Summary and Recommendations

• Overall Conclusions
• Recommendations

The Accident Compensation Corporation Te Kaporeihana Awhina Hunga Whara (ACC) handles a wide variety of injury claims – from small events requiring a single doctor’s visit to life-changing accidents requiring years of treatment and rehabilitation. Claims that are likely to last months or years need ongoing individual attention and are assigned to case managers in ACC branches.

ACC branches manage the claims that are likely to be costly and complex. These are also the claims where those affected have a great deal at stake, and where there is the greatest risk of something going wrong. We looked at the way that ACC undertakes case management at the branches. We did not look at the outcomes (the end point of individual case histories) provided by that case management. We looked at specific cases to help us understand the wider issues of case management, although the rights or wrongs of specific cases are properly dealt with through external dispute resolution bodies.

In the context of ACC’s overall work, the complicated and lengthy claims are few in number but high in costs. Of the approximately 1.5 million claims that ACC receives each year, only about 105,000 (7%) require rehabilitation and compensation, and hence management, either at ACC’s contact centres or branches. Of the 105,000, around 7% go on to become long-term claims – claims that receive assistance from ACC for more than 12 months. At present, the pool of long-term claims makes up about two-thirds of ACC’s compensation and rehabilitation costs.

Overall Conclusions

Overall, ACC’s case management practices are thorough and work well, and ACC staff have a professional approach. ACC places emphasis on performing its legal functions and duties, and sometimes claimants do not fully appreciate the legal limitations placed on ACC staff, and what they can provide. However, we consider that there are areas where ACC can improve, particularly in the way it communicates with claimants. In this report, we describe how case management works at ACC, and how it could be improved.

ACC was once essentially a payment-processing organisation. However, the introduction of case management in the mid-1990s gave the organisation a stronger focus on the rehabilitation of claimants. There is now greater rigour in reassessing ongoing cover and entitlements, and promoting a return to work or independence as quickly as possible. This approach is consistent with ACC’s governing legislation, the Injury Prevention, Rehabilitation, and Compensation Act 2001 (the Act). ACC has a strong emphasis on process, and aims for continual progress on claimants’ files.

We interviewed a selection of claimants, both short-term and long-term, to obtain their views on the standard of service that they are receiving, or have received, from case managers. These claimants expressed divergent views about their experiences with ACC, which is consistent with the range of views recorded through ACC’s claimant satisfaction surveys. For example, differing views were that:

• ACC is not providing them with everything they are entitled to.
• They had been forced through the process, had been treated like a number and like everyone else, without reference to their individual circumstances.
• While they had been treated badly in the past, the level of service is much better now.
• ACC could not have been more helpful during their recovery.

Given this range of views, it is not possible for us to arrive at an opinion on a majority claimant perspective of ACC. However, our interviews proved extremely useful in allowing us to understand some of the underlying issues that claimants experience in their dealings with ACC. We have referred to information gained through our claimant interviews throughout this report.

Overall, ACC’s case management function is performing well. We found no systemic failings, and ACC has measures in place to try and ensure consistency of individual practice throughout its offices, as well as compliance with legislation. Staff performance is also regularly monitored and assessed against a range of measures. Case managers are well supported in their work by staff and managers, and technological resources. Regular training sessions also support case management and assist with the professional development of staff members.

Many people, both inside and outside ACC, told us that the organisation is performing better now than in the past. In particular, employers, health service providers, and some claimants commented that a positive change has occurred over the last few years in that ACC is now actively addressing rehabilitation.

ACC is aiming for continual reassessment and improvement of its processes. In line with this, new initiatives are launched regularly after consultation with key stakeholders, including Māori and Pacific peoples’ advisory groups. It has also set up new projects with the intention of improving community awareness of ACC rehabilitation services.

In relation to Māori, Te Puni Kōkiri (TPK) found in its 2001 review¹ that ACC had made significant progress in addressing the findings of TPK’s 1998 report², but noted several areas for improvement. Although we did not specifically audit progress against the areas for improvement identified by TPK, we saw what ACC was doing to improve its responsiveness to Māori. In addition, ACC told us that it is planning a strategy to improve access for Pacific peoples to all rehabilitation services.

