Changing for the Better

In the value-based era, radiologists must step out of the reading room and take on new roles to enhance patient care. To succeed in this new paradigm, radiologists need more than interpretive expertise. They also need negotiation, hospital administration, and financial know-how. However, most medical schools don’t teach these noninterpretive skills. Without leadership training, radiologists can find themselves in dire straits — with a faltering practice, transitioning leadership, and no one to spearhead change.

In 2009, this was the situation in which Radiology Consultants of Little Rock (RCLR) found itself. After one of its two outpatient imaging centers shuttered due to a lack of profit, the group was in debt and its leaders were struggling. Several radiologists left the group while others blamed one another for the group’s problems. “No one wanted to be president,” recalls Scott B. Harter, MD, FACR. “We spent a couple of months trying to figure out who was going to take charge of the difficult situation.” Several of Harter’s colleagues approached him and asked him to take the lead. After consulting his wife and close friends, Harter agreed to run for the position and was elected.

Harter spent the beginning of his presidency stabilizing the group. He helped integrate a new practice manager and spent time re-establishing relationships with administrators at Baptist Health, the hospital RCLR serves. He also developed relationships with the radiology group’s various departments, including accounting and billing. Things were improving for RCLR, but Harter worried he still didn’t have a strong enough business or administration background to succeed in the position.

Scott B. Harter, MD, FACR, used change management techniques gained at the Radiology Leadership Institute to guide his practice towards embracing new technology.

In 2012, Harter received an invitation to the ACR Radiology Leadership Institute® (RLI) Leadership Summit and discovered an opportunity to learn the financial, communication, collaboration, and other leadership skills he needed to strengthen his practice and his team. He also realized that the event would provide an opportunity for him to learn from and network with the specialty’s top thought leaders and business experts.

“The RLI offers leadership programming tailored specifically to radiology,” Harter says. “I immediately recognized that I could benefit from many of the topics presented at the summit, including negotiation and business skills taught mostly by business school professors. It offered me a new perspective that I could leverage as my practice’s president — especially since I am someone who believes all radiologists, regardless of title, should be involved in moving the practice forward.”

With the business challenges ahead of him as president, Harter asked his group to sponsor him to attend the RLI Leadership Summit in 2012. He considers it one of the most important steps he has taken to advance his career and his practice’s transformation from instability to steady ground.

Negotiating for Change

One of the concepts Harter learned at the RLI Summit and valued most was change management, a transformational process that follows key stages to build change over time. It was one of several skills Harter says he has learned through the RLI that helped him make specific improvements within his practice. One of those changes was to implement voice recognition technology with structured reporting into a practice that was a late adopter of that technology.

Starting in 2013, hospital administrators at Baptist Health had approached RCLR about incorporating voice recognition technology into their practice. Although the radiology group knew about the technology, they resisted adopting it, believing it would decrease their efficiency and reduce productivity. Radiologists in the practice wanted to hold onto the status quo — using transcriptionists, with radiologists editing the reports.

“The radiologists had a lot of concerns,” recalls Gerald C. Raymond, information systems manager at Baptist Health. At the time, Raymond was the PACS administrator and spearheaded the hospital’s transition to voice recognition technology. “Some radiologists had used voice recognition technology before and believed it didn’t work well.” Harter says, “Initially we thought that adopting the voice recognition technology would decrease our productivity by forcing us to become transcription editors, and we were resistant to the proposed change.”

Harter knew implementing voice recognition technology would also be an opportunity to initiate structured reporting for the group. Having a standardized reporting process would add value because other departments would consistently know where to look for sought-after information in radiology reports, and physicians could immediately receive clear, significant findings.

At the time, the radiology practice’s process of transcriptionists typing and editing the report before a written copy was sent to referrers left other departments uneasy. “Any time there was a significant finding, the radiologist would give us a verbal report,” explains Wendell Pahls, MD, medical director of emergency services at Baptist Health. “By the time we received the written report, we were concerned we wouldn’t know whether something changed between the initial and final reports that could have an impact on patient care.”

Despite the expected benefits of structured reporting, many radiologists were against that transition, too. “Initially, several people believed their own report structures were better than standard templates,” Harter recalls.

Most departments within the hospital were implementing voice recognition technology, making radiology an outlier. Hospital administrators became somewhat frustrated with the radiologists because they recognized that voice recognition technology would save money and benefit the entire hospital system. Harter worried that RCLR’s resistance made them seem unsupportive of the organization as a whole.

