Radiology Leadership | Interactive Dashboard | November 2026
The Leaders Who Make People Believe Again
How radiology leaders turn a shared purpose into a better place to work and receive care.
- 10 steps
- 3 phases
- 24 months
- 20 scored metrics
- 400+ employees, multiple hospitals
Kelly Emrick, DHSc, PhD, MBA, BSRT(ARRT)R
The BELIEVABLE Model at a Glance
Most low engagement scores in radiology are not a verdict on the people who do the work. They reflect whether those people still believe speaking up changes anything, that their leaders mean what they say, and that their daily work connects to something worth doing.
Engagement lags behind belief.
Engagement lags behind belief. Belief is built in a predictable sequence: leaders tell the truth about the current state, anchor the work to a patient-centered purpose, fix themselves first, invite the front line into the decisions, remove the daily friction that makes good people tired, recognize contribution visibly, hold everyone to the same standards without fear, build careers, connect every exam to a patient, and then embed the whole system in a rhythm that does not depend on one personality. Skip the early steps, and the later ones read as public relations. Do them in order and, in the author’s experience, the survey score follows.
The belief gap, in six numbers
The BELIEVABLE Model: ten steps, three phases
Select any step to open its full chapter in the Step Explorer.
The belief chain
- TruthLeaders name reality honestly
- PurposeWork tied to a patient
- TrustWords match actions
- EngagementDiscretionary effort returns
- ReliabilityFewer errors, faster care
- PatientsBetter experience and outcomes
Visible results feed back into belief: every kept promise makes the next request easier to trust.
The Belief Index
Twenty scored metrics, two per step, each worth 0 to 5 points. Ten domains of ten points. Reviewed quarterly, by site and modality.
Illustrative profiles from the report, not reported results.
Five design principles
- 1Truth before visionDescribe the current state honestly before describing the future.
- 2Small promises, kept publiclyBelief compounds from kept promises, not large announcements.
- 3One department, many sitesEqual standards, recognition, and access to leadership, measured by site.
- 4Measure the experience, not the activityWhether staff feel heard, helped, and recognized.
- 5Physicians are inside the systemRadiologists, residents, and fellows meet the same standard.
The operating rhythm that keeps belief alive
- 10-minute modality huddle
- One patient story
- One barrier
- One thank-you
- Leader standard work
- Rounding for connection
- Recognition log review
- Site and modality councils
- “You Said, We Did” board
- Pulse poll
- Belief Index review
- Town halls at every site
- Leader scorecards
- Full engagement survey
- Purpose renewal
- Career ladder review
Every image is a person waiting for an answer.
The leaders who make people believe again never let their teams forget it, and never give them a reason to doubt that leadership remembers it too.
Why People Stop Believing
When belief disappears, the symptoms show up operationally: late starts, travelers filling permanent lines, technologists who stop volunteering ideas, and patients who feel the chill in the waiting room.
Belief is a working judgment
Belief is not optimism. A technologist can be optimistic about her own future and still not believe a word that comes out of the department’s leadership meeting. Belief, in the sense that matters for engagement, is a working judgment that three things are true: leaders will tell the truth, effort will be noticed, and raising a problem will lead to something other than silence or retaliation. When those judgments turn negative, people usually don't quit on the spot. They first withdraw discretionary effort, then stop suggesting improvements, then stop answering recruiter messages.
1.1 The national picture
The broader workforce offers little cushion. Gallup found that 31 percent of U.S. employees were engaged in 2025, unchanged from 2024 and well below the 2020 peak of 36 percent, with the largest declines since 2020 in clarity of expectations and in feeling cared about at work [10]. Globally, Gallup’s 2026 State of the Global Workplace placed engagement at 20 percent, with manager engagement falling from 27 to 22 percent in a single year [11]. Managers, the people expected to rebuild belief, are running low on it themselves.
Healthcare is a partial exception. Press Ganey’s 2026 analysis of more than 2.6 million healthcare employees and physicians found engagement rising from 3.97 to 4.03, the largest gain in eight years [3]. The same report, however, shows that the recovery is uneven and that trust is the bottleneck: more than a third of employees and providers lack confidence in senior leadership, seven of the top ten engagement drivers relate to safety culture, and units with strong climates of trust are 2.4 times more likely to achieve top performance on patients’ overall hospital rating [3]. Press Ganey’s 2025 report concluded that trust, respect, and belonging, rather than pay, were the strongest predictors of engagement and intent to stay [12].
1.2 Why radiology is especially exposed
Chronic staffing pressure
Radiology departments combine three conditions that erode belief faster than in most service lines. The first is chronic staffing pressure. In the 2025 ASRT Radiologic Sciences Staffing and Workplace Survey, CT vacancies rose from 17.7 to 19.4 percent and MRI vacancies from 16.2 to 17.4 percent, while radiography vacancies eased from 18.1 to 15.6 percent; most imaging disciplines remain at or near record highs [4]. Every unfilled line becomes overtime, a traveler, or a delayed exam, and each sends the remaining staff a message about how much the organization values them.
Physician strain
The second is physician strain. About 45 percent of radiologists report burnout in the AMA’s most recent national data, placing radiology fifth among specialties, and hospital-based specialties including radiology performed worse than benchmark physicians on three of five well-being measures [5]. In an earlier Medscape survey, radiologists named lack of respect from administrators, colleagues, or staff as the leading contributor to their burnout [13]. Burned-out radiologists and stretched technologists interact dozens of times a day, and the quality of those interactions becomes the culture. When Cincinnati Children’s surveyed its imaging staff, only 48 percent of technologists, reading room assistants, and child life specialists rated their interactions with radiologists as very good or excellent [14].
Structural fragmentation
The third is structural fragmentation. A multi-hospital academic department is really many departments: different sites, modalities, managers, histories, and often different versions of the same policy. Staff at a community hospital may experience the academic center as a distant authority that sets rules without understanding their reality. Fragmentation lets inconsistency hide, and nothing destroys belief faster than inconsistency between what leaders say and what people see.
1.3 The cost of disbelief
Disbelief has a price. Radiology-specific turnover cost data are scarce, but the closest well-measured comparison is instructive: the 2026 NSI National Health Care Retention and RN Staffing Report placed the average cost of turning over one staff registered nurse at $60,090 and estimated that the average hospital loses about $5.19 million per year to RN turnover [15]. Advanced-modality technologists are also hard to replace, and downstream costs from idle scanner time, overtime, and premium labor add to the total. A 400-person imaging department that loses even ten more people per year than it should is spending real money on a problem that the survey only describes.
Self-check: five symptoms of a belief deficit
Leaders inheriting a struggling department usually recognize these before reading a single survey comment. Check the ones you see.
3. The department: a composite starting point
This report presents the department as a de-identified composite of the setting in which the model was developed and implemented. It is an academic radiology department within a multi-hospital health system: a flagship academic medical center, several affiliated community hospitals, and a network of outpatient imaging centers. More than 400 employees work across radiography, CT, MRI, ultrasound, nuclear medicine and PET, mammography, interventional radiology, and imaging nursing, supported by schedulers, patient access staff, transporters, PACS and informatics analysts, and modality managers. Faculty radiologists, residents, and fellows share the same reading rooms, hallways, and patients.
When the leader arrived, the department sat near the bottom of its health system and its national comparison group on the annual employee engagement survey. Participation was low. Comments described leaders as invisible, decisions as arbitrary, equipment as unreliable, schedules as unfair, and the relationship between technologists and some radiologists as strained. Turnover and vacancies at the community sites were higher than at the academic center, and travelers filled lines that had once been permanent. Patient experience scores lagged in the same areas where staff comments were most negative, which is a pattern the Press Ganey data would predict [3].
None of these problems was unusual. What made the situation difficult was that previous improvement attempts had been announced, partly launched, and quietly abandoned. The staff had learned that new initiatives were temporary. In that environment, a new leader’s first job is not to inspire anyone. It is to become believable.
The Science of Belief
The BELIEVABLE Model is not built on a single study. It is built on the convergence of several lines of evidence about what makes people trust their leaders, find meaning in their work, and stay. The strength of that evidence varies, and the model accounts for those differences.
- TruthLeaders name reality honestly
- PurposeWork tied to a patient
- TrustWords match actions
- EngagementDiscretionary effort returns
- ReliabilityFewer errors, faster care
- PatientsBetter experience and outcomes
Figure 2, rebuilt. Truth and purpose create the conditions for trust; trust releases discretionary effort; engagement shows up as reliability and, eventually, as patient experience.
