Timothy V. Myers, MD

As we enter this year, having narrowly missed the fiscal cliff, we continue the hair-raising episodes of life in American health care.

The problem with writing down a list of New Year's resolutions is that at some point, someone is going to remind you that last year, you actually took the time to write a list. And so, it is time to review my list and see how well I did.

Last year, the radiology leadership pushed many things. By far the best has been the Image Gently campaign. The most important effort I did last year was to increase the number of calls I made to clinicians. This is a great place to start. A simple conversation goes a long way in changing the way our colleagues think about using imaging. A collegial discussion on the best algorithm to use for imaging specific problems can yield very positive results.

Recommending ultrasound or MRI as the first test where appropriate, decreasing the use of contrast when not needed and eliminating imaging completely when possible benefits patients and decreases costs.

Can we ever learn too much - not just about radiology but about health and health care in general? Reading more tweets, blogs, Facebook pages and articles outside radiology raised my awareness significantly as to what is happening in other parts of the health care system. Radiology, while a foundation, is not the end of the story when it comes to health care. Understanding the trials and tribulations of our colleagues is important. What is happening in health care in general, and not just in the United States, will impact your practice, like it or not.

I must admit, this is one area where I came up short of my goals. I did step up significantly and increased my participation within a national professional organization, the American Society of Emergency Radiology; however, my involvement in nonprofessional, political activities that affect radiology did not receive the same focus. During a presidential election cycle, the number of voices clamoring for something drowns nearly every opportunity to actually be heard.

This year, I want to continue to increase my participation in other professional organizations. More importantly, I also want to seek more opportunities and become involved in the political process. Between now and approximately 12 to 15 months from now, the government actually governs. After that, the next cycle of elections begins and politicians tend to stop hearing though they continue to look like they listen. So, now is the time to get involved if we want to actually make real changes.

I am a member of a number of professional organizations within radiology. This number did not significantly change from previous years. A number of our professional organizations did see a loss of membership due to a variety of issues including the continuing economic problems our country has been facing.

Now is not the time to abandon these organizations. Sometimes, involvement is just paying dues so these organizations can continue to do their good work. I have selected those organizations I want to support. Every radiologist should do the same to their fullest extent.

So, there we have it. There were some areas of improvement, and some where I fell short of my goals. I believe that 2013 is going to offer us the same roller coaster of issues we saw in 2012. As noted, there is the potential for even greater changes as Congress and the president try to govern and make substantial changes before the next election cycle.

Professional organizations are continuing their mission and vision as well as gearing up to impact any changes positively for patients and their members. We - and when I say “we” I mean “you” -need to be heard. To be heard, you need to be involved.

And so I leave you with a quote from Sean Connery, and the movie The Untouchables: "What are you prepared to do?"

Perhaps you also took time to write a list, if not physically, at least mentally. Share some of your thoughts and how you did with last year's resolutions.

Articles

Let’s review my 2012 goals to image gently, learn more, be heard, and get involved in the health care community. There were some improvements, some shortfalls.

A Radiologist’s New Year’s Resolutions, Revisited

“Four score and seven years ago our fathers brought forth on this continent, a new nation, conceived in Liberty, and dedicated to the proposition that all men are created equal.  Now we are engaged in a great civil war, testing whether that nation, or any nation so conceived, and so dedicated, can long endure.” - Abraham Lincoln, Gettysburg Address

As we close in on the 150th anniversary of these words, it occurred to me there is a parallel playing out before us in radiology. Certainly it does not have the force and depth of meaning as the civil war, but the forces at work within and around radiology will shape how we practice for years to come.

The words from Lincoln came to me while reading about the partnership of 

 (ORP). According to press releases, this partnership will form “the nation's first integrated national radiology practice.”

But wait, isn’t ADI already part of at least the beginning of a “collaborative model in which data and best practices are shared, clinical practice information is interchanged, and certain practice expenses are consolidated. [Whose] goal is higher quality and more cost-efficient delivery of medical imaging.” In other words: 

The concept of SR began as a vision of a consortium of large, strategically placed large groups who would, in time, form a national radiology group. The question was, and continues to be, can a group so conceived long endure - at least if run by and for radiologists?

With the formation of ORP, does this signal the end, or at least the beginning of the end of SR? Certainly there have been significant issues and roadblocks as SR has tried to live up to its potential. Not the least of which is the difficulty of herding such a large number of feral cats, a.k.a. radiologists, in any specific direction.

Each group comes with its own list of problems and difficulties as well as a wish of what the vision, mission and future of SR could and should be. On one side these issues include pressure from hospitals and systems to become employees, loss of income and the difficulty of moving from large, but basically mom-and-pop radiology groups to corporate radiology companies. On the other side, there is pressure from the more advanced radiology groups to move more rapidly and seize the momentum created by the formation of SR and benefit from their “first-to-market” position.

