Case Manager’s Role Leadership and Accountability
Suzanne K. Powell
Hussein M. Tahan
LEARNING OBJECTIVES
Upon completion of this chapter, the reader will be able to:
Define leadership and leadership style.
List four essential components of effective leadership.
Explain how case managers demonstrate role accountability.
Differentiate between aggressive and cooperative negotiation.
Describe components of emotional intelligence.
Identify key critical thinking strategies and skills for case managers.
Describe the role of the case manager in delegation and supervision.
Compare and contrast hard and soft savings.
Discuss the role of the case manager as an agent of change.
Describe motivational interviewing and its use in case management.
IMPORTANT TERMS AND CONCEPTS
Accountability
Change Agent
Communication
Conflict Management
Cost-Benefit Analysis
Critical Thinking
Delegation
Emotional Intelligence
Empowerment
Hard Savings
Leadership
Motivational
Interviewing
Negotiation
Soft Savings
Succession Planning
Introduction
A. Case management requires a wide array of management skills: accountability, delegation, conflict resolution, crisis intervention, collaboration, consultation, coordination, communication, motivational interviewing, advocacy, and documentation. However, case managers are no longer just managers of care.
Case managers are leaders, and there is a difference. Managers manage systems; leaders lead people.
Case managers do both; they manage cases (a number of clients) and lead, or guide, people.
Leadership is one step up the ladder of professional growth and development. As case management responsibilities continue to grow, leadership qualities will necessarily be presumed (Powell, 2000a).
B. Management and leadership are not the same thing; they are not synonyms, and case managers must recognize the difference.
A manager is an individual who holds an office—attached to which are multiple roles.
Leadership is one of those roles (Shortell & Kaluzny, 2000).
C. Leadership is about the ability to influence people (e.g., clients, health care professionals) to accomplish goals. Leaders can be formal (by their position in the organization or society) or informal (by the amount of influence they have on others). Case managers are constantly in a position to influence people to accomplish health care goals, and sometimes they are leaders by virtue of their positions.
D. Leadership is defined as a process by which an individual exerts influence over other people and inspires, motivates, supports, and directs their activities to help achieve individual, group, or organization goals. Effective leadership is demonstrated when a leader assists others to realize their potential and creates opportunities for them to excel and contribute to a higher purpose or bigger cause.
E. Six core components within the definition of leadership expound on the description (Shortell & Kaluzny, 2000) (Box 16-1).
F. How the above definition and criteria relate to case management roles and responsibilities:
BOX 16-1 Core Components of Leadership
Leading is a process, an action word, a verb.
The locus of leadership is a person; only individuals (as opposed to corporations or inanimate objects) can lead.
The focus of leadership is other people or groups. This connection must exist for leadership to take place.
Leadership necessitates influencing. It is the leader’s ability to influence others that sets apart an effective leader from an ineffective one. This may be the most critical of the leadership components.
The object of leadership is goal accomplishment.
Leadership is intentional, not accidental.
Leadership is about inspiring others to achieve their maximum potential.
Case management is a process where the case manager (the leader) must assess multiple variables that relate to the patient, the family, the disease process, the treatment, the insurance, the psychosocial situation, the desired goals and outcomes, and the interdisciplinary health care team.
The goals chosen are the road map for the creation of best outcomes; the case manager must intentionally influence the situation to bring about the best outcomes for the patient and family.
The ability to influence others may be the case manager’s “center of gravity” and most critical skill. Influence is a multipronged concept. On a daily basis, case managers intentionally influence patients/families, for example, to take appropriate medications, to think carefully about possible treatment choices, or to eat a diet that is best for their disease state. Case managers also influence insurance companies, and other important health care team members.
Descriptions of Key Terms
A. Accountability—Feeling, having the willingness to, and acting with a true sense of obligation toward others, one’s role, organization, and society.
B. Critical thinking—Purposeful, outcome-directed thinking that aims to make judgments based on facts and is based on scientific principles. It is an intellectually disciplined process of actively and skillfully conceptualizing, applying, analyzing, synthesizing, and/or evaluating information gathered or generated from observation, experience, reflection, reasoning, or communication, as a guide to belief and action.