2.1 Leaders shape engagement more than any program
Gallup’s long-running estimate that managers account for at least 70 percent of the variance in engagement scores across business units is the most widely cited figure in the field [1]. Healthcare evidence points the same way. In Shanafelt and colleagues’ study of 2,813 Mayo Clinic physicians and scientists, supervisors were rated on 12 leadership behaviors, including informing, engaging, inspiring, developing, and recognizing. Each 1-point increase in the composite score was associated with a 3.3 percent decrease in the likelihood of burnout and a 9.0 percent increase in the likelihood of satisfaction, and the division or department chair's leadership rating explained 47 percent of the variation in satisfaction across work units [2]. A systematic review of 129 nursing leadership studies found that relational leadership styles were repeatedly associated with higher job satisfaction, while task-focused styles were associated with lower satisfaction [16]. These studies are observational and cannot prove that better leaders cause higher engagement. They do show that leadership behavior is the most consistently associated variable, which is why the model places “Leaders First” in Phase I.
2.2 Purpose and meaning are not soft variables
A meta-analysis of 44 articles, including 23,144 workers, found that meaningful work had large correlations (r = 0.70 or above) with work engagement, commitment, and job satisfaction, and moderate to large correlations with intentions to withdraw [7]. In academic medicine, faculty who spent less than 20 percent of their effort on the activity they found most meaningful had burnout rates of 53.8 percent, compared with 29.9 percent among those above that threshold, and time on meaningful work was the strongest predictor of burnout in the study [17]. For technologists, the most meaningful activity is almost always direct patient care and the satisfaction of a diagnostic image done right. Purpose work that does not protect time for that activity is decoration.
2.3 Trust has measurable returns
Paul Zak’s research comparing high-trust and low-trust companies reported that people in high-trust organizations described 74 percent less stress, 106 percent more energy at work, 50 percent higher productivity, 76 percent more engagement, and 40 percent less burnout [18]. These are survey comparisons, not trials, but Zak’s list of trust-building behaviors (recognizing excellence, sharing information broadly, delegating, building relationships intentionally, and showing vulnerability) maps closely onto what high-performing healthcare units report. Press Ganey’s 2026 safety analysis adds that among organizations in the top decile for engagement, three of the five largest performance differentiators relate to respect, trust, and confidence in senior leadership [19].
High-trust versus low-trust organizations [18]
2.4 Recognition and action are the proof points
Gallup and Workhuman followed more than 3,400 workers over two years and found that those who received high-quality recognition were 45 percent less likely to have left their jobs [8]. By contrast, Gallup reports that only 8 percent of employees strongly agree that their organization acts on survey results, and it identifies action planning as a top predictor of engagement [6]. Radiology has its own small but useful evidence. A RadioGraphics quality improvement report on pulse surveys in a large academic department found that faculty responses rose from an average of 11 in the first three surveys to 35 in later surveys, while trainee engagement stayed low [20]. At the University of Chicago, a simple daily recognition practice raised wellness survey participation from 21 to 61 percent within a year [21]. These are single-site reports, but they illustrate the same principle: people respond when they see that their voice and their effort register.
RadioGraphics pulse surveys: faculty responses rose from an average of 11 to 35 [20].
2.5 What the evidence does not settle
Two popular ideas deserve more caution than they usually receive. The first is psychological safety. The concept, introduced to healthcare largely through Edmondson’s work on team learning [22], is foundational to the model, but a 2025 systematic review found only nine quantitative studies linking it to objective patient safety outcomes, with five showing a significant relationship and no clear overall conclusion [23]. A review of interventions to improve psychological safety and speaking up found no consistent improvements [24]. The second is just culture. An integrative review of just culture implementation found that most of the literature is theoretical and that leadership commitment, education, accountability, and open communication recur [25]. The model uses both ideas, but it measures them directly rather than assuming that a training session produces them.
A third caution concerns rounding. The AONL and Crucial Learning study of 1,559 nurse managers and 562 clinical staff found that employee rounding had no effect on whether nurses planned to quit within three years; 81 percent of managers said they rounded regularly, but only 36 percent of clinicians said their managers did. Retention was predicted by whether staff experienced care, growth, and help from their manager; nurses who did were 80 percent more likely to stay [9]. The BELIEVABLE Model therefore treats rounding as a tool for connection rather than a compliance metric, and it measures the experience of the person being rounded on.
Rounding: what leaders log versus what staff experience [9]
Psychological safety and objective patient safety [23]
Only nine quantitative studies; five significant; no clear overall conclusion. The model measures safety directly rather than assuming training produces it.
Table 2. The evidence base and its relative strength
| Evidence theme | What it supports in the model | Strength of evidence |
|---|---|---|
| Leader behavior and engagement [1, 2, 16] | Step 3 (Leaders First); leader scorecards in Step 10 | Consistent observational evidence across large samples |
| Meaningful work [7, 17] | Step 2 (Purpose); Step 9 (Link to Patients) | Meta-analytic correlations; strong |
| Trust and transparency [18, 3, 19] | Steps 1, 4, and 5 | Large surveys; correlational |
| Recognition [8, 21] | Step 6 (Value People Visibly) | Longitudinal survey plus single-site reports |
| Acting on feedback [6, 20] | Steps 1, 4, and 5 | Practitioner research and single-site reports |
| Psychological safety and just culture [22, 23, 24, 25] | Step 7 (Accountability Without Fear) | Conceptually strong; outcome evidence mixed |
| Connection over ritual [9] | Steps 3 and 10 (how rounding is done and measured) | Large cross-sectional study |
The BELIEVABLE Model
The BELIEVABLE Model organizes the work of rebuilding belief into ten steps grouped in three phases. The phases overlap, and later steps begin before earlier ones finish, but the sequence still matters. Each phase earns the credibility the next one needs.
Earn the Right to Be Believed
Months 0 to 6 Steps 1 to 3
Tell the truth about the current state, anchor the work in a shared purpose, align the leadership team, and make it visible before asking the front line for anything.
Prove It on the Floor
Months 3 to 12 Steps 4 to 7
Involve staff in the fixes, remove daily friction, recognize contribution, and apply one standard of behavior to everyone. This is where belief is either confirmed or lost.
Make Belief Last
Months 9 to 24 and beyond Steps 8 to 10
Give people a future in the department, connect the work to patients every day, and embed the system so it survives leadership turnover.
4.1 Five design principles
- Truth before vision. Leaders describe the current state honestly before they describe the future. When people don't believe a leader understands their reality, they hear a vision as spin.
- Small promises, kept publicly. Early commitments are deliberately modest and visibly completed. Belief compounds from kept promises, not from large announcements.
- One department, many sites. Standards, recognition, and access to leadership are designed to be equal across the academic center and the community sites, and measured by site to prove it.
- Measure the experience, not the activity. The model measures whether staff feel heard, helped, and recognized, not merely whether leaders held meetings or rounded.
- Physicians are inside the system. Radiologists, residents, and fellows are part of the culture and are held to the same behavioral standards. A model that exempts the most powerful people in the room will not be believed by anyone else.
4.2 How each step is built
Each of the ten chapters that follow uses the same structure. How to design it describes the decisions a leader makes before launching the step. What it measures lists the metrics, their definitions, and their targets; the two metrics marked with an asterisk in each table are the scored metrics for that step’s Belief Index domain. How to implement it sets out actions, owners, and timing. How to track and maintain it describes the review cadence, the warning signs that the step is slipping, and what to do about them. Each chapter closes with a short account of how the department carried out the step.
Table 1. The ten steps
| # | Step | What it does | Build window (Figure 7) | |
|---|---|---|---|---|
| B 1 | Baseline the Truth | Establishes an honest, shared picture of the current state through data and a structured listening tour, and publishes it. | Months 0 to 3 | Open |
| E 2 | Elevate the Purpose | Co-creates a patient-centered purpose that every role can see itself in, and uses it to make decisions. | Months 1 to 4 | Open |
| L 3 | Leaders First | Aligns, selects, and develops the leadership team, and holds leaders accountable for the experience they create. | Months 1 to 6 | Open |
| I 4 | Involve Everyone | Builds shared governance across sites and modalities so the front line designs the fixes. | Months 3 to 9 | Open |
| E 5 | Eliminate Daily Friction | Removes the recurring obstacles that drain good people, and closes every loop with “You Said, We Did.” | Months 3 to 12 | Open |
| V 6 | Value People Visibly | Creates timely, specific, peer and leader recognition, and audits fairness in pay, schedules, and opportunity. | Months 4 to 12 | Open |
| A 7 | Accountability Without Fear | Sets one behavioral standard for everyone, including physicians, and applies it through a fair, consistent process. | Months 5 to 12 | Open |
| B 8 | Build Careers | Opens career ladders, cross-training, and internal leadership pathways so people can grow without leaving. | Months 9 to 18 | Open |
| L 9 | Link Every Exam to a Patient | Brings patient stories, patient experience data, and quality outcomes into the daily work. | Months 9 to 18 | Open |
| E 10 | Embed and Sustain | Hardwires the operating rhythm, the Belief Index, and succession so the culture outlasts its founder. | Months 12 to 24 | Open |
Step Explorer: the Ten Chapters
For every step: how to design it, what it measures (the two scored Belief Index metrics are flagged), how to implement it with owners and timing, and how to track and maintain it.
