Charting the Leadership Course: Tales From the High Seas

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What qualities make a radiology leader? What experiences best prepare leaders to assume their roles? How do leaders know whether they are performing to the best of their abilities? These were among the questions that Radiology Business Journal recently asked four undisputed industry leaders: a radiology-department chair, a practice president, a practice CEO, and a hospital radiology executive. All four shared a wealth of perspectives and philosophies, using anecdotes and other glimpses into the workings of their organizations to illustrate their points. The Radiology Chair: Putting Creativity to the Test Four years ago, Steven Seltzer, MD, FACS, and his colleagues determined that the department of radiology at Brigham and Women’s Hospital in Boston, Massachusetts, needed a cyclotron to support molecular-imaging research and other endeavors. Seltzer knew that the acquisition would present obstacles, from budgetary and logistics standpoints, but he was determined to succeed in his endeavor—and he didn’t mind spending time coming up with a solution. The solution: A consortium of Brigham and Women’s Hospital, Harvard Medical School, the Dana-Farber Cancer Institute (Boston), and faculty and corporate sponsors was formed to finance what Seltzer calls the 50-ton monster, while a crane was used to hoist it above nearby buildings and to its destination. Seltzer has served, since 1997, as chair of the Brigham and Women’s Hospital radiology department and as the Philip H. Cook professor, department of radiology, at Harvard Medical School. He says, “Dealing with seemingly ubiquitous people problems is my least favorite part of being a radiology leader, but applying creativity and thinking out of the box to handle bigger challenges (such as this one) are what I like best. They keep me on my toes.” RBJ: As the leader of a large and prestigious academic department, you have responsibilities for teaching, research, and patient care. How do you balance their varying leadership needs? Seltzer: I position myself as a convener who sets the overall strategic direction of the department. Beneath this layer is a very capable, very effective management team, and each of its members concentrates on one aspect of our mission, be it clinical/medical, educational, or financial. RBJ: What have you done to ensure that after you move on, the organization will continue to thrive? Seltzer: I keep it an open topic of discussion among members of the department and the leadership of the health-care system. I believe in being as transparent as possible in identifying the specific individuals who should be groomed for positions of leadership. Some hospitals and academic institutions are sheepish about the fact that they have CEOs because they think it smacks of the corporate realm. The management of a $2 billion organization, however, has to take on the characteristics of the management of a corporation, when it comes to carrying out the mission and handling succession. RBJ: How do you assess the job that you are doing as a leader? Seltzer: We have reasonably robust IT tools to track performance through performance metrics. I review this information with hospital leaders and others at least once a year—and often, more frequently than that. I also conduct informal 360° evaluations of myself as part of my annual performance review, inviting comments and feedback from subordinates and supervisors. We look at subjective issues, such as whether the physicians and technicians believe I am going in the right direction with the department and all of its initiatives, as well as quantitative issues—for example, the number of research grants procured. RBJ: What are the most important reports that you need (weekly, monthly, and annually) to do your job? Seltzer: The most important weekly report—really, the most important daily report—isn’t an in-house one, but rather, news of what is happening on Boston’s Beacon Hill and on Capitol Hill. This is because so much short-term direction is shaped by politics and what is going to happen, or probably going to happen, with health-care reform. Monthly, it is very detailed reports of procedure volumes, performance efficiencies, and our financial status. On a yearly cycle, the most critical reports have to do with research and teaching—the number of federal individual grants we have received to support research, the number of peer-reviewed publications in which work has appeared, and teaching accomplishments. RBJ: What experiences, in your life and education, best prepared you for leadership? Seltzer: I’ve had the good fortune to have worked with a series of amazing role models and mentors, including Herbert Abrams, MD, who was chair of our radiology department when I was a resident, and the late B. Leonard Holman, MD, whom I succeeded. Len took me under his wing and helped me to assimilate leadership and management skills and provided invaluable guidance as to how to approach operational improvements within the department. He freely shared his thinking about how to tackle global issues that affect the department, not just issues that affect the department alone. For a leader, this last ability is critical. RBJ: Why is leadership in radiology so important today? Seltzer: Radiology is at a challenging and pivotal point. After years of uninterrupted growth and development connected to clinical-service expansion, technology introductions, and a supportive economic environment, radiology is coming up against external forces—like the congressional 12-member supercommittee—that want to tip the scales in the other direction, with cuts and other measures. Without good radiology-department leadership, and strong leadership in general, those scales will tip way too far. RBJ: What are the one or two most important lessons that you have learned as a leader? Seltzer: Be patient, be open-minded, accept criticism of your ideas, and don’t act impulsively. Some leaders, especially new ones, have trouble resisting the temptation to implement