Decatur Morgan Hospital

Brandon Fisher

Medical Innovation Authority

When I first entered leadership in radiology, being a successful imaging director was largely about being a strong clinical and operational leader. You needed to understand your modalities, manage your staff, maintain your equipment, control your budget, meet regulatory requirements, and make sure patients moved efficiently through the department.

Those responsibilities have not gone away. If anything, they have become more complex. What has changed is everything that has been added to them.

Today’s imaging director is still responsible for the clinical operation. But the role now reaches into information technology, workforce strategy, capital planning, construction, finance, regulatory compliance, patient access, data analytics and increasingly, artificial intelligence. Decisions that once may have involved selecting a piece of imaging equipment can now require months of planning involving IT infrastructure, interfaces, cybersecurity, construction, service agreements, software licensing, data storage and integration with other hospital systems.

Staffing is a good example of that evolution. Earlier in my career, staffing was not nearly the challenge it is today. There were more technologists available and competition for staff was significantly different. Today, particularly since COVID-19, we face technologist shortages while also adapting to a workforce looking for schedules that better fit their lives—four 10-hour shifts, three 12-hour shifts, Baylor shifts and other alternatives.

Technology has undergone an equally dramatic transformation. Imaging services is now one of the most technology-dependent areas of the hospital. Picture archiving and communication system (PACS) is only the beginning. Quality-control applications, analytics, advanced processing, AI, interfaces, servers, data storage and integration with the electronic medical record have become part of our daily environment.

That means an imaging director no longer has the luxury of saying, “That’s an IT issue.” We do not have to be IT engineers, but we need to understand enough to ask the right questions. How will the system interface with PACS and the EMR? Where will the application reside? Who provides the server? How much storage will be required? What happens during downtime? What are the ongoing licensing and support costs?

Even adding a single new imaging service demonstrates how involved the role has become.

Consider implementing amyloid brain PET/CT imaging for Alzheimer’s disease evaluation. On the surface, it may sound as simple as developing a protocol and adding a new exam to the schedule.

In reality, the imaging director has to understand the entire process from beginning to end. Do we have access to the appropriate radiopharmaceutical, and what purchasing or vendor agreements are required? Do we have the necessary software to process the study, and does that software need to be purchased, installed, interfaced, or integrated into the existing imaging environment? Are the technologists trained to perform and process the examination? Are the radiologists prepared to interpret it? How will the exam be built in the EMR and billing systems? Are the appropriate charges established, and do we understand the requirements necessary to obtain reimbursement?

“Successful imaging leadership still comes down to people—supporting our teams, making thoughtful decisions and never losing sight of the patient at the center of it all.”

A new service is not truly ready simply because we can acquire the images. We have to make sure we can perform it, process it, interpret it, charge for it, and get reimbursed for it. Missing any one of those pieces can mean investing significant time and money into a service that cannot function as intended. That is why today’s imaging director needs enough knowledge of technology, clinical operations, contracts, IT infrastructure, physician workflows and revenue cycle to see how all the pieces fit together.

That understanding matters financially as well. I have inherited projects where significant expenses were overlooked during the initial planning. Few things are more difficult than returning to hospital leadership for additional funding after a project was approved based on what everyone believed was a complete cost. Understanding the technology behind the project has therefore become part of responsible financial leadership.

A recent hospital acquisition demonstrated just how broad the imaging director’s role has become on an even larger scale. Our organization assumed responsibility for a small rural hospital and began transitioning it into an urgent care and diagnostic center. From an imaging perspective, that meant much more than assuming responsibility for another department. We had to transition employees into our processes and policies, establish new sites and cost centers within the EMR, upgrade software and storage, migrate imaging studies into PACS, review contracts and integrate the operation into a larger health system.

The technology was only part of the challenge. Bringing employees into a new organization requires leadership. You cannot simply walk in and say, “This is how we do it now.” You need to understand their processes, recognize what they may already be doing well and determine whether some of their practices could improve the larger organization. Most importantly, people need to feel that they are becoming part of the team rather than simply being absorbed by it.

Capital planning requires the same long-term perspective. I work from a five-year plan based on equipment age, functionality, emerging technology and potential new service lines that could benefit the communities we serve. Imaging equipment represents some of the largest capital investments a hospital makes, and replacing aging equipment can compete directly with opportunities to introduce new services. Even the best plan must remain flexible because an unexpected equipment failure can quickly take priority over planned capital spending.

Patient access is another responsibility that extends well beyond scanner availability. Scheduling may be a patient’s first meaningful interaction with imaging services. Every imaging examination has different preparation requirements, clinical considerations, arrival times and expectations. Giving scheduling teams the knowledge and tools to communicate those differences correctly can directly influence the patient’s first impression of their imaging experience.

Leading multiple locations adds yet another dimension. A director cannot be everywhere, which makes developing strong managers and supervisors essential. Those leaders need the ability to handle local issues while also knowing when something needs to be elevated. It also makes succession planning critical. If we advance in our own careers, we should not leave behind a department that was dependent upon us to succeed. Part of leadership is developing the people who can lead after us.

Despite all of this complexity, my most important leadership lesson is to lead with a servant’s heart. Be willing to help. Treat people with respect. Make sure they know you have their back, and help them understand not only what decisions are being made, but why. When employees understand productivity, expenses, supply stewardship and how organizational performance affects the resources available to their department, they become partners in improvement rather than simply employees following instructions.

Looking ahead, I expect enterprise imaging, automation and artificial intelligence to make the role even more complex. Radiologist shortages and greater reliance on teleradiology are already changing workflows. Technologies capable of identifying higher-risk studies and prioritizing radiologist worklists may become increasingly important in improving turnaround times and getting critical studies interpreted sooner.

A successful imaging director today has to be more than a clinical and operational leader. At different moments, we are asked to think like a COO, CIO, construction manager, financial analyst, technology strategist and workforce strategist.

The role has become more complicated, more technical and more strategic. But at its core, successful imaging leadership still comes down to people—supporting our teams, making thoughtful decisions and never losing sight of the patient at the center of it all.