Baseline the Truth
The first step is to establish a shared, honest description of where the department actually stands, built from data and from the people who do the work, and to publish it. Its purpose is not diagnosis for the leader’s benefit. Its purpose is to show staff, in the first 90 days, that the new leader sees what they see.
1How to design it
A strong baseline combines four sources: the most recent engagement survey broken down to the smallest reportable unit, including every comment; workforce data (turnover by site, modality, and tenure band, vacancies, overtime, traveler use, sick time); operational and quality data that staff experience directly (equipment downtime, schedule changes, add-on volume, delays, incident reports); and patient experience data for imaging. The most important design decision is the listening architecture. The leader plans a listening tour that reaches every site, every shift, and every modality, including nights and weekends, through small-group sessions without managers present, short one-to-one conversations, and an open channel for written input.
Three questions anchor every session: What makes it hard to do your best work here? What should we stop doing? What would make you proud to tell a friend you work here? Leaders take notes in front of people, read them back, and promise only one thing at this stage: that a written summary of what they heard will be shared with everyone by a stated date.
2What it measures
| Metric | Definition or formula | Target |
|---|---|---|
| Listening coverage Scored | Staff who attended a listening session or one-to-one in the first 90 days, divided by total staff; reported by site, shift, and modality | 90 percent or more, with no site below 80 percent |
| Survey participation Scored | Completed engagement or baseline pulse surveys divided by eligible staff | 75 percent or more |
| Baseline engagement profile | Engagement score, percentile rank, and the five lowest-scoring items for each unit | Documented by day 60 |
| Friction inventory | Count of distinct, recurring obstacles named by staff, coded by theme and site | Complete and published by day 90 |
| Trust in action item | Percent favorable on “I believe action will be taken based on the results of this survey” or an equivalent item | Baseline captured; target set for month 12 |
3How to implement it
Check actions off as you complete them; progress is saved in this browser.
| Action | Owner | Timing |
|---|---|---|
| Department leader and chief technologist | Week 1 to 2 | |
| Department leader | Weeks 2 to 10 | |
| Business manager and HR partner | Weeks 2 to 6 | |
| Department leader with an analyst | Weeks 6 to 11 | |
| Department leader | By day 90 | |
| Department leader and site managers | Days 90 to 100 |
4How to track and maintain it
The baseline becomes the reference point for every later measurement, so store it, date it, and never quietly revise it. Listening does not end at day 90. It changes form: small-group sessions become quarterly, and a short pulse micro-survey (three to five items) runs monthly once Step 5 is producing visible results. Warning signs that Step 1 is slipping include falling pulse-survey participation, comment themes that repeat without change, and any site where listening coverage drops below 80 percent. The remedy is the same in each case: return to the floor, in person, and say what has and has not changed.
Elevate the Purpose
The second step turns a list of problems into a reason to solve them. It defines a shared, patient-centered purpose that every department role can recognize as its own, and it makes that purpose the test for decisions. Purpose is elevated, not invented: the meaning is already present in the work, and the leader’s job is to name it and protect it.
1How to design it
The purpose is written with staff, not for them. A design team drawn from every role and site (technologists, nurses, schedulers, transporters, PACS analysts, managers, radiologists, and trainees) reviews the listening themes from Step 1 and the patient stories collected during the tour, then drafts a single sentence that describes why the department exists in terms a patient would understand. A good radiology purpose statement passes three tests: a scheduler, a transporter, and a neuroradiologist can each explain how their work serves it; it names the patient, not the department; and it can be used to settle a disagreement.
The design team also writes three to five behavioral commitments that translate the purpose into daily conduct, such as introducing yourself and explaining what will happen next to every patient, answering a colleague’s call as if a patient were on the line, and never walking past a safety concern. These commitments become the foundation for the accountability standard in Step 7.
2What it measures
| Metric | Definition or formula | Target |
|---|---|---|
| Line of sight to purpose Scored | Percent favorable on “I understand how my work contributes to the care of our patients” (or an equivalent survey item) | 90 percent or more |
| Purpose recall Scored | Percent of staff, in a monthly rounding sample, who can state the purpose in their own words and give one example from their week | 80 percent or more |
| Purpose in decisions | Percent of major departmental decisions whose written rationale references the purpose | 100 percent |
| Meaningful time protection | Percent of staff reporting enough time for the part of their work they find most meaningful (single pulse item) | Baseline, then improve by 15 points |
3How to implement it
Check actions off as you complete them; progress is saved in this browser.
| Action | Owner | Timing |
|---|---|---|
| Department leader | Month 1 to 2 | |
| Design team | Months 2 to 3 | |
| Department leader and design team | Month 3 to 4 | |
| Department leader and business manager | Month 4 | |
| All leaders | Month 4 onward |
4How to track and maintain it
Review the purpose annually at a renewal session where staff asks whether it still describes the work and whether leaders have used it honestly. The most important warning sign is cynicism: if staff start quoting the purpose sarcastically, leaders have made a decision that contradicted it and failed to explain why. Respond by naming the contradiction openly, explaining the trade-off, and showing what you will do differently. Leaders who never visibly sacrifice for a purpose are not believed.
Leaders First
Before asking the front line to change, the leadership team changes. Step 3 aligns leaders on the purpose and findings, sets clear expectations for how they lead, develops the skills they lack, and makes the experience they create for their teams part of their evaluation. Most organizations skip this step, and in the author’s experience, skipping it is a common reason engagement initiatives stall.
1How to design it
The leadership team in an academic radiology department includes modality and site managers, supervisors and lead technologists, the nursing leader, the business and operations leaders, and the physician leaders: the chair, vice chairs, section chiefs, and medical directors. The design starts with a leadership compact that every leader signs, describing what they owe their teams (visibility, honesty, follow-through, fairness, development) and what they can expect from the department leader in return (support, resources, cover for reasonable risk, and candid feedback).
Leader standard work defines the minimum weekly rhythm: time on the floor during each shift pattern, one-to-one conversations with each direct report at a set frequency, a weekly huddle, and a recognition practice. The design deliberately borrows from the evidence on connection rather than ritual [9]: every leader conversation is expected to answer three questions from the employee’s point of view. Does my leader care about me? Is my leader helping me grow? Does my leader help me get my work done?
Leader selection and development are part of the design. Gallup estimates that organizations choose the wrong candidate for manager roles in most hiring decisions [1], and many radiology supervisors were promoted because they were excellent technologists. The department adopts structured interviews for leadership roles, a 12-month development curriculum (communication, coaching, difficult conversations, just culture, data literacy, and finance basics), and peer coaching circles.
2What it measures
| Metric | Definition or formula | Target |
|---|---|---|
| Leader behavior score Scored | Mean direct-report rating of each leader on a 12-item, 5-point behavior scale (range 12 to 60), adapted from the Mayo Clinic leadership instrument [2]: informs, engages, inspires, develops, recognizes, and related behaviors | Mean of 50 or more; no leader below 42 |
| Leader standard work completion Scored | Percent of required floor time, one-to-ones, huddles, and recognition entries completed, by leader | 90 percent or more |
| Care, growth, and help | Percent of staff who agree their leader cares about them, helps them grow, and helps them get their work done (three pulse items) | 80 percent or more on each |
| Leader development | Percent of leaders enrolled in or completing the development curriculum | 100 percent enrolled by month 6 |
| Leader stability | Leader turnover and vacancy in modality and site leadership roles | No unplanned vacancy over 90 days |
3How to implement it
Check actions off as you complete them; progress is saved in this browser.
| Action | Owner | Timing |
|---|---|---|
| Department leader and chair | Month 2 | |
| Department leader | Month 2 to 3 | |
| Department leader and HR partner | Month 3 | |
| HR partner and department leader | Months 3 to 15 | |
| Department leader | Months 4 to 12 | |
| Department leader and HR | Month 6 |
4How to track and maintain it
Leader behavior scores are collected twice a year and reviewed in private coaching conversations, never ranked publicly. Leader standard work is reviewed monthly by the department leader. Warning signs include a widening gap between what leaders report doing and what their staff report experiencing, a site where staff cannot name the last time they saw senior leadership, and any leader whose team scores fall for two consecutive cycles. The most difficult part of this step is acting on the last of these. Staff watches closely what happens to leaders who do not change, and a department that tolerates one corrosive manager will struggle to convince anyone that the compact is real.
