It’s time for case managers to change their stories
It’s time for case managers to change their stories
Here’s how to come out on top when shift happens’
Dramatic changes have swept the health care industry in the past 10 years. Those changes have affected the type of care we deliver, the way we deliver it, and how we pay for it. Now, change experts warn that the only way for case managers to ride this wave of change successfully is to face the world of complex technology, medical miracles, financial hardships, and multiplying data sources with a willingness to give up their old health care stories and take an active role in shaping a new story.
"Shift happens. What you have in front of you in health care today is a time of great change and great opportunity to influence that change," says Nicole Schapiro, MA, president of Nicole Schapiro & Associates, an organizational training and consulting firm in Sausalito, CA. Shapiro addressed case managers at the 10th annual meeting Case Management Society of America held recently in Tampa. "You are unsung heroes of health care. Case managers have not done a good job of using their influence in this time of change," she explains.
The ability of case managers to use their influence has never been more important, agrees Jenifer James, PhD, a cultural anthropologist, president of an organizational training and consulting firm in Seahurst, WA, and a former professor of psychiatry and behavioral sciences at the University of Washington Medical School in Seattle. "Telling your story helps you gain understanding and financing for the problems you are facing in your efforts to advocate for your patients. It’s also extraordinarily important in helping you convince your patients to take increasing responsibility for . . . the much more complex life management skills that [this] complex world requires.
"The story is a common-sense version that folds the available data into a set of ideas about the way things ought to be,’" says James. "Case management leaders must be able to tell the new story,’ if they expect their staff, constituency, or clients to accept their leadership or their products and services."
The ability to tell a compelling story requires the following four elements, says James:
1. A set of ideas you believe represents the future and fits the current reality. "If your ideas don’t fit the current marketplace, they won’t work," explains James, citing tobacco companies as an excellent example. "The tobacco companies failed to adopt new ideas that fit a changing marketplace, and it has cost them millions. Medicine proved that tobacco was causing disease, but the tobacco companies refused to address this new information. Now, they’re being sued by every country in the world."
James notes that the story shaping today’s health care marketplace is self-care. "We’ve created a do-it-yourself health care marketplace: do-it-yourself appointments, injections, support groups. Patients are attempting to control their own destinies. They’re going on-line for health information. Your story has to fit that model of helping people take more responsibility."
2. A set of values connected to those ideas. "Your ideas won’t be useful if they don’t resonate with deeply held values," says James. "The values health care holds deeply include personal choice, kindness, quality, fairness, and honesty. The tobacco companies got into trouble because their values didn’t resonate. They didn’t understand that the value of good health’ had replaced the value of being cool.’"
Even though you are shaping a new story, you must tell it without letting go of those core values, she notes. "Those values are bedrock. The new story must include them," cautions James.
3. A personal ability to model the story with your own emotional energy, creativity, and edge. If you want others to listen to your story, you must be able to tell it with enthusiasm, integrity, and care, she says. "Pharmacists have done a wonderful job of telling their story. Their trust level is up with the public. They have made themselves part of the solution — part of the new self-care story."
If you don’t have the ability to connect with others, to really bond with them, your patients won’t listen and neither will their families, your team, providers, or the people who finance health care, warns James. "If you are not being genuine, or you don’t have energy for them, they won’t hear your story."
4. A willingness to influence others by telling the new story and motivating cultural change. "Your most powerful tool in leadership is the ability to tell the story — your story. If you don’t exert that power, you don’t exert your leadership," says James. "You ability and willingness to tell that story to your team, or your patient, or that physician will make a big difference in what gets done."
As health care undergoes rapid change, patients, health care professionals, and others with a role in the health care industry, such as payers, become frightened by their inability to see where the industry is headed, notes Schapiro. "It’s not a fear of the story changing, but a fear of loss for the old story."
There are several do’s and don’ts case managers should keep in mind as they tell their new stories, says Schapiro:
• Pay attention to the things you already know.
• Include people in the change process so they retain a sense of control.
