Strong Leadership in the Era of Value-Based Care

Scott Hazelbaker, CRA, MS, remembers a time when leaders in the radiology industry were unapologetically firm and new hires were expected to do as they were told, no matter what.

“I got out of X-ray school in 1987 and was in an X-ray department back when leadership had a whole different approach,” he says. “It was an initiation when you were a new employee, and the feeling at the facilities was, ‘you better be loyal and do what I say.’ There was a little bit more fear and intimidation, and it was the driving force to motivate employees. It worked, because if you wanted a job and a paycheck, you had to comply.” Paying your dues was part of the fabric.

Hazelbaker has watched leadership in radiology become more friendly and welcoming since those early days. “It shifted over the years to, ‘if you want to keep employees, you better meet their needs,’” he says.

Hazelbaker is now a leader himself, working as the director of radiology at Providence Alaska Medical Center in Anchorage, Ala. Effective management today, he says, includes transparency, honesty and open communication. Hazelbaker presented on leadership strategies at the AHRA 2016 Annual Meeting in Nashville, Tenn. The way he sees it, both CEOs and directors must establish a sense of trust among employees. Compassion can play a big role as well—both to keep employees happy and to keep patients coming back. 

“It makes perfect business sense to have a department that is positive and friendly,” Hazelbaker says. “A lot of people see being positive and friendly as being about morale or to increase scores, but it’s also about the bottom line. The only way you are going to stay in business is to provide not only quality, but extremely friendly compassion.”

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Common qualities of an effective leader

So which management tactics and styles work best? And which are recipes for disaster? Several experienced leaders spoke with the Radiology Business Journal, sharing their thoughts on what, exactly, it takes be a successful leader in today’s imaging industry.

Many themes and adjectives emerged over and over: Staying positive, having vision, being adaptable yet consistent and being a good communicator.

To Geraldine McGinty, MD, MBA, vice chair of the American College of Radiology (ACR) Board of Chancellors, leadership starts with forward thinking and adaptability.  “For me, a positive leader is someone who is very forward-thinking and adaptive, someone who is generous and interested in developing the people who work with them, someone who believes in diversity and inclusion, and someone who really walks the walk and puts patients at the center,” she says. “It’s also somebody who is inspiring and who understands the importance of being influential. If you have all of those things, I think you have a very effective leader. When I think of the people who I’ve worked with and who have inspired me—they haven’t all had all of those qualities, but they’ve had many of them.”

Alexander Norbash, MD, chair and professor of radiology at the University of California, San Diego School of Medicine, echoes back to Hazelbaker’s vision, emphasizing the importance of communicating honestly and openly with your staff.

“The leader has to be consistent, on message, and a clear communicator,” Norbash says. “You have to talk about where you are heading, you have to say it consistently, you have to create a crystallized vision that others can follow, and you have to set an example. If you are hypocritical, you will not have a buy in from the individuals around you. If you change the message too often, you have to realize there will be progressively greater lags in others following you or believing in your vision.”

Norbash also says a good leader should always be wary of making too many last-minute changes. Both organizations and individuals grow tired of this behavior, and you do not want to switch gears without a compelling reason to do so. Instead, be consistent and stay on message.

“If you go too fast, you will lose them and they will stand still and stop moving,” Norbash says. “If you go too slow, you are not representing a change mandate and they will lose faith in your leadership.”

In addition to his years of experience in management, Norbash has written widely on the topic, delivered presentations about it and encountered countless other opinions as a member of the Journal of the American College of Radiology’s editorial board. One of his biggest takeaways from all that research, he says, is that leaders should remain calm and collected, even in times of crisis.

“Have a steady and consistent approach to how you deal with crises and problems that allows you to solve them with a cool head,” Norbash says. “And that helps you frame the rest of your life. It helps you think in a more structured and ordered fashion about the trajectory of what you are accomplishing and whether it is effective or ineffective. So when you study leadership, you’re continuously examining the framework of what you do rather than simply the details of what you are doing.”

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Roll with the changes

Leaders in radiology also must be prepared to handle the rapid-fire changes that go along with the specialty. Policies, technologies and exam recommendations and protocols are evolving all of the time, often leaving employees of groups, departments and private practices uncertain of where things are headed. Uncertainty can breed anxiety—and that’s where a strong, committed leader steps in.

“You have to reassure people and help them understand they are in an organization where, if you don’t know everything now, there is a process to find out,” McGinty says. “Giving them a sense that change is possible is important, and use lots of communication and lots of different ways to communicate.”

McGinty uses the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) as an example of how to reassure employees during big periods of change. When MACRA was first announced, she says, the ACR didn’t have a lot of information, but it told its members what it did know, how they were moving forward based on that information, and that they would continue to provide updates as time went on. “It was a lot of communication,” she says. “A lot of saying, ‘we do have your back.’”

Hazelbaker believes it is the leader’s job to “quell the fear of the crew” and keep everyone calm during rough transition periods.

“If there’s a new PACS or RIS, for example, there’s going to be a lot of pushback, because people like how things used to be,” he says. “Any time there’s change, it takes a lot of effort and time, and it’s semi-disastrous at first. And then over time, it becomes nice, and over more time, it becomes great.”