C. Delegation—The process of assigning tasks to a qualified person and supervising that individual as needed.
D. Emotional intelligence—Also called EI or EQ; describes an ability, capacity, or skill to perceive, assess, and manage the emotions of one’s self, of others, and of groups.
E. Empowerment—Allowing employees or subordinates to make decisions with support from the leader or manager.
F. Hard savings—Occur when costs can be measurably saved or avoided.
G. Leadership—A process by which an individual exerts influence over other people and inspires, motivates, and directs their activities to help achieve group or organization goals.
H. Motivational interviewing—A counseling-like and purposeful style of interaction that aims to facilitate and engage intrinsic motivation and desire within the client in order to change behavior. This method is goaloriented, client-centered communication that is able to elicit lifestyle behavior change by assisting the client to explore and resolve existing ambivalence or fear of uncertainty.
I. Negotiation—Essentially a communication exchange for the purpose of reaching agreement.
J. Soft savings—Also called potential savings (or potential costs or charges); are less tangibly measurable than are hard savings (see hard savings, above).
K. Succession planning—Is a process for identifying and developing internal people with the potential to fill key leadership positions in
an organization or department. Succession planning increases the availability of experienced and capable professionals who are prepared to assume leadership roles as they become available.
an organization or department. Succession planning increases the availability of experienced and capable professionals who are prepared to assume leadership roles as they become available.
Applicability to CMSA’s Standards of Practice
A. The Case Management Society of America (CMSA) describes in its standards of practice for management that case management extends across all health care settings (e.g., preacute, acute, postacute) and various professional disciplines such as nursing, social work, pharmacy, vocational rehabilitation counseling, and others (CMSA, 2010).
Leadership, responsibility, and accountability for effective practice are then a priority for every involved health care professional, especially case managers, and in every care or work setting.
Leadership and accountability in areas of change management, performance improvement, communication, emotional intelligence, motivational interviewing, negotiation, and conflict resolution are among important skills of successful case managers. These allow case managers to have productive and effective relationships with patients, families, other health care professionals, and peers.
B. The CMSA standards of practice for case management describe a number of case manager’s roles, functions, and activities where the topics addressed in this chapter are necessary for case manager’s success in these roles. Examples of these functions and activities are the following:
Conducting a comprehensive assessment of the client’s health and psychosocial needs, including health literacy status and deficits
Development of a case management plan collaboratively with the client and family or caregiver, as well as other health care professionals
Planning care with the client, family or caregiver, other health care professionals, and the payer to maximize quality, safety, cost-effective outcomes, and access to services
Assisting the client in the safe transition of care to the next most appropriate level or provider
Promotion of the client’s self-determination, self-advocacy, informed and shared decision-making, and autonomy (CMSA, 2010)
C. Leadership and accountability are necessary for effective facilitation of communication and coordination among members of the health care team, involving the client in the decision-making process in order to minimize fragmentation in the services.
D. Leadership and accountability are also important traits of case managers for use in empowering the client to problem-solve and explore options of care and alternative plans to achieve desired outcomes.
E. The CMSA standards of practice cite “advocating for both the client and the payer to facilitate positive outcomes for the client, the health care team, and the payer” (CMSA, 2010, p. 14) as a case manager’s role.
Leadership and accountability are important skills for case managers to be effective in executing this responsibility.
These skills are even more important when a conflict arises and case managers are expected to resolve it while advocating for the patient
and placing the patient’s interests above all. The standards state “if a conflict arises, the needs of the client must be the priority” (CMSA, 2010, p. 14).
F. “The case manager should be aware of, and responsive to, cultural and demographic diversity of the population and specific client profiles” (CMSA, 2010, p. 22). Communication and conflict resolution skills, discussed in this chapter, are necessary for meeting the expectation of cultural competency in the provision of care, especially delivery of patient-centered care.