• Brag strategically. "Many of us were told growing up, don’t brag.’ That’s luggage you must let go," says Schapiro. "You must learn to very quickly, very efficiently, and very appropriately sell yourself and your story. It’s a form of education, and education is the way to manage change."
• Don’t get distracted by anger when you are telling your story.
• Align yourself with positive influences. "If the people around you are giving off nothing but negative energy, leave the room," Schapiro says.
• Ask. "Many times people don’t get what they want when they’re negotiating because they simply don’t ask," she notes.
• Speak to others in a language they understand. (For tips on how to speak to others in their own language, see p. 129.)
• Take a chance on breaking the rules.
• Maintain eye contact with the person you’re attempting to influence.
• Create similarities with people. Finding common ground — whether it’s that you and the person you hope to influence both have children, or that you both grew up in the same part of the country — is important in influencing change, says Schapiro. "Tell that doctor you need to persuade to change his behavior, You and I are in the same boat. We both want what’s best for our patients.’"
Schapiro learned firsthand the value of establishing similarities with others at the early age of 15. She and 20 others were caught trying to cross the border during an attempt to escape communist Hungary. They were held overnight in an old barn awaiting execution. "My mother had told me that the border guards were between 15 and 17 years old, just like me, and she was right," she says.
She began a whispered conversation with her young captor on the way to her own execution. "We are both about 15 years old," she said. "I have a family. Do you have a family? I bet you could run away with me to America."
However, you not only must establish similarities but you also must offer others solutions, she cautions. "I had to give him a way to do his job, which was to kill me. I said, You shoot. You try to miss me. I’ll fall and act dead. Then after everyone else is gone, I’ll meet you in the barn to run away to America.’"
The soldier did shoot and miss. Schapiro did drop to the ground and wait until everyone else was gone before going back to the barn she had been held in overnight. "That young soldier never met me in the barn, but he’s still with me today." Her story illustrates an important point: "You can’t expect people to make too many changes at once. You can’t expect too much from them. The soldier was willing to change enough not to kill me, but not so much as to run away."
• Start with people where they are at the moment. "Give people back a sense of control by working with them from where they are at the moment rather than pushing them too quickly where you want them to go," suggests Schapiro. "Assure them that you know how they feel. Say, I can see where this might be confusing to you.’ Acknowledge their loss. Say, I don’t blame you for feeling the way you do.’ Treating them with respect is the best way to get them unstuck from their old ideas and listening to your new ones."
• Leave before you lose your control.
• Don’t defend, argue, or negotiate too early. "When people attack your story, don’t defend or argue too early. Use it as an opportunity to bridge from the old story to the new story. Listen respectfully to them. Don’t over talk’ in times of change because people are overwrought with emotions," she cautions. "Instead, ask them to tell you more about their position before explaining yours."
• Anticipate change. "If you are more than 21 years old, you have already experienced at least 2,000 shifts in your life," says Schapiro. "Realizing that you have experienced change and survived makes accepting the next change less threatening. When people are afraid of change, it helps them to realize that they are already successful change makers and they have translatable skills they can use to survive this most recent change."
Schapiro suggests you try the following exercise to help others work through their fear of change:
- Ask each individual to remember up to 10 changes he or she has lived through.
- Ask each individual to mark each change with a "plus" for a positive change or a "minus" for a negative one. For example, a marriage might be marked with a "plus" and a divorce with a "minus."
- Ask each individual to mark each change with an "o" to indicate a change brought on by someone else or an "i" to indicate a change the individual initiated.
4 Ask each individual to list the skills used to survive each change.
"After doing this exercise, people begin to see that they have successfully managed many changes, and they begin to relax. They also see that they have some translatable skills they can use," says Schapiro.
Not just the facts
It also helps if you take the time to identify the facts, assumptions, hopes, and fears about the changes you face and are trying to influence others to accept, she notes. Schapiro says you must ask yourself these questions before attempting to influence others:
• What are the facts about this moment?