Gerald C. Raymond, information systems manager at Baptist Health, spearheaded the transition to voice recognition technology.

In 2014, the hospital began putting more pressure on providers to align with other physicians and adopt voice recognition technology. Resisting change also made radiology’s image more problematic, says Harter. “Any time information is communicated verbally instead of written down, there is a concern. And by resisting change, they weren’t addressing that,” says Pahls.
Harter says it quickly became apparent that the group either had to take ownership of implementing the technology or be forced to do it. “I knew that this change was inevitable and that I had to convince my colleagues that it was the right thing to do.”

Applying Lessons Learned

Harter saw an opportunity to put some of the change management skills he had gained at the RLI Summit into action. He determined he would use the lessons learned to overcome resistance, get consistency of buy-in from his group, and plan and execute the transition.

Some of the change management principles that the faculty taught at the RLI Summit were first published in a Harvard Business Review article by John Kotter, PhD, business and management thought leader, business entrepreneur, and Harvard professor. In “Leading Change: Why Transformation Efforts Fail,” Kotter lays out a structured design approach to making change and overcoming resistance by those who are holding on tightly to the status quo.

According to Kotter, the steps to successfully leading change are:

• Establish a sense of urgency
• Form a powerful guiding coalition
• Create a vision
• Communicate the vision
• Empower others to act on the vision
• Plan for and create short-term wins
• Consolidate improvements and produce more change
• Institutionalize new approaches

Harter acknowledged that “change is hard, and you often see it fail more than it succeeds.” He was determined to succeed and decided to follow Kotter’s approach to implement the voice recognition system in his practice. “Convincing the group to change was smoother and easier because we followed the change management steps, got the right people together, and paid strict attention to the details,” he says.

Applying Change Management Skills

Following Kotter’s principles of change, Harter initially worked to understand the issue better. He connected with radiologists across the country whose practices had already implemented the voice recognition technology software and solicited opinions about the transition process and using the technology. “I heard lots of people saying it was not as difficult as they imagined to make the transition. Those who were most successful advised committing considerable administrative time toward group communication and to the development of voice recognition templates.”

Harter also talked to several people in his own practice who had used voice recognition — including board members and younger radiologists who had used the technology in residency. And he recruited people to collaborate with him on the transition group.

From that point, Harter says, establishing urgency was easy. “I went to my board and told them we would continually get pressured to do this and that it was in our best interest to be proactive about it. That way we’d have the most influence in installing the system that worked best for us,” he notes. “Otherwise, we’d be coerced to use a system we were unfamiliar with and might not like.”

With board members receptive to the idea, Harter took steps to further educate his guiding coalition about voice recognition technology. He arranged for board leaders to attend professional conferences and site visits to learn about various voice recognition systems, and the group identified vendors they thought would best fit the radiologists’ needs. “We spent time understanding what different vendors were offering,” Harter explains. “We weighed the pros and cons, and we spoke with practices who had implemented different systems. After narrowing the field, in cooperation with hospital administration, we had a couple of different vendors do onsite demonstrations.”

Wendall Pahls, MD, medical director of emergency services at Baptist Health, was a great supporter of the radiology department's change to voice recognition technology and to standardized reporting.

This education also helped Harter and the board determine their vision for the change process, the third step in successful change management. “With hospital administration, we collectively decided which vendor to use. We under-stood that implementing voice recognition and structured reports would take a full year from start to finish, and we knew what physician training for it might look like,” explains Harter. “Our goal was to make the change as clear as possible so that radiologists wouldn’t be deterred by unknowns.”
Convincing the Practice

Next, Harter and the board communicated their vision. In a corporate meeting in January 2015, they explained their decision to the rest of the practice, as well as the timeline. “One of the reasons everyone was so skeptical — and remained skeptical — was that they were afraid of the unknown. So, it was my goal to help explain the technology and process as much as possible,” explains Harter.

For the next year, the voice recognition project was placed on each agenda for every board meeting and corporate meeting to keep the project at the forefront of group members’ minds. “We talked about where we were on the time-line and what progress we’d made. That way, everyone knew the change was coming, and there would be no surprises,” he says.