Work together, ‘play to win’

Leaders should also remember to always encourage free and open thinking, says Chris Tomlinson, MBA, CRA, senior director of radiology at the Children’s Hospital of Philadelphia, executive director of radiology at Radiology Associates of the Children’s Hospital and finance director of the AHRA Board of Directors. Strong leaders get and keep everyone on the same page while still encouraging employees to speak their minds. When nobody speaks up, he adds, it means you’ve created “artificial harmony.”

“You have to be interested in different perspectives and where they are coming from;” Tomlinson says. “You have to be very open. Getting people aligned doesn’t just mean you set the course and force. To facilitate that group and make everyone understand they are being heard requires a lot of diplomacy.”

Effective leaders also need to know how to deal with diversion and discourse. Frank J. Lexa, MD, medical director of the ACR’s Radiology Leadership Institute (RLI) and author of the book, Leadership Lessons for Health Care Providers, notes that it’s perfectly fine for radiologists to disagree with their supervisors when behind closed doors. Once the doors are open, however, that dynamic must come to an end.

“It’s probably very healthy for people to feel that, in a closed meeting, they can bring in different opinions, have frank discussions and examine options,” Lexa says. “But once that decision is made and once they are out of the room, even if they were bitterly divided behind closed doors, you want them to act like a team and play to win. That means no more arguing.”

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Training the leaders of tomorrow

Lexa, a longtime diagnostic radiologist who currently works as an adjunct professor of marketing at the Wharton School of the University of Pennsylvania and the Spain and East Asia regional manager for the Wharton Global Consulting Practicum, has been in his position at the RLI since July 2015. Since then, he has seen pressures increase across the board for radiologists—to cut more costs and comply with more policies. And no doubt, those pressures will continue, even accelerating in the near future.

It was those mounting pressures that brought the ACR to establish the RLI. In addition to being the voice of radiologists during negotiations with policymakers, the ACR wanted to provide more specific support in training the next generation of leaders.

“We recognized that, despite how effective we were, we needed to support radiologists in terms of getting them leadership training,” McGinty says. “This was always important, but it has become more and more important as we’ve seen healthcare systems consolidate and physicians and radiologists become not as automatically involved in decisions around things like equipment purchasing, the direction of the healthcare system and the kinds of payment models to adopt. So it was important to help radiologists be more effective both nationally and locally, because of course, the two are tied.”

RLI’s mission is “to prepare leaders who will shape the future of radiology to ensure quality, elevate service and deliver extraordinary patient care.”  That means a collection of formal classes, webinars and face-to-face courses that focus on less clinical skills, giving radiologists skills they need to make it to that next level in their careers.

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“Most radiologists can benefit from what we’re doing with the RLI,” he says. “Even if they have zero interest in leadership, and their ideal job would be sitting in their basement reading studies, they would still benefit from understanding what it is leaders do, how to be a good citizen in the group, and how to support their own leaders.” 

Mentorship is one more key ingredient RLI offers to take leadership to the next level, Lexa adds.  In addition to participating in the RLI, radiologists are gaining perspective by taking part in mentor and mentee relationships.

“I think mentoring is an example of one of the things we don’t do enough of in radiology,” says Lexa, who gave a presentation on mentors at RSNA 2015. “If you compare us to many other industries like, say, the military or large police forces, most of them have mentoring. And probably the best mentoring is when someone just does it as opposed to a formal program where it’s, ‘here are three people, these are their names, you are their mentor.’”

Being A Part of the Conversation

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As healthcare delivery continues to prioritize value over volume, radiology finds itself at a crossroads that may very well define its role as a specialty for decades to come. It is a time for leadership to step up, McGinty says.

“A lot of the value-based payments have been targeted at primary care and managing chronic conditions, but I think the opportunity to improve care and reduce costs through more appropriate imaging is something that has not yet been fully leveraged,” she says. “We haven’t implemented the clinical decision support program yet, and even in this MACRA environment, we’re not using metrics that are ideally relevant to radiologists.”

McGinty says it comes down to whether she and her fellow radiologists are ready to step forward and be a part of the conversation. The battle cry is clear: Speak up and be heard or watch as other stakeholders gain all the influence.

Taking the lead on enterprise imaging projects is another way to have radiology’s voice heard and influence solidified, Tomlinson notes. Radiology departments need to be strong leaders, guiding the vision of enterprise imaging throughout the health system.

“At our institution, we’re leading the enterprise imaging strategy, the management of those images and where they are stored,” Tomlinson says. “It’s a perfect example of an area where we’re being looked at not just to make our part look solid, but to lead hospital-wide initiatives.”

This visibility locks in the radiology department as an indispensable part of the hospital and not just another department looking for funding. It is an enabler for greater clinical, operational and financial excellence.

“Instead of competing for equipment and money to buy PACS and that kind of stuff, now we’re helping the hospital save money by coming up with an enterprise imaging model,” Tomlinson says. “It’s about seeing the big picture and understanding that you’re not just looking out for yourself. You’re not seen as a radiology group just trying to get more money from the hospital. Helping to make these changes is how you become that valued member and how you become viewed as a partner.”