The culture of a radiology practice can be seen as both a barrier to and mechanism for making a practice more businesslike. Several authors have discussed the subtle yet pervasive nature of the role that culture plays in an organization.[1-3] Not recognizing the underlying values and belief systems of the radiology practice ignores basic human drives. Since a radiology practice is a professional organization, the role of culture is even more crucial to ensuring the viability of the group.
ROLE OF CULTURE IN GROUP PRACTICE
The culture of a group can be defined as the organization’s mind.3 Culture encompasses the shared beliefs and tangible and intangible habits and traditions of the members of the organization. It is manifested by what you do when no one is watching. The culture of the practice can be detected through everything: the clothes the radiologists wear to work; the style of leadership; the way the partners handle conflict or change; the attitude toward income and practice perks; how the technologist greets patients; how a radiologist reports a test result to a referring physician; the way in which rumors are handled; and how the leadership manages damage control.
By addressing the culture of a radiology group practice, each radiologist is compelled to think about and articulate his/her personal values, the underlying problems with the practice, interpersonal tensions, and resistance to change. Radiologists were not taught these soft topics in their residencies. Even addressing the subject of culture could become a source of tension and create uncomfortable feelings among the members in some practices, generating questions such as: Why are we talking about this? What does this have to do with practicing quality radiology? Some radiologists may say that these are the kinds of things we do not talk about. Although culture is a soft concept, research has demonstrated that organizations with a pronounced culture that supports their goals perform significantly better than even their closest competitors.3
If culture is subtle and an attitude, how does it get communicated from one generation to another? This process begins before the first interview of a potential candidate. The tone and subtext of the first phone call to the candidate will most likely indicate the nature of the practice. One way to understand exactly the culture of a radiology group practice is to listen to the senior members tell stories about the past. These stories (whether apocryphal or not) will give clear insight into the norms, values, and attitudes of the practice.
THE CULTURE AUDIT
To facilitate this discussion, we have created a tool called the culture audit, which we have used with radiology and other physician practices. The culture audit can be thought of as similar to a financial audit of a practice (although a lot less painful). The audit reveals two critical aspects of a practice:
- The degree to which the practice is well-positioned to respond to competitive challenges in its market
- The degree to which the physicians agree on the practice’s basic tenets and approach to the market.
Before any attempts at strategic planning are made, each member of the practice should complete a Culture Audit Assessment prior to the first planning session. The results would be tabulated and presented to the group at that first meeting, to help frame the discussion.
The audit consists of ten pairs of dichotomous criteria. Radiologists are asked to identify two aspects for each set of criteria:
- Where they perceive the practice is now (Now criteria)
- Where they would like the practice to be in the future (Preferred criteria).
The criteria are:
- group-oriented vs individual-oriented
- aggressive vs reactive
- collegial vs competitive
- short-term focus vs long-term focus
- democracy vs dictatorship
- action-oriented vs deliberate
- a physician practice vs a business
- customer focused vs internally focused
- entrepreneurial vs professional
- creative vs conservative.
From our experience, these criteria capture the broad range of interpersonal and organization dynamics pertinent to a radiology group practice.
THE CULTURE AUDIT IN ACTION
It is important to note that all strategic planning efforts and decisions must be framed within the context of the Now and Preferred criteria gleaned from the culture audit. For example, if the management of a practice develops an aggressive marketing strategy and ignores a practice culture that values professionalism over entrepreneurial spirit, there might be severe resistance to actually implementing the strategy.
The culture of a radiology practice has a direct impact on how decisions are made within the practice and how the culture of the practice can change. One president of a radiology group used an entrepreneurial and free-wheeling approach to make business decisions about the practice. A new imaging center was hastily organized and built; a teleradiology consultation service was created; state-of-the-art imaging equipment was purchased; new radiologists were hired. The other members of the practice trusted the president to manage and grow the practice. Several years later, partially due to the laissez-faire culture, the practice ran into financial trouble. The president was ousted. At that time the culture shifted from entrepreneurial to passive, from freewheeling to deliberate and slow (even at times delaying decisions). There actually came a time when no one knew if a decision was actually made.
There is an innate resistance to change, whether it is a personal decision or a corporate decision (for instance, IBM’s decision to move away from making mainframe computers). Whether it is the technicians at IBM who had to unlearn a lifetime of work habits or the radiologists who have to adapt to a new practice environment, the resistance is felt. Sticking to old strategies means following the old culture. Radiologists have been bombarded with external changes: declining reimbursement, self-referral, and capitation, just to name a few. No wonder there is resistance to change internally.
