Practice the Five Disciplines in Case Management
By Jeanie Davis
Hospital case managers, just as case managers in all work settings, have faced unbelievable challenges this year. Many were pushed back into clinical nursing practice because they were needed as frontline workers.
Hospitals are slowly transitioning back to more of a “normal” environment. With the new year approaching, it is a good time to revisit the Five Disciplines that help case management teams refocus on the business side of client care, says Teresa M. Treiger, RN-BC, MA, CCM, FABQAURP, current commissioner for the Commission for Case Manager Certification and past national president of the Case Management Society of America (CMSA).
“In the pre-COVID-19 environment, case managers ensured each client got the right care, at the right time, in the right place,” Treiger says. “We can all benefit from a recharge for the new year.”
InterQual and Milliman are two healthcare technology platforms that align payers and providers with actionable, evidence-based clinical intelligence, all to support appropriate care and foster optimal resource use, she explains. “If client care does not meet both the guidelines, there are consequences of payment denial.”
It is essential case managers work smarter, both as individuals and on a team. Treiger refers to “The Five Disciplines” described by Peter Senge, a systems scientist, as one way to optimize efforts as professional case managers and as case management team members.
To maintain a high-functioning team, all members must provide consistent, high-quality case management support, Treiger says. It is in that environment the five disciplines of success can be applied:
- shared vision;
- mental models;
- team learning;
- personal mastery;
- systems thinking.
A shared vision is the result of a common spirit, Treiger says. “The hospital’s mission statement is intended to inspire that vision, but often it doesn’t always connect with day-to-day work life in a client unit. In some hospitals, there may never be an effort to help case managers connect with the mission or vision.”
More importantly, Treiger espouses the personal mission statement that comes from thinking deeply about one’s work and employer’s mission and vision statements. “If you really take case management to heart, and seriously consider it your professional life’s work, you have to find a construct to make your employer’s mission statement meaningful to you,” says Treiger.
She also advises looking to professional organizations like CMSA for support. “They will share your values,” she explains. “You might not have an employer who supports your professional perspective, but you can find it in professional and credentialing organizations that seek to advance case manager skills and knowledge. You will learn about standards of practice, codes of conduct, and adopt those as your own personal work ethos. Take the time to make those connections yourself.”
“Mental models are the bumper pads in our minds,” says Treiger. “They frame the way we think and act upon that thinking.”
These may be negative stereotypes or biases of any type. For example, in the 1980s, “more than one of my co-workers refused to care for an AIDS client,” she says. More recently, Treiger witnessed a case manager who neglected to work with an individual with a substance use disorder on post-hospital care coordination. “The person was recovering from a systemic infection, and spent six weeks in the hospital,” she says. “During that time, no attempt was made to develop a discharge plan. He simply walked out of the facility.”
How will you react? “If someone comes from a different culture, ask yourself if you can put aside your mental constructs, and provide the care the person needs on their terms,” Treiger suggests. “It’s a problem if you cannot.”
Mental constructs “were not meant to be rigid, steel-enforced beams,” she explains. “They were meant to be flexible, expandable so you can apply empathy in all situations. Professional case managers should embody impartiality and keep our personal mental models in check, because we have a code of ethics.”
Empathy is the key to adapting in these situations, she says. “Maybe I don’t understand what this client is going through. I can’t always be sympathetic, but this is a human being and I can be empathetic because the person is under stress and needs support. I can certainly broaden my perspective and do my best for them. Mental models help guide how I act and react in different situations.”
That is especially important today, when the country is so divided, says Treiger. “People should strive to understand each other. It’s the saying, walk a mile in someone’s shoes. That may be a cliché, but it rings true.”
Team learning is about aligning individual efforts toward achieving a greater purpose. What pulls your team together? Do you recognize each other’s strengths and weaknesses, and focus on working in harmony?
If your day is fairly light but your colleague is slammed with admissions, what would you do? Would you head home on time or offer to help your colleague?
Care coordination is a team effort and should be embraced beyond an “assignment” perspective, says Treiger. “Some may say the physician is the care team leader, but the case manager is also a team leader where care coordination is concerned. You can set an example by helping your team members. After all, any failure reflects on all team members.”
The team’s culture is how people on the team behave toward each other, she explains. “One person might not be able to make a huge difference. This where really good case management leadership comes in. If you have bad leadership, it’s going to be a tough work environment. But if you can find colleagues who hold similar values, you have the beginnings of a great team.”
If one team member is bent on being disagreeable, “take the high road,” says Treiger. “Or maybe there’s one co-worker who always seems positive and does a really good job with clients. That’s the person you want to get with.”
She adds: “Maybe others will see you and that other person doing great things. It is the start of your own ‘revolution,’ so to speak. In my career, there was always at least one naysayer or Debbie Downer. I could not change that person, and that’s fine. But I did not let it determine who I was or how I worked.”
When coaching other case managers, Treiger often finds this problem: “Don’t let them dictate your frame of mind. Get your head out of the sand, start noticing. Change your frame of reference. If things are not working out no matter what you have tried, then it may be time to move on. Teams learn together.”
Ongoing and disciplined personal growth and learning are imperative, says Treiger. “Beyond the pursuit of knowledge, skills, and competencies, personal mastery transcends through all layers of life. Inquiry is a companion of personal mastery.”1
Professional organizations have helped many case managers gain personal mastery, she explains. “Look for those points under your control. Where can you improve your knowledge of case management? Your ability to make assessments? Your interview skills? Computer skills?”
These are necessary skills to perform well in case management, she says. “Personal mastery is knowing where you need to improve, then pursue improving it. Make a conscious effort every day to work toward that goal.”
With today’s technology, continued learning has become easier, she adds. “Online courses abound. Even if a course is not a perfect match for your needs, you’ll gain from the expanded perspective.”
She also advocates personal activities that stretch your experience: “Do something you’ve wanted, like kayaking that local river; just do it. Seize opportunities to improve your all-around self.”
Treiger adds: “If the pandemic has taught us anything, it should be ‘don’t wait.’ Do things while you can. Make yourself a more well-rounded person. Reflect on your life, what you’re doing, what your goals are, what makes you happy. At the end of your life, will you have achieved your goals?”
In case management, systems thinking is imperative, says Treiger. “We should be looking at the big picture in our day-to-day lives and thinking about the whole of each client, each work setting, and each colleague.”
What is systems thinking? The weather provides a good analogy: “How many variables create rain showers in a particular place and time? Case management is much the same. Our clients arrive and with them come untold variables ,which resulted in the circumstance that requires our intervention.”1
When a case manager intervenes, they add even more variation to the equation, Treiger says.
“Consider the factors that affect how we perform our responsibilities every day,” she explains. “A new case manager may have had a really bad commute to work, or another is just one week away from retirement after 25 years.” However, while the circumstances in their lives are different, that should not affect how they perform their case management responsibilities, she says. “Instead, these circumstances should challenge us all to push for greater professionalism, for a mental model and personal mastery that brings our best talents to our work setting.”
Treiger adds: “The more we practice this, the better we get at seeing the big picture and thinking about the whole of each client, each work setting, each colleague, and the kind of team which we aspire to create.”
- Treiger TM. Revisiting five disciplines in case management. Prof Case Manag 2020;25:232-234.
Hospital case managers, just as case managers in all work settings, have faced unbelievable challenges this year. Hospitals are slowly transitioning back to more of a “normal” environment. With the new year approaching, it is a good time to revisit the Five Disciplines that help case management teams refocus on the business side of client care.
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