Moving the Immovable Object

Humans resist change: This is the bane of leaders, both seasoned and new to the game—particularly, at the moment, in health care. N. Reed Dunnick, MD, says, “We have many things going on, in our field, that require us to change.” Dunnick, Fred Jenner Hodges professor and chair of the department of radiology at the University of Michigan Health System (Ann Arbor), shared truths and tactics during his segment of “Change Management in Radiology,” presented on December 3, 2013, at the annual meeting of the RSNA in Chicago, Illinois.

At the top of the change list in health care is quality. “The Institute of Medicine has pointed this out to us several times,” Dunnick notes. “When you look at health statistics, we rank in the middle of the entire world, which means undeveloped countries are in the bottom half—but we are nowhere near the top, in most categories.” In response, radiology must learn about quality, develop quality-measurement methods, and engage in outcomes research, Dunnick suggests. 

Right below quality on the list is the cost of health care. “We are at approximately 18% of our gross domestic product,” Dunnick says. “That is not sustainable. Western Europe is at around 11%, Japan is at around 9%, and other countries are at even lower levels.” 

In response, the specialty has attempted to practice more efficiently by increasing RVUs per FTE; this also is unsustainable, in Dunnick’s opinion. “We have to accept fewer perks in our practices and accept lower incomes,” he says. 

Complying with an increasingly lengthy list of regulations also requires radiologists to change. “This is all under the quality banner,” he notes. “Our hospitals are being accredited, our facilities are being accredited, and our physicians are being certified. I think our response, here, is that we must comply with these regulations, and I encourage everyone to participate in maintenance-of-certification programs.” 

Patient-centered care represents another change mandate, he says. Radiology has responded by improving hours of operation, patient safety, and report timeliness. With greater patient access to reports, radiologists will find themselves in a growing number of conversations with patients themselves.

Practice patterns, already in flux, must change even more. “We are having to work more and more in shifts, and we have to be more careful with those reports. Patients email me and say, ‘I didn’t really have a such-and-such,’ and they’re looking at their history. It’s a different environment than we are used to,” Dunnick says.

Change Tactics

To be successful in changing an organization, understand that culture trumps strategy. Culture is the set of shared values, goals, and practices characterizing our institutions or organizations; you will not find it in the organizational mission statement or the strategic plan. 

Dunnick offers the example of the section of Interstate Highway 94 that connects Chicago with Detroit, Michigan. “The speed limit—the strategic plan, if you will—is 70 mph,” he says. “The culture, however, is that the speed limit is merely a suggestion: I drive 75 mph, but I am careful to stay out of the left lane because, in practice, the speed limit is really 80 mph—and it seems the highway patrol has accepted that.”

Sell the problem before you sell the solution, Dunnick recommends. Bring together the thought leaders and develop a consensus on where you are and where you want to go. “When you do this, you don’t want just the people who are talking the party line,” he says. “You want those outliers’ opinions. We need them to buy into the change, but we also need to find out why they are outliers. Do they have opinions to which we need to pay attention?”

Dunnick’s department works (in teams) to develop lists (called stop-do lists) of activities that do not add value. For example, patients arriving at the radiology department typically have already registered in at least two places—the front desk and their physician’s office—and they are asked to check in again. “This gives us multiple chances to make an error, and we usually take advantage of those opportunities,” he quips. “How can we streamline this process?”

Complementary lists of new activities to engage in are also developed, and he urges leaders to celebrate the wins. “As we go along, there will be plenty of resisters who are used to the old way,” Dunnick says. “If we make progress, it is very important to celebrate those wins—to empower supportive groups and groups that are doing well. Help them, reward them, and recognize them.” 

Don’t fail to specify time frames for each project, or it will drag on, and be sure to share information on strategic initiatives. “We need to be very transparent, and if possible, provide metrics that we can measure ourselves against,” Dunnick adds.

Changing Cultures

Dunnick has used a tactic that he refers to as the leaning elephant to make incremental changes: “I lean on a group to make a change,” he says. “It makes a small change, and I move over; it makes another change and another change.” 

In order for an organization to embrace continuous quality improvement (versus small, episodic changes), the culture has to change. “We’ve done Six Sigma™, we’ve done the Toyota Way, and we’ve done lean management,” he reports. “It’s the culture that’s got to change in order for these tools to work.”

There are tangible and intangible manifestations of culture, and the leader must reflect that culture. The tangible manifestations of culture, such as dress and department decor, are easy to discern. The intangible manifestations of culture are more critical and involve how problems are handled; how success is celebrated; who the stars of the department are; and whether the atmosphere is one of mutual respect, in which people can be open and honest with one another.

“Our strategy consists of the services we provide, the processes we use, and the outcomes,” Dunnick notes. “Our culture is made up of the people, and it’s the culture—not the strategy or vision—that is the most powerful factor in any organization.” His advice to radiology chairs who are taking new positions is to do nothing until they understand the culture; assess whether the culture is viable, in the current health-care climate; and see whether it is consistent with the strategic plan under development. 

“Can we continue to work from 8 am to 5 pm in a 24/7 environment?” Dunnick asks. “I think we all know the answer to that: We can’t continue with those schedules. Each organization has a different culture—each with positive aspects. I think, ultimately, the answer has to be a patient-centered approach.”

When implementing change, recognize the human components. “That’s what we are: human,” Dunnick says. “Recognize the people (the employees). Everyone will be anxious about change. Seek input, and let the everyone be heard. I think that’s very important: People feel better if they’ve been able to express themselves, even if the ultimate decision is not in favor of the direction in which they want to go.”

Develop a plan, and communicate that plan very clearly, Dunnick recommends. “Successful organizations undergo these continuous changes, monitor their environments, and often have a series of small steps,” he says. “Other organizations have more bumpy, incremental changes, with intermittent periods of peace before a bigger change. I recommend the former method: constant improvement.” 

Reference:

1. Wilensky GR. Developing a viable alternative to Medicare’s physician payment strategy. Health Aff (Millwood). 2014;33(1):153-160.