Guest Column

Is it time for case management redesign?

Redesign requires engagement of all stakeholders

By Patrice Spath, RHIT
Brown-Spath & Associates
Forest Grove, OR

The ever-increasing demands on case management services require a fresh new look at work practices. One way to do this is through a role redesign project. Role redesign is an improvement technique that involves looking at ways to improve the internal workings of the case management department to better meet the needs of the health care team and patients. Role redesign is about making case management services better. The systems approach of role redesign requires engagement of all the stakeholders in planning, implementation, development, and evaluation. Role redesign is not a way of getting staff to do more for less, nor is it a cost-cutting exercise. It is a systematic technique for responding to a widening gap between case management service demand and delivery, which cannot be filled simply by hiring more staff. Think about employees in the case management department and the way work is done now. Do you feel that:

  • People fully use all of their training and skills?
  • There are enough staff to ensure accurate, timely and effective services?
  • Staff roles are designed around customer needs?
  • People effectively use all the technology available?

If you answered NO to any of these questions, then it may be time to redesign roles in the case management department.

Getting started

Your starting point for redesigning roles must be, "What needs to improve?" Begin by being specific about what you are trying to accomplish and turn a problem into an aim.

For example:

Problem: Insurance payment rejections are not communicated to case management in a timely manner, causing missed opportunities to respond by the deadline.

Aim: Improve timeliness of receipt of insurance payment rejections.

Next, determine the root cause of the problem. This is not always obvious, especially where current work practices are based on local customs or simply habit. To pinpoint the root of the problem, start by creating a description of the current situation and problem and then work backward to identify the cause. The steps below will help you focus on the root of the problem and discover how role redesign and other improvement ideas can help you find a solution.

1. Hold a meeting with the people involved in the process. Post lots of flip chart paper on the walls to give you plenty of room to work. Ask the group to consider the way things are done right now and the problem. Have the group answer questions, such as:

  • What works well?
  • Why does it work well?
  • What has been troubling you about the problem, e.g., the way the reports are filed in records of discharged patients?
  • What do you think is the problem?
  • What have you tried in the past to fix this problem? Did it work? If not, why?
  • What ideas do you have for improvement?

2. Write the problem on a Post-It Note and place it on a flip chart paper. Begin a detailed analysis of possible causes by asking WHY questions. Start with a question such as, "Why are coders waiting too long to get complete inpatient records?" There will be several possible answers to the starting question. Continue asking WHY for each of these answers. Ultimately, the group will arrive at the underlying or root causes of the problem.

3. Identify the people who have job roles linked to the root causes. Have the group consider how changes to existing staff roles or the development of a new role can help solve the root causes of the problem. It may be helpful to go back to the list of issues developed in step one. You should have a clear understanding of everyone’s current job responsibilities and the current mix of skills. This information is useful for understanding the available resources in the department.

Dig into the process

Develop a flowchart of the current process to really understand what happens at each step and who is involved. But make sure that all employees feel involved and it is not just being "done to them." Once you have some data about who does what and how it affects the outcome of the process, get everyone together to look at what the data show.

Creative thinking is an essential part of role redesign. Give people permission to think differently and imagine the unimaginable. Then begin to talk about how things could be done differently, including expanding current roles or creating completely new ones. Encourage people to ask, "Why are we doing it this way?" Start making small changes and work up to the bigger ones. Small incremental change often is not as threatening to staff. Most likely, you’ll need to make a persuasive case for redesigned roles, so gather as much evidence as possible to support the changes.

If a new role is to be added to the case management department, it may be necessary to persuade the organization’s leaders to increase the department’s budget. To prepare for this eventuality, during the early stages of the role redesign project start building the business case for change. Information that should be included in the business case is listed below. If your organization has its own template, then of course you should use it.

Proposition or summary. This is a two- to three-sentence statement of the change that is being proposed.

Context. Provide two or three sentences about why the proposed change really matters to case management services and the organization.

Scale of change. State how many new or amended roles you are proposing.

Financial analysis.

— Detail the estimated costs split between:

[ ] Nonrecurring (one-time) costs: project management, equipment, recruitment, initial training, evaluation, changes to accommodations, etc.

[ ] Continuing costs: Salaries, etc.

Estimated savings. If the proposed change will result in increased revenue for the hospital, provide an estimate of this increase. For many role redesigns, increased revenue is not the goal, and in these situations it may be difficult to quantify savings. But remember that you are looking at ways of doing things differently, not just adding extra staff. Look for savings in staff costs, such as reduced use of temporary staff, fewer complaints, less paperwork, etc.

Evidence and risk. Here you should say why you believe the proposed change will work. Give examples of your small-scale test of the role redesign or history of successes in other organization. Also include potential risks and how you plan to prevent them.

In role redesign, individuals in the department or throughout the organization take on different case management-related tasks. This can be accomplished in several ways. A task can be moved down the skills ladder. An example would be moving the task of report filing to a clerk rather than having case managers perform this task. Tasks or individuals can be moved up the skills ladder, such as the case manager who takes on concurrent documentation enhancement responsibilities on the nursing units. The breadth of an existing role can be extended.

For example, data analysts can be trained to phone in patient information to insurance companies. Role redesign also can involve developing new roles that combine selected tasks normally done by a variety of traditional roles.

To help convert your role redesign ideas into practical working realities, start by taking a fresh look at problematic processes and functions in the case management department. Get everyone involved in identifying ways of changing roles or the way work is done to improve services and customer satisfaction.