They can explain them to others and can recognize when daily decisions conflict with the plan. They can carry pieces of the work without waiting for the owner to remember, remind, and rescue.

Feeling “lonely at the top” isn’t solved by handing the team a finished plan. It’s solved by building a planning rhythm where you as the owner set the frame, your team helps test reality, and the quarter starts with shared priorities, clear champions, and visible follow-through.

Strategy shouldn’t live only in your head, but in the operating rhythm of the practice.

References

1. Collins JC. Good to Great: Why Some Companies Make the Leap…and Others Don’t. Harper Business; 2001.
2. Collins JC, Porras JI. Built to Last: Successful Habits of Visionary Companies. Harper Business; 1994.
3. Treacy M, Wiersema F. Customer intimacy and other value disciplines. Harv Bus Rev. 1993;71(1):84-93.
4. Kaplan RS, Norton DP. The balanced scorecard: measures that drive performance. Harv Bus Rev. 1992;70(1)71-79.

Originally published in Impact Magazine, the Magazine of the Private Practice Section of the APTA, October 2026.