Editor’s Note: Healthcare is subject to continuous regulatory change, and the theme of this issue—the ICD-10 transition—is an excellent target for the process Dr. Lexa discussed at RSNA: managing change when you have limited control. For radiology practices meeting the ICD-10 mandate, the objectives go beyond meeting regulatory requirements and include maximizing reimbursement, minimizing impacts to cash flow and improving patient outcomes with better clinical histories. As Dr. Lexa walks you through the phases of change management, consider how you can sharpen your ICD-10 compliance to better manage this complex transition—before the one-year grace period ends in October.
How do you lead change—even when you’re not in charge? The answer to that question is both simpler and subtler than one might think, and it’s readily applicable to radiologists, radiology business managers, radiology technologists and everyone else within the sphere of medical imaging.
That’s according to Frank Lexa, MD, MBA, who explored the matter in some detail at RSNA 2015. His talk, “Practical Techniques for Leading Change in Radiology,” part of a hospital administrator’s symposium, drew from his long and varied background as a teaching radiologist, a marketing professor at The Wharton School, a venture capitalist and, as of last summer, the chief medical officer of the ACR’s Radiology’s Leadership Institute.
Underscoring how closely he can relate to those who lack direct responsibility for leading change, Lexa recounted the first major healthcare project in which he had a hand. As a fellow in neuroradiology, he was tasked with rationalizing his department’s carotid endarterectomy pathways by documenting outcomes, quality and cost.
“Neuro fellows weren’t very powerful in the hospital,” Lexa explained. “We spent a lot of the day being told what to do. And yet we were able to actually do a great project.”
He then presented a five-phase plan, stressing that it pertains primarily to leading change by taking on specific projects. “Most of what you are going to do in change management is projects,” he said. “And these don’t have to be huge projects. This is designed for both major revenue-impacting projects and bite-size ones that you can do at any level in your career.”
Lexa outlined five phases of change leadership. Based on a book by Roger Fisher and Alan Sharp called “Getting It Done, How to Lead When You’re Not in Charge,” they are summarized below.
Leading begins with a clear aim, Lexa said. He pointed to the usefulness of taking the “SMART” approach, which calls for setting a goal that is specific, measurable, attainable, realistic and timely.
“If you can come up with aims that meet the SMART criteria, you are actually ready to invest your time in the project,” he said. “If not, you have to keep brainstorming and talking.” Lexa described a radiology department that came to him with the decidedly fuzzy goal of being a better radiology department during a recent consulting project.
“Being a great radiology department is a good thing to do, but that’s a bad way to start a project,” Lexa said, adding that the department also sought to “provide better service.”
“What does that mean? A lot of our service involves trade-offs,” Lexa said. “If we are going to read faster, other things might suffer. If we decide we are going to be a high-touch department, we have to rethink our productivity. You have to think about the trade-offs.”
The revised department’s goal was improving report turnaround time. That still was no bulls-eye, but it did represent a step in the SMART direction.
How about seeing that all the rule-out-stroke CTs in the ED are reported back within 10 minutes of completion? Lexa suggested. “That’s a good way to start. Now we’ve got clear purpose and a measurable goal.”
Here Lexa pointed out that, sometimes, we all do things reflexively, without stopping to think about what, exactly, we are doing.
For example, a carrot-and-stick approach might help meet the 10-minute goal for reading rule-out-stroke CTs in the ED, but it’s not likely to bear much fruit over the long haul.
He urged those who would lead change to think in terms of forming and guiding teams. “If you’re smart, you are going to also include the people in the emergency room,” he suggested. “They’re the first people to catch these folks who are coming in with rule-out stroke. It may mean bringing in the transport people. Your nurse practitioners and your technologists are going to be important.” Think, also, Lexa said, about how to implement the project and quantify its results.
“Let’s say you come up with a good plan, and you implement the changes in the project,” Lexa said. You’re going to have to pay very close attention,” he continued, “because some of the smartest things that you are going to get out of the project are what you learn while you’re doing the implementation.”
He gave as a real-world example of a rule-out-stroke CT improvement project he was part of earlier in his career. After the team got the procedure down to 10 minutes as a matter of practice, the ED started changing the definition of a stat examination—and the number of “strokes” in the city “skyrocketed” overnight.
“All of a sudden…pretty much everybody who was drunk and fell down was suddenly a stat exam and got fast-tracked,” Lexa recalled. Adjustments were made and, along the way, the practice learned that the nurse practitioners and technologists were often the most important people in determining whether or not a CT was categorized as a stat exam.
It’s not enough just to have a great idea.
“I have lots of ideas about how to improve service in radiology, but I have to constrain them to what is achievable,” Lexa said. He stressed the criticality of engaging the participants and receiving affirmation that they do indeed wish to work together on the project.
“We need to work together, pull a team together, get people to do the right things and then assign roles and tasks,” he said. “A big part of these types of projects involves radiology collaborating with other elements within the hospital.”
Once the project is completed, do an after-action analysis, as the military calls it, Lexa advised. “Find out if you had the right people,” he suggested. ‘Were people helpful? Did they talk a good game but not get anything done? What did you do well? What went wrong?”
Certainly the ED changing its definition of a stroke protocol was an important thing to watch out for in the example described earlier, Lexa said. If his team had not done a 360° feedback loop, it may not have discovered that the stat stroke protocol was being widely applied by technologists and nurse practitioners.
Lexa closed by summarizing the simple but powerful formula behind effective change management: Build great teams, have a plan, and keep using it and improving it.
“I think it was Eisenhower who said that plans are worthless, but planning is everything,” he said. “You can change your plan on the fly, but if you don’t have a plan you’re going to get into trouble.
“Don’t be afraid to lose little fights. What matters is winning the war. And it’s a good way to develop leadership skills. Plan to lead and learn to lead.”