This latest move - by one of the largest, most advanced and entrepreneurial groups, ADI - to seek an alternative path to formation of a national radiology company, has three potential outcomes. First, SR could throw in the towel and come to the conclusion that while the idea of a national radiology group is the right move, SR is not the correct vehicle to get there. Second, other aggressive groups could move in their own direction to both position themselves for more aggressive growth and counter ADI’s bold move, also leading to the demise of SR. Or third, SR could find its way out of the doldrums and begin its own move to aggressively lead the remaining aligned groups to realize its potential.

I don’t know which of these will happen. I happen to share the original view of the best way forward: private practice radiology groups aligning to form a strong, organized, entrepreneurial collective that can support its own as well as each individual group’s strategy for growth and expansion. I believe that only this type of association of radiologists will have the long-term best interests of radiology and the radiologists at heart. But, Lincoln’s question remains: Can “any (group of radiologists) so conceived, and so dedicated, long endure?”
 

The formation and alternative approach of national radiology group Advanced Diagnostic Imaging has three potential outcomes for Strategic Radiology.

Strategic Radiology: The Beginning of the End?

October is Breast Cancer Awareness month. I don't think anyone living anywhere near the mainstream of society has missed that fact. Pink ribbons can now be found on just about everything. Clever slogans regarding breast cancer can also be found in abundance, including:


• Big or Small, Save Them All!
• Real Men Wear Pink

Another women-related issue also shares the month of October. "There is another issue?" you ask. Yes, but it is not typically spoken of in society, the way breast cancer is. In fact, the subject is avoided as much as possible. The very fact most people have no idea what I'm talking about is a clear indication this is true.

National Coalition Against Domestic Violence

, October is also National Domestic Violence Awareness Month.

But, isn't breast cancer much more important? It must be since we are so aware of it; Or does it just have better marketing?

Domestic/Intimate Partner Violence in Perspective



Let's see if you know the answer to a few questions:

1. According to statistics, 39,510 women will die from breast cancer this year. What is the number of women estimated to die from domestic/intimate partner violence this year?

A. 1,000 B. 5,000 C. 10,000 D. More than 15,000.

D. It is estimated that 16,800 murders will occur as a result of domestic/intimate partner violence. In a report from New York, 44 percent of murdered women were killed by their partners.

2. Which of these carries a higher probability to occur during a woman's life?

A. Breast cancer. B. Domestic/intimate partner violence.

B. According to statistics, women have a probability of one in eight for developing breast cancer during her lifetime. In the United States, the probability of a woman suffering from domestic/intimate partner violence is one in four.

3. Which is higher, the number of women living with breast cancer or the number of women living in a violent environment?

B. Approximately 2.6 million women were alive with a history of breast cancer in January 2008. An estimated 5.3 million victimizations occur each year. These result in 2 million injuries, of which 550,000 will require medical treatment. And, as noted above, nearly 17,000 murders.

Domestic/intimate partner violence should be considered a serious health concern among women. More than 95 percent of cases involve women. Certainly, it can be proven it is as serious in the lives of women, day-to-day, as breast cancer. The issue is that we are not "aware" of it.

This is just the good news. The bad news is that while the United States numbers are not good, we are not the worst; not by a long shot. The World Health Organization and others estimate that in some locations, up to 70 percent of the women have suffered domestic/intimate partner violence at some point during their lives, and up to 70 percent of female murder victims were killed by an intimate partner. To put it in perspective, if this were true in the United States, of the estimated 157 million women, 110 million women would have suffered from domestic/intimate partner violence. Nearly every woman you know would have been abused at some point during her life. And don't even get me started on the fact that an estimated 2.8 million children live in households touched by violent crime.

Billions of dollars are spent each year diagnosing, evaluating and treating women afflicted with breast cancer. With domestic/intimate partner violence, not only are there no large national programs at multiple medical centers to study and help these victims, there are no real, high profile programs to even begin an open discussion similar to that seen with breast cancer.

I am not saying we should in any way lose sight of breast cancer as a significant health issue for women; However, there are other real, and potentially more severe and ever present women's health issues. I believe we should be aware of all the issues women face.

Three Things Radiologists Can Do to Raise Awareness:



1. We can become aware of the fact that we see evidence of domestic/intimate partner violence nearly every day, in every practice, and we don't even recognize when it has occurred. In pediatrics for example, with every case we review, we look for the subtle and overt signs of abuse. We need to do the same thing with every women's imaging case we see.

2. When we see signs of potential abuse, we need to raise the question with the patient’s clinician or emergency room physician. Again, in pediatrics, when we have even the slightest suspicion of abuse, we immediately sound the alarm. This needs to be done with domestic/intimate partner violence as well.

