Welcome Back, Kotter

Uncertainty is permanent, chaotic times are normal, change is accelerating and instability will likely characterize the rest of our lives.

—Jim Collins and Morten Hansen

Radiology and other technology-dependent fields should focus on how to maximize the value of medical imaging and other tests and procedures by becoming integrated better into patient care by being members of care delivery teams. Specialists in these disciplines, including radiology, can recommend strategies that maximize the benefit of medical imaging while reducing risks and costs.

—Steven Seltzer, MD, and Thomas Lee, MD

Leaders in all sectors of American business have been leaning on John Kotter’s 1996 change management bible, Leading Change, for close to 20 years.  In his talk on “Changing the Culture of Radiology: How to Thrive in Turbulent Times,” on November 30 at the 2014 meeting of the Radiological Society of North America, ACR CEO William T. Thorwarth, MD, suggests the time is right for leaders in radiology to pick up a copy.

Thorwarth first aimed to convince skeptics that the need for change is urgent by sharing a few choice quotations (see above). “Accountability will be the most important factor influencing radiology care delivery in the United States over the next decade, and that means we have to step up and embrace accountability,” he says. “If we really believe we are better than the pretenders out there who think they know how to do what we do, then we should embrace the opportunity to be accountable for that care.”

Heed the words of Seltzer and Lee as a directional for where radiology needs to be in 2020, Thorwarth advises. To find the way, he shares a radiology’s-eye view of Kotter’s eight-step process for leading change, with the following caveat: “It’s a process it’s not an event. You aren’t going to go back to the practice, flip a switch and see the change.”

Step one: Identify and accept the urgency and need for change. Thorwarth cites healthcare costs that consume near 18% of GDP, 13 major cuts in the Medicare Physician Fee Schedule since the Deficit Reduction Act of 2005 and the rise of corporate radiology. “Radiology and healthcare is, in a sense, looking at a burning platform,” he says. “We need to step forward and make these changes happen.”

Step two: Build a small guiding team. Thorwarth recommends a group of three to five people, all with credibility and conviction to the change. It can’t be just the chair and the vice chair, president or president elect, he says. Include a range of ages and make sure that everyone understands not just the future needs, but the current mission of the group or department. “They are not starting from scratch, they are reinventing the wheel from the existing culture,” he adds.

Step three: Develop the change vision and strategy. The change vision should be abrief, two- to three-sentence articulation of the desired future—and it must be achievable. “It can’t be so ‘Star-Wars’ that people don’t think they’ll get there,” Thorwarth advises. To convince the group that this future is achievable, preselect a few short-term goals to move change forward.

Step four: Communicate the change vision. Thorwarth says the need to talk openly and honestly about the change vision and strategy is critical.  Devise a concise elevator speech about the vision and how the practice will achieve it, and enlist the entire team in promoting the change vision. “Be prepared for questions and anxieties because people do not like change,” he warns. Above all, lead by your own conviction: If the leader is not behind the need for change, it will not occur.

Step five: Empower all involved for broad-based action. The three- or five-person guiding team cannot drive the change. “You have to identify the network of those who progressively accept the opportunity and want to be empowered in order to bring that change about,” Thorwarth says. “When your partners have ideas that will facilitate the change, you have to be willing to listen and embrace those additions to the plan.”

Recognize and reward the champions—not just the inner circle—and counsel those who are slow to adopt, he advises. Differentiate between slow adopters, those who are not going to take the ride and those that you have to get off of the bus, in the parlance of Jim Collins. Take the time, periodically, to proactively remove barriers that need addressing so that change can occur progressively throughout the practice.

Step six: Celebrate short-term wins. Your objective is to create a chain reaction so that enthusiasm builds day-to-day behind getting through the change process, Thorwarth says. The best way to do this is to celebrate the short-term wins by visibly recognizing the people who are making change happen. His advice: Avoid early targets that are expensive, and look for opportunities to demonstrate that your desired change has had a ripple effect throughout the organization.

Step seven: Consolidate gains and keep moving ahead. When short-term wins are in hand, build on that momentum, and set new goals.  Find further efficiencies, continue to improve on relationships with referring providers or improve patient satisfaction. Add additional champions to the effort, evaluate what went right and what went wrong and determine how you might improve the process of change as you approach the finish line, he advises. Incorporate a culture of continuous quality improvement.

Step eight: Anchor change into the new culture. “As you make these changes, you can’t let them sit,” Thorwarth says. “The have to become part of the culture of the organization.” Continue to incorporate new goals into the strategic plan based on what you have already achieved. Incorporate the new values and expectations into hiring practices and recruit people who buy into the new framework and the new culture of your organization. Finally, ensure succession planning in the event that change agents move to other organizations to effect change.

Don’t make the mistake of sitting on the sidelines and waiting until you know what healthcare’s new business or reimbursement model will be before initiating change. “You’re never going to know exactly what it is going to be,” Thorwarth says. “We are going to be in a constant state of change, so pick the things you want to change and move ahead.”


  1. Collins J, Hanson M. Great by choice: Uncertainty, chaos, and luck—why some thrive despite them all. 2011. New York, NY; HarperBusiness; 2011.
  2. Seltzer SE,  Lee TH. The transformation of diagnostic radiology in the ACO era. JAMA. 2014;312:227-8