With reimbursement declining, more practices are wading into the dangerous waters of tracking radiologists’ productivity No matter how common measuring productivity becomes, there is a deficiency behind it: tracking does not always reflect reality and, as a result, can cause diligent workers to appear less productive. Output-tracking authority Richard Duszak, MD, a diagnostic and interventional radiologist with Mid-South Imaging and Therapeutics in Memphis, Tenn, warns, “When looking at productivity, groups must always use objective benchmarks so that there is a real, honest, legitimate discussion, rather than finger pointing and recriminations.” Fred Gaschen, MBA Fred Gaschen, MBA, is executive vice president of Radiological Associates of Sacramento, Sacramento, Calif. His group is composed of more than 75 radiologists and radiation oncologists operating 17 imaging centers, in addition to providing services at five hospitals. He believes there is no escaping the need to measure productivity. “Groups are interested, as never before, in quantifying who is working hard and who isn’t because there is a general feeling that physician compensation has been eroding and will continue to erode. The thinking is that if it’s going to get harder to earn a living, then let’s at least make sure everyone in the boat is pulling the oars with the same amount of effort,” Gaschen says. “If work is not being performed well, groups want to know that in order to be able to make the necessary improvements.” The Hawthorne Effect After collecting the data that will provide such insights, groups then often publish report cards on their physicians’ performance and distribute copies of the data to every partner, associate, and medical employee. “Some organizations blind the data first before releasing them,” Gaschen says, explaining that the anonymity allows individual radiologists to know where they stand in relation to all the other radiologists, without fear of becoming stigmatized if they happen to be less than genuinely productive. Other groups, however, release the data unblinded, with the name and performance of every radiologist in the group disclosed to all. Either way, the hope, according to Duszak, is that radiologists will be spurred to work more efficiently. “Just knowing you’re being measured can be all it takes to motivate you to change your behavior—the Hawthorne effect,” he says. The Hawthorne effect is a social phenomenon first observed during a multiyear study conducted by Harvard University researchers in the late 1920s at a Western Electric plant (called Hawthorne) outside Chicago. The researchers wanted to understand how employees are motivated to become more productive. Among other things, they learned that workers put their shoulders to the wheel more if they know that they are being observed, whether by superiors or through the collection of productivity data. Moreover, they found that it is not necessary to reward observed improvements in performance in order to encourage more improvement: the Hawthorne effect suggests that mere awareness of being monitored causes employees to imagine themselves receiving approbation for their productivity (or, conversely, punishment if they fall short). Baseless Fear The Hawthorne effect explains why some groups find it unnecessary to engage their radiologists in a conversation about productivity, once tracked output data have been disclosed, Gaschen says. More than a few groups, however, elect not to have the follow-up conversation out of fear that talking about who is (and is not) productive will tear at the cohesiveness of the group. The thinking, Gaschen says, is that it’s better not to go there. Such fears may be baseless, though. One group with which Gaschen is familiar went ahead and initiated a productivity discussion with its radiologists, to good effect. “The radiologists were gently told that if the next year’s numbers did not show increases in individual productivity, each underperformer would be penalized through the loss of vacation time,” he says. “For the most part, everybody’s productivity improved after that. The combined improvement was so good that it was the equivalent of having added 2.2 FTEs. The gains in output were the same as if no one on the team had changed any habits and the group, instead, had recruited two more full-time radiologists.” The radiology group at Massachusetts General Hospital in Boston is among those that track radiologist productivity. Each report card formulated from those data, however, details the performance not of individual radiologists, but of a functional imaging team. Sanjay Saini, MD, MBA, the department’s vice chair for finance and a professor of radiology at Harvard Medical School, says, “We do it this way because we believe clinical work in diagnostic radiology is unique in that patients are referred to the department and not to individuals; thus, radiologists who are members of a functional group must work together to get the worklist cleared.” He continues, “Our teams are formed on the basis of organ-based subspecialization, such as neuroradiology, breast imaging, pediatric radiology, and so on. We don’t provide individual team members with their individual productivity information because we don’t want to create an environment where radiologists cherry pick the easy studies or, if they are working in an inefficient setting such as inpatient fluoroscopy, then (as individuals) are made to feel they are in some fashion contributing less than their colleagues who are assigned to outpatient cross-sectional studies.” He adds, “Furthermore, for some radiologists, not being at the top of the productivity scale might be a real psychological blow that could lead to any number of attitudinal and performance difficulties.” Saini believes that his organization’s approach works because the culture at Massachusetts General Hospital is built on team spirit, and this approach both supports and reinforces that culture. “Management’s challenge to each team is to think of ways in which the team can increase the per-FTE productivity of the team as a whole,” he says. “It is important to note that a team’s per-FTE productivity reports are provided together with quality metrics, such as report-turnaround time, use of standardized report templates, and critical-result communication. Thus, physician productivity and quality metrics are two sides of the same coin and must be viewed together.” Addressing Anomalies As a nationally recognized expert on productivity, Gaschen often is asked for advice regarding the best way to initiate and conduct conversations about performance without antagonizing members of the group or provoking high-output individuals to turn against low producers. “You’ll always get push back from your radiologists if you start tracking their productivity—no way to get around that,” he cautions. “The biggest challenge of measuring productivity is securing the buy in of the entire group. A complaint is that it isn’t fair to compare a neuroradiologist’s productivity to an interventional radiologist’s, or to a nuclear medicine doctor’s, because they all have different performance standards, and that’s true. You must compare apples with apples, which is why, here at Radiological Associates of Sacramento, we compare all body imagers with body imagers only, all the nuclear medicine doctors with nuclear medicine doctors only, and so on.”

