Building a world-class radiology department: identifying the challenges
January 29, 2020
I had the privilege to serve as Chief of the Department of Radiology at Hamilton Health Sciences for two terms and as Chair of the Academic Department for the past 12 years. As Chief, I was recruited to align the provision of radiology services at our three major sites with the new Access to Best Care strategic vision of the hospital, where each hospital would be specialized in order to provide the best expertise to the population we serve.
I thought it would be an easy ride, and that it would take me a few months to restructure, but it turned out that this was an overly optimistic assumption.
During my tenure as Chief, I had numerous challenges to address to move away from a community practice mentality and turn our Department into an internationally recognized academic organization.
Fortunately, I had support from wonderful colleagues, without whom we would not have been able to reach our goal.
First, burnout was prevalent among our interventional radiologists, with a high turnover at one of our sites. Coming into HHS with a fresh eye allowed me to see areas of dysfunction where quick improvements could be implemented – such as organizing a system-wide interventional call, which reduced stress levels and improved the quality of life for our radiologists by decreasing the call frequency.
I also found it was very useful to take LEAN 6 Sigma training, as I learned how to improve workflow by identifying the hidden factors which can so easily block an organization.
Secondly, we faced a chronic lack of funding for our department and the need to maintain its equipment at the level required of a leading-edge academic centre. The hospital had committed to a certain amount of funding which would have allowed us to purchase new equipment for the three sites, but it never fully materialized due to ongoing financial constraints.
However, I could participate in strategic planning sessions and advocate for a Managed Equipment Service (MES) arrangement, which would engage us in a long-term plan to evergreen our equipment. It would also allow us to get away from a disastrous situation, where we had to wait for aging equipment to crash before it was replaced as a contingency!
The MES takes the financial burden out of capital investments and places it into the operational budget, where the cost is spread out over time. The cost becomes predictable and there is no need to wait for a contingency in order to acquire new technology.
The scope of MES is variable, and can include not only equipment, but also full services. The MES provider expects to sell the hospital a certain amount of its equipment, usually around 50 percent of the allocation. Ideally there should be a pause at mid-term where the parties can assess if the goals and commitments have been attained and if the solution is viable.
A third challenge involved managing our people. In my experience, there were two major issues:
The disruptive physician. For a leader, this is a draining experience and it can consume a great deal of time. Yet, it’s important to keep in mind that disruptive behaviour may be induced by personal problems, burnout, anxiety, and insecurity. And that the individual can be helped. But it requires time, patience and understanding to identify the causes of disruption and to support the distressed colleague.
Culture is often underestimated. Like many others, I had seen posters displaying an iceberg, where culture is the larger part hidden under the water. Culture is said to “eat strategy for breakfast”, and I believe this is true. The Rogers curve shows that 15 to 20 percent of people are opposed to change, and they will do anything they can to prevent the change from happening. Culture will help them find any and all possible reasons to explain why we cannot change the way we function. How many times did I hear that we always did things the way it is now, and that it worked? So why change?
But often, the culture is more pervasive, and the leader will painfully discover that the entire system is blocking attempts to change. Communication is key, not only conveying and explaining repeatedly the message you want people to understand, but also listening with care to others.
The fourth major challenge was quality and how to improve outcomes. We cannot just wait for complaints and try to fix the gaps. Instead, we must be proactive and work hard to prevent errors from happening.
A recent study at Harvard showed more than 250,000 people die every year from medical errors in the United States, a considerable number, and the Chief’s role is to identify all the steps where critical errors may occur, from booking and check-in to communication of findings and subsequent action.
One of the measures we are implementing is a state-of-the-art, fully anonymized cloud-based peer learning solution to help radiologists learn from errors and misses, and to also benefit from great findings of others. A lot can be learnt from others’ experience and we need to move away from blame and shame, the way airlines did 40 years ago, if we want to see significant improvements in outcomes.
In conclusion, leadership is not an easy task. There are new challenges and opportunities every day. Leadership is not innate and can be learnt; I found useful tools in the LEADS framework in a caring environment, which is now part of our residency curriculum and guides the leader in each step – from knowing one’s self to achieving system-wide transformation. Would I do it again? Certainly yes, mainly with the knowledge I have acquired over the years.
David Koff, MD is Professor and Chair, Department of Radiology, McMaster University in Hamilton, Ontario.