As radiology appears on the radar screen of lawmakers and those who set national health policy, greater pressure will descend on radiology practices and departments to maintain service and profitability in an environment of extreme change. To meet those challenges, two key elements emerge as critical to the organization’s ability to adapt, evolve, and prevail: culture and leadership.

For perspective on what it takes to develop a healthy practice and department culture as well as how to identify leaders to bring radiology through the shifting landscape ahead, Axis Imaging News turned to Jim Collins, one of the leading business thinkers in America and author of the best-selling Good to Great: Why Some Companies Make the Leap … and Others Don’t (Harper Collins, 2001).

Although Collins is not a radiology or medical practice expert, his research into what makes businesses succeed has special relevance to radiologists who want to bring their practices to the next level. Collins and his research team undertook a laborious, 5-year process to identify all of the companies that achieved 6.9 times the cumulative stock returns of the general market in the 15 years following their transition from good to great. Sifting through the universe of companies that appeared in the Fortune 500 between 1965 and 1995, Collins’ team identified 11 good-to-great cases and contrasted them with 11 other companies that had not made the grade. From this research, Collins gleaned the common leadership qualities and culture trends that make companies great.

IE: In Good to Great, you give great importance to getting the “right people on the bus” and the “wrong people off the bus.” How do you handle disruptive nonparticipating owners in a medical practice, which is essentially a family-owned business model?

Collins: The research we focused on has been in large, publicly traded companies, but if you rewind the tape of history, a lot of them started as small family businesses. Two basic differences show up between the companies that did better as small family businesses and those that became great, versus the companies that were small family businesses that didn’t do as well over time.

The key difference—they were able to see that the business itself had a purpose that was bigger than simply serving the needs of the family. And that meant they limited operating responsibilities for the business only to family members who could be the best at moving the business forward.

So, if someone is the best person to have an impact on the business, he or she is the one who should be having an impact on the business, whatever that seat [or role] is. And if not, that person shouldn’t have that seat. Whether the person is a family member is really not relevant. Just because you are a family member doesn’t entitle you to impede the progress of the business, but being a family member should not exclude you from contributing to the business if you really are the right person for that role.

IE: What are the responsibilities for those who “vote in” a leader to support the enterprise?

Collins: It depends to some extent on whether it is viewed in a traditional business perspective, where you have a key chief executive, or whether you are in a partnership model, where there is no key chief executive. For those businesses that are evolving toward a model that is essentially a chief executive or a business leader in a more corporate style, the responsibility of those who vote is not to manage the person, it is to pick the right person, work with that person to ensure clear objectives, and then largely stay out of the way and let him or her lead.

IE: In the book, you describe Level 5 leaders, who are clearly exceptional people in that their ambition is “first and foremost for the institution and not themselves.” How does a practice keep from burning out its best leaders and avoid the outcome of rapid rotation of leadership or the ascent of a truly unfit leader to simply fill a job void that no one wants?

Collins: If someone is getting burned out and there is a constant rotation, I would ask: Is he or she the right person for that kind of seat, or is that seat the right kind of thing for the person? Now, what is really clear is that some people are constructed for that kind of role—they like it and are good at it. Just as there are some academics who become fabulous deans because they really flourish in that role, I would imagine that there are medical practitioners who gravitate toward the analogy of being the dean of the practice, and they flourish in the system really well.

It is very hard to sustain doing something that you don’t have great passion for doing, that you are not genetically constructed to do, and that is not necessarily your best contribution. And, of course, if you put someone in that kind of situation, anyone would get burned out.

In Good to Great, we talk about the Hedgehog Concept [which focuses on finding the unifying idea for the organization]: what the organization is best at, what it’s passionate about, and what drives its economic engine. For individuals, there’s also the question of [three key dimensions called] the three circles: What are you passionate about and love to do, what are you genetically encoded to really be good at, and where can you add true value to make a real contribution that society values? Part of the key to an enterprise running well is to ensure that for persons in a seat, their individual three circles fit with the demands of that seat. If they do, they will tend to be less burdened. If their own personal three circles don’t line up with the demands of those seats, then there is a mismatch.

That would lead to asking a very simple question: If the enterprise needs to be managed, if there needs to be someone dedicated to that task, whom do you pick—is it someone from the internal practice, or is it someone who is not necessarily a medical practitioner for whom that is their three circles? That’s what they should be doing; that’s how they will flourish.

IE: Why are temperament, integrity, and longevity important in an organization’s leader? How do you identify that person?

Collins: Leadership is a burden of responsibility, and as a burden, it requires someone who can carry a big, heavy pack in order to do it. If someone doesn’t have that incredible, almost off-the-charts self-renewability and energy level keeping them going, it’s very, very hard to sustain it.

IE: What about culture? What is it, and why do groups need a healthy, disciplined culture other than what passes for culture in some radiology groups: time off and money?

Collins: Well, those aren’t culture. Here is what our research shows on culture, and this applies to small, medium, and large organizations. Number one, the best run organizations over time have very strong and distinctive cultures. Without question, all organizations have a culture, whether they acknowledge it or not. What is special about the best ones is that culture is very distinctive and very, very tight and strong—so much so that those who tend not to fit with the culture find themselves uncomfortable and eventually leave.

Part of the role of culture goes to a deeper idea, which is that any really successful company that thrives over a long period of time has a strong and passionately held set of core values. It is not always the same values, [and] there is no one right set of core values. So the key is to have a set of core values, and then they build a culture and a set of practices, norms, and ways of doing things that reflect those core values. The culture is like the operating system that brings to life the underlying core values.