3. Finally, we can work more closely with the emergency room team when they suspect abuse. In pediatric cases, we frequently get a heads up about that potential. With women's imaging I have rarely in my 21 years as a radiologist been alerted to the possibility we were imaging a patient with suspected domestic/intimate partner violence.

A great case in point can be found this week on the 

Case of the Week file from Virtual Radiology

, where domestic/intimate partner violence was initially suspected by the radiologist reading the case.

I encourage victims, their loved ones and anyone concerned about this issue to learn more by calling the National Domestic Violence Hotline at 1-800-799-SAFE, or visiting 

If you do nothing else during October to be aware of the issue of domestic/intimate partner violence, visit the Remember My Name Online Memorial to see some of the names of those who have had their lives taken from them as a result of these senseless acts of violence.

National Coalition Against Domestic Violence domestic violence facts

Costs of Intimate Partner Violence Against Women in the United States

October isn’t just for breast cancer awareness. It’s also National Domestic Violence Awareness Month. Here’s what you as a radiologist can do.

October Awareness Month - The Other Killer of Women

Health care has become an environment where some organizations judge success by the financial well-being of those with an “MD” behind their names. Although doctors are responsible for the end product of the practice - patient care - sustained, long term success is inseparable from the success of the team driving the patient, referring physician and radiologist experience.

The support team begins with the front desk and clerical staff who answer calls and greet patients and referring physicians as they enter the department or imaging center. The team includes the technologists who perform the examination and prepare the case for interpretation by the radiologist. The team is completed by the billing staff responsible for properly preparing the patient’s bill and answering question from the patient and third party payers. Hovering over this team are the “middle managers.” These professionals are outside the upper leadership circles and act as the bridge between the radiologists, the CEO or business manager and the team that supports them.

Forward-thinking practices that want to make great gains in patient satisfaction, client retention, overall productivity and profitability will work to cultivate a team approach, involve team members in planning and take time to listen to what their team has to say. Creating a new culture around team participation, honesty and respect will result in greater gains for the organization and ultimately drive practice growth.

From a middle manager’s point of view, there are four things that every great medical organization needs to do to create a successful team environment:

. A poor leadership team brushes things off, deflects questions when the answers are negative and doesn't respond to staff concerns. Although answers may be hard to come by, providing your entire team with an answer, no matter how painful, is always better than silence. Team members don't hate bad news as much as they hate no news. Silence from the leadership will breed more dissatisfaction and stress among the staff than the realization of even their worst fears. Even if they don't want to hear it, in today's economy it has become expected that tough decisions must be made.

Between the health care reform bill, slashed reimbursement rates and hospitals attempting to take over independent practices, radiology has a large target on its back. A successful practice will acknowledge these facts to everyone - not just partners and board members. If your staff is aware of the difficulties the practice faces, and hears directly from the group leadership what is being done to prepare for these challenges, the team can go to work with greater confidence, even if they are going into a tougher day-to-day job.

If a middle manager comes up with a great idea, validated by those doing the work, it would be prudent for the leadership to give it some consideration. If the idea has merit, a timely course of action should follow.

Keeping the middle manager in the loop throughout the decision-making process will create transparency. If the answer ends up being a no-go, be sure to give feedback on what didn’t work. When your team knows explicitly what didn’t work, a good manager will motivate the team to come up with alternatives or changes to the original suggestion.

A specialty as medically and technologically sophisticated as radiology needs to allow room for growth and experimentation. Many managers who find themselves locked in comfort zones will shy away from trying new workflows, adhering to the familiar adage "this is the way we've always done it." It is important to recognize that not every idea is successful. Your team works just as hard trying new things and being open to radical changes that don’t pay off as when they hit a home run. Ensuring your team will remain open to changes and trying new things depends on how the senior leadership rolls with the positive and occasionally negative outcomes of the changes that are implemented.

 When your practice is considering changes, ask your team what you are doing well and what could be done better. Hearing nothing or only that you're "not doing anything wrong" is not the same as doing everything well. If your team believes something can be improved, discuss those items and have the team work out the needed modifications.

Take suggestions from your patients. You would be amazed how many of them work in similar process-driven environments and can point out areas where their experience would have been improved. This can also be done via online surveys sent to a patient’s email following their visit. This information can furnish your practice critical data for advertising, such as “over 90 percent of our patients are satisfied with our practice.”

Finally, take time to listen to your referring clinicians. Remember, these are your target clients. Their experience in obtaining information or improving their patient’s care will impact what they think about your service. Have a support team in place to investigate and consider any suggestions they make. Your next great workflow idea could be standing next to you asking if you could take a quick look at this case.

4. Create a reward culture to keep your best team members happy.

 Providing incentives and the potential for upward mobility within the company are paramount to keeping your best team members happy. Taking care of your “all-star” team members sets a precedent that hard work and innovation are appreciated and rewarded. This not only keeps your staff working hard, but incentivizes every team member to reach that goal.

