Competence isn’t the same as performance
For many case management departments, simply coming up with a workable job description for case managers presents such a challenge that measuring competency often is hardly considered at all. "People have a hard enough time trying to figure out what a case manager is supposed to do," says Tahan Hussein, MS, DNSC(c), RN, CNA, director of cardiovascular nursing, Nursing Administration, at Columbia Presbyterian Medical Center in New York City.
Hussein says the existing body of knowledge and literature does not offer any consistency or standardization in terms of case management practice and case managers’ functions. "That makes it difficult to measure competencies or performance," he notes.
Hussein says there often is confusion about what competence and performance mean. "People sometimes use the two terms interchangeably when they are not," he says.
Hussein emphasizes that competence and performance must be differentiated before measuring competence can even be considered. "Performance is basically associated with task completion and not necessarily the rationale behind the task, or how well the task was completed and what its outcomes were like," he explains.
For example, a case manager may assess a patient and complete that assessment. "That does not mean the case manager was competent in finishing that task effectively, efficiently, appropriately, or thoroughly," he says. It also does not mean that the desired outcomes were achieved. "Performance is basically the act of completing something — an activity," Hussein explains. "There is no judgment on or evaluation of the outcome of that task."
By contrast, competence points to a case manager’s ability to complete a task through a process that integrates knowledge, skills, behaviors, and attitudes, Hussein says. In addition to simply completing the task, he says, it also means:
- identifying the knowledge areas that must be applied for effective completion of that task;
- determining the kinds of skills that are required for successful completion of that task;
- selecting the specific performance behaviors that must be applied to ensure meeting the expected outcomes.
Only then can a case manager say he or she has finished that task effectively, successfully, and competently, Hussein says.
"Competence is the ability to tie all those different areas together as you are involved in a situation, event, function, role, or task," he says. It also means making sure the outcome of completing a task is the desired outcome for the organization, the patient, the provider, and the insurer/payer.
When it comes to applying this framework to case management, the place to start is the focus and goals of the case management program, Hussein says. Hospital leaders should begin this process by reviewing the goals and objectives of their case management program. Based on that assessment, they should then identify core measures they can use to evaluate the competencies and performance for case managers.
For example, if the primary focus of the case management program is utilization review and management, "it will be necessary, for example, that you measure the case manager’s competence in areas of certification/authorization of services, reversing denials, writing appeal letters, and enhancing reimbursement," he says. In other words, there is no point in measuring the clinical dimension of the case manager’s role if your goal is basically utilization management and resource management, he says.
In this case, Hussein says the hospital should measure competence in terms of the case manager’s ability to conduct appropriate managed care reviews and negotiate lengths of stay and transitional plans. "The case manager must be able to negotiate the plan of care that will meet the resource or utilization management guidelines with the health care team," he says. Most of these aspects of the role are cost-based or utilization and resource management-based but aren’t necessarily concerned with actual direct care provision or clinical care at the bedside, he points out.
According to Hussein, this is where many people become confused. They design their case manager job description and determine how they are going to measure the performance or competence of the case manager as if they were two separate and independent entities, he says. They also lose sight of the goal of their case management program, he argues.
Hussein says this approach results in a disconnection between the goals of the case management program, the case manager’s job description, and the case manager’s competency measures. Such fragmented planning makes the process of measuring competencies more challenging and less fruitful. "In designing a competence-based performance evaluation of the case managers, you have to integrate the three components together — program goals, job description, and competency measures — rather than separate them," he says. "One is going to lead into the other."