That leads to one of the key things about culture: The very best companies and organizations remain clear on the difference between values and practices. So time off and academic tenure are not values; they are practices. Whether you wear suits or white shirts is not a value; it’s a practice. What you need to say is that your culture is made up of the set of practices that reflect your core values. Over time, your practices are going to evolve, but your values must remain fixed. So, if you are a small enterprise, and you find yourself growing really fast, what you need to do is to say, “As we are growing, we need to hire people who fit with our values.” That’s really critical, and it means you must know what your core values are so you can do that.

There’s one other piece. Not only do we find strong and distinctive cultures that are rooted in a set of core values, but also, in Good to Great, we discovered that they are cultures of discipline, that discipline is a consistent aspect of the best-performing organizations. Now, a culture of discipline is very key. It means that people in that culture understand that they have responsibilities, not jobs. And they are responsible to the values of the company, to the standards of the company, and to the purpose that it serves. That is very different from saying, “I have a job.”

So, if you are an air-traffic controller, and you say, “Well, I did my job right today, I did all of the things on my checklist,” but the airplanes crashed, it wouldn’t matter [that you’d completed the checklist], because you don’t actually have a job; you have a responsibility. You need to make sure the airplanes don’t crash. In a great culture—and I imagine this must be especially true in medicine—the critical thing is not whether you have a job or a way to make a living. The critical question is, what is your responsibility to the practice, to the values, to the patient, and to the profession? That’s what a culture of discipline is all about.

IE: Many practice presidents report that it is getting harder to hire people willing to take ownership of the practice and serve as a chief of staff or even a section head. Is this a societal ill, the result of what education, psychology, and parenting author Alfie Kohn calls the “carrot-and-stick system,” or is it the failure of the organization?

Collins: When looking at companies that became great in contrast to others in very similar situations that did not, one of the really big differences is the amount of time, energy, and attention that is spent on the question of finding and cultivating the right people for those kinds of seats. I know that sounds tautological and simplistic, but it’s not.

Think about it this way: If you are going to build a house, do you think first about what kind of house you want, or do you think about who should be your architect? If you are going to climb mountains, do you think about which mountain you are going to climb, or about who should be your climbing partner? Do you think first about what kind of career you want, or about who are the kind of people you’d like to work with?

And the reason I bring up this concept is because a number of professions are “what” oriented professions—what’s the diagnosis, what’s the treatment, what’s the legal answer, what’s the academic answer. But, in fact, when you start building an organization, your fundamental default has to be who, not what. My hypothesis would be that perhaps the world of medical practice is a very “what” driven culture, which means that the questions of obsessing on whos, finding whos, developing whos, cultivating whos—especially for these leadership roles that are not viewed as part of the core medical enterprise—get sort of shunted to the side. So, you say, “We have to deal with that now; we have got to find somebody,” as opposed to saying, “Everything else is secondary until we have the right who.”

These kinds of chief-of-staff roles—managerial roles in a difficult, complicated environment with really high standards and tremendous pressure and consequences—are like finding great fighter pilots. They are very hard roles to fill, and not many people are really great at it, which means that you need to spend that much more time on it. It’s not one of those things you can spend a limited amount of time on and expect it to turn out great.

IE: You quote Eisenhower when you discuss how great companies strategize: “Planning is invaluable; plans are useless.” You differentiate the goods from the greats by describing their planning processes as “vigorous debate infused with brutal facts seeking insight from which comes an iterative series of decisions that add up over time.” What are the implications of this for medical practices operating in a completely volatile regulatory and reimbursement environment?

Collins: For the past 5 years, we’ve been studying the question of what separates those who prevail in environments characterized by turbulent disruption. So, I like to think of it this way: You wake up at base camp in the security of your tent below Mount Everest, and a storm comes in. You can hunker down in your tent, and you’re going to be OK. But if you wake up at 27,000 feet as a small, vulnerable little speck high on the side of Everest where the storms are bigger and faster moving, everything is more unpredictable, and the environment is so much more severe, and a storm comes in and you are caught unprepared—you might just die. In this research, we are studying those that have prevailed at what I would describe as 27,000-foot environments—industries like semiconductors and biotechnology and airlines and medical devices, your really brutally disruptive environment—and comparing those to ones that didn’t do as well in the same kind of disruptive environments.

What you have just described to me is that radiology practices are moving higher on that mountain. They are not a 7,000-foot environment; they are maybe a 19,000-foot environment, and they are vulnerable to those big forces out of their control. So, if that is true, as we study this question of why do some prevail amid turbulent disruption and others do not, the Eisenhower quote becomes even more important in two ways. Let’s step outside of even business for a moment. If you look at people who have done well climbing mountains, climbing big rocks in environments that are full of these situations, the ones who prevail best over time plan like utter fanatics. I have a friend who has done Everest multiple times, and he has a binder that is 6 inches thick of all of the contingency plans—A, B, and C, for everything that can go wrong on the mountain. The guy is a complete paranoid neurotic, but that’s part of why he is still alive. At the same time, once you are on the mountain, you must be willing to adapt to what the mountain throws at you that you cannot expect.

Eisenhower planned fanatically for D-Day, but when they landed on Omaha Beach and no one expected the degree of fire they had, they had to adapt. Plans must adapt to reality. I eventually came to see it this way: The real key is preparation, and it’s preparation for what you cannot predict. You can’t predict what the world is going to throw at you. You can’t predict what is going to happen with health care reform, what the next administration is going to be, or what is going to happen with managed care and reimbursement. And because you can’t predict them, you must be prepared for what you can’t predict, which means you have slack in the system, and people who can adapt to whatever is thrown at you.

Cheryl Proval is the former editorial director of Axis Imaging News and a contributing writer. For additional information, contact .