ACC does make mistakes, and has measures in place to try to resolve disputes with claimants. Nevertheless, some claimants are critical of ACC’s performance, and consider that ACC does not fulfil its legal obligations. We are of the view that ACC is generally operating in a manner consistent with its legislation. However, we have recommended that key areas of ACC case management practice could be improved to the benefit of both ACC and claimants.

Claimant satisfaction surveys illustrate that some claimants view ACC’s service delivery as impersonal. Additionally, the surveys show that some claimants consider that ACC lacks empathy for them by being too assertive and inconsiderate of the circumstances of their injury.

These criticisms are symptomatic of the gap that exists between the level of personal service that claimants expect from ACC and the level that ACC believes it should provide. For example, some claimants expect close and regular face-to-face communication with their case manager. ACC, on the other hand, considers that its present level of personal service is sufficient and fulfils its legislative obligations to claimants.

Problems arise particularly when long-term claimants, whose rehabilitation has not been adequately managed by ACC in the past, are contacted by ACC with new requirements – for example, that they participate in rehabilitation with the aim of returning them to work or independence. Some claimants perceive this as an attempt to “get them off the scheme”, while ACC views this action as good rehabilitation practice and in keeping with its obligations under legislation. Often, these different views are manifested in the form of complaints, review, or appeal proceedings by claimants against ACC.

In our view, the following recommendations will assist ACC to build on the improvements it has made over the last few years.

Recommendations

Resources for Case Management

Information Systems (paragraphs 4.4-4.16 on pages 55-58)

Within branches, we found that case managers’ work is well supported, through support staff at the branch, or comprehensive information systems available on-line. We were impressed with the detail contained within Informe, which is ACC’s on-line policy and procedures manual. Other on-line tools are available to case managers to assist them to monitor their workload and to prioritise their work. However, the weekly case listing report, which we believe is a useful means of ensuring that tasks are completed within the deadlines defined by the Act and by ACC’s internal policies, is currently not used by all case managers.

We recommend that ACC promote the wider use of the case listing report by case managers.

The Individual Rehabilitation Plan (paragraphs 4.35-4.52 on pages 62-65)

For all claimants assessed as needing more than 13 weeks to return to work or independence, ACC is legally required to prepare an Individual Rehabilitation Plan (IRP), in consultation with the claimant.

The intent of the IRP is to set rehabilitation goals and a proposed schedule for treatment and social and vocational rehabilitation, agree rights and responsibilities, and record the claimant’s progress.

The preparation and implementation of an IRP provides impetus and structure for the rehabilitation process, but the approach taken to prepare and confirm the IRP varies between branches. The quality of the IRPs prepared by case managers also varies. In fact, we found instances where the content of IRPs appeared to have been copied, with little to differentiate them in detail from others.

We saw examples of IRPs that complied with timeliness requirements under the Act and ACC policy, but the quality of the plans was compromised because they were produced in haste to meet the deadline. This is one possible reason why some IRPs appeared uniform.

We recommend that ACC ensure that all case managers tailor the content of each Individual Rehabilitation Plan to the claimant’s rehabilitation needs.

Case managers may be more intent on processing IRPs to satisfy branch targets, rather than allowing time for claimants to fully discuss and understand how the rehabilitation process will assist their recovery. The planning and content of the IRP sometimes require the case manager to engage in more discussion with the claimant, so that the claimant has a clearer understanding of their goals, rights, and responsibilities in regard to their own rehabilitation.

We recommend that ACC case managers make sure that a claimant fully understands their goals, rights, and responsibilities before the claimant is asked to sign the Individual Rehabilitation Plan.

The Act requires all Individual Rehabilitation Plans to be prepared within 13 weeks of claims being accepted by ACC. ACC has set a target for branches of 90% compliance with this requirement. Notwithstanding ACC’s reasons for a 90% target, the target is not consistent with the statutory requirement, which (in our view) contemplates no exceptions to full compliance.

Measurement and Monitoring of Branch Performance (paragraphs 4.65-4.73 on pages 67-69)

Branch performance is regularly measured, monitored and ranked according to a range of key performance indicators (KPIs) that are set annually by Head Office. ACC’s KPIs are a mixture of quantitative and qualititative measures. Branches are measured against an extensive list of KPIs, not all of which are included in the Annual Report. ACC generally does a good job of reporting statistics in relation to rehabilitation, though it should include more KPIs relating to the quality of claimant outcomes, such as the rate of reactivated claims.

