 Denise Palumbo, RN, MSN |
Today’s complex health care environment calls for a sophisticated level of leadership. Radiology, in particular, continues to grow and change at a rapid pace; it is imperative for its leadership to evolve at the same speed. Many hospital radiology departments continue to employ a historic leadership model that faces many challenges. This model operates with a predominantly flat management structure handling day-to-day workflow. Given the rapid growth of radiology, departments need to implement a professional leadership model that can cope with these changes, provide distinct role definitions, and allow strategic planning. Radiology is a capital-intensive specialty, so its leaders must know how to maximize operational efficiency to cover costs, as well as how to generate revenue that can be invested in additional capacity.
Radiology departments that have not scaled their leadership to their growth need to redesign their leadership models for success. The leadership structures of many hospital radiology departments have not changed over the past two decades. These structures have not kept pace with the explosion of imaging innovation and the dramatic change in the role of radiology in patient care. Departments using the historic leadership model are unable to position themselves for the future because they are occupied with solving problems in day-to-day operations.
In the early 1990s, the Department of Radiology at Massachusetts General Hospital, Boston, undertook the evaluation of its leadership team and management model, beginning massive reorganization and restructuring. This process involved redesigning positions and required all department leaders to reapply for their positions under new job requirements. Leadership expectations were set to coordinate with an extensive leadership-development program that focused on enhancing skills in the areas of finance, process improvement, project management, and leadership.
During transition to the professional leadership model, people who had been in leadership positions for many years stepped down to technologist positions when they did not meet the requirements for the new positions or were not hired back into their positions. The staff technologists questioned the leadership changes because they believed that the historic structure was very effective. That perspective changed as the redesigned structure began to take hold. The transition took approximately 6 months and resulted in the development of a leadership team with expanded skills and a fresh perspective on how to manage a radiology department. A professional leadership model provides staff with the necessary skills and experience to move the radiology agenda forward, managing radiology effectively, efficiently, and strategically.
PROFESSIONAL LEADERSHIP MODEL
 Anar Pathak |
This leadership structure dramatically changes to support clinicians and clinical-support operations. Roles, responsibilities, and educational requirements are clearly defined. This model is driven by a high level of expertise in financial, operational, and project management analysis, as well as improved communication and strategic thinking. The acquisition of these skills is facilitated by ongoing leadership development and the establishment of formal educational guidelines. In addition to charging leaders with clearly defined responsibilities, the new model delineates responsibility in both clinical and clinical-support areas. For example, the role of operations manager can apply to an imaging modality as well as to transcription or scheduling. The role expectations, and the operational and financial responsibilities, are identical.
Of course, radiology departments differ widely, both internally and according to the nature of their parent institutions. If they are to become or remain competitive, however, radiology departments of all types and sizes must have effective leadership. A leadership model must be scaled to a department’s size, use available resources, and be consistent with current staff capabilities.
LEADERSHIP DEVELOPMENT
There is a dearth of leadership development in hospitals, and particularly in radiology departments. At conferences and other external venues, it is difficult to find leadership development curricula that focus on the specific skills and competencies that a given individual might require. Leadership development can be arranged only after clear performance expectations have been set and specific skills that warrant development have been identified. For example, the chief technologist would receive financial management training if his or her role included a budget-development expectation. Training might also be provided in tracking volume and analyzing financial performance on a regular basis. Completing performance evaluations and giving feedback are other parts of leadership that could be made more effective through training.
 Table 1. Role expectations for radiology administrators and clinical support services: Historic and New Professional Leadership Models. (Click the image for a larger version.) |
Strategic planning is an activity that starts with the hospital’s senior leadership. It is conducted in conjunction with the chief and director of the department and then trickles down to the core staff and support levels. Since cohesive, coordinated strategic planning is not a common practice, disparate plans may be developed within a department. Often, these plans cannot be supported financially and operationally because they lack solid, underlying business plans to justify expending the resources required. The lack of a unified long-term vision results in a plan of incremental ideas that fails to move the department in a positive direction and creates confusion, with no measurable result.