When your team finds and implements workflows and changes, these can be tied to performance goals for departments, individuals or even those across different sections. Whether it's done as bonuses, team target goals or outside the box rewards like additional time off and flex hours, giving team members and managers a goal to strive for will keep the gears moving and promote an entrepreneurial atmosphere.

Make no mistake - each of these items is very difficult. They may require extensive commitment, planning and a possible cultural shift from the top down of your entire organization. Practices that do these things well will be positioned not only to have happy, committed team members for the tough road ahead, but the potential for even greater gains in the new business atmosphere of modern radiology.

Frederic Smith is the client operations manager for St. Paul Radiology in St. Paul, Minn., one of the largest private practice radiology groups in North America and serving the greater Twin Cities metropolitan area for more than 90 years.

From the front desk to technologists to billing staff, a strong support team in a culture of honesty and respect will ultimately drive practice growth.

4 Ways to Build a Successful Radiology Support Team

The conclusion that the leadership of a radiology group is the direct cause for a failing practice is typically not well received. In radiology it is easier to place the responsibility for the failure on the clinicians, the administration, the changing markets, changes in health care, governmental changes or changes in reimbursement. Placing the blame on these external factors forms the root cause of the primary failure.

In a landmark article, Theodore Levitt first discussed the concept of "

." This idea has now been extrapolated and applied to many other companies and industries. Radiology, being in the business of medical care, also needs to evaluate its view of the future and potential for growth or decline within this framework.

Marketing myopia is the idea that with time, a business's growth stalls or fails due to a failure of the leadership to understand the true and/or changing nature of its actual product or service. This is not a failure 

 leadership. What this means is that even groups with good leaders are not immune to the process of developing a fatal, myopic view of what the group’s purpose and services are.

The leadership fails to take the broad view of the niche that radiology fills, opting instead for a narrow, constricted view of product rather than service. Many believe our product is the report. Not true! In radiology, we are in the service business, not the product business. Our service, working in conjunction with our clinician colleagues, is to deliver accurate and appropriate patient care to injured or ill patients. In this paradigm we are a part of a team and not in a vacuum. We deliver our service - performance of procedures or interpretation of images - to the patient and our clinician colleagues functioning as a part of this team.

How we provide our service to the patient and our patient care team determines whether we are a necessary member of that team - or simply available. In a myopic radiology culture, the leadership ceases to 

evaluate or look for cues in the environment

 that will lead to improved satisfaction by the patient care team. The outcome is that the group stops addressing the care team’s concerns and requirements. Instead, the group is lead towards a more introspective or insular view of radiology as a product and concentrates more on increased speed, production and efficiency.

This lack of vision leads to a failure by the local group to maintain its place as 

necessary to the team. The result is that radiology becomes a commodity which can potentially be delivered by any radiologist, anywhere. By failing to focus on service and the patient care team, radiology services become a product that can be obtained by other radiologists and radiology groups. Once this commoditization is complete in the minds of those that depend on radiology as a partner, the group is expendable and a change to another provider of radiology services is not uncommon.

A "self deceiving cycle," as discussed by Theodore Levitt, is one in which a group locks itself into a course of action that appears to be the right choice, but is actually the catalyst behind the group’s failure. All further actions revolve around this flawed choice.

So, how does a group avoid this trap? There are three basic questions to ask when moving from a product focus to a service focus:

1. Is the course of action or goal designed to improve patient care 

 will it result in the clinician being better prepared to treat the patient?

2. Is the course of action or goal designed to answer a client (patient or clinician) concern or question 

 will it result in improved patient care?

3. Is the course of action or goal designed to improve the group’s visibility as a provider of world class radiology services 

 will it be seen by your clients (patients or clinicians) as an improvement that will have a positive impact on patient care?

All of the group’s actions and goals should result in improved patient care and demonstrate that the service the group provides cannot be obtained as efficiently or effectively from any other source.

Creating a successful vision of what the group does and who it serves is the key. Generating a firm foundation requires keeping an eye on the environment and the needs of the group's clients. Effective group leaders continually look for ways to keep their group in front of the changes that are on the horizon. By 

, effective leaders can steer their groups through the good times and the tough times with equal confidence.

Radiologists are in the service business. A narrow view of your practice’s role focuses only on production and efficiency rather than improved patient care.

Radiology Myopia: How Good is Your Group’s Vision?

The industry is facing a call to arms for radiologists to prepare themselves for the changes that are coming. We must adapt to the changes already present and prepare for those still to come. In this series, we are discussing how to transform a radiology group to create and drive a new culture of activism.

In our first article, we explored some of the 

 and the importance of a strong culture binding a radiology group. In the second segment, we discussed how a 

 is the most valuable change-agent to ensure success now, and the future. In this installment, we begin discussing the specifics of our transformative model, AICI.