Involve Everyone
Step 4 moves from listening to sharing power. It creates a shared governance structure in which front-line staff identify problems, design solutions, and make recommendations that leaders must respond to. Involvement bridges hearing people and proving that hearing them matters.
1How to design it
The structure has three layers. Modality councils (radiography, CT, MRI, ultrasound, nuclear medicine and PET, mammography, interventional radiology, and imaging nursing) address practice standards, protocols, and workflow across all sites. Site councils address the issues specific to each hospital and outpatient center, from parking and break space to local scheduling. A Department Coordinating Council, chaired jointly by a front-line staff member and the department leader, reviews recommendations that cross sites or require resources. Councils are majority front-line, rotate membership on staggered two-year terms, meet monthly during paid time, and include schedulers, transporters, and informatics staff alongside technologists and nurses. Radiologists and residents sit on modality councils where protocols and communication are on the agenda.
The central design rule is that every recommendation receives a written answer within 30 days: yes and when, yes with modifications and why, or no and why. Silence is not an allowed response. An open idea channel, available on paper and electronically at every site, feeds the councils, and every idea gets the same 30-day answer.
2What it measures
| Metric | Definition or formula | Target |
|---|---|---|
| Front-line participation Scored | Percent of staff who served on a council, joined an action team, or submitted an improvement idea in the past 12 months | 40 percent or more |
| Response within 30 days Scored | Percent of council recommendations and submitted ideas that received a written answer within 30 days | 95 percent or more |
| Idea implementation rate | Percent of answered ideas that were implemented in full or in part | Track and report; expect 40 to 60 percent |
| Voice item | Percent favorable on “My ideas and suggestions are seriously considered” or equivalent | Improve by 20 points from baseline |
| Site equity of voice | Participation rate at the lowest-participating site divided by the department rate | 0.8 or higher |
3How to implement it
Check actions off as you complete them; progress is saved in this browser.
| Action | Owner | Timing |
|---|---|---|
| Department leader and coordinating council co-chair | Month 3 | |
| Site managers | Months 3 to 4 | |
| Quality lead | Month 4 | |
| Coordinating council | Month 4 | |
| All councils | Months 4 to 6 |
4How to track and maintain it
The coordinating council publishes a monthly dashboard of ideas received, answered, implemented, and declined, by site. Warning signs include councils that become complaint sessions without recommendations, recommendations that wait in leadership queues, and sites where the same few people do all the participating. Membership rotation, facilitation training, and a firm 30-day clock prevent most of these. When a council declines a recommendation, the leader explains the reason in person at the next meeting; respectfully handling declined ideas still builds belief.
Eliminate Daily Friction
Engagement often erodes in small increments: the scanner that goes down every Tuesday, the badge reader that never works, the schedule posted too late to plan childcare, the order that arrives without the information needed to process it. Step 5 treats these recurring obstacles as the first and most visible test of leadership credibility. Removing them shows leaders that listening wasn't theater.
1How to design it
The friction inventory from Step 1 becomes a ranked list based on two criteria: how many people the obstacle affects and how often, and how quickly it can be fixed. The design produces three tracks. Quick wins are fixed within 30 days, often at little or no cost, and are chosen deliberately to build momentum. Structural fixes require capital, IT, or cross-department work and are scheduled with owners and dates. Not-now items are explained honestly, with the reason and the condition under which they will be revisited.
Every resolved item is reported through a “You Said, We Did” board at each site and in a monthly department message, written in the same plain language staff used to describe the problem. Shanafelt and Noseworthy’s framework identifies workload, efficiency, and resources as core drivers of burnout and engagement [26], and in imaging those drivers are concrete: staffing grids, schedule templates, equipment reliability, protocol clarity, order quality, and the speed of IT support.
2What it measures
| Metric | Definition or formula | Target |
|---|---|---|
| “You Said, We Did” closure Scored | Percent of committed friction items completed by the date promised | 90 percent or more |
| Top-20 friction resolution Scored | Percent of the 20 highest-ranked friction items resolved, or formally explained, within 90 days of being ranked | 75 percent or more |
| Schedule stability | Percent of schedules posted at least four weeks in advance; count of short-notice changes per FTE | 100 percent posted on time |
| Equipment reliability | Unplanned downtime hours by scanner and site | Improve 20 percent from baseline |
| Workload balance | Overtime hours per FTE and traveler FTEs by modality and site | Declining trend quarter over quarter |
3How to implement it
Check actions off as you complete them; progress is saved in this browser.
| Action | Owner | Timing |
|---|---|---|
| Coordinating council and department leader | Month 3 | |
| Site and modality managers | Months 3 to 4 | |
| Department leader | Months 4 to 6 | |
| Site managers | Month 3 onward | |
| Modality managers and councils | Months 5 to 12 |
4How to track and maintain it
The coordinating council reviews the friction list monthly. Councils, the idea channel, pulse surveys, and leader conversations bring in new items. Warning signs include overdue promises and quick wins that reverse, such as a fixed process that drifts back within weeks. Announce a missed date before it happens, with a new date and a reason. This discipline matters more than any single fix because, at this stage, belief depends on whether a promise from leadership can be relied on.
Value People Visibly
People who feel invisible don't believe they matter, no matter what the mission statement says. Step 6 builds a recognition system that is timely, specific, and fair across every site and role, and it pairs recognition with an honest review of the tangible signals of value: pay equity, schedule fairness, and access to opportunity. Recognition without fairness is quickly read as manipulation.
1How to design it
The recognition system has four layers. Everyday recognition is a specific, same-week thank-you from a leader or peer that names the behavior and its effect on a patient or colleague. Peer recognition uses simple cards or an electronic channel available to everyone, including radiologists recognizing technologists and technologists recognizing radiologists. Purpose awards are given quarterly at town halls for actions that exemplify the purpose and behavioral commitments, nominated by peers and selected by a front-line committee. Milestones mark certifications, anniversaries, and completions of career ladder steps. Zak’s research suggests that recognition builds the most trust when it comes soon after the achievement, comes from peers, and is personal and public [18], so the design emphasizes speed and specificity over the size of any reward.
The fairness review runs alongside. HR and finance examine pay compression and equity by modality, site, and tenure; rewrite scheduling rules with council input so weekend, holiday, and call burdens are distributed transparently; and track access to education funds, conference time, and special assignments by site and role. Results are shared openly, including what cannot be fixed immediately and when it will be revisited.
2What it measures
| Metric | Definition or formula | Target |
|---|---|---|
| Recognition climate Scored | Percent favorable on “I receive appropriate recognition for good work” or equivalent | 80 percent or more |
| Recognition reach Scored | Percent of staff who received at least one documented recognition in the quarter, by site and role | 90 percent or more; no site below 80 percent |
| Peer recognition share | Percent of recognitions that come from peers rather than leaders | 40 percent or more |
| Schedule fairness | Percent favorable on a schedule fairness pulse item; variance in weekend and holiday burden across staff | Improve 20 points; variance declining |
| Pay equity actions | Percent of identified pay compression or equity gaps addressed or scheduled | 100 percent addressed or scheduled within 12 months |
3How to implement it
Check actions off as you complete them; progress is saved in this browser.
| Action | Owner | Timing |
|---|---|---|
| Department leader | Month 4 | |
| Recognition committee | Month 5 | |
| Department leader and committee | Month 6 | |
| HR and finance partners | Months 4 to 8 | |
| Modality councils and managers | Months 5 to 9 |
4How to track and maintain it
Site and role review recognition reach monthly, because recognition naturally concentrates on visible people at the main campus. Warning signs include recognition that becomes generic (“thanks, team”), recognition that skips night shift, community sites, or support roles, and awards that go to the same people repeatedly. Leaders who see a name absent from the recognition log for a full quarter treat it as a prompt to look harder, not as evidence that the person contributed nothing.
Accountability Without Fear
Belief depends on fairness, and fairness depends on standards that apply to everyone. Step 7 converts the behavioral commitments from Step 2 into a single standard of conduct for every department member, from transporters to section chiefs, and applies it through a fair, consistent process. The goal is to make it safe to report errors and raise concerns while making it clear that no one will tolerate disrespect, unsafe shortcuts, or reckless behavior.
