Good Governance

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Imaging providers are well aware of the many challenges that radiology groups are facing today. Considering all of the various external threats, one is reminded of the motto sometimes attributed to Blackbeard (Edward Teach, 1680–1718): The floggings will continue until morale improves. It is in this environment that many radiology groups must rethink their governance structures and processes. Many groups operate in a manner better suited to the golden age of medicine, but woefully inadequate in today’s market. Effective governance is important; it is difficult to achieve, but there are steps that you can take to improve your group’s governance.

As many experts conceptualize it, governance is a set of structures, processes, and rules, established by the group. That set guides business operations within the group and with external parties, and it steers the organization toward accomplishment of its vision. It is critical to recognize that governance is not something just for big groups that have boards or executive committees. Many elements of governance are as important to a group of three physicians as they are to a group of 300. For example, if they are to make progress, even three physicians must decide how they will handle situations where they don’t all agree.

Good Governance

In more than 20 years of working almost exclusively with medical groups on governance issues, I’ve identified a number of obstacles that radiology groups must overcome to achieve effective governance. Three of the most important factors are overemphasis on autonomy, on individual rights, and on including all physicians in decisions.

Many physicians desire a high degree of autonomy, and they want all the benefits of group practice along with all the benefits of solo practice. A preference for protecting the rights of the individual over the rights of the group is the reason that so many groups require high (supermajority) vote levels on many issues.

In addition, many physicians feel that as owners of the group, they should have the right to participate in every group decision. I’ve heard several radiologists say that even if their groups included 1,000 physicians, all should meet and make decisions together. The result of these three factors is that many radiology groups fall into ineffective governance structures (Table 1).

imageTable 1. Ineffective Governance Structures

Making Decisions

Two fundamental questions that every radiology group must resolve are how the group will make decisions and what group decisions will mean. Many kinds of groups have something called a dirty little secret; in medical groups, the dirty little secret is that individual physicians in the group believe that if they didn’t vote for a group decision, or don’t like a group decision, they don’t have to comply with it. Such an attitude makes every group decision subject to the individual physician’s decision to adhere to it (or not). Many groups that think that they are making decisions are really making paste: They are throwing ideas against the wall and hoping that some will stick. They hope that individual physicians will actually adhere to group decisions.

If your group operates this way, it is a recipe for endless frustration. The best groups ask and answer three important questions. First, how will we make decisions as a group? Groups typically have four choices (Table 2): All decisions require unanimity; decisions require consensus; the majority rules; or consensus will be sought, but in its absence, decisions will be made by voting.

imageTable 2. Decision-making Methods

Second, what is expected of each physician once the group has made a decision? The answer to this question is crucial. Each member of the group should commit to the principle that once a decision has been made using the agreed-upon decision-making method, all physicians (whether they agree with the decision or not) will support it. That means that they will do what has been agreed to, will not sabotage it, and will continue to follow the agreement unless they can get it changed through proper channels.

Third, what are physicians’ options if they still don’t like the decision? There should be only three options. One is to support the decision anyway. That’s group practice. A second is to try to change it. The proper environment for this is typically the group meeting. Physicians must keep adhering to the decision until it is changed, however. The final option is to take themselves out