In evaluating how organizations successfully react and adapt to their environment, we have proposed a model using cultural dynamics as a change-agent for both tactical and strategic organizational policy initiatives. Our model is defined by four elements - AICI:

• Awareness
• Involvement
• Commitment
• Incentives

. Within the AICI model, awareness has two main components. First, the leadership of the radiology group needs to evaluate the total environment in which the group practices. Second, the culture of AICI requires collaboration and consensus, not command and control. To create a setting of collaboration and consensus, the group leadership needs to engage all the stakeholders in an understanding of that environment.

Environment and the concept of becoming aware of an organization's environment are the basic business building blocks for success. Environment is more than just the organization's setting. An organization has two business environments, internal and external. We’ll discuss the internal environment in future articles.

The external or business environment includes all those factors which are typically beyond its direct control. Business environments are constantly changing, modifying and adapting to new problems and opportunities as they arise. These changes will have a significant impact on organizations operating within the environment; and organizations, reacting to these changes, will in turn, have an impact on the overall environment. To be successful, an awareness of these interacting dynamics is of absolute necessity.

, Theodore Levitt first discussed the concept of "

," the idea that with time, a business's growth stalls or fails due to a failure by the leadership to maintain a broad view of the niche their companies fill, opting instead for a narrow, constricted view of product rather than service. A 

, developed over time by the leadership, ceases to evaluate cues in the environment that lead to improved client satisfaction by addressing their concerns and requirements, favoring instead a more introspective or insular view of growth through increased production and efficiency within the organization.

A myopic culture within radiology focuses on increasing technology and efficiency. Clinician, administration and patient needs and issues take a back seat.

To avoid this trap, radiology leaders must take the broad view of the service radiology provides and the role of imaging in patient care. To do this, we must accurately evaluate and understand the business environment in which radiology and radiology groups function. From the point of view of a radiology group, the business environment includes:

• Hospital administration, both local and system wide.
• Health plans and local, regional and national third party payers.
• Referring clinicians in both cooperating and competing medical groups.
• Patients.
• Local and regional cooperating and competing radiology groups.
• Local, regional and national medical-political issues.
• Local, state and national governmental and legal issues.

To begin an assessment of the group’s environment, it is easiest to begin with the microenvironment, that which is encountered every day. Radiology is a service industry and that service is judged solely on how well it fits into the care of the patient from the standpoint of the clinician.

The clinicians you encounter every day are an excellent place to start your evaluation. While there are a number of ways to gauge how your service stacks up, direct interaction with your clinician colleagues is the best, most direct and inexpensive way to begin. It also has the secondary benefit of beginning a dialogue with your most important clients, the clinicians who use and value you most.

From a business sense, a radiologist not only has medical colleagues but also business colleagues. In a hospital, those business colleagues are the supervisors, directors, hospital administrators and executives of the hospital and/or hospital system. Too many times we look at these people not as colleagues working towards a common goal, but as adversaries and obstructions to the way we want to practice medicine. Unfortunately, thinking of them this way tends to make them exactly what we anticipate. Opening a dialogue with these business colleagues is as important as opening a dialogue with your medical colleagues. Working with your administrative resources, as team members, will significantly improve the outcomes of any projects you jointly enter.

Next, your group needs to understand the competition. Look at those medical groups in competition for turf. We believe that radiological turf includes any radiological CPT code. If you are unfamiliar with CPT codes, now is a great time to become familiar with them.

We also believe radiology and radiologists should never give up diagnostic or interventional radiology segments to any competing nonradiological group. Saying that is the easy part. However, enforcing it is much more difficult. Holding onto what you have during a turf-battle will require significant interaction and trust with both your business and clinical colleagues. A myopic fortress mentality, all too often seen in radiology, only leads to we/they and win/lose types of scenarios. Alienating your colleagues and supporters only promotes ceding the battleground to your opponents.

A final and crucial area of the microenvironment you need to evaluate is the group itself. This includes all members of the group regardless of station or status. Becoming aware of what the radiologists within the group think and what they need is important as a concept of mission for the group takes shape. For example, are there areas where additional training is needed or where new radiologists will be required to complete the stated mission or obtain agreed upon goals?

Similarly, the opinions, feelings and outlook of the employees of the group should be considered. These are the individuals who will be integral to changing the culture, obtaining goals or executing any strategy. Direct interaction from the leadership with everyone in the organization is imperative. Employee surveys with open-ended questions are an important tool and promote further direct interaction and communication.

Next, evaluate local, regional and state radiology groups that may be in competition with your own local contract(s) and/or may soon be in competition with more statewide or regional contracts. Look at them as if your group were going to consider merging. This was discussed in our 

• Evaluate the concept of mission within each group,
• Evaluate the adaptability or level of aversion to risk/entrepreneurial activity,
• Evaluate the involvement of physicians and team members in the organization as well as within the environment in which they practice,
• Evaluate the consistency within the organization, which includes the ability to follow through on a course of action.

