Taking charge when you’re not in charge

When you have responsibility without authority

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

Case managers often find themselves charged with the responsibility for solving problems without the accompanying authority needed to fix the problem. This can be very frustrating. You can’t issue direct orders to solve the problem, so why should anyone listen to your suggestions?

Perhaps the head of finance has requested that all physicians document a definitive diagnosis in patient records within 12 hours of hospital admission. You are held responsible for making sure this gets done, although you lack the clout necessary to change physician behavior.

If you are like most case managers, you regularly find yourself in situations where you have the responsibility but not the authority to get things done.

For instance, case managers often arrange for patients’ post-hospital care needs, and yet the power to order some services rests with the discharging physician. Maybe you head up a multidisciplinary clinical process improvement team whose members don’t report to you. Or maybe you do have nominal authority but find that your charges don’t respond to your directives. How do you approach situations like this? When you’re not the boss, how can you gain the cooperation of other members of the health care team?

You won’t get support from others by issuing directives. Even those in senior management positions shy away from directives, choosing instead to manage by persuasion.

Management by persuasion involves listening seriously to other peoples’ ideas, valuing their suggestions, and turning to others for advice. Unless you really are in charge, you’re not likely to elicit cooperation from other members of the health care team by telling them what to do. In fact, colleagues may resist your instructions precisely because they don’t like being told what to do by someone who isn’t their boss.

Use the word "teamwork" cautiously. Team-work does not mean people should do exactly as they are told. Instead of issuing directives, ask questions to solicit input from others, offering your ideas as part of a solution. And then do something that models or demonstrates what you’d like to see happen. If you’re advocating a cost-savings initiative, for example, spend some time researching one particular patient care practice and then propose some ways to reduce costs.

Real leadership, of course, has never been a matter of mere formal authority. You’ve seen it — a meeting is meandering, the outcome uncertain, and then one participant introduces significant new facts or insights. Suddenly, the tenor of the meeting changes, and information carries the day.

Occasionally, the information provider is smarter or more experienced than other participants. More often, the participant has done his/her homework and so knows things that others don’t. Having information elevates your ability to negotiate change when you’re not the one in charge.

When approaching a problem situation that can only be solved through cooperation among several individuals, the first order of business is to write down exactly what you want to achieve. People typically plunge right into a discussion of the problem and start arguing over what to do.

To be effective leaders, case managers must think systematically — that is, set a goal, gather and lay out the necessary data, analyze the causes of the situation, and propose actions based on the analysis. When discussing the problem situation with others, keep people focused by asking appropriate questions, such as: "Do we have the information we need to analyze this situation? Can we focus on figuring out the causes of the problem we’re trying to solve?"

Develop synergy, not divisiveness. By helping caregivers achieve their goals, case managers will be more effective. Don’t think of the world in two views: Either, I win, or you win. This leads to divisiveness. Case managers must work with others to constantly do more with fewer resources. Thus for case managers to be successful, they must make sure that everyone wins — this produces synergy.

To create synergy among the health care team, start by finding out the answer to, "What’s in it for me?" from each group of caregivers (physicians, nurses, therapists, post-hospital providers, etc.). You’ll likely discover that each group values something a bit differently.

By knowing what each group values, you can create collaborative partnerships that seek to meet everyone’s expectations. The health care team cannot even begin to agree on how patient care should be provided until there is a common definition of the goal — one that reflects an understanding of everyone’s values (including the patient) and how the values diverge and converge.

If you’re not the boss, what kind of feedback can you provide to others? One thing that’s always valued is simple appreciation — "I thought you did a great job." Sometimes, too, case managers will be in a position to help other members of the health care team improve their performance through coaching.

Effective coaches ask a lot of questions. ("How did you feel you did on this project?") Effective coaches recognize that people may try hard and fail anyway. ("What made it hard to accomplish this task?") Even when you are not in charge, you can offer people a few suggestions for improvement. But be careful that you explain the observations and reasoning that lie behind them.

Gaining buy-in for process changes can be difficult when you are not the boss of everyone involved in the process. Engaging others and responding candidly to their questions and concerns is the best way to gain support, yet there are likely to be some quiet dissidents.

Don’t wait for 100% buy-in to the process change, or new ideas will never move forward. Early, credible supporters of the change will bring others into the fold over time. One-on-one personal interaction with opinion leaders to gain their support is usually time well spent.

It is always worthwhile to step back and review your style of personal interactions and ask how effective it is in solving problems.

If you are goal-oriented, authoritative, and decisive, you may find that these traits inhibit collaboration with other members of the health care team. If you are primarily focused on maximizing the collective creativity and innovation of everyone, your personal problem-solving goals may be easier to achieve.