1How to design it
The design has three components. The first is a department behavior compact, written with staff and physician representatives, that defines expected behaviors in observable terms: how colleagues communicate, how concerns are raised, how disagreements about protocols or add-ons are handled, and how patients are treated. The RESPECT initiative at Cincinnati Children’s offers a radiology precedent, built specifically around in-person, telephone, and trainee interactions between radiologists and staff [14].
The second is a just culture process for events and behaviors. Drawing on Marx’s framework [27], the department distinguishes human error (console the person and fix the system), at-risk behavior (coach and remove the incentives that made the shortcut attractive), and reckless behavior (discipline), and it evaluates behavior rather than outcome. Because the evidence base for just culture remains largely conceptual [25], the department measures whether staff experiences the process as fair.
The third is a tiered response to professionalism concerns that applies to physicians and staff alike: an informal, private conversation for a single report; a structured conversation with a leader for a pattern; and a formal plan with defined consequences for persistent behavior. Physician leaders handle physician concerns using the same tiers and timelines.
2What it measures
| Metric | Definition or formula | Target |
|---|---|---|
| Safety to speak up Scored | Percent favorable on “I feel safe reporting a concern or mistake without fear of blame” or equivalent safety culture item | 85 percent or more |
| Timely, consistent resolution Scored | Percent of behavior and event reviews completed through the just culture process within 30 days, with the same tier applied to physicians and staff for comparable behavior | 90 percent or more |
| Respect between roles | Percent of staff rating interactions with radiologists, and radiologists rating interactions with staff, as very good or excellent | Improve toward 90 percent, the RESPECT goal [14] |
| Event and near-miss reporting | Safety events and near misses reported per 100 exams | Rising in year one, then stable |
| Perceived fairness | Percent favorable on “Rules and policies are applied fairly to everyone here” | Improve 20 points from baseline |
3How to implement it
Check actions off as you complete them; progress is saved in this browser.
| Action | Owner | Timing |
|---|---|---|
| Department leader and chair | Months 5 to 6 | |
| Quality and HR partners | Months 5 to 7 | |
| Department leader | Month 6 | |
| Department leader and chair | Months 6 to 12 | |
| Coordinating council | Month 7 |
4How to track and maintain it
Reporting rates can rise as staff feel safer speaking up, so an increase in event reports during the first year signals trust rather than declining quality, and leaders explain this openly. Warning signs include a drop in reporting after a visible disciplinary action, which suggests fear, and any perception that physicians or favored staff are exempt from the standard. Leaders review a de-identified summary of behavior cases by role quarterly to confirm that comparable behavior receives comparable responses.
Build Careers
By the end of the first year, belief usually returns to the present tense: people trust their leaders more, and the daily work improves. Step 8 extends belief into the future by showing staff that they can grow without leaving. In a labor market where CT and MRI vacancies sit near record highs [4], a department that develops its own advanced-modality technologists and leaders also reduces its dependence on premium labor.
1How to design it
Career architecture has four components. Clinical ladders within each modality define levels based on skills, certifications, precepting, and quality contributions, with attached pay steps. Cross-training pathways move interested radiographers into CT, MRI, mammography, or interventional radiology through structured, paid training with protected preceptor time. Leadership pathways identify emerging leaders, offer them stretch assignments such as leading a council project, and prepare them for lead and supervisor roles. Education support connects tuition assistance, continuing education, and academic partnerships to the department’s workforce plan.
Each employee has a short development plan reviewed at least twice a year with their leader. The AONL findings support making growth an explicit part of the leader relationship: nurses who experienced care, growth, and help from their manager were far more likely to stay [9]. Press Ganey’s 2025 report also notes that millennial and Gen Z employees value career growth, inclusion, and strong leadership [12].
2What it measures
| Metric | Definition or formula | Target |
|---|---|---|
| Internal fill rate Scored | Percent of advanced-modality, lead, and supervisor positions filled by internal candidates | 60 percent or more |
| Development plan coverage Scored | Percent of staff with a current development plan reviewed in the past six months | 85 percent or more |
| Cross-training throughput | Number of staff completing cross-training into a shortage modality per year | Set annually from the workforce plan |
| Growth item | Percent favorable on “I have opportunities to learn and grow here” | 80 percent or more |
| Early tenure retention | Percent of new hires still employed at 12 and 24 months | Improve 10 points from baseline |
3How to implement it
Check actions off as you complete them; progress is saved in this browser.
| Action | Owner | Timing |
|---|---|---|
| Modality councils, HR, and finance | Months 9 to 12 | |
| Chief technologist and education coordinator | Month 10 onward | |
| Department leader and HR | Months 9 to 11 | |
| Department leader | Month 12 | |
| Business manager and education partners | Months 12 to 18 |
4How to track and maintain it
The workforce plan is updated annually with vacancy, retirement, and volume projections, and the cross-training cohorts are sized to it. Warning signs include ladders that stall because criteria are unclear or budgets are cut, cross-trained staff who leave soon after certification, and internal candidates who are passed over without explanation. Every unsuccessful internal candidate receives specific feedback and a development plan because how the department treats people who don't get the job tells everyone else whether the pathway is real.
Link Every Exam to a Patient
In radiology, many people never see the end of the story. A technologist completes the scan, a radiologist reads it, and the patient disappears into another department. Step 9 restores the connection between the work and the person it serves, so people feel the purpose every day rather than recalling it at town halls. It also aligns engagement with patient experience and quality, which is where the organization ultimately measures the department.
1How to design it
The design uses three channels. The site shares patient experience data for imaging, such as likelihood to recommend, courtesy of staff, explanation of what to expect, and wait times, by site and modality monthly, in the same huddles as staff metrics. Radiologists and referring physicians share clinical impact stories describing cases in which an image, a protocol decision, or a technologist’s observation changed a patient’s care.
Research on career fit suggests that people need meaningful time, not just meaningful messages [17], so the design also protects the patient-facing parts of the work: adequate time for patient preparation and explanation, staffing that allows technologists to talk with frightened patients, and radiologist availability for direct conversations with patients where appropriate.
2What it measures
| Metric | Definition or formula | Target |
|---|---|---|
| Patient experience Scored | Imaging likelihood-to-recommend percentile rank, or top-box score, by site and modality | 75th percentile or higher |
| Patient voice in huddles Scored | Percent of daily huddles that include a patient story or patient feedback item | 80 percent or more |
| Explanation and courtesy | Top-box scores on staff courtesy and explanation of the procedure | Improve 10 points from baseline |
| Quality and safety signals | Repeat or rejected image rates, protocol errors, and patient identification events | Declining trend |
| Access | Days to third next available appointment for outpatient MRI and CT | Within the department’s access standard |
3How to implement it
Check actions off as you complete them; progress is saved in this browser.
| Action | Owner | Timing |
|---|---|---|
| Site and modality managers | Month 9 | |
| Patient experience partner and business manager | Month 9 onward | |
| Chair and vice chairs | Month 10 onward | |
| Modality councils | Months 10 to 14 | |
| Patient experience partner | Month 12 onward |
4How to track and maintain it
Review patient experience and staff metrics together each quarter, by site, because the pattern described in Press Ganey’s data, in which trust climates and patient ratings move together [3], often shows up at the unit level. Warning signs include huddles that skip the patient story when the day is busy, patient scores that fall at a site while staff scores rise (usually meaning workload or access is slipping), and patient feedback used only for blame. Share patient comments for learning first; individual accountability for patient complaints runs through the Step 7 process.
Embed and Sustain
A culture that depends on one leader is a performance, not a culture. Step 10 makes the gains durable by hardwiring the operating rhythm, institutionalizing the Belief Index, building leadership succession, and renewing the system each year. The test of this step is simple: if the leader who started the work left tomorrow, would the department keep believing?
1How to design it
The design has four components. The operating rhythm (Figure 4) defines what happens daily, weekly, monthly, quarterly, and annually, and assigns each element to a role rather than a person. The Belief Index (Section 5) becomes a standing agenda item in quarterly department reviews and in the health system’s performance reviews of imaging. Leadership succession identifies at least one ready or nearly ready successor for every leadership role, drawing on the emerging leader program in Step 8. Annual renewal brings staff, physicians, and leaders together to review the purpose, the compact, the Belief Index, and the engagement survey, and to decide what to keep, change, or stop.