• What do we assume to be true about this change?
• What is our hope for what this change will bring?
• What is our fear for what this change will bring?
"Change is a beginning, but it is also an ending," says Schapiro. "It is a loss of the way things were and a realization that they will never be the same again. When problems arise around changes in organizations or systems, it’s because people did not take the time or were not allowed to mourn. It’s that last piece — that recognition of the human part — that makes us willing to accept even the most difficult changes."
Schapiro often works with health care organizations that are downsizing. "I remember one hospital administrator who was faced with having to let go of a large number of employees," she says. "He called everyone together and said, These are the facts. These are the reasons we must make this change, and I’m genuinely sorry this is how things must be. And, I will miss every one of you I have enjoyed working with.’ People were sad to lose their jobs, but they were willing to accept that loss because he was willing to tell the complete story and connect with them on a human level."
Although he agrees with Schapiro that facts alone are not enough to navigate changes in health care successfully, facts are a vital part of the story case managers must tell in order to influence physician behavior change and sustain a vital role in health care delivery, cautions David B. Nash, MD, director of health policy and clinical outcomes at Thomas Jefferson University Hospital in Philadelphia.
"Case management cannot work in a vacuum," he says. "Without an information infrastructure, without physician support, without a culture devoted to measurement and improvement, case management is just a paper exercise, and its days are numbered. To survive this time of tremendous changes, case managers have to be the shock troops of quality improvement."
Nash says case managers must conduct rigorous research that proves the value of their work to gain stronger acceptance and survive the changes facing every health care setting. "Scientific research will be case management’s salvation as you tell your story," he says. "Case management and disease management work to improve quality by recognizing that unexplained clinical variance exists and costs money. Show physicians, show administrators how your cohort of diabetes patients has managed their hemoglobin A1C under your care. Base your interventions on scientific evidence and then find the arguments that will sell your proposed change to your target audience."
Prove your way is best
If influencing physician behavior change is your goal, go for the academic detailing approach, says Nash. "Help physicians understand by using evidence in the literature, or your own data, to demonstrate that if they follow your clinical path or your treatment plan, then they will achieve a better outcome, create fewer hassles, receive fewer telephone calls, and have happier patients and a busier practice," he advises.
Nash’s No. 1 rule for influencing physician behavior change is that if you help physicians be more efficient in their daily practice, they will give you their unending love and admiration, he says. "If you understand what the currency is of the audience you’re trying to influence, then you can hand it out and get the desired outcome," he says. "For physicians facing today’s changing health care system, the currency is improving the quality of their daily lives and the efficiency of their practices."
He suggests case managers use the following methods for telling their stories to physicians to influence behavior change:
• Provide physicians with information in a nonpunitive way about their daily practice performance. "If you want to see a physician change behavior fast, tell him that his clinical outcomes are two standard deviations away from the norm for his area and then jump out of the way," says Nash.
• Give physicians appropriate incentives. "Physicians are not motivated as much by money right now as by quality of life," says Nash. "Help them become more efficient and remove some hassles from their daily life, and they will follow."
• Get physicians involved in the process. "Find out who has an interest in the process and bring them on board, but don’t assume that every physician in your organization will be interested."
• Create administrative challenges to discourage bad behavior. "Tell them, OK, smarty-pants, you can have that MRI. Here’s the 17-page carbon form that you must fill out first.’ You’ll be amazed how quickly MRI utilization drops," says Nash.
Case managers are the bridge holding patients, providers, and payers together during this time of tremendous change in health care, says James. "The learning curve is straight up. There is tremendous grief among health care professionals. Deep in their gut is a story. The story is shifting. That shift is painful, and the people you work with may not be able to lay it out logically."
"Civilization is simply the long process of learning to be kind," James said at the conference. "When I look out, I see a roomful of people whose heart, whose reason for staying in such an extraordinarily difficult role, is that they know they are teaching a higher and higher level of civilization this process of being kind. Tell your story, and take good care of yourself, because you are taking care of the rest of us."
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