AHRA 2026 · ORLANDO, FL · JULY 14
What I Told Imaging Administrators in Orlando: Theranostics Is an Operations Problem
By Dustin Osborne, PhD, CRA, DABSNM, DABR
Director, Molecular Imaging and Theranostics Research Program, UT Medical Center
Principal Investigator, Appalachian Radiotheranostics Coalition
I spent 90 minutes on Tuesday standing in front of a room of imaging administrators at AHRA in Orlando, and I didn't talk about physics once. Well, that isn't exactly true. I maybe mentioned physics a little bit.
That's a strange thing for a medical physicist to say, but it was the point of the session. The talk was called "From Concept to Clinic: Implementing a Theranostics Program," and the audience wasn't nuclear medicine physicians or physicists. It was imaging directors, department administrators, and the people who get handed a theranostics program to launch with a tight timeline and limited bandwidth, often with no background in nuclear medicine at all.
I want to walk through what I told them, partly because it's useful outside that room, and partly because it's the same operating philosophy behind everything ARC wants to help build in the corridor.
The Central Idea
If you take one thing from this post, make it this: successful theranostics programs are built by designing around first principles. In this case, it is first principles of process management where it is critical to design an appropriate operating system, not by purchasing equipment or gaining access to a radiopharmaceutical.
I've watched enough programs launch and stall to know the barriers are almost never technical. They're operational. Unclear ownership. Poor coordination across departments. Site planning that ignored the actual workflow. Staffing treated as an afterthought. No standard work. Incomplete documentation. Authorization delays. An administration day that depends on one person being available. Imaging capacity nobody accounted for. Growth assumptions built on optimism instead of evidence.
Every one of those is fixable if you design for it in advance. That's the whole talk in one paragraph. Everything else is detail.
Five Key Domains
I organized the session around five operational domains, and I deliberately didn't force them into a clever acronym.
1
Governance: Name Every Owner
You cannot define your space, staffing, equipment, or capacity until you've settled ownership first. A governance model that works has three distinct roles at the top that get confused constantly: the executive sponsor who funds the program, the physician champion who owns clinical eligibility, and the operational owner who runs daily operations and is the primary daily champion and cheerleader of the program. Next is a therapy coordinator that owns each patient's journey end to end. Convert your team list into a RACI matrix, responsible, accountable, consulted, informed, and make sure every function has exactly one accountable owner. If you can't name who's accountable, that's where your program will stall.
2
Site & Capacity: Your Scanner May Be the Real Constraint
This section got the most time in the room, about 25 minutes, because siting decisions are the ones you live with for a decade. You cannot design the space until you define the work: what the patient needs for a multi-hour encounter, what the dose and waste flow requires, and what post-therapy imaging demands. Everyone plans treatment-room capacity. Almost nobody plans imaging capacity until therapy scans start colliding with the routine diagnostic schedule.
3
People: An Owner, Not a Committee
When a program struggles, it's almost never because nobody cares. It's because everyone is a little bit responsible, which means nobody is accountable. The coordination role needs five things regardless of which discipline holds it: a named owner, protected time, authority to escalate, access to the required systems, and defined backup coverage. At UTMC that's technologist-led coordination with radiology nursing providing clinical backup, but nurse-led, administrative, and hybrid models all work elsewhere. What matters is that one person owns it. I also pushed hard on rehearsal: tabletop exercises, a mock dose receipt, a full dose-day simulation, a spill drill. The programs that launch smoothly are the ones that made their mistakes in rehearsal.
4
Workflow: One Gate Before Anyone Orders a Dose
I mapped the full patient pathway, 21 steps from referral received to readiness for the next cycle, color-coded by owner. Three handoffs break more programs than everything else combined: authorization not confirmed before the dose is ordered, dose receipt not communicated to the treatment team, and post-therapy imaging not scheduled at release. The single most valuable tool in the whole session is the pretreatment readiness checklist: fifteen items, and the rule is simple. Every box checked, or you escalate. That gate is what separates a program that runs smoothly from one that lurches from crisis to crisis.
5
Measurement: Watch What Moves First
I deliberately compressed the financial content in this talk, because dollar estimates would have been guesses, and guesses presented in a national session are worse than useless. Instead I gave the room a distinction that changes how you manage day to day: leading indicators versus lagging indicators. Lagging indicators, cancellations, denial rate, days to payment, tell you what already happened. Leading indicators, authorization aging, readiness-checklist completion, scanner-capacity utilization, move first and let you intervene. Manage from the leading column. Confirm with the lagging one.
Three Failure Points, Three Fixes
I spent the back third of the session on the three problems that cause most of the pain in year one: prior authorization, dose-day logistics, and post-therapy imaging capacity. For each, the same structure: what goes wrong, why it happens, how to prevent it, what contingency you need, and which metric reveals the problem before it becomes a cancellation.
Authorization:
no authorization, no dose order, unless an approved exception is documented. That control alone prevents most of the financial pain in a program's first year.
Dose-day logistics:
a timeline set the day before and held to, with a morning readiness huddle that catches problems while they're still fixable.
Imaging capacity:
protect therapy-imaging blocks the same way you'd protect treatment-room time. Therapy growth without imaging growth is the trap that quietly erodes quality.
The First 90 Days
I closed with ten actions that require zero capital and can start this quarter. Do these and you'll be further along than most programs that have spent a year "planning."
Why This Matters for ARC
I didn't spend time focused on the Appalachian corridor in that session. It was a national audience with no reason to care about our regional work specifically. But every principle in that talk is the same one behind what we're building here.
The workshops we've run in Knoxville and Roanoke exist because the barrier to community theranostics has never really been the radiopharmaceutical. It's the operating system around it: who owns the program, whether the site was planned around the actual patient flow, whether staff rehearsed before the first real patient, whether the pretreatment gate exists before a dose gets ordered. The AHRA talk was the general version of the same argument we make every time we run a workshop, just aimed at a different room.
If you run a community imaging department and you're weighing whether to add theranostics, the checklist above is a good place to start regardless of whether you ever come to one of our workshops. Name your owner. Walk your space. Build the checklist. The rest follows from there.
We're working on adapting the full toolkit from this session, the readiness checklists, the responsibility matrix, the dashboard template, the phased roadmap, into resources for ARC partner sites. If that would be useful for your program, reach out below.
What's the operational gap you're wrestling with at your own institution?
I'd genuinely like to hear where you are. Reach out at dosborne@arctheranostics.org.
