Find your program improvement opportunities
By Patrice L. Spath, ART, BA
Consultant in Health Care Quality and
Resource Management
Forest Grove, OR
Your case management program, like many other new health care initiatives, may be suffering from some common start-up problems. If that holds true for your program, the first step is to determine whether those problems exist internally or are due to external factors.
Early identification of problems is to your advantage. If you can identify program difficulties early, you'll be better equipped to resolve them. Listed below are five frequent causes of case management program failures, and possible solutions you can try:
1. Inadequate communication.
Sometimes staff are kept in the dark, especially when leaders practice what is called "mushroom management" -- keeping knowledge at the top of the organization and leaving everyone else in the dark. There is a natural reluctance to share proprietary information with everyone. Case managers frequently do not have enough information to understand the proper context of their job tasks and activities, and they often do not know how well they are performing.
2. Lack of common commitment.
Case management effectiveness can be limited by the presence of hidden agendas and by a lack of clear commitment to do whatever is necessary to realize the organization's explicit mission, goals, and objectives. When people work at cross-purposes, coordination is not possible. Agreement, such as "I'll go along with that," is fundamentally different from commitment, or "I'm ready and willing," and it is the latter that is essential for effective patient care coordination.
3. Unclear roles and responsibilities.
Part of the price of growth and change in health care is role ambiguity. Such developments require frequent and intense communication in order to avoid overlapping functions and confusion. An extreme solution is to codify everything and cast jobs into concrete. This strategy, however, can impede the progress of a case management initiative. To avoid role ambiguity, communication between case managers and health care leadership should take place on an ongoing basis.
4. Lack of integrity.
There is almost always a gap between the espoused values of an organization and the actual behavior of its members. The flaw is more serious when it is obvious that leaders, or administrative and medical staff, do not "walk the talk." Case management goals usually represent ideals or long-range targets. The tension that can be generated by lack of integrity between espoused goals and actual behavior, however, can be paralyzing.
5. Aversion to confrontation.
The term "confrontation" is avoided in many organizations; it is often considered to be a four-letter word. People usually associate confrontation with shootouts or face-to-face fights. But confrontation also means that case managers are requiring another person to give consideration to what they think is important. The process can focus on positive situations, as well as on situations that need attention. When case managers are unwilling or unable to be confrontational, care coordination priorities may go unmet.
Get case managers' opinions
A survey of the case management initiative's effectiveness can be used by the case management director to determine if any of the common problems mentioned above exist within the hospital. (See the survey, inserted in this issue.) Ask the case managers to complete the survey, but remind them to provide their opinions -- not necessarily what they think is correct or right. Case managers answer each question using a score scale of one to six. Score the results using the following instructions:
1. Add the scores for each dimension.
List the five areas, or dimensions, of effectiveness and the corresponding items from the survey that measure them in a table. (For a sample of how the scoring table should look, see the Dimension Scoring Table below.)
Determine the total score by adding together each surveyed response for the items listed for that dimension. For example, item numbers 1, 6, 11, and 16 added together would give a case manager director the total score for the communication dimension.
2. Profile your case management program.
Create a profile of the case management initiative in your organization by plotting your five total scores from step one on a Case Management Program Profile. (To see how to create a profile scale, see the Case Management Program Profile above.)
Shade each of the bars, stopping at your total score. The shaded areas create a visual representation of your organization's patient care coordination effectiveness and activities in each of the five dimensions. A high score indicates high effectiveness in a particular dimension.
3. Develop an action plan for improvement.
Identify the dimensions in which your case management program scored the lowest. A clearer picture of the problem area can be gained by answering a series of questions. First, however, it might be helpful to review the survey items that relate to the problem dimension.
Next, bring together the most appropriate people impacting the weak dimensions to develop a specific, detailed action plan. Use the following questions as a starting point for improvement discussions:
* What case management program fault needs the most attention right now?
* What seem to be the root causes of that situation?
* What is that situation costing the organization and the case management department right now?
* What would be the payoffs to the organization and to the case management department for improving that situation?
* Who besides people in the case management department needs to be involved in developing improvements to that situation?
* How might those people be involved meaningfully in determining what improvements need to be made?
* What steps do we need to take to get the process started?
* What should our next step be?
By identifying common weaknesses and designing action plans to correct those problems, health care providers are more likely to realize a significant return on their case management investment. *
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