Evaluating each of these areas will help determine whether these groups have the ability, resources and entrepreneurial spirit required to carry through with plans for expansion and to potentially become adversary. Alternatively, it will help to determine which groups may become good partners as your group begins plans for the future.

As with your clinical and business colleagues, getting to know the radiologists in other local and regional groups is important. This can be done at or through state radiological society meetings. Dinners, presentation of research or other conferences are also great ways of beginning relationships that can defuse potential problems before they occur. Working with other local and regional groups towards a common goal may prove beneficial from the standpoint of joint operations or full mergers.

Finally, from the perspective of the regional, state and national macroenvironments, it’s important to get involved in industry organizations important including the Radiology Business Management Association, state radiological societies, the Radiological Society of North America and the American College of Radiology. These organizations are frequently looking for volunteers, and opportunities to get involved are easy to find. Becoming involved pays huge dividends and provides access to academic, business and governmental leaders on a regional and national level that would otherwise not be readily available.

The second step of awareness requires the leadership of the group to bring all of the information found back to every level of the organization. As we have previously noted, all stakeholders - not just the leaders and managers - need to be "read in" to the issues and opportunities the group is facing. This cannot be done in one setting and should be planned with several different presentations concentrating on specific areas over several different meetings.

The money used to bring everyone together will be well spent if everyone in the organization works as a team. Input from team members is only relevant if each team member understands not only the big picture but also the nuances of potential problems or opportunities. Working on a solution to a problem that does not exist or developing an opportunity or goal that is not reachable or not in the mission plan only wastes time and resources and is frequently the result of an inadequate information base.

Once team members are apprised of the micro- and macroenvironmental realities, the next step is developing reachable goals for capitalizing on opportunities and devising workable solutions to existing and upcoming problems. The team can create creative, entrepreneurial and out-of-the-box plans and goals . They can then generate logical, stepwise and focused operational plans using collaboration and consensus. Creating matrices are an excellent management tool that can be used to help the team better envision opportunities/issues, assess requirements and develop appropriate specific tactical and strategic strategies.

Throughout this process, the role of the leadership is as steward and guide, stepping in directly only when absolutely necessary. Hands-on direction or micromanagement frequently stifles the process and leads to unimaginative and potentially myopic outcomes.

Leadership, like governing, is by the consent of those being lead. Being the "boss," in whatever form that may take, does not make you a leader. A well run, aggressive, focused and thriving organization needs leaders. "Leaders lead," is a well-worn catch phrase, however many leaders forget the critical importance of their followers. Simply put, a leader is someone others want to follow. Every discussion and every meeting where information is relayed from team leaders to the team is an opportunity to demonstrate the importance of each individual to the organization. And, it is at these meetings leaders demonstrate their leadership not by sermonizing or lecturing, but by involving the entire team in the process.

Awareness is the critical first step in the AICI process. Understanding the environment in which the group practices is a key essential before planning, staging or executing any operational plan. Awareness of the microenvironment in which the group practices and the macroenvironment in which the specialty of radiology is only a part, needs to be considered when creating an objective.

Bringing all of this information together gives the group leadership an opportunity to demonstrate its leadership to the organization by discussing issues, challenges and opportunities with the group and beginning the process of empowering every individual. The leadership needs to consider managing from the street level, not the rooftop i.e. management from the bottom up, not the top down. Finally, generating collaboration and consensus will create the greatest opportunity for the success of the group in any undertaking.

Understanding the radiology group practice environment is essential before planning or executing any operational plan. Here’s how to build that awareness.

Building Awareness of the Changing Radiology Landscape

The industry is facing a call to arms for radiologists to prepare themselves for the changes that are coming. What we have seen so far 

, and we are now entering a different phase in the process of change. We must adapt to the changes already present and prepare for those still to come.

In this series of columns, we will be describing specifics on how to transform a radiology group to create and drive a new culture of activism. 

we explored some of the issues facing radiologists

 and the importance of a strong culture binding a radiology group. 

Here we will describe how a new, energetic culture is the most valuable change-agent to ensure success now, and the future.

Culture trumps strategy - each and every time. 

In short, culture is the heart and mind of the organization. Regardless of the time, effort and energy put into developing a new strategy, without readying the culture to accept and embrace the new strategy, there will be no buy-in. So, how do we, in essence, change the culture to maximize desired performance behavior?

We have developed a transformational model for evaluating and integrating cultural dynamics in order to use culture as a change-agent for both tactical and strategic policy initiatives. Our model breaks the critical components of cultural changes into four elements - AICI:

Awareness is defined as a comprehensive understanding of the needs and requirements of the organization. All members of the organization - all stakeholders, not just the leaders and managers - need to be "read in" to the issues. If revenues need to expand to remain viable as a business unit, this fact needs to be communicated to all members of the group, not just a select few. If costs have to be reduced, the same process applies. The culture of AICI requires collaboration and consensus, not command and control.

