Case managers must be the source for solution in conflict control
Here’s how you can learn to defuse emotional patients
Conflict thrives in competitive and uncertain environments, and no industry in the United States today is more competitive or rife with uncertainty than health care.
The new millennium brings with it a change in the way businesses view conflict resolution, and in the case of the health care industry, case managers are often an organization’s first line of defense. Make no mistake — how you handle frustrated patients and overburdened providers directly affects your organization’s bottom line. Learning to keep your cool when those angry calls come in is a skill that will make you even more valuable to your organization than you are right now and, more importantly, just may prevent minor disputes from becoming major lawsuits.
"Case managers must view themselves as diplomats and problem solvers," says John P. Biancardi, MA, chief training officer for Conflict Solvers, a health care training firm in Laguna Niguel, CA, which specializes in conflict resolution and mediation. "If I’m in the middle of a battle and the bullets are flying, I want General George Patton by my side. However, if I’m trying to bring an end to the war, or keep the war from escalating for that matter, I want former Secretary of State Henry Kissinger. It’s time for case managers to develop a new mindset. Don’t be task-oriented," he urges. "Tell yourself you are a problem solver, not an administrator."
Veteran case managers know that in many situations what a patient says he needs isn’t the best, most appropriate, or most cost-beneficial option, adds Marc Miller, MD, president of Conflict Solvers, who formerly managed a case management department. "One of your jobs is to come up with options that address what the patient really needs."
"There is always a solution," adds Biancardi. "The case manager’s job is to make the answer more palatable."
To put this in perspective: "Case managers, whether they work in a managed care organization or a hospital, often find themselves in positions of responsibility without the necessary authority they need to get things done," notes Miller. "I have seen case managers use mediation skills intuitively without a formal framework for what they are doing. If you, as a case manager, have mediation training, your effectiveness improves and you become an invaluable asset to your organization."
Dan E. Wax, Esq., general counsel for Conflict Solvers, agrees. "A single case manager trained in mediation methods can head off a future lawsuit," he notes.
Words to live by
So, how do you reinvent yourself as the Henry Kissinger of the health care industry? The key, says Biancardi, is to make the following three statements your work credo for 2001:
- I will exercise patience in the face of adversity.
- I will not take the anger of physicians, other providers, or my patients personally.
- I will be a problem solver.
The crux of problem solving is being able to defuse verbal attacks and prevent minor irritations from escalating into major headaches for your organization. The first step to solving a problem is to make sure you understand it. To do that, says Biancardi, you must become an "active listener."
Active listening is an excellent method for defusing and disarming verbal attacks, says Biancardi. "Active listening is the primary skill for managing conflict during emotional and value-laden discussions. It’s a communication skill in which the listener hears and feeds back accurately the emotional content of a speaker’s message," he says.
This feedback, explains Biancardi, serves these four main purposes:
- to demonstrate to a speaker that the message has been heard;
- to let the speaker know that the emotional intensity of the message has been heard;
- to legitimize the fact that having and expressing these emotions is acceptable;
- to build feelings of empathy between the listener and speaker.
Simple as 1-2-3
"Most of the time an angry caller is just looking for someone to unload on," says Biancardi. "Active listening is a skill that goes way beyond just saying uh-huh’ or OK’ occasionally just to let the caller know you’re still there. Active listening goes straight to the heart and lets the caller know you really understand where they’re coming from."
There are three important techniques for active listening, he notes. Those are:
1. Reframing. Reframing is your attempt to paraphrase the speaker’s statement while conceptualizing it in a different context, says Biancardi. This can be done, he says, by changing the wording of the speaker’s message so that the speaker will listen and hear the "real message."
It also helps, Biancardi notes, to begin "turning the focus away from the speaker’s position and defining the problem in terms of mutual interests. You have to learn to turn negative statements into positive statements. When the caller expresses a negative attitude, express the positive value. People may be 180 degrees apart and still have mutual interests."
• Example A: The caller says, "I’ve been paying you people premiums for a long time now, and the first time I really need you, you tell me no.’ What does HMO stand for anyway, Hand Money Over?!"
— Reframing possibility: "What I think I hear you saying is, from your perspective, you’ve kept your part of the bargain by paying your premiums faithfully, but it seems to you that we haven’t kept ours."
— Or: "Just so I understand, although you’ve paid your premium faithfully, you feel you have not received the services which we have agreed to provide."
• Example B: The caller says, "Look, whoever you are, I am sick and tired of being put on hold, or into someone’s voice mail who never gets back to me. I want answers, not the runaround."
— Reframing possibility: "If I hear you correctly, it sounds as if you’ve made several attempts at getting answers, but either we didn’t respond, or our answers were unsatisfactory."
— Or: "If I’ve heard you correctly, it sounds as if you feel we’ve dropped the ball, or haven’t given adequate explanations when you have called us."
Biancardi stresses that it doesn’t matter if you’ve measured the caller’s situation accurately as long as you make an honest attempt. "It’s your attempt to get to the real message that counts, not your accuracy in interpreting it," he says. "Eventually, reframing will get you to the real message behind what was said."
2. Asking questions. In this case, cautions Biancardi, it’s not enough to simply ask questions. The key is to ask questions that invite responses.
Often the first word of a question leads to a variety of responses and results, he explains. For example, "what" questions lead to facts; "how" questions lead to feelings; "why" questions lead to reasons. "Questions help you defuse an angry caller in several ways," he adds. "They help begin the communication. They also open new areas of discussion and clarify issues."
Biancardi likes to open with "could" questions. "Could’ questions invite a response. A could’ question says, without actually putting the thought into words, help me to help you."
Good opening questions include:
- Could you tell me more about your situation?
- Could you give me an example of what you’re telling me?
He cautions that the way questions are framed can either "open" or "close" a dialogue. Open questions are those that require more than a few words to answer and encourage people to provide maximum information, while closed questions can easily be answered in very few words. In addition, he suggests case managers practice reframing statements as questions. "This is an active listening technique which lets your caller know that you’ve been listening closely to him," says Biancardi. "But don’t overdo it. If you overuse this technique, it becomes annoying to the listener rather quickly."
3. Validating the speaker’s feelings. "There’s an accepted stereotype that women are taught to express feelings more than men and that . . . women have a better feelings vocabulary’ to refer to when they need it," says Biancardi.
If you downplay the level or degree of emotion your caller is feeling, you risk escalating the caller’s anger and missing an opportunity to resolve the caller’s conflict, he notes. "I don’t expect case mangers to be mind readers. But I do think with practice a case manager can honestly and genuinely assess the level of someone’s emotion in the course of a three- to 30-minute phone call."
"Remember, part of your job is customer relations and learning skills such as active listening can take you a long way," says Biancardi. "Case managers are on the front line and learning to defuse hostility, whether in providers [or] patients, prevents a variety of problems from plan abandonment to future lawsuits."
The simple art of active listening may be all that’s required to defuse a potentially volatile situation, he adds. "The simple fact that I called and you allowed me to vent is sometimes enough. Sometimes, patients make outrageous requests. They want to go to a heart specialist in Switzerland and expect the health plan to pay for it. If you can listen actively and patiently, you can often start moving the patient through a menu of more reasonable options — like maybe a heart specialist locally who has a national reputation and also is part of your network."
"If you’ve done a good job listening and reframing the caller’s message, the caller will be more willing to listen to your explanation for why [his request] isn’t possible," stresses Wax.
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