There are two types of radiology practices, says Lawrence R. Muroff, MD, FACR. The majority of them, which are governed haphazardly, and a small elite minority that ensure their success with a clear sense of direction and a proactive approach to problems.
Muroff, president and CEO of Imaging Consultants Inc, Tampa, Fla, providers of consulting services to radiologists, hospitals, and corporations, is also a clinical professor of radiology at the University of Florida and University of South Florida Colleges of Medicine. At the 2005 Radiology Business Management Association’s Fall Educational Conference, Muroff shared his views on practice governance.
Muroff said the place every practice needs to start is with a solid mission statement and business plan.
“A mission statement is not what hangs on the office wall,” he said. “It defines who you are, what you want to do, and where you want to do it.” He said that a good business plan lists specific goals to fulfill its mission statement, for example, pursue a certain contract, hire two subspecialty radiologists by July, and purchase a 64-slice CT by October.
Radiology practices need these guiding documents, Muroff said, because they are pathologically addicted to democracy. “Decisions are frequently revisited, often overturned, and the end result is a paralysis of action. Without a mission statement, business plan, and effective governance structure, there just is no way to be effective and time-efficient in decision-making,” he said.
CHOOSE WISE LEADERS
A key part of effective governance, Muroff said, is having the right people in leadership positions, but not everyone is right for the job.
“Leaders need to be respected by group members. They need to work effectively with hospital administrators, community leaders, and managed care entities. They need to be able, when necessary, to discipline their fellow group members,” he said.
While most committee positions can be rotated, Muroff recommends that two leadership positions hold some tenure: the president (physician CEO) of the radiology group and the chair of the group’s hospital department.
“The weakest practices, those most vulnerable to being kicked out of their hospitals or trivialized by competition, are those that rotate their president every 2 or 3 years,” he said. “You get people in the job who don’t have the skills. Just as they’re learning how to do something, they’re rotated out.”
Muroff said the chair of the hospital department also should not rotate. “That’s where the action is in a hospital. If you have your radiologist on that committee for 15 years, he or she exerts an influence that is far out of proportion to their individual vote. They learn how to make that system work most advantageously for your practice,” he said.
While the finance and marketing committees also are important, Muroff says that in most radiology groups, the operations committee is where all the governance “action” is. With this committee lies responsibility for personnel needs, practice credentialing, quality measurements, and utilization management. Its members also deal with vacation, education, days off, practice site/ambience, workplace policies, support staff, subspecialty opportunities, call, and partial retirement.
Muroff had advice for practices on several governance aspects of operations.
DEALING WITH CALL
“If you ask radiologists what is their most problematic issue in a practice, it’s call,” he said. “I am a strong believer in the three-step program: equalizing, minimizing, and possibly eliminating call. This should be the goal of every practice.”
Muroff opposes situations in which certain cadres of radiologists are excused from call. “It’s disruptive and divisive,” he said. “For example, situations where, if you’re over 60, you don’t have to take call. Sounds great, but what if you’re a prospective hire? You like what you see, then they tell you about the over-60 call policy and you look around and you’re the only one without gray hair.”
Muroff believes that when radiologists work half-time, they should work half the call. Call can be bought and sold, but should never be a coercive option (in which a partner forces a nonpartner to accept more call).
Muroff sees substantial value in using nighthawks (radiologists who provide night-time coverage for the practice).
He says that he is seeing more practices structuring nighthawks as a partnership slot or some percentage of partnership. “A nighthawk that is a 75% partner feels like a part of the practice. They have a vote and an income stream,” he said.
Nighthawk companies also can be an effective option. “There are very competent, credible, and well-recognized companies,” he said. “Even if the nighthawk company provides only preliminary reads and you still have to do the definitive read in the morning, your quality of life will be better.”
He cautions that in using nighthawk companies there are licensure, perception, and accountability issues. “Look very carefully to make sure they can solve those issues and meet your needs,” he said.
Interventional radiologists present a whole other issue when dealing with call. “You can’t stick a femoral artery from Newfoundland,” he said. “It demands hands-on response. So you have to take that into consideration. Even if they just carry the beeper and don’t come in, it’s still a quality of life issue. They can’t drink wine or go to the beach. So even when they don’t get called in after hours, they have reason to be compensated.”
The potential for problem partners exists in every practice. Muroff believes the best way to deal with this is to develop written, group-accepted, proactive policies and apply them consistently. He recommends having specific policies for:
- Leave (family, medical, sabbaticals)
- Impairment (substance abuse, psychological)
- Behavioral issues (rudeness, absence/habitual tardiness, acting contrary to interests of group)
- Sexual harassment/creation of a hostile work environment
Muroff said that policies can be group specific but they also can have state or federal implications. After the operations committee develops policies, the practice should have an employment attorney make sure they conform to regulations. “But don’t have attorneys write the policies,” he said, “because they don’t know the culture of radiology.”
Muroff called policy breaches the “or else factor” and said there must be a meaningful consequence if a policy is not adhered to by a member.
“This is what most practices fail to understand,” he said. “If a radiologist throws a forceps at a file clerk and is fined $100, that’s chump change. Remember, only two things get a radiologist’s attention: financial or quality of life penalties. A $25,000 fine or losing 3 weeks of vacation will get their attention, and of course, the ultimate consequence is termination.”
Muroff also said that consequences should vary for different types of breaches (zero tolerance for sexual harassment, for example, versus a fine for tardiness), but the consequences cannot vary from one individual to another.
Well-governed practices, Muroff said, make informed decisions and are proactive in their pursuit of success. Most, however, make random decisions based on insufficient information. “If they succeed,” he said, “it’s in spite of what they do, not because of it.
“A radiology practice is a moderate-size business with gross receipts ranging from $10 million to $100 million,” Muroff said. “There is nothing that says good business and good medicine can’t coexist. If you practice good business, it frees up the resources for you to practice better medicine.”
Tamara Greenleaf is a contributing writer for Decisions in Axis Imaging News.