Perhaps the most obvious example of how culture affects a radiology practice is to look at what happens when two practices merge. Five years ago, two radiology groups in the Southeast came together. One practice was conservative, laissez-faire, using an traditional fraternal model of governance. The other practice focused on steady growth, had a flair for business, and worked very hard, valuing compensation over a relaxed lifestyle. When the two practices merged, the culture clash was so evident that it manifested itself in the following ways:
- Even after 5 years, members of each of the former practices sit together in meetings.
- During the course of a day, members from each group refer to each other as the X-Ray Associates guys or the Rad guys (inferring an us vs them posture).
- Both of the practices’ business managers remained.
- There is an attitude that anytime a suggestion is made by someone from one group, the other group tries to derail it.
- One of the most contentious issues brought up in executive management sessions concerned the type and style of logo for the new practice.
Almost every practice struggles with the issue of whether the practice is a group of radiologists committed to a common goal or an amalgamation of individuals practicing under a loose billing confederation. Some radiologists believe that the purpose of a group is to allow them the autonomy to practice as they wish. Others believe that the group as a whole is the entity to deal with and that individual radiologists must behave within the context of what is best for the group.
Figure 1 represents a snapshot of the culture of a group practice of 25 radiologists on the East Coast. The culture audit was conducted prior to a strategic planning retreat in 1999. The audit results were presented to the group at the start of the strategic planning session. There was a lot of interest and the radiologists were eager to hear the results.
The culture of this group practice can be summarized as a traditional, reactive, conservative, loose federation of radiologists who are not willing to take many risks. However, they aspire to be more group-oriented, aggressive, action-oriented, and creative.
There was only one set of criteria that did not have any consensus. When asked whether the practice was a physician practice or a business, there was no agreement. The answers ranged across the spectrum. This lack of consensus could pose a threat to the development of business-oriented strategies. Unfortunately, the members of the strategic planning group chose not to address this problem, by tabling any strategies that were primarily business-oriented.
The most significant challenge for this group in implementing its strategic plan, based on its culture, was to discuss and resolve the type of culture they had versus where they want to be. Some of the radiologists minimized the role of culture while others felt relieved that this topic was finally being discussed in a nonthreatening and constructive way.
The open discussion of the role and impact of culture in their practice paved the way for the development of several practice-oriented strategies, such as a clinical/quality strategy. This strategy called for the development of a quantifiable quality control/assurance program. The components of the strategy included:
- Creating an external peer review program
- Implementing a patient satisfaction survey program
- Implementing an access-to-care analysis
- Creating a referring physician education program
- Becoming accredited in ultrasound and MRI.
The culture audit revealed that the partners in this practice wanted to be more action-oriented and less deliberate. By implementing this clinical/quality strategy, the practice members demonstrated that they could do so. This strategy also met their need to develop a long-term focus rather than a short-term focus.
The biggest gap between where the practice is and where the partners want it to be was on the conservative vs creative scale. Members felt comfortable with doing things the old way but also recognized that they needed creative and new ways to deal with the changing landscape of the practice of radiology. This gap was complicated by their existing style of leadership (the laissez-faire, democratic model). No one person was willing to take the risk and nudge the practice toward a more dominant leadership style. However, to their credit they did form a task force to assess alternative management models. The task force recommended (and the partners ultimately approved) the creation of a managing partner position, with broad authority to manage the practice and to propose and implement major initiatives.
Based on the culture audits that we have conducted with radiology groups and other medical group practices, the following lessons can be observed.
- If the culture of the practice is ignored, the practice can not be moved effectively forward.
- It is possible to change the culture of a practice with the current leadership and without completely disrupting the core values of the practice.
- The results of the culture audit can not be sugar-coated. The information must be dealt with in a straightforward manner.
- Always translate the group’s cultural issues into concrete implications for the business and/or clinical enterprise.
- Do not expect the culture audit to change the culture of the practice. Rather, it will reveal many of the sources of tension within the practice.
The culture audit is a powerful tool in understanding the underlying dynamics of a radiology group practice, and is especially effective when used in the early stages of planning any new clinical service or in the development of an overall strategic plan for a radiology practice.
Evan Leepson, MBA ([email protected]), is a radiology practice management consultant based in Potomac, MD. Douglas E. Hough, PhD ([email protected]), is a partner at a strategy development firm focused exclusively on physician practices, hospitals, and health systems, Fairfax, VA