EXECUTIVE SUMMARY
Case management leaders experience many daily challenges, including time constraints, resource limitations, and other decision-making pressures.
- One way to help leaders make the best decisions is by building a decision-making framework that includes identifying stakeholders, looking for internal evidence, and other actions.
- Leaders can identify patients at high risk for readmission and figure out where to put their biggest efforts.
- In assessing evidence to find the best solutions, leaders can look for resources, such as the Critical Appraisal App that helps people judge the trustworthiness of a study.
Leaders working in case management are under unforgiving time constraints, pressures, and resource constraints that make decision-making challenging.
The challenge relates to the way healthcare is moving and the speed with which change is occurring within organizations as they continue to change, form partnerships, and other issues, says Joan Sevy Majers, DNP, RN, FACHE, CENP, CCM, assistant professor and coordinator of the graduate programs in nursing administration at the University of Cincinnati.
“It is difficult to take time to figure out what are the best practices, and that’s what evidence-based decision-making is all about,” she says.
For instance, when case management leaders need evidence-based methods for keeping patients safe, they could address ways to improve safety during transitions.
Sevy Majers teaches graduate students about how to create a framework for making decisions. The goal of decision-making is to come up with the best solution possible under the circumstances, she says.
Use these steps to build a decision-making framework:
• Identify stakeholders. “We often forget there may be other stakeholders important to this decision,” Sevy Majers says.
Stakeholders include physicians, medical directors, and payer sources.
• Look for internal evidence. Identify what information is available to you, internally, she says.
“This is where it becomes difficult, sometimes,” Sevy Majers says. “There may be data, so find out what’s available to you. Not every organization is the same.”
Ask these questions to find internal evidence:
- Which patients are at high risk for readmissions?
- Where are you going to put your most important efforts?
- Can you get that information?
- What are your quality indicators?
- Are any items falling through the cracks?
“There is information that might be outside your area, and you need to get that information that will help you with whatever decision you make,” Sevy Majers says.
• Use external evidence. “This is where it becomes a challenge,” she says. “If you don’t have [other] resources, maybe there are external resources in the literature.”
Case management leaders can decide when looking at studies whether these questions apply to the hospital’s patient population:
- Is this a good study?
- Is the sample size big enough to think about?
“Evaluate that study to see if it’s worth considering,” Sevy Majers says.
• Identify the correct decision-makers. Whether the decision is for strategic or operational purposes, case management leaders need to identify the decision-makers in the health system.
For example, a case management problem might involve obstacles to bed turnover. In some hospitals with high-acuity patients, the emergency department could be overcrowded as people wait for beds that are occupied by patients ready for transfer, but are held up for nonmedical reasons. A leader will identify decision-makers who can help take a solution proposal and turn it into an operational change or a pilot project.
“The PACU is holding patients overnight. They can’t get inpatients discharged, and they can’t get new patients into those beds,” Sevy Majers says.
One solution would be to develop huddles that bring different disciplines together to discuss discharge obstacles. This method could lead to a central command center for transfers and discharges, and improve throughput, she says. With information technology support, patient discharge information and bed availability could be automated, making it easy for hospital staff to see where beds are open.
Case manager leaders can develop a process like this through an evidence-based framework, Sevy Majers says.
• Handle logistics. Making the best decision takes time. “How does a case management leader fit this into everything they have to do?” Sevy Majers asks. “Time is a constraint. Do I have the resources to support me?”
Leaders need help, so they must identify reliable partners. They also should know how to evaluate evidence.
“Do you work in an organization that supports this kind of approach?” she says. “Is the culture such that they’re interested in seeing a significant operational or strategic issue from this approach? Do we have a culture that supports this?”
• Assess evidence. Create a performance improvement committee, Sevy Majers suggests. “If there is a robust performance improvement process within the organization, this certainly is an option to bring forward as a tool to be used.”
Leaders can find resources, such as the Critically Appraisal Topic (CAT) Manager app that helps people judge the trustworthiness of a study. (More information is available at: https://www.cebma.org/resources-and-tools/cat-manager-app/.) For instance, the CAT Manager will show whether a study is qualitative, which might include weaker evidence than a study that used a randomized, controlled clinical trial, which contains among the highest-level of evidence, Sevy Majers says.
“Performance improvement projects frequently are qualitative,” she adds. “Most hospitals don’t have the money or energy to do randomized, controlled trials for management studies, which are frequently used for oncology research, drug trials, and other clinical trials.”
There also are some good, higher-quality studies with methods for discharging patients that will not fit every organization, she notes.
“That doesn’t mean they don’t have some use in some organizations,” Sevy Majers says. “They may have the best evidence for some organizations.”
Leaders working in case management are under unforgiving time limits, pressures, and resource constraints that make decision-making difficult. The challenge relates to the way healthcare is moving and the speed with which change is occurring within organizations as they continue to change, form partnerships, and other issues.
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