Involvement is defined as engagement in the issues, challenges, problems and/or opportunities that face or will face the new organization. This means involves empowering each member of the organization. If someone sees something happen that requires action, they take it upon themselves to generate that action, either individually or collectively, with the help of others to fix the problem, or recommend a solution.

Brad Hewitt, President and CEO of Thrivent Financial

 stated, “Both individual and community (in this case company) responsibility is required in a civil society. This is not an ‘either/or’ proposition.” In essence, everything is up to everyone at every level. There is no they; we are all collectively responsible for the outcomes either positive or negative.

Commitment indicates and requires each individual member of the new organization be on board and proactive with respect to their responsibilities and requirements within the organization. All successful organizations develop a must-win attitude amongst its individual members. It is a prerequisite for success not only for the merger and the cultural changes; it is an absolute requirement for the success of the new organization.

The order of the day is lead no matter what your level or position. Do not follow when leadership is required. Initiate rather than respond. Be part of the solution, rather than part of the problem. This kind of commitment requires a proactive culture that emphasizes and reinforces performance over politics, and results over good intentions.

Incentives are a just reward when goals are reached. Whether we are seeking major change on a large scale, or alternatives at the margin, there need to be incentives - both tangible and intangible - at the end of the long, hard road. Without incentives, good actions and good intentions will falter and, in the end, fail. All members of the group must be made to understand not only their roles and obligations within the new organization but also that they will reap their just benefits from the changes they are helping to enact.

And they need to know what those benefits are. Specific roadmaps with attainable goals need to be established. Everyone needs to know where they are on the roadmap and when, without favoritism, incentives for reaching those goals can be expected. Properly aligned goals and incentives ensure each member can participate not only in the hard work of creating and running a successful business, but they will also share in the returns derived from their efforts.

Whether we like it or not, change has been thrust upon us. The question is not whether to respond, but how to respond. As we react and develop our response, two things should be kept in mind: First, as Hemingway said, “Never confuse movement with action.”

Second, when an astronaut was asked what he would you do if he had only 10 seconds of oxygen left, the astronaut replied, “I'd think for nine seconds and then act.” It is not the rapidity of our response that will determine our future, but the stability. When we have a lot of at risk, the surest way forward is most frequently found by slowing down, understanding the issues and problems and then laying the proper groundwork for success. If yours is the group that keeps its head amongst the turmoil surrounding health care, your group will likely survive and thrive in the new paradigm.

In the accompanying articles that will follow, we will explore the process for this groundwork and the keys to success.

Radiology Mergers and Acquisitions: Remain Independent or Join Together?

The Radiologists’ Primer: Partnerships, Mergers & Acquisitions


Diagnostic Radiology and Oncology Services: 

Historical Review of Mergers and Acquisitions in Diagnostic Imaging

 [PDF]
Adkins, B. and Caldwell, D. (2004). "Firms or subgroup culture: Where does fitting in matter most?" Journal of Organizational Behavior, 25(8) pp. 969-978
Hofstede, Geert (1980) Culture's Consequences: International Differences in Work Related Values, Beverly Hills, CA, Sage Publications, reprinted 1984
Hofstede, Geert; Hofstede, Gert Jan (2005). 

Cultures and organizations: software of the mind

(Revised and expanded 2nd ed.). New York: McGraw-Hill. ISBN 978-0-07-143959-6. OCLC 57069196.

Does your radiology group have a strong culture? Here’s why a new, energetic culture is the most valuable change-agent to ensure success now, and the future.

How to Transform Radiology Group Culture to Embrace Change

For the past few years, nearly every writer and every organization in radiology have been issuing a call to arms for radiologists to prepare themselves for the changes that are coming. In a recent article, 

ACA and Radiology: The End of the Beginning

, we described what we have seen so far as the beginning. 

This is not to say we have seen the end of the changes. We believe we are now entering a different phase in the process of change. This case includes adapting to the changes already present and preparing for additional changes that are sure to come.

The real questions for groups who intend to be around for the end-game should be: What changes should we consider? How do we begin the process of making those changes, and how can we ensure those changes will help us be successful now and in the future? 

In this series of columns, we will be describing specifics on how to transform a radiology group to create and drive a new culture of activism. This new culture will lead each member of the group to increased awareness of the issues facing the group, improved involvement in creating solutions, enhanced commitment to drive those solutions to a successful completion, and an understanding of how to create positive incentives to ensure each member of the group remains focused for the long term.

