BY JOSE ALEJANDRO, PhD, RN-BC, MBA, CCM, FACHE, FAAN
Oftentimes, we as case managers find ourselves in difficult situations due to our complex roles and responsibilities, the diverse populations being served, limited resources if not also conflicting viewpoints that we encounter when advocating for our patient population. As these situations occur, case managers can be thrust into ethical dilemmas without realizing that this crossroad has occurred. Unsound decision-making could impact our practice, licensure and/or certification if boundaries are crossed, even if it was unintentional or accidental.
From a systems perspective, it is important for an organization to investigate where the process broke down versus pointing blame at the individual as to the reason adverse events occurred. Case managers, regardless of practice area, are given so much to do without having a true understanding of what their roles, responsibilities and expectations are. Senior case management leaders need to provide continuous education within the department and across the organization, so that all stakeholders have a clear understanding of ethical boundaries. Research does demonstrate that when employees are overwhelmed, they sometimes will take short-cuts that can result in unexpected outcomes.
The Case Management Society of America (CMSA) provides the Standards of Practice for Case Management (2016 revision) as a guide that can be referenced during ethical dilemmas. More importantly, the Standards should be referenced as a learning tool and a reminder throughout our careers. Education on our Standards of Practice and general ethics should be provided during new hire orientation and during annual competencies.
The assumption that everyone knows what to do during an ethical dilemma could result in a potential violation. Ethical codes, procedures and policies have been established by professional organizations and healthcare organizations as a way to guide professional practice and behavior. Ultimately, these standards aim to help professionals do the right thing for the patient populations they serve. All case managers are first beholden to the regulations that underlie their professional licensure, as well as state-regulated certifications. Then come dependent credentials, including specialty case management certification, for they are traditionally dependent on professional licensure. Professional association standards of practice and codes of ethics follow suit.
Our complex healthcare system can cause case managers to feel pressure to cut corners in order to save time, meet productivity metrics, financial metrics, family expectations, etc. Unfortunately, this puts patients at risk, which could result in less than ideal quality of life decisions or impact the patient or caretaker’s ability to make informed decisions. Many times, that queasy feeling we may have is a warning sign that we may be heading down the wrong path. At this point, we need to stop and take time to make sure that we are “doing the right thing.” It is important to also consider whether at this point we need to escalate our concerns to the appropriate organizational leader or potentially to an organization’s ethics committee.
As a front-line case manager, I can recall several instances when case management leaders have set unattainable departmental outcomes, which resulted in case managers’ being challenged in making the right ethical decision. Unrealistic expectations can result in our inability to appropriately care for individuals and their families. In my senior case management leadership experience, I have observed even the most ethical case managers being challenged because of the business needs of the organization. Senior case management leaders also have an ethical responsibility to advocate for all of their employees, so that healthcare system executives understand that case management professionals are required to follow the Code of Ethics and do what is right for the patients they are representing.
As advocates, case managers need to continue to champion for more internal and external resources to meet the needs of the individuals being served. We need to be knowledgeable and culturally sensitive to the needs of at-risk populations. Our goal should be to make sure individuals have the opportunity to make informed decisions about their future health or the healthcare needs of the individual they are entrusted to care for. Care management systems need to be continuously evaluated to ensure that processes are efficient and not overly complex. As we know, complexity typically results in delays and the creation of workarounds.
Licensure and certification boards also have ethics committees and other resources to prevent and address potential violations of their Code of Ethics. Case managers have a unique opportunity to marry advocacy and ethics so that each patient, client or resident served is given the opportunity to thrive through appropriate allocation of resources and education. Professional association and certification entities traditionally provide ethical advisory opinions as requested by those who are members, and/or credentialed. As professional case managers, it is important that we collaborate with our interprofessional colleagues in providing safe and exceptional care, and ultimately make the right decisions for the individuals we serve.
Jose Alejandro, PhD, RN-BC, MBA, CCM, FACHE, FAAN
President, CMSA, 2018-2020
Dr. Alejandro is the Director of Case Management at UC Irvine Health, Orange County’s only Level 1 Trauma and Burn Center.
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