"The biggest challenge of measuring productivity is securing the buy in of the entire group. A complaint is that it isn’t fair to compare a neuroradiologist’s productivity to an interventional radiologist’s . . . and that’s true." —Fred Gaschen, MBA Radiological Associates of Sacramento, Sacramento, Calif

The difficulty begins in measuring the productivity of radiologists who take on nonclinical, yet nonetheless vital, roles for the practice, acting as president of the group being one of those. “The president may work 200 days of the year like everyone else in the group, but half of his or her time is devoted to managing the business office, engaging in marketing outreach to hospital decision makers, sitting in on contract negotiations, and more,” Gaschen says. “If those nonclinical, but no less important, contributions are not somehow factored into the productivity numbers, then you’re only going to discourage members of the group from stepping into leadership positions. Duszak says that groups address this anomaly in various ways. “Some exempt the president from being measured at all,” he offers. “Others count the president as a fractional FTE—60% or 70% of one FTE, for instance—which, in effect, credits back a portion of the hours spent in nonclinical pursuits, so that the clinical productivity numbers better reflect that part of the president’s contribution, relative to everyone else’s.” Before entering a discussion about productivity, the group needs to be aware of any deficiencies in the measurement system, Duszak advises. “The work RVU is the best measure of radiologist productivity, yet it is imperfect because there are instances where it can make it appear that one radiologist is less productive than another, even though both have completed a similar amount of overall work,” he says. Gaschen, who also holds the yardstick of work RVUs in high regard, says that the imperfection is the result of CPT® codes not having been fully analyzed when the RBRVS first was fashioned. “The relative, relational rankings of the CPT codes were not really valued for the professional work component—or for the technical component, for that matter,” he says. Some groups hoping to develop the most accurate and realistic picture of their productivity use multiple measures. Gaschen says, “My group is a large practice, and we track everything from appointment backlogs and throughput to transcription speed and report turnaround. Other groups look at number of procedures performed, billed charges, and hours worked.” The Need to Track A concern raised by groups that have yet to begin tracking output, or that are still in the early stages of collecting data, is that their hardest workers will see no point in continuing to toil with such alacrity once they learn how many others in the group are not working quite as hard as they are. Gaschen predicts, however, that it will not be the dissatisfaction of the top performers that will command the most attention. Rather, he says, it will be complaints from radiologists at the opposite end of the productivity spectrum. “The lower producers complain because they understand that tracking is going to change the way they do business,” he says.

"I would not advocate the use of productivity data to purge radiologists, but I would, instead, advocate using those data as a tool to help improve the efficiency of all radiologists in the group. Where data reveal poor performance, groups should be exploring ways to help those radiologists accomplish more and to be able to align their total overall work with the rest of the group." —Richard Duszak, MD Mid-South Imaging and Therapeutics, Memphis, Tenn

The radiologists at Massachusetts General Hospital are salaried, so incentives to work harder are not the same as those of a practice where the radiologists are business partners who have a financial stake in the group’s fortunes. According to Saini, his colleagues work hard mostly for the personal satisfaction of it, taking pride in knowing that the work is being accomplished correctly in the most efficient manner possible. Perhaps as soon as the next budget year, though, Massachusetts General radiologists could have an additional reason to push for greater productivity if a plan to reward improved output with bonus pay is adopted. “It’s something we’re looking into,” Saini says. Duszak, meanwhile, discourages groups from using productivity tracking as either a subtle or blunt mechanism for pushing poor performers out the door. “Radiology will continue, for the foreseeable future, to face its current crisis of manpower, and as such, groups need to retain good radiologists already aboard,” he says. “I would not advocate the use of productivity data to purge radiologists, but I would, instead, advocate using those data as a tool to help improve the efficiency of all radiologists in the group.” He continues, “Where data reveal poor performance, groups should be exploring ways to help those radiologists accomplish more and to be able to align their total overall work with the rest of the group. For example, some radiologists are not technologically savvy enough to be able to take advantage of all the shortcuts available in their PACS or voice-recognition system; providing them with the training to know those shortcuts and how best to use them would be one way of enabling those radiologists to use the technologies more effectively.” Gaschen says, “I personally believe we’re going to win the self-referral battle, and that is going to result in more and more business for radiology groups.” He says, “That, with other indicators pointing to growth in the demand for imaging, means we’re all going to have to become more concerned about our productivity. Tracking is the way we can ensure that productivity is being measured and can then set the stage for improving it. Growth in the face of a manpower shortage will make it all the more imperative that the conversations groups have about productivity be handled with utmost wisdom, tact, and purposefulness.” Additional Reading-Enhancing the Practice’s Lifeblood: Turnaround Time