From there, Harter engaged several colleagues who were familiar with voice recognition software and understood its potential advantages to help lead the change. Harter named a point person, a radiologist who was tech-savvy and could talk about the benefits of voice recognition software. He also got section leaders within the radiology practice involved.

This powerful coalition built structured report templates, which each section leader vetted through their own areas. Harter also arranged training for a transcriptionist on the voice recognition software so that she could provide support and answer additional questions. “Prior to that, she was in danger of losing her job, but we found a way to empower her to find a new role in the practice,” explains Harter. “Our internal IT company associates were also trained in the technology.”

Harter and his coalition also spent time talking to members of the practice who weren’t on board with the project. Knowing it would be more effective coming from multiple sources, Harter asked several members of the practice who understood the technology and were positive about it to allay fears in the group and convince them the new technology wouldn’t hurt their practice.

Knowing that this change process would take time out of everyone’s schedules, Harter gave his team administrative time for these activities. “They were excited about it,” Harter notes. “It was a fine opportunity for established leaders to increase their stature and for young leaders to emerge.” The approach worked, convincing many skeptical members of the practice that adopting voice recognition technology was the way to go.

Structured reporting implementation took a little more effort. “I had to assert the influence and power of the board — we told resisters it was a mandate, not a choice. In some cases, we really had to give them some tough love if they refused to use the report template. And they would have to explain to me why they believed their report structure was better than the one the team developed,” says Harter. “Eventually, all of our members adopted the templates.”

Achieving Victory

Due to the collective efforts of the board and the section leaders, more and more of the group signed on to embracing the technology and report templates. Three months before the technology went live in the hospital’s radiology department, they installed the voice recognition software in RCLR’s remaining outpatient office to get all of the radiologists familiar with using the software. “We made sure every single doctor rotated through the office so that they could experience the technology and could call on IT support if they were stuck,” Harter says. “They ended up feeling more comfortable with the technology, and this way, there wouldn’t be any surprises to them during the hospital’s rollout.”

The result of all the communication and the practice was an overwhelming success. RCLR stuck to its timeline and switched completely over to voice recognition software with no transcriptionist backup in one day on Feb. 2, 2016 — moving completely over to the new technology and structured reporting. “Radiology did amazing work. By eliminating the need for transcription services so quickly, they ensured patients would get faster, more standardized results. Having a quick turnaround, accurate results, and standard formatting are valuable things the radiologists can provide to speed patient recovery, and Dr. Harter helped introduce that here,” says Raymond.

Despite their initial resistance, the radiologists were pleased with relatively how little impact the change had. “Over time, productivity actually improved, and we weren’t having to spend time after hours signing and editing reports,” says Harter. Feedback from the other departments was also very positive. “The perception that we were getting a more thorough read of the report was extremely comforting,” adds Pahls. Says Harter: “The hospital was excited that we had been able to accomplish the task and get on board. We were seen as being part of the team, supportive of the hospital, and administration strongly supported us. We received lots of positive feedback.”

Looking to the Future

The lessons Harter learned from the RLI don’t end with change management. Harter continued to apply leadership skills to ongoing challenges and changes within the practice. For example, Harter leveraged the success of the voice recognition process to continue making changes within the practice, including adding clinical decision support technology in 2017.

Although Harter stepped down from his presidency in January of 2020 to prepare for a move to the local teaching hospital, he continues to advocate for radiologists learning how to lead. “Taking on a leadership role was one of the best decisions I ever made, but I couldn’t have been as successful without the skills I learned through the RLI,” Harter says. “The fundamentals I learned through the RLI carried me through my tenure as president and allowed me to lead our practice back to stability. The overall experience was a platform from which I was able to become a more effective leader.”

Now Harter is focused on mentoring the next generation, using what he learned through the RLI to inspire his col-leagues and empower them to take on leadership positions of their own. In recognition of the value that the RLI provides, RCLR now sponsors a radiologist to attend the RLI Summit each year to build leadership skills in the practice. “The RLI has been a valuable investment in developing new leaders in the practice,” Harter says. “The opportunity for new leaders to emerge is embodied by the ascendance of the new group president Dr. Greg Baden.”

Harter believes all radiologists should make leadership a priority. “I think it’s important for everyone to learn these skills,” Harter says. “Radiologists must do more to demonstrate that they’re willing to step out of the reading room to lead change and enhance the care we give our patients. Acquiring communication, negotiation, collaboration, and other leadership skills will position radiologists for success well into the future.”