Communication, education, planning, and implementation are the keys to successful leadership. The responsibility to educate the senior leadership lies with the chief and director. Both must be committed to serving as the voice of radiology, educating leaders on clinical advances, and identifying opportunities to enhance efficiency and financial standing. This commitment includes the development and implementation of a 3-year to 5-year strategic plan that addresses personnel, space, assets, and information technology such as the radiology information system (RIS), picture archiving and communications system (PACS), and voice recognition. All of these aspects of strategic planning require business planning as a foundation if they are to secure both operating and capital funding. Leaders must also communicate the results of planning and report their successes and failures.
The radiology department’s director reports to both the chief and a hospital vice president. This individual holds a master’s degree in business and/or a health-related discipline and is responsible for both daily operations and strategic planning. This position requires a strong financial-analysis background, along with tactical and strategic skills. Working in partnership with the chief, this person drives change through business development, asset management, and the development and implementation of imaging innovations. In addition, the director and chief set expectations for individual performance and for achieving volume, financial, and production targets.
The operations manager reports to the director. This individual holds a bachelor’s degree and is responsible for modality-based operational and clinical management. While immersed in operations, he or she is not expected to provide direct care. This individual has both the natural talent and educational background to function in a complex department. Responsibilities include management of the clinical and support staff, which encompasses hiring, orienting, and completing annual performance appraisals. This level of leadership has financial responsibility that includes preparing the annual operating and capital budgets for the modality. In addition, operations managers prepare monthly reports on volume, revenue, and expense variances. This person is responsible for change management, identifying problems using root-cause analysis, and developing and implementing viable, sustainable solutions. The ongoing leadership development for this position focuses on high-level systems thinking and the ability to develop business plans by understanding financial and economic principles.
 Figure 1. Organizational chart describes reporting duties for radiology personnel in the New Professional Leadership Model. (Click the image for a larger version.) |
Under the professional leadership model, the department should develop radiologist clinical directors for each modality to achieve a high level of clinical expertise and consistency. Their responsibilities are developing and enhancing protocols, developing and growing service lines, and communicating clinical changes in imaging to specialists. In addition, they should play an active role in equipment selection and ongoing upgrades, in understanding reimbursement changes, and in educating referring physicians on emerging technologies and their impact on specific modalities. The radiologist clinical director should also hold regular, scheduled meetings with the operations manager and technologists to discuss clinical operations and develop new imaging protocols. It is equally important for the radiologist group to develop a service culture, ensuring that there is a radiologist present in the reading room at all times for consultation with technologists and referring physicians.
The new leadership model includes dedicated radiology nurses who play a critical role in the delivery of radiology services. As radiology moves into performing more complex procedures and caring for patients directly, dedicated nurses for radiology will be required. Nurses are responsible for patient assessment before, during, and after procedures. Nurses also administer medications (including conscious sedation) to both pediatric and adult patients. The care provided by these nurses is integral not only to performing the procedure but to providing follow-up care.
CLINICAL SUPPORT SERVICES
Clinical support services such as scheduling, image management (film library), transcription, engineering, quality management, finance, and information technology infrastructures form the support link between the modalities and other hospital departments. The strategic development of these areas has a significant impact on customer service.
 Figure 2. Organizational chart shows radiology personnel reporting duties in the Historic Leadership Model. (Click the image for a larger version.) |
Scheduling is critical to the workflow of any radiology department, particularly in a PACS environment. The professional leadership model includes an operations manager who develops standards and sets expectations for tasks such as answering the telephone and scheduling same-day examinations. The operations manager has deep knowledge of the RIS and imparts that knowledge to the staff. The operations manager measures key performance indicators such as call-response times and call-abandonment rates. The new model incorporates a formal staff training program lasting 3 to 6 months for scheduling, in addition to an orientation period with a preceptor.
The traditional film library quickly becomes an image service center with the implementation of PACS. During the transition, the film librarian becomes an image service representative.
The interpretive report is radiology’s product, and timely availability of this critical information is paramount. As a result, proper training and frequent performance assessments are necessary for transcriptionists. The need for transcription may be eliminated with the implementation of voice recognition; whether a department chooses this route should depend on turnaround times.