Embedding also means writing things down. Council charters, the behavior compact, the just culture process, recognition standards, scheduling rules, career ladders, and leader standard work are all codified as department policies, so they survive leadership turnover and health system reorganizations.
2What it measures
| Metric | Definition or formula | Target |
|---|---|---|
| Voluntary turnover Scored | Voluntary separations in the past 12 months divided by average headcount, by site and modality | 10 percent or less, and below the health system average |
| Operating rhythm adherence Scored | Percent of scheduled huddles, council meetings, town halls, and Belief Index reviews held as planned | 90 percent or more |
| Succession coverage | Percent of leadership roles with an identified ready or nearly ready successor | 80 percent or more |
| Engagement outcome | Annual engagement survey score and percentile rank, by unit | Top quartile in the health system and national comparison group |
| Durability | Belief Index change in the two quarters after any leadership transition | No decline greater than 5 points |
3How to implement it
Check actions off as you complete them; progress is saved in this browser.
| Action | Owner | Timing |
|---|---|---|
| Department leader | Month 12 | |
| Department leader and HR | Months 12 to 18 | |
| Department leader and coordinating council | Months 12 to 14 | |
| Department leader and HR | Months 15 to 18 | |
| Department leader | Quarterly from month 12 |
4How to track and maintain it
The coordinating council audits the operating rhythm quarterly, not the leader, so the people it serves verify adherence. The warning signs of decay are familiar: huddles become announcements, councils stop receiving answers, recognition thins out, and leaders stop appearing on nights and weekends. Because the index is reviewed quarterly, these signals are designed to surface there before they surface in the annual engagement survey.
The Belief Index Calculator
The Belief Index is the BELIEVABLE Model's scorecard. It converts the twenty scored metrics, two from each step, into a single 100-point measure of the conditions that produce engagement. It is designed to be calculated quarterly from data the department already collects or can collect cheaply: pulse survey items, leader logs, council and recognition records, HR data, and patient experience reports.
Enter each metric’s actual value. Leave a field blank if it is not measured; the report scores unmeasured metrics as 0. The two presets reproduce the report’s illustrative Figure 5 domain profile exactly; the report publishes domain scores, so the metric values behind them are constructed for teaching. Your entries are saved in this browser only.
Table 24. Converting each metric to points
| Attainment of target | Points | Interpretation |
|---|---|---|
| 100 percent or more of target | 5 | Target met |
| 90 to 99 percent | 4 | Close to target |
| 75 to 89 percent | 3 | Progressing |
| 50 to 74 percent | 2 | Early |
| 25 to 49 percent | 1 | Minimal |
| Below 25 percent, or not measured | 0 | Absent |
Formula. Attainment = actual ÷ target, or target ÷ actual when lower is better. Domain = metric 1 points + metric 2 points. Belief Index = sum of the ten domains.
Table 26. Belief Index tiers
| Range | Tier | What it usually means |
|---|---|---|
| 0 to 39 | Disbelief | Staff does not expect leaders to act. Focus entirely on Phase I and on a few visible quick wins. |
| 40 to 59 | Skepticism | Staff is watching. Keeping promises now matters more than any new initiative. Protect the 30-day response rule. |
| 60 to 74 | Cautious belief | Belief is real but fragile. Broaden involvement, recognition reach, and fairness across sites. |
| 75 to 89 | Belief | The culture is self-reinforcing in most units. Shift attention to careers, patients, and succession. |
| 90 to 100 | Conviction | Belief survives setbacks. Guard against complacency and keep renewing the purpose. |
Two rules keep the index honest. First, it is reported by site and modality, not just for the department as a whole, because averages hide the community hospital or night shift where belief has not yet arrived. Second, the index is not tied to individual bonuses. Because engagement varies most from one work unit to the next [1], the index is built for team-level action, and paying people for higher scores invites gaming the measures meant to reveal the truth.
Index Math: What the Scoring Rules Imply
The Belief Index is simple to calculate, and that simplicity has consequences leaders should understand before they set targets or report results.
These are properties of the scoring rules in Section 5, worked out for this dashboard. They are arithmetic consequences of the published method, not new rules, and each is reproduced live by the calculator.
Finding 1. The tier floors line up with uniform attainment
If every one of the twenty metrics sits at the same share of its target, the index can only take six values. Half of target everywhere scores exactly 40, the floor of Skepticism. Three quarters scores 60, the floor of Cautious belief. Ninety percent everywhere scores 80. Only full target everywhere reaches 100.
Finding 2. Conviction requires at least ten metrics at full target
A metric below target earns at most 4 points, so twenty near misses cap the index at 80. Each metric that reaches its target adds one point to the ceiling: the maximum possible index is 80 plus the number of metrics at target. Conviction (90 or more) therefore needs at least ten metrics fully at target. Belief (75 or more) can be reached with none.
Finding 3. Every unmeasured metric costs up to five points
The report scores a metric that is not measured as 0. A department that measures only what is easy cannot score well: the ceiling falls by five points for each gap, and starting to measure a metric at even a quarter of its target adds a point.
Finding 4. Reading the leader behavior score
The scale runs from 12 to 60 (twelve items, five points each). The target mean of 50 equals 4.17 per item; the floor of 42 for any single leader equals 3.5 per item. A neutral leader (3.0 per item, a score of 36) reaches 72 percent of target and earns 2 points, which is “Early.” The lowest possible score, 12, attains 24 percent and earns 0.
Finding 5. Patient experience is scored on percentile rank
The target is the 75th percentile. A department at the national median (50th) attains 67 percent and earns 2 points. The 68th percentile is the first rank that earns 4, and the 75th earns 5. Moving from the median to the 68th percentile is worth two index points, before the 75th is reached.
Finding 6. Turnover points, lower is better
With a 10 percent target and attainment = target ÷ actual:
| Voluntary turnover | Points |
|---|---|
| 10.0% or less | 5 |
| 10.1% to 11.1% | 4 |
| 11.2% to 13.3% | 3 |
| 13.4% to 20.0% | 2 |
| 20.1% to 40.0% | 1 |
| Above 40.0% | 0 |
A department with zero voluntary turnover is treated as meeting target.
Step 10 sets durability as “no decline greater than 5 points” in the two quarters after a leadership transition. The red flag table (Table 29) triggers a steering group review when the index “falls 5 or more points in a quarter.” A drop of exactly 5 points therefore meets the durability target and also trips the red flag. The Quarterly Tracker follows the red flag rule, flags a 5-point drop, and labels it as within the durability target so the steering group can decide how to treat it.
Quarterly Belief Index Tracker
The Belief Index measures the conditions that produce engagement; the annual survey measures the result. Tracking it quarterly lets leaders see belief rising, or slipping, before the annual survey confirms it.
Two rules keep the index honest. First, it is reported by site and modality, not just for the department as a whole, because averages hide the community hospital or night shift where belief has not yet arrived. Enter each unit’s quarterly Belief Index (0 to 100) at the months you have measured. The chart compares every unit with the report’s design trajectory and the tracker raises the red flags from Section 7.
| Unit | M0 | M3 | M6 | M9 | M12 | M15 | M18 | M21 | M24 |
|---|---|---|---|---|---|---|---|---|---|
Belief Index by unit against the design trajectory
Dark line: the report’s design trajectory (Figure 6), an illustrative planning target rather than a reported result.
Flags and readouts
- Enter at least two quarters for a unit to see trend flags.
The 24-Month Implementation Roadmap
The ten steps unfold over roughly 24 months, with Phase I beginning on the leader’s first day and the full operating rhythm in place by the end of the first year. The roadmap below is a planning guide; departments with stronger starting conditions can move faster, and departments in deeper distress should spend longer in Phase I.
Solid bar: build and launch. Light bar: sustain and renew. Dotted lines mark the report’s milestones.
Table 27. What the roadmap looks like from both sides
| Period | Leader priorities | What staff should see |
|---|---|---|
| Days 1 to 30 | Listening schedule published; data pulled; leadership team convened | The leader on every site and shift, asking questions and taking notes |
| Days 31 to 90 | Listening tour completed; purpose team formed; leadership compact drafted | “What We Heard” published, including what leadership got wrong |
| Months 4 to 6 | Purpose launched; leader standard work and first leader feedback; councils chartered; first quick wins | First “You Said, We Did” results; leaders visibly present; councils recruiting |
| Months 7 to 12 | Recognition system, behavior compact, just culture, schedule and equity reviews | Recognition across all sites; one standard for everyone; schedules posted early |
| Months 13 to 18 | Clinical ladders, cross-training, patient stories in every huddle, policy codification | Visible career paths; patient voices in daily work |
| Months 19 to 24 | Succession plans, annual renewal summit, Belief Index reported to the health system | A department that runs on its own rhythm |
6.1 Governance
A small BELIEVABLE steering group meets monthly: the department leader, the chair or vice chair for clinical operations, the chief technologist, the nursing leader, the business manager, the HR partner, and the two co-chairs of the coordinating council. It owns the roadmap, the Belief Index, and the friction list. It summarizes its minutes for all staff. Physician leadership participation is essential; the steering group should not be an administrative project that radiologists observe from a distance.