change or come up with a strategy for handling an external threat without first obtaining colleagues’ buy-in. Getting that buy-in is much easier when you’ve developed a culture that prioritizes open communication and serious consideration of other peoples’ ideas. RBJ: Are you optimistic or pessimistic about the future of the specialty? Seltzer: I’m highly optimistic. Many of the contributions radiology makes to ensure firm diagnoses for patients—for example, image-guided intervention—are indispensible to 21st-century medical practice. I’m not so much of a Pollyanna as to say the federal government won’t take measures to cut back sharply on payments for clinical care and funding for National Institutes of Health research, but considering the importance of the specialty, unless we’re overcome by a tsunami of bad economic and political news, I would remain optimistic about the future of radiology (in general) and academic radiology (in particular). The Practice President: Continuing Education Eric Mansell, MD, PhD, president of Greensboro Radiology in North Carolina, learned a lot about leadership while a medical student at the University of Florida College of Medicine–Gainesville and during his residency at Wake Forest Baptist Health (Winston–Salem, North Carolina). He believes, however, that ongoing education is critical to effective leadership performance in any discipline, medical or otherwise. Accordingly, he continues to read as much as he can about organizational culture, change, and leadership, in addition to attending conferences that cover these topics. Mansell and other Greensboro Radiology principals work with a leadership coach on best practices. They also participate in the Greensboro Leadership Academy, a small, rotating group of radiologists who meet regularly to discuss leadership issues and strategies. “All radiologists, not just the designated leaders, are included in the academy, but we rotate so that the group, at any one time, remains small,” Mansell explains. “We want every radiologist becoming a more effective physician leader and member of the medical community by learning communication skills and behaviors. The more open to learning leaders remain, the better—not just for their careers, but for the practices they head.” RBJ: With the advent of accountable care and the renewed interest of hospitals in physician ownership, what are the greatest challenges for practice leadership and in the practice setting? Mansell: The big all-around challenges remain how to position the practice as part of a larger health-care enterprise and how to ensure it delivers high-value services at a sustainable cost. It’s also difficult, now, to know how to build a plan for fostering practice growth in the environment we’re in: The facts that the landscape is changing—and we will have to change, too—only complicate matters. Still, we’re moving ahead, because if we wait, it may be too late to take advantage of alliances and opportunities. RBJ: As the person with the primary responsibility for setting a strategic path for the practice, how do you approach the challenge of leading so many independent thinkers? Mansell: I welcome input from each and every one of these thinkers because they are all highly intelligent and have much to contribute to the practice. If I waited for each of them to weigh in on every possible issue or change, though, nothing would ever be accomplished. For this reason, I work with a very small executive committee on strategic planning and direction, taking into consideration what constituents have to say, but not involving them in the actual nitty-gritty of it all. I try to keep the executive committee thinking strategically, so day-to-day and managerial issues are handled by other committees. RBJ: Why did you choose the leadership path? Mansell: I like strategizing—helping to find solutions, instead of being part of the problem. One of my most gratifying projects had to do with the procurement of our own PACS. We had contracted with a new hospital and were at the mercy of its PACS, which had a negative impact on service and left us no control of our brand. To take control of everything, from orders to final reports, we came up with the strategy of buying our own PACS, voice-recognition platform, and interface engine. The results were that report turnaround decreased from 24 to 36 hours to less than an hour, and we can offer more value to the partners we serve. RBJ: What do you like most (and least) about leadership? Mansell: For me, the best part is innovating within the organization, as happened with the PACS. I also very much enjoy coaching and teaching. With 44 radiologists and 200 staff members, there’s never a shortage of people to assist. On the flip side, balancing being a leader with the needs of a family is difficult. I have two sons, ages 15 and 14, and both of them are very active in sports. I want and need to be involved in their lives, but much of the relationship building that comes with leadership doesn’t happen during regular business hours. RBJ: What are the three most important reports that you need (weekly, monthly, and annually) to do your job? Mansell: It’s easier for me to do my job when I can see the number of reports read, the number of work RVUs generated, and other group productivity measures by the day and by the week. Weekly, I like to look at scheduling waits and third available appointments booked per modality and individual center, so as to identify week-over-week trends. When looking at weekly trends, however, I am careful to take variances into consideration; for example, maybe productivity is down in one area because a big referrer is out on vacation. Once a month, I review our financial dashboard to understand where we are, in terms of our budget, and to ensure that we aren’t seeing any creep on the expense side. RBJ: Why is leadership in radiology so important today? Mansell: We know that health-care delivery is going to change, but nobody has a clear picture of how. Radiology leadership is important because those who are involved in the field need to get off