G. Motivational interviewing (MI) is an essential skill case managers must possess to influence patient’s healthy lifestyle behavior. It is an approach case managers should use to impact patient’s self-management skills and abilities and to overcome undesired situations or behaviors patients may exhibit, such as those included in the CMSA standards of practice for case management. For example:
Nonadherence to plan of care (e.g., medication adherence)
Lack of health education or understanding by patients in areas such as disease processes, medication lists, insurance benefits, and community resources
Lack of a support system or presence of a support system, especially when under stress
Patterns of care or behavior that may be associated with increased severity of condition (CMSA, 2010)
H. The case manager should maximize the client’s health, wellness, safety, adaptation, and self-care through quality case management, client satisfaction and optimal care experience, and cost-efficiency. Case managers’ leadership and accountability enhances performance in this role responsibility.
Accountability
A. Case managers cannot lead or influence others without accountability. They are able to demonstrate accountability in many ways, such as those shared in Box 16-2.
B. Case managers in their roles as managers, facilitators, and coordinators of care and client advocates pay careful attention to and apply the
various aspects of role accountability to effect desirable outcomes (quality, safety, cost, and access to care) and maintain successful relationships with fellow health care professionals and clients/families (Box 16-3).
various aspects of role accountability to effect desirable outcomes (quality, safety, cost, and access to care) and maintain successful relationships with fellow health care professionals and clients/families (Box 16-3).
BOX 16-2 Examples of How Case Managers Exhibit Role Accountability
Accepting responsibility to act
Owning their actions and their impact on achieving desired outcomes
Willingness to collaborate with the client/support system and other members of health care teams
Obligation to answer, respond to, or report on the outcomes of their own actions
Safeguarding the client and public interest: quality, safety, cost-effectiveness, and timely access to necessary health care services
Taking initiative, identifying opportunities for improvement in systems of care, and effective desirable change
Advocating for clients and their support systems
BOX 16-3 Aspects of Accountability in Case Management
Leadership
Moral
Ethical
Legal
Relationships
Quality and safety
Cost-effectiveness
Professional
Organizational
Political
Health and public policy
C. Successful case managers are accountable for own professional development, advancement, and growth. They are also responsible for promoting an environment of professional practice.
D. As part of their accountability, case managers assure the provision of care in accordance with ethical, regulatory, accreditation, and evidencebased standards. They also adhere to the scope and standards of their professional organizations such as CMSA.
E. Case management leaders and executives have an obligation for succession planning. Because of the continued lack of academic programs that prepare health care professionals for the roles of case managers and case management leaders, it is important for those in leadership positions to develop mentoring and coaching programs to create new talent and assure succession planning.
Leadership Styles
A. A leader’s style is often based on a combination of beliefs, values, personal traits, and preferences, in addition to the leader’s organization’s culture and norms, which will encourage some styles and discourage others.
B. There are several styles of leadership (Box 16-4). Case managers use these styles differently, depending on the situation and the role they are playing at the time. However, personality traits may make one or two styles predominant (or nonexistent).
C. Authentic leadership—An approach to leadership that emphasizes building the leader’s legitimacy through honest, open, and transparent relationships with followers, which value their input and are built on an ethical foundation. Generally, authentic leaders are positive people with truthful self-concepts who promote openness (Wikipedia, 2015b).
Characteristics of authentic leaders include the following (Kruse, 2013):
Self-awareness and genuine attitude. Authentic leaders are selfactualized individuals who are aware of their strengths, their limitations, and their emotions. They also show their real selves to their followers. They do not act one way in private and another in public; they don’t hide their mistakes or weaknesses out of fear of looking weak.
Being mission driven and focused on results. Authentic leaders are able to put the mission and the goals of the organization ahead of their own self-interest.
Leading with the heart, not just with the mind. Authentic leaders are not afraid to show their emotions and their vulnerability and to connect with their employees. This does not mean authentic leaders are “soft.” In fact, communicating in a direct manner is critical to successful outcomes, but it’s done with empathy; directness without empathy is cruel.
Focus on the long-term goals and vision, and be future oriented in actions and plans.