6.2 Resources
Most of the model costs time, not money. The largest investments are paid time for council participation, leader development, cross-training wages and preceptor time, recognition materials, and any pay equity corrections identified in Step 6. Present these costs to the health system alongside the cost of the problem they address: turnover, vacancy, overtime, traveler premiums, and lost scanner capacity. Using the NSI estimate of roughly $60,000 per registered nurse turnover as a conservative proxy [15], preventing even ten avoidable departures per year in a 400-person department represents savings in the range of $600,000 before any gains in productivity, access, or patient experience are counted.
Show the published Figure 7
The Operating Rhythm
A culture that depends on one leader is a performance, not a culture. The rhythm makes belief a habit owned by roles, councils, and sites.
Daily
- 10-minute modality huddle
- One patient story
- One barrier
- One thank-you
Weekly
- Leader standard work
- Rounding for connection
- Recognition log review
Monthly
- Site and modality councils
- “You Said, We Did” board and pulse poll
Quarterly
- Belief Index review
- Town halls at every site
- Leader scorecards
Annually
- Full engagement survey
- Purpose renewal
- Career ladder review
Figure 4, rebuilt. The BELIEVABLE operating rhythm: what happens, and how often, to keep belief alive. Each element is assigned to a role rather than a person.
Operating rhythm adherence
Scored metric 2 of domain 10: scheduled huddles, council meetings, town halls, and Belief Index reviews held as planned. Target 90 percent. Example values shown; enter your own for the period.
| Element | Scheduled | Held | Held as planned |
|---|---|---|---|
| Huddles | 91% | ||
| Council meetings | 86% | ||
| Town halls | 94% | ||
| Belief Index reviews | 100% |
Step 10: Embed and Sustain
The design has four components. The operating rhythm (Figure 4) defines what happens daily, weekly, monthly, quarterly, and annually, and assigns each element to a role rather than a person. The Belief Index (Section 5) becomes a standing agenda item in quarterly department reviews and in the health system’s performance reviews of imaging. Leadership succession identifies at least one ready or nearly ready successor for every leadership role, drawing on the emerging leader program in Step 8. Annual renewal brings staff, physicians, and leaders together to review the purpose, the compact, the Belief Index, and the engagement survey, and to decide what to keep, change, or stop.
The coordinating council audits the operating rhythm quarterly, not the leader, so the people it serves verify adherence. The warning signs of decay are familiar: huddles become announcements, councils stop receiving answers, recognition thins out, and leaders stop appearing on nights and weekends. Because the index is reviewed quarterly, these signals are designed to surface there before they surface in the annual engagement survey.
Tracking, Red Flags, and Failure Modes
When leading and lagging indicators diverge, the leading indicators usually tell the truth first.
The model separates leading indicators, which change within weeks, from lagging indicators, which change over quarters or years. Leaders manage leading indicators and monitor lagging ones. When the two diverge, the leading indicators usually tell the truth first.
Leading indicators: manage these
Leader standard work completion, recognition reach, huddle adherence, 30-day response rate
Weekly by leaders; monthly by steering groupPulse items on voice, care, growth, help, fairness, and safety to speak up
Monthly pulse; quarterly trend“You Said, We Did” closure, friction resolution, schedule posting
MonthlyComposite
Belief Index by site and modality
QuarterlyLagging indicators: monitor these
Voluntary turnover, early tenure retention, vacancy, overtime, traveler FTEs
Monthly data; quarterly reviewAnnual engagement score and percentile; patient experience; quality and access
Quarterly and annually7.1 Red flag triage
Check any early warning sign you are seeing. The report’s response appears beside it and collects in the action list below.
Response: Return to in-person listening at the affected sites; report what changed since the last survey
Response: Announce the delay before the date, with the reason and a new date; never let it pass silently
Response: Leaders round on that site or shift specifically; review the recognition log by name
Response: Structured coaching plan with 90-day review; consider role change if no improvement
Response: Review the case for consistency; reinforce the just culture message in person
Response: Steering group review within 30 days; identify the domains that moved and return to the corresponding steps
7.2 Seven ways the model fails
An honest pre-mortem. Check any that describe your department today.
The Cost of Disbelief
Present the model’s costs to the health system alongside the cost of the problem it addresses: turnover, vacancy, overtime, traveler premiums, and lost scanner capacity.
Cost of Disbelief calculator
Default cost per departure is the 2026 NSI average cost of turning over one staff registered nurse ($60,090) [15], which the report uses as a conservative proxy because comparable national data for imaging technologists are limited. Actual costs vary by modality, region, and labor market. Savings exclude productivity, access, and patient experience gains.
Why the number matters
Disbelief has a price. Radiology-specific turnover cost data are scarce, but the closest well-measured comparison is instructive: the 2026 NSI National Health Care Retention and RN Staffing Report placed the average cost of turning over one staff registered nurse at $60,090 and estimated that the average hospital loses about $5.19 million per year to RN turnover [15]. Advanced-modality technologists are also hard to replace, and downstream costs from idle scanner time, overtime, and premium labor add to the total. A 400-person imaging department that loses even ten more people per year than it should is spending real money on a problem that the survey only describes.
Most of the model costs time, not money. The largest investments are paid time for council participation, leader development, cross-training wages and preceptor time, recognition materials, and any pay equity corrections identified in Step 6. Present these costs to the health system alongside the cost of the problem they address: turnover, vacancy, overtime, traveler premiums, and lost scanner capacity. Using the NSI estimate of roughly $60,000 per registered nurse turnover as a conservative proxy [15], preventing even ten avoidable departures per year in a 400-person department represents savings in the range of $600,000 before any gains in productivity, access, or patient experience are counted.
Derived for context: the NSI estimate that the average hospital loses about $5.19 million a year to RN turnover implies roughly 86 RN departures per hospital per year at $60,090 each.
Evidence, Limitations, and Sources
The Belief Index targets are informed starting points, not validated thresholds, and the index has not been psychometrically validated. Treat the first year as a test of the model in your setting.
8. Limitations
The BELIEVABLE Model is a practice framework developed and refined through implementation in academic radiology. It has not been tested in a controlled trial, and the department described here is a composite. The evidence behind its components is strongest for the association between leader behavior and staff outcomes, and for the relationship between meaningful work and engagement; it is weaker and more mixed for psychological safety interventions and for just culture as a measurable driver of patient safety [23, 24, 25]. Much of the supporting evidence is correlational, drawn from large surveys conducted by organizations that also sell engagement measurement services, and several radiology examples are single-site quality improvement reports. The Belief Index targets are informed starting points, not validated thresholds, and the index itself has not been psychometrically validated. Departments adopting the model should measure their own baseline, adjust targets to their context, and treat the first year as a test of the model in their setting rather than a certainty.
The financial illustration in Section 6 uses registered nurse turnover costs as a proxy because comparable national data for imaging technologists are limited. Actual costs vary by modality, region, and labor market.
9. Conclusion
The leaders who turn struggling radiology departments around are rarely the loudest people in the room. They show up on the night shift at the community hospital, write down what they hear, come back with an answer, and keep doing it after the novelty wears off. They tell the truth before they describe the vision. They fix themselves before they ask anyone else to change. They make small promises and keep them in public. They hold the chair and the transporter to the same standard. And they build a system that does not need them to keep working.
That is what belief is. It is not a mood, and you can't announce it. It is the accumulated evidence, gathered by every employee every day, that the people in charge mean what they say. When that evidence becomes overwhelming, engagement scores follow, turnover falls, and patients notice the difference in how they are greeted, prepared, scanned, and cared for.
The BELIEVABLE Model offers a sequence, a set of measures, and an operating rhythm for doing that work deliberately. Radiology departments facing record vacancies, persistent burnout, and a widening trust gap with senior leadership do not need another program. They need believable leaders and a system that keeps them that way.
