When a private practice owner recognises that they have a span of control problem, a common strategic step is to fill a practice manager (PM) role, either through hiring or by promoting from within. 

At face value, the logic behind this is sound. 

The owner’s time and attention are stretched thin across too many direct reports and too many decisions – they need someone to help triage and absorb the load. 

The role is created, advertised and filled by a new PM who fits all the criteria in their job description. 

A few months later, however, the owner realises that they are still fielding the same volume of questions and approving the same number of decisions, leaving them to wonder if anything has actually changed. 

While their PM is visibly busy and competently fulfilling all their responsibilities, the span of control is still sitting primarily with the owner. 

This is one of the most common patterns I see in practices and it is worth understanding why this role fails to properly address the owner bottleneck when incorrectly executed. 

A role without a corresponding shift 

The pattern usually looks something like this. 

A team member has a question about a minor stock purchasing decision, a patient report follow-up or a roster change. 

Previously, this question would have been fielded directly by the owner but now it goes to the PM. 

However, the PM isn’t entirely sure whether they are empowered to answer it independently and so they quickly check in with the owner before responding. 

The owner makes the call and the PM relays it back to the team member. 

While it looks like the PM has effectively reduced the owner bottleneck, the decision is still made by the owner. 

The only change is that there is now an added step and an additional person within the same decision-making process. 

Rather than resolving the owner’s span of control, the PM role has unintentionally widened it, with the owner still managing the original team members indirectly and managing the PM directly. 

This is the failure point in a PM role that doesn’t actually solve the bottleneck problem it was created for. 

The role was added without the accompanying transfer of decision authority, so instead of becoming an effective leadership layer within the practice, it sits as just another communication node in the owner’s widening span of control. 

For the PM role to properly manage the owner bottleneck problem, the structure of the role must be intentionally designed to allow the PM to independently handle or triage decisions appropriately. 

The transfer of decision authority 

This pattern is common because designing an effective transfer of decision authority is the hardest and least visible aspect of creating a true leadership layer within a practice, particularly when the owner is under pressure to quickly ease their span of control problem. 

There are a few reasons why this transfer doesn’t happen automatically. 

Owners are often hiring reactively while feeling the pressure of an already overloaded week and so the PM role is defined according to the most urgent tasks (rosters, stock orders, patient correspondence, general admin tasks) rather than decision-making processes. 

The job description is therefore built on tasks, which tell a PM what to do but not what they are able to decide or influence within their role. Another reason is the ingrained habit that the team has formed over the years of bringing the owner every question, concern and problem outside of their own clinical scope. 

As with any habit, unwinding this and establishing a new system takes structured effort – something that is usually overlooked with the addition of a PM. Team members continue to default to the owner and the owner reflexively responds without redirecting them, reinforcing the old habit and undermining the transfer of decision authority. 

Finally, owners themselves often find it difficult to genuinely give up decision-making control, even when they have made the conscious decision to do so. 

This is a natural response when an owner has built their business from the ground up and feels responsible for everything in the practice. 

But if every decision the PM makes is silently checked, revisited or overridden, the team quickly realises where the real decision authority sits and the PM role is reduced to senior administrative tasks and message passing rather than a true leadership position. 

The difference between a coordinator and a leader 

While the two versions of the role can look similar from a task perspective, there is a vast difference between a coordinator and a leader. A coordinator executes tasks and follows instructions and processes. 

When something falls outside of a defined scope, they revert to asking the owner. 

A leader is given a defined scope of decision-making within their role and a clear process for how these decisions are made, either unilaterally, in discussion with the leadership team or signed off by the owner. 

The difference is not in what they do but in which decisions they are given to make within their role. 

While most owners believe they have hired a leader, they have in fact built a highly capable coordinator instead. 

How to effectively transfer authority 

For a PM role to actually reduce owner dependency in the practice, there are three things that need to occur. First, there should be a clearly defined scope of decisions the PM can make within their role. 

These might include leave approvals, day-to-day rostering modifications, purchasing decisions under a certain threshold, first-line handling of patient complaints or routine HR conversations. 

The specifics will differ by practice but the principle holds: if a category of decision hasn’t been explicitly defined as the PM’s, it will naturally default to the owner because that is the path of least resistance for the team. 

Second, the team needs to understand and be reminded of which decisions now belong to the PM rather than the owner. 

This is a step that often gets skipped when designing a transfer of authority because an owner will define the scope internally but fail to clearly articulate that to the wider team. 

For example, if the team doesn’t know that the PM now owns all purchasing decisions under a certain threshold, they will keep bringing purchasing questions to the owner out of habit, while the PM’s decision-making authority is unintentionally eroded. 

Third, the owner needs to intentionally hold the transfer boundary once it’s been set. 

This means continually redirecting any questions that are within the PM’s decision scope back to the PM and, most importantly, visibly supporting their decision, even when the owner might have made a different call. 

This helps to teach the team the new process of decision-making within this scope and allows the PM to exercise real decision ownership and leadership. 

However, this does not mean that oversight is removed entirely. 

Rather, the oversight occurs at a defined review cadence between the owner and PM, which further strengthens the leadership layer in the practice. 

Signs the PM role hasn’t shifted the bottleneck 

A few patterns tend to show up in practices where the PM role hasn’t yet achieved what it was designed to do: 

• the owner is still consulted or copied into decisions that sit squarely within the PM’s decision scope
• team members habitually continue to go to the owner first for decisions or questions, even when the PM is available
• the PM’s week is filled with task execution and coordination, with most decisions repeatedly defaulting to the owner rather than being made independently. 

These examples reflect a structure where the role has been upgraded but the underlying decision architecture hasn’t changed. 

If left unaddressed, this pattern produces a familiar and costly outcome: the capable, high-performing PM role is reduced to a message-passer function, while the owner continues to carry an ever-increasing span of control. 

Is your PM role built to reduce your bottleneck? 

The following questions will help you to quickly determine whether your PM role is actually reducing your span of control or adding to it: 

• Can you list the specific categories of decisions your PM is authorised to make without consulting you first?
• Does your team know which of those decisions belong to your PM rather than to you?

When was the last time you actively redirected a team member back to your PM instead of answering their question yourself? 

If any of these questions were harder to answer than you expected, it might indicate that your PM role hasn’t yet been structurally designed as a genuine leadership layer. 

A PM role alone does not fully resolve the owner bottleneck but it is the first structural test of whether a practice has the capability to transfer decision authority outside of the owner. 

Greg Goh APAM is a physiotherapist, practice owner and organisational systems consultant working with allied health practices across Australia. Greg writes and consults on organisational design in allied health private practice via Thrive Foundation. 

Next up: decisions that should never reach the owner.