the sidelines and frame the discussion of where radiology fits into the health-care landscape. If we leave that task to those outside radiology, we don’t know what we’re going to get. RBJ: Are there leadership qualities that you find to be most helpful in an uncertain, rapidly changing radiology environment? Mansell: The abilities to get past the status quo, to be innovative, and to look for opportunities to grow the practice—rather than to continue to do what was done in the past, simply because that once worked—are very valuable. RBJ: Are you optimistic or pessimistic about the future of the specialty? Mansell: I’m optimistic; if I weren’t, I could not be doing what I’m doing. Everyone in the discipline, especially leaders, needs to understand that we have opportunities to redefine radiology, in terms of value and service provided to patients and the medical community, but those opportunities aren’t going to be handed to us. We need to pursue them. The Practice CEO: Preparation by Parenthood Many adults credit their parents with helping them to become the individuals that they have grown up to be—and Marcia Flaherty’s four grown children are no exception. Flaherty, however, also believes that the experience of bringing up her offspring was instrumental in fostering her professional growth and preparing her to serve as CEO of Riverside Radiology & Interventional Associates (RRIA), Inc, and Premier Imaging Ventures (both of Columbus, Ohio). Parenthood offers the highest volume and breadth of challenges, Flaherty says, “to provide an environment in which everyone can grow, be respected, enjoy what he or she does, and feel good about himself or herself.” She notes that she was also fortunate to have had several mentors who supported and guided her on the road to leadership and throughout her career; in particular, she cites Robert S. Chaloner, who now serves as president and CEO of Southampton Hospital in New York. When Flaherty joined RRIA in 1999, it had 17 radiologists and three staff members. Today, the practice has more than 70 subspecialty radiologists. RBJ: There are few women in practice-leadership positions; has being female been an asset or hindrance to your career? What advice would you give to women interested in following in your footsteps? Flaherty: I can’t say that being female has been a factor, one way or the other. What has mattered is what RRIA has been able to accomplish as a team. We have physicians who trained at some of nation’s most respected medical centers, but you would never know it by the way they interact with and support their colleagues and staff, regardless of whether they are male or female. Trust, mutual respect, and recognition of what each of us brings to the table are the backbone of our success. My advice for other female health-care professionals would be to seek out an organization that is exciting, that provides you with an opportunity to do something you are passionate about, and that motivates you to go to work each day and be your best. RBJ: On a day-to-day basis, what are the most important things that a practice CEO must do? Flaherty: Make sure you have the right people in the right places in the organization; then, provide them with opportunities to maximize their talents and excel. At the end of the day, it all comes down to people. It’s just as important to communicate the vision and stay focused. If people don’t have a clear vision of where the group is going, it’s hard to do that. Each person must understand the practice’s strategies and his or her role in contributing to its overall success. RBJ: Why did you choose the leadership path? Flaherty: I never remember seeking to be a leader; it was more of an evolution—a journey. I have always been a strategist, and I like to be challenged. I originally planned to become a college professor because I liked to see young people learn and excel, but while I was in graduate school, I worked in patient relations at a hospital, and my supervisor encouraged me to channel the sense of compassion he saw in me into a health-care career. I still enjoy the gratification of watching people maximize their potential, and it’s a big part of what I do now. Seeing our physicians and staff mature and develop new skills, over time, is very rewarding. RBJ: How do you assess the job that you are doing as a leader? Flaherty: Leaders have to ask themselves: Is the organization growing (and not just in size)? Is it evolving to meet the challenges of the current environment? Are we a disciplined organization, with well-defined governance and evaluation processes? Are we organized and coherent? Do we communicate effectively with one another and our customers? Again, it goes back to the makeup of the people within the group. The right people in the right leadership positions will challenge and police themselves in many ways. RBJ: Why is leadership in radiology so important today? Flaherty: We have challenges, on all fronts, with reimbursement and increased regulation; there is also an inherent lack of understanding of the importance of radiologists and the role they play in the health-care–delivery system. We need to take a leadership position and educate decision makers and patients about the value added to the system through appropriate imaging utilization. RBJ: What are the greatest challenges in the practice setting today? Flaherty: They are reimbursement challenges, particularly multiple-procedure codes and the sustainable growth rate. Health care is so complex, and decision makers seem to look for easy answers on what to cut. They choose to cut those items with increasing utilization, rather than look at the value that utilization brings to the patient. I know of no industry where you might (or might not) get paid, and the payor decides whether it will pay you after the service is rendered. It is very challenging to make long-term plans when you don’t know what next year will bring. RBJ: What are the most important lessons you have learned as a leader? Flaherty: Be humble. Listen to what others have to say, and let them know you appreciate their