Verification ledger
What this dashboard checked against the report before building on it.
| Item | Values | Check | Result |
|---|---|---|---|
| Figure 5 low-trust profile (digitized) | 3, 2, 3, 2, 3, 3, 4, 3, 4, 4 | Sums to 31, matching the figure legend | Reproduced |
| Figure 5 month-24 target (digitized) | 9, 9, 8, 9, 8, 9, 8, 8, 9, 9 | Sums to 86, matching the legend and the Figure 6 endpoint | Reproduced |
| Figure 6 trajectory | 31, 37, 46, 55, 64, 71, 77, 82, 86 | Start and end agree with Figure 5; month 12 (64) sits in Cautious belief | Consistent |
| Section 6.2 savings | 10 departures × $60,090 | $600,900, stated as “in the range of $600,000” | Reproduced |
| Figure 1 values | CT 17.7 to 19.4; MRI 16.2 to 17.4; Radiography 18.1 to 15.6 | Match the text of Section 1.2 and the key findings | Reproduced |
| Phase timing | Table 3 against Figure 7 build bars | Every step's build window falls inside its phase window | Consistent |
| Scored metrics | Two per step in Tables 4 to 22 | Match the twenty metrics and targets in Table 25 | Consistent |
| Durability and red flag thresholds | Step 10 against Table 29 | A drop of exactly 5 meets one and trips the other; see Index Math, Finding 7 | Disclosed |
The published figures
References
- 1. Beck R, Harter J. Managers account for 70% of variance in employee engagement. Gallup Business Journal. April 21, 2015. https://news.gallup.com/businessjournal/182792/managers-account-variance-employee-engagement.aspx
- 2. Shanafelt TD, Gorringe G, Menaker R, et al. Impact of organizational leadership on physician burnout and satisfaction. Mayo Clin Proc. 2015;90(4):432-440. doi:10.1016/j.mayocp.2015.01.012
- 3. Press Ganey. State of Healthcare Employee Experience 2026. Press Ganey Associates; 2026. https://www.pressganey.com/resources/blog/were-making-progress-in-employee-engagement-now-comes-the-hard-part/ and report summary at https://www.pressganey.com/?p=889772
- 4. American Society of Radiologic Technologists. ASRT staffing and workplace survey shows vacancy rate increases near record highs, aligning with overall health care profession trends. News release. July 24, 2025. https://www.asrt.org/main/news-publications/news/article/2025/07/24/asrt-staffing-and-workplace-survey-shows-vacancy-rate-increases-near-record-highs-aligning-with-overall-health-care-profession-trends
- 5. Stempniak M. Radiology among the most burned out specialties, new AMA survey says. Radiology Business. April 2026. https://radiologybusiness.com/topics/healthcare-management/leadership/radiology-among-most-burned-out-specialties-new-ama-survey-says
- 6. Efron L. Gallup Workplace guidance on acting after an employee engagement survey. Gallup. https://www.gallup.com/workplace/467504/administered-employee-engagement-survey.aspx
- 7. Allan BA, Batz-Barbarich C, Sterling HM, Tay L. Outcomes of meaningful work: a meta-analysis. J Manag Stud. 2019;56(3):500-528. doi:10.1111/joms.12406
- 8. Hsu A. Want to keep good workers? Praise them, a new study finds (reporting on Gallup and Workhuman research). NPR, via GPB. September 18, 2024. https://www.gpb.org/news/2024/09/18/want-keep-good-workers-praise-them-new-study-finds
- 9. American Organization for Nursing Leadership and Crucial Learning. Connection Is Retention: Lessons from Leaders with Unusually High Nurse Retention. 2023. https://www.aonl.org/system/files/media/file/2023/06/Research%20-%20Connection%20Is%20Retention%20%281%29.pdf
- 10. Gallup. U.S. employee engagement in 2025: 31% engaged, unchanged from 2024 and below the 2020 peak. Gallup Workplace; January 2026. As reported by Allwork.Space, January 28, 2026. https://allwork.space/2026/01/new-gallup-study-shows-there-are-eight-million-fewer-engaged-workers-since-2020/
- 11. Gallup. State of the Global Workplace 2026. Gallup; April 2026. https://www.prnewswire.com/news-releases/global-employee-engagement-falls-to-lowest-level-since-2020-302732859.html
- 12. Press Ganey. What keeps healthcare workers engaged? New report points to trust and teamwork (Healthcare Employee Experience 2025). News release. April 23, 2025. https://www.pressganey.com/resources/news/what-keeps-healthcare-workers-engaged-new-report-points-to-trust-and-teamwork/
- 13. Stempniak M. 49% of radiologists surveyed say they’re burned out, with “lack of respect” a top driver. Radiology Business (reporting Medscape survey data). https://radiologybusiness.com/topics/healthcare-management/leadership/radiologists-burn-out-medscape-radiology-physician
- 14. Towbin AJ, Smith RL, Smith EA, et al. RESPECT: Radiology Employees Striving for Productive and Effective Communication. RadioGraphics. 2020;40(7):2068-2079. doi:10.1148/rg.2020200041
- 15. Becker’s Hospital Review. The cost of nurse turnover in 10 points, 2026 (reporting the 2026 NSI National Health Care Retention and RN Staffing Report). 2026. https://www.beckershospitalreview.com/workforce/the-cost-of-nurse-turnover-in-10-points-2026/
- 16. Cummings GG, Tate K, Lee S, et al. Leadership styles and outcome patterns for the nursing workforce and work environment: a systematic review. Int J Nurs Stud. 2018;85:19-60. doi:10.1016/j.ijnurstu.2018.04.016
- 17. Shanafelt TD, West CP, Sloan JA, et al. Career fit and burnout among academic faculty. Arch Intern Med. 2009;169(10):990-995. doi:10.1001/archinternmed.2009.70
- 18. Zak PJ. The neuroscience of trust: management behaviors that foster employee engagement. Harv Bus Rev. 2017;95(1):84-90.
- 19. Press Ganey. State of Healthcare Safety 2026. Press Ganey Associates; 2026. https://www.pressganey.com/?p=889244
- 20. Bass RZ, Smith EN, Dunn A, Canon CL, Rothenberg SA. Quality improvement report: pulse surveys for departmental engagement, finding the pebble in your shoe. RadioGraphics. 2026;46(2):e250080. doi:10.1148/rg.250080
- 21. Stempniak M. Radiology department says simple, low-cost strategy can bolster workplace cohesion (reporting Hamimi A et al., Academic Radiology, April 27, 2026). Radiology Business. April 2026. https://radiologybusiness.com/topics/healthcare-management/leadership/radiology-department-says-simple-low-cost-strategy-can-bolster-workplace-cohesion
- 22. Edmondson A. Psychological safety and learning behavior in work teams. Adm Sci Q. 1999;44(2):350-383. doi:10.2307/2666999
- 23. Montgomery A, Chalili V, Lainidi O, et al. Psychological safety and patient safety: a systematic and narrative review. PLoS One. 2025;20(4):e0322215. doi:10.1371/journal.pone.0322215
- 24. O’Donovan R, McAuliffe E. A systematic review exploring the content and outcomes of interventions to improve psychological safety, speaking up and voice behavior. BMC Health Serv Res. 2020;20(1):101. doi:10.1186/s12913-020-4931-2
- 25. Murray JS, Lee J, Larson S, Range A, Scott D, Clifford J. Requirements for implementing a “just culture” within healthcare organizations: an integrative review. BMJ Open Qual. 2023;12(2):e002237. doi:10.1136/bmjoq-2022-002237
- 26. Shanafelt TD, Noseworthy JH. Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout. Mayo Clin Proc. 2017;92(1):129-146. doi:10.1016/j.mayocp.2016.10.004
- 27. Marx D. Patient Safety and the “Just Culture”: A Primer for Health Care Executives. Columbia University; 2001.
About the author
Kelly Emrick, DHSc, PhD, MBA, BSRT(ARRT)R, is a healthcare executive, author, and registered radiologic technologist whose career spans technologist practice and senior imaging leadership, including leadership of imaging organizations of roughly 600 employees. Her published work addresses healthcare leadership, adaptive leadership, radiology outcomes, fiscal management, population health, value-based care, and predictive analytics. Through kellyemrick.com, kellyemrick.org, and kellyemrick.blog, she provides free interactive tools, dashboards, and research for healthcare leaders.
Kelly Emrick developed the BELIEVABLE Model and the Belief Index as original frameworks. © 2026 Kelly Emrick. All rights reserved.
Suggested citation: Emrick K. The Leaders Who Make People Believe Again: How radiology leaders turn a shared purpose into a better place to work and receive care. Radiology Leadership Investigative Report. November 2026. kellyemrick.com
The Emrick BELIEVABLE Model