Part 1 - Introduction to a transformational model integrating cultural dynamics and changing health care forces to create the radiology groups of tomorrow

Over the past several years, due to the general economic turmoil, there has been more upheaval in business than most of us have ever witnessed. Health care has been particularly hard hit with changes and uncertainty. A significant transformation in the way health care is provided is already underway with the passage of the Affordable Care Act (ACA), and its recent validation by the Supreme Court.

There are now, and will continue to be, greater pressures to decrease reimbursement, decrease overall costs and generate ”appropriate” (read reduced) utilization. All of this is happening at a time of drastically increased utilization of resources by an aging population and a potential tidal wave of new participants in health care brought in through the ACA.

New models for the delivery of health care, including the accountable care organization (ACO) and its variations, are being tried in order to decrease utilization and costs while improving the quality of patient care. Mergers and acquisitions among health care providers have increased to improve efficiencies and decrease costs. Consider, for example, the information released by 

Irving Levin Associates on hospital mergers and acquisitions

Radiology has not escaped these pressures. 

, 21.5 percent of the radiologists responding stated they were considering an acquisition by or partnering with a teleradiology or third party company. Nearly 8 percent said they were in negotiations.

In general, the survey demonstrated radiologists were moderately concerned (2.82/5) about mergers or buyouts with a hospital or other private practices. Mergers or buyouts with a teleradiology company were of only slightly less concern overall.

Issues of expanding coverage and greater pressures on "turf" protection, coupled with changes in reimbursement, force small to midsize radiology groups to consider merging with other local or regional groups. Larger groups, seeking more volume to decrease excess capacity, expand their reach by acquiring hospital contracts with or without the radiologists. From the open microphone sessions at the 

American College of Radiology's May 2011, AMCLC meeting,

 slightly over 16 percent of radiologists present stated they had been a part of a practice that had lost its hospital contract.

All of these pressures to merge or die provide exactly the wrong atmosphere for a successful relationship. Under the best of circumstances, when all parties are interested and positive about the anticipated partnership, the process of joining two groups of radiologists can be difficult. And when the incentives to merge are driven primarily by fear, when that fear has passed, the partnership frequently fails due to those misaligned incentives, among other things.

When these partnerships are contemplated, the consequences for both groups must be anticipated before the final deal is consummated. If they are not, negative outcomes will be the order of the day. Assuming the reasons for merger are sound, a key component of successful partnership is the culture of the newly formed and soon to be integrated organization. Consider the words of 

: “To make a deal work, it really is about integrating cultures. Although you have to get the best and brightest of both systems, you also have to let your culture evolve as well.”

What is culture and why is it important? 

Culture, whether in society or an organization, is the sum of the values, vision, beliefs, habits and accepted norms of behavior of the individuals within the group. Culture will determine whether a group is visionary and entrepreneurial, or fortress-like, or collegial and open. Whether featured in a mission statement or unspoken, this culture will govern the way the group interacts with its own members and its environment.

With a radiology group as an example, the environment is not only the hospital. The environment includes the clinicians and clinician groups with which it interacts, the hospital administration and other local or regional radiology groups.

What drives a culture depends on the issues the group is facing. These can be short or long term issues. Right now, the culture of most radiology groups is driven by "uncertainty avoidance," which is derived from a lack of tolerance to risk and relative intolerance to entrepreneurial activities and/or change. In the current atmosphere of significant change, the majority of groups are just trying to hold on to what they have had in the past. They attempt to create a vision of the future based on an idealized version of the past.

When creating a new organization, the change process can be daunting. Assessing each culture requires hard work and honesty on the part of all members. Four specific areas need to be evaluated:

• The concept of mission within each group,
• Adaptability or level of aversion to risk/entrepreneurial activity,
• Involvement of physicians and team members in the organization as well as within the environment in which they practice,
• Consistency within the organization, which includes the ability to follow through on a course of action.

Based on these reviews, the ability for each group to adapt to a new paradigm following the merger can be determined with some reasonable certainty.

Changing the culture, while exceedingly complex and prone to failure for any of a number of reasons, is basically a two-part process. First, there must be a recognition and evaluation of differences between the cultures and acceptance of the existence of the differences. Second, there needs to be a reconciling of the differences between the cultures with no focus on or attempt to justify any component of either old culture. The focus should be on the new culture and what will work best for the future success of the combined organization.

Developing the new culture will require a new integrated mission and vision. The new mission and vision needs to be understood by everyone in the group, with the recognition that the new culture will be stronger and more advantageous for the groups collectively and for the individuals. Next, there will be a need to establish and affirm the new culture within the organization. This requires clearly describing and explaining the differences from the old culture and the change to the new, and where necessary, plainly and honestly giving the reasons for the changes. A new mission or vision statement for the combined organizations should be written and distributed to the members.

In the second part of this series, we will describe how a new, energetic culture is the most valuable change-agent to ensure success now, and the future.

In this first part of a series on the changes facing radiology, we describe how to transform a radiology group to create and drive a new culture of activism.