Technology is changing so rapidly that it is difficult for in-house engineering staff to remain proficient in dealing with both software and hardware, in addition to completing the hours of training required to stay up to date with changing imaging technologies. Service functions are often outsourced for this reason, but there must also be leadership involvement in contractual oversight and manufacturer accountability.
A financial strategist or team should be dedicated to analyzing and reporting on the financial performance of the department. This key role also encompasses budget preparation and analysis, business planning, billing/revenue enhancement, and expense reporting. This individual or team must possess strong financial and operational skills. In addition, the finance team is involved with professional-billing revenue and with physicians’ compensation and benefits. Regardless of the size and needs of a department, accurate, comprehensive financial reporting and analysis enable it to plan, both internally and in collaboration with the hospital’s administration.
Radiology departments should consider creating an interdisciplinary quality management and education (QME) team that can aid decision-making through training, education, and process improvement supported by information technology. QME establishes relationships with each modality area, sets measurable goals, and tracks its performance quantitatively and qualitatively. QME facilitates continuous improvement initiatives for the entire department and supports senior leadership decisions with appropriate data. This team also focuses on helping staff members cope with the challenging demands of health care, new technologies, and patient requirements. QME provides professional development opportunities for staff members. Upon the introduction of a new technology, QME ensures that it is appropriately implemented and leveraged through the integration of clinical and technical operations.
Protocols to measure operations allow decisions to become outcome driven. QME helps to create predictability and efficiency through initiatives that drive system-wide thinking. Specific initiatives include failure-point analysis, workflow analysis, and measurement of operations volume.
Although the transition to a digital environment eliminates the intricacies of a conventional film-based system, it adds new responsibilities for those who manage or use the system. Therefore, it is imperative to employ an information technology support team to oversee the PACS. In addition to maintaining PACS functionality, the team manages related technologies such as speech recognition. This team, in partnership with QME, will organize a training program customized to meet the department’s needs. Formal training that incorporates assessment of defined competencies ensures the effective, timely training of technologists, nurses, and support staff.
MARKETING
Given the evolving marketplace and increasing competition, radiology departments must maintain relationships with patients, referring physicians and their staffs, and payors. As radiology practices expand, communication is vital to serving these customers, and a dedicated marketing council can facilitate optimal communication. The marketing council is responsible for coordinating marketing efforts, for presenting a recognizable image for the radiology department, and for promoting the department’s services. As the field of radiology changes, the available services also change. The marketing team plays a vital role in patient care by continuously educating referring physicians and patients about new applications.
CONCLUSION
The implementation of a new professional leadership model includes an intense focus on leadership development. Compared to other industries, health care spends little on employee development. It is critical to the success of any department or organization (especially one that has been reorganized) that existing skills be strengthened and that new skills be developed. This will ensure that the necessary expertise exists to manage the organization effectively. The department must develop educational sessions that focus on leadership skills and should encourage creative learning through online courses, teleconferences, and book clubs. These media can be excellent teaching tools and can be cost-effective, efficient resources for educating off-shift staff.
Another important step in leadership development is the clear definition of formal education requirements for specific positions. The days of on-the-job training are over for management positions. Leaders must have formal education as a foundation for critical thinking, problem-solving, understanding human behavior, and systems thinking. The complexity of health care requires staff to have a well-rounded perspective on the environment in which they work, as well as on the influences around them. At a minimum, a bachelor’s degree is required for a line management position; formal educational requirements increase with greater levels of responsibility.
Once the correct leadership model has been established and has had time to take effect, departments will develop a greater understanding of their daily operations and performance. With properly trained staff focusing on financial analyses, quality-management projects, ongoing educational programs, information technologies, and marketing initiatives, radiology departments will be well positioned to operate effectively.
Denise Palumbo, RN, MSN, is administrative director, Department of Radiology, Massachusetts General Hospital, Boston.
Anar Pathak is senior project specialist, RCG HealthCare Consulting, Boston.