Key components of authentic leadership are self-awareness, relational transparency, balanced processing, and internalized moral perspective. These allow leaders to have the capacity to understand personal strengths, limitations, opportunities for improvement or further development, and impact on others (Shirey, 2015).
Self-awareness requires the leaders to pursue self-discovery, selfimprovement, reflection, and renewal. These demonstrate the leader’s understanding of the world around them.
Relational transparency refers to the leader’s ability to present his/her true self when engaging with others, be genuine, and share openly.
Balanced processing focuses on maintaining objectivity, seeking out pertinent insights, and ensuring nothing important is missing before making final decisions.
Internalized moral perspective allows the leader to adhere to ethical and moral standards; to demonstrate integrity, self-regulation, and alignment of own behaviors with personal values; and to assure that actions are consistent with spoken words (Shirey, 2015).
BOX 16-4 Various Leadership Styles Case Managers May Use
Authentic leadership
Charismatic leadership
Participative leadership
Situational leadership
Transactional leadership
Transformational leadership
Quiet leadership
Servant leadership
D. Charismatic leadership—The word charisma is derived from a Greek word meaning “divinely inspired gift.”
Charismatic leaders feel that charm and grace are all that is needed to create followers and that people follow others that they personally admire.
Charismatic leaders pay a great deal of attention in scanning and reading their environment and are good at picking up the moods and concerns of both individuals and larger audiences. They then will hone their actions and words to suit the situation (“Leadership Styles,” 2006).
E. Participative leadership—Participative leaders believe that involvement in decision-making improves the understanding of the issues concerned by those who must carry out the decisions. Further, people are more committed to actions when they have been involved in the relevant decision-making, and are less competitive and more collaborative when they are working on joint goals (“Leadership Styles,” 2006) (Table 16-1).
F. Situational leadership—Situational leaders use a range of actions and styles that depend on the situation. This style may be transactional or transformational (see below) or any of the leadership styles discussed.1
G. Transactional leadership—Transactional leaders believe that people are motivated by reward and punishment. Social systems work best with a clear chain of command. When people have agreed to do a job (the transaction), a part of the deal is that they cede all authority to their manager. The prime purpose of the subordinates is to do what their manager tells them to do (“Leadership Styles,” 2006).
H. Transformational leadership—While transactional leadership attempts to preserve and work within the constraints of the status quo, transformational leadership seeks to subvert and replace it and looks at the greater good (Shortell & Kaluzny, 2000).
Transformational leaders believe people will follow a person who inspires them, has vision and passion, and can achieve great things. The way to get things done is by injecting enthusiasm and energy.
Transformational leadership starts with the development of a vision (by the leader or by the team)—a view of the future that will excite and convert potential followers (“Leadership Styles,” 2006).
Transformational leadership is about the leader developing other leaders from the followers and creating opportunities for them to expand and recognize their potential.
I. Quiet leadership—The quiet leader believes that the actions of a leader speak louder than his or her words. People are motivated when you give them credit rather than take it yourself. Ego and aggression are neither necessary nor constructive (“Leadership Styles,” 2006). Quiet leaders
promote a sense of calm, peace, and comfort in their environment and people around them.
promote a sense of calm, peace, and comfort in their environment and people around them.
TABLE 16-1 Participative Leadership Styles | ||||||||||||
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J. Servant leadership—The servant leader believes the leader has responsibility for the followers and toward society and those who are disadvantaged. The servant leader serves others, rather than others serving the leader (“Leadership Styles,” 2006).
Leadership Skills
A. The jury is still out about whether leaders are born or made. However, experts have noticed specific actions that successful leaders share, regardless of the type of organization they lead.
B. Qualities of effective leaders are listed below. Note the similarities between effectively working with patients/clients and leaders working within their organizations. Effective leaders:
Promote empowerment. They emphasize the strengths and utilize the talents of others in the organization. Leaders share decision-making with others, allowing those people at the point of care or service to be the key decision makers. Then they share in the success and give credit where it is due.
Promote a vision. People need a vision of where they are going. Leaders provide that vision.
Follow the golden rule. Anyone who has been demeaned or treated with disrespect knows what effect that treatment has on the work.
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