In a world marked by growing data dependency, radiology practices looking to excel in things that really matter must look past their performance metrics and consider, in depth, the quality of their culture.

Making the case for conducting such an exercise is Richard Gunderman, MD, PhD, MPH, of Indiana University.

In an opinion piece published Feb. 9 in Academic Radiology, Gunderman, writing with co-author Aleksandar Alavanja, argues that equally important to metrics, if not more so, are intangible factors such as radiologists giving their buy-in to the clinical mission of the practice, sensing that their work is making a difference and feeling that they get recognized for doing good work.

To introduce their supporting material, the authors go to that most reliable of examples of pure metrics run amok—Nazi Germany under Hitler.

“In terms of the measurements by which national economies, militaries and influence are usually assessed, Germany was a wonder,” they write. “But in terms of culture, something was very rotten at the core of the German nation. It is possible to generate great numbers but fail miserably.”

In like manner, radiologists may produce more but worse interpretations, while the practice might grow fast in personnel, revenues and margins, but treat people “in an ever more dismissive way.”

What is culture in the context of a radiology practice? Gunderman and Alavanja break down the concept into three interconnected components.

1. Communication. The authors point to the use of structured reporting as an example of a standardized system that can, in practice, weaken that which it is, in theory, intended to improve.

“It is not our intent to establish whether structured reporting is a good idea or not,” they write. “But attempts to restrict the lexicon can be dangerous when applied to the management of a radiology practice, particularly when using one set of terms blinds the group’s members to other important realities. Suppose, for example, that a practice adopted a management vocabulary that recognized only financial terms.”

2. Cognition. Ideas have consequences, as evidenced by the current healthcare payment system’s tendency to prioritize performing procedures on patients rather than talking with them, write Gunderman and Alavanja. It would be a mistake, they add, to assume alignment between payments received and care provided.

“When people perform particularly well as radiologists, what are they doing and how do we explain their conduct? Are they working really fast or noticing things that others might miss? Are they attempting to maximize their compensation or focused on helping a patient or a colleague?”

As such stories are shared, the authors write, “they play an important role in shaping organizational culture, and organizations striving to improve should give some thought to the stories they are sharing.”

3. Conduct. “Some radiologists may treat referring physicians brusquely, whereas others may exhibit more warmth and cordiality,” Gunderman and colleague write. “From some points of view, such as statistical process control, permitting such diversity smacks of a quality control problem. From the perspective of culture, however, it is important that individuals have an opportunity to express their distinctive style.”

They add that, in many respects, medical culture mirrors the culture of our society’s culture at large—not least in its discouragement of differences and its rewarding of compliance.

Many radiology practices deliberately or unwittingly seek “to diminish diversity,” they write, “with predictably adverse consequences for organizational vitality and creativity.

The implications of the above for radiology practices and their leaders are deep and far-reaching, write Gunderman and Alavanja.

“Efforts to create dashboards of quantitative gauges by which to evaluate the performance of radiology practices are doomed to fail,” they conclude, “at least for those who suppose that any such dashboard could ever supply all the information needed.”

“Really good work requires more than metrics. Truly effective radiology leaders see past the narrow confines of statistical process control and appreciate that great organizations are built less on metrics than on culture.”