support. Be accessible; engage your team in the challenges you’re trying to overcome. RBJ: Are you optimistic or pessimistic about the future of the specialty? Flaherty: I’m extremely optimistic. Any time you have an environment of rapid change (such as the one that we are in today), there is also opportunity. I am fortunate to be part of a group that is proactive, versus reactive—and very nimble as well. For example, when we saw that the radiology marketplace was growing increasingly competitive, we expanded our base of radiology service from one hospital to a current total of 17 hospitals, and we developed additional subspecialties, such as cardiac radiology and neurointerventional radiology. Although there will be challenges down the road, we have already anticipated many of them and are working on preparing for what might lie ahead of us. The Hospital Imaging Executive: Staunch Support Good leadership involves a fine balance between offering staff members the support that they require to fulfill their responsibilities and allowing them to get the job done without an unwarranted dose of micromanagement. Such is the philosophy of Richard Guarino, vice president, hospital-based clinical services, at Lahey Clinic Medical Center (Burlington, Massachusetts). In overseeing the hospital’s radiology service (as well as its laboratory, clinical-pathology, and pharmacy services, and part of the cardiac ICU), Guarino actively maintains open lines of communication with directors and other staff so that he can be readily informed of any assistance they require to execute tasks and initiatives. At the same time, however, he respects his constituents’ expertise—and his leadership style reflects it. Guarino says, “You can give a person goals to attain, but if you’ve hired that person to do a certain job, he or she is the expert and should be treated that way. Otherwise, you’ll undermine your whole relationship—and, quite possibly, your department.” RBJ: As the leader of a hospital radiology department (with broader responsibilities throughout the institution), do you perceive opportunities for radiology to engage in a greater leadership role within the organization? Guarino: Yes; when I first started in radiology, in 1979, radiologic technologists were considered button-pushers. As the technology has grown, however, radiology has assumed a much larger role in patient care. We’ve stepped up our game, making it more natural and creating opportunities for larger numbers of radiology-trained individuals to assume leadership roles. RBJ: You were involved in a turnaround experience in your previous position, as director of radiology at Newton–Wellesley Hospital (Newton, Massachusetts). What attributes did you draw upon in that experience, and what did you learn about leadership? Guarino: Honesty was one. Many times, I had to tell staff that while they could ask questions about what was going on, I might not know the answer. I think this helped to establish trust. Another was a sense of directness—the ability to say to people, “This is what we need to do next, and this is why.” During this period, though, I learned the importance of keeping a balance between being honest regarding everything that is happening, including tense staff communications, and revealing too much. I learned the benefit of not showing all the cards in my hand because it’s impossible keep people motivated that way. In the end, the turnover rate dropped from 17.4% to 8%, and the patient experience improved dramatically. RBJ: What do you like most (and least) about leadership? Guarino: I like the strategic-planning aspect, especially now, with health-care reform happening. It seems that the job is changing every week, calling for different strategies to be developed and keeping things very interesting. I don’t like the lack of instant gratification, though. It can take months, or even years, to realize your goals, because there are so many mitigating factors. RBJ: How do you assess the job that you are doing as a leader? Guarino: I take the same form I use to evaluate my directors, and I give it to them to evaluate me. They tell me whether I am providing the support they need and what I can do better to support them. RBJ: What are the three most important reports that you need (weekly, monthly, and annually) to do your job? Guarino: Every week, I take a close look at variances and whether they are being followed because it helps us to make cost corrections, adjust, and set a percentage or dollar-amount threshold. Patient satisfaction scores are critical, too, as unhappy patients just don’t come back. I also go over the hospital’s Joint Commission-type tracer reports; often, some of the information will have relevance for my departments. RBJ: What, in your life and education, best prepared you for leadership? Guarino: I once had a boss who told me that he had hired me to be the CEO of MRI. He was clear in his expectations of me, and he gave me some guidelines, but then he stepped back. That became a leadership mold for me. RBJ: What is the greatest challenge in the hospital setting today? Guarino: Health-care reform: We’ve always been able to justify FTEs and advancement, and to use radiology money to take care of other departments. It isn’t happening anymore. In 12 to 18 months, radiology could become a cost center as a result of health-care reform, and that alone will be a very difficult transition. RBJ: Are there leadership qualities that are most helpful in an uncertain, rapidly changing environment? Guarino: One is the ability to answer questions honestly—to tell people, straight out, that you will give them your opinion, but they may not like it. Knowing how to say no so as not to turn staff off is also key. I won’t say, for example, “We didn’t get it” or “You can’t have it,” but instead, “We didn’t get it because of this” or “Your case needs to be stronger.” I once had an employee tell me I have the nicest way of saying no. I take that as a great compliment. Julie Ritzer Ross is a contributing writer for Radiology Business Journal and the editor of Radanalytics.com.