We recommend that ACC include more KPIs relating to the quality of claimant outcomes, such as the rate of reactivated claims, in its Annual Report.

File Review and Audit

Branch File Reviews (paragraphs 4.75-4.80 on pages 69-70)

ACC, through performance agreements, expects its team managers to review their case managers’ files monthly to check that entitlement decisions and IRPs comply with the Act. These reviews are not always done because of other work priorities. These reviews are important.

We recommend that ACC ensure that team manager file reviews are completed in accordance with the team manager’s performance agreement.

Catalyst Injury Management Limited (paragraphs 4.90-4.114 on pages 72-76)

An ACC subsidiary, Catalyst Injury Management Limited (Catalyst), selected some long-term claims from ACC branches for case management. Catalyst specialised in managing such claims through intensive rehabilitation with the aim of returning claimants to work or independence within 12-15 months.

ACC announced on 1 September 2003 that Catalyst’s role of case management of some long-term claims would be returning to Long Term Claims Units within ACC. Despite this, we have retained our discussion of Catalyst in this report. We consider that the lessons learned from ACC’s Catalyst experience have relevance to ACC’s future dealings with long-term claimants.

Specific issues identified by Catalyst claimants through ACC-commissioned surveys included the frequency of case manager turnover and not enough faceto- face contact and communication with their case manager. Claimants who were with Catalyst often required more intensive management than other claimants, so ACC needs to take particular care in future to communicate with them regularly and fully. Clear communication with former Catalyst claimants is especially important now, given the transfer of their claims back to ACC.

We recommend that ACC communicate regularly and fully with former Catalyst claimants about progress in their rehabilitation.

Case Manager Induction Programme (paragraphs 5.10-5.15 on pages 80-81)

A case manager’s role includes assessing a claimant’s needs, co-ordinating services, monitoring progress, and liaising with providers and a claimant’s employer. ACC’s induction programme recognises all the knowledge and skills required for new staff to perform these roles.

However, where staff turnover is high, workload pressures mean that the full induction programme is not always completed before case managers are assigned a full caseload. This may be disadvantageous to both the case manager and their claimants.

We recommend that ACC ensure that new case managers complete the induction programme before they are assigned a full caseload.

Case Manager Monitoring and Assessment (paragraphs 5.23-5.29 on pages 82-83)

As with branch performance, case manager performance is thoroughly monitored and assessed. ACC’s various electronic systems allow team managers to track the performance of their case managers against clearly defined KPIs. These KPIs are split into “results” (quantity and process) and “quality” (e.g. customer service and teamwork) objectives.

The results KPIs are measured statistically, and all case managers are assessed to the same standards. However, the quality KPIs are more difficult to evaluate consistently, and their measurement was variable. It was not clear how those measures could be assessed consistently throughout ACC.

We recommend that ACC ensure that team managers objectively and consistently evaluate case managers’ performance against quality KPIs.

Claimant Service Performance

Part 3 of the Act requires ACC to establish a Code of ACC Claimants’ Rights. The Code came into force on 1 February 2003. Some staff suggested to us that the Code simply expresses the customer service values to which ACC already aspires. However, we consider that the Code has given increased prominence to these values, and has helped to standardise and clearly articulate internal procedures, particularly for dealing with complaints.

Claimant Service (paragraphs 6.8-6.20 on pages 90-92)

ACC has implemented a number of useful initiatives with the aim of improving claimant service. However, we consider that the notification of a change of case manager could be more consistent. While ACC requires case managers to notify their claimants of such changes, this does not always happen. In line with the Code of ACC Claimants’ Rights, ACC is obligated to effectively communicate with claimants to keep them fully informed.

We recommend that ACC ensure that claimants are notified when their claim is transferred to another case manager.

In our view, when a claimant leaves the accident compensation scheme for any reason, there needs to be some form of follow-up by ACC to allow it to gauge the success, or otherwise, of the service that it provides. ACC periodically commissions a survey of former ACC claimants about their experience. This survey should be commissioned more regularly as a way for ACC to obtain information on the durability of claimant rehabilitation outcomes.

We recommend that ACC more frequently commission the survey of former ACC claimants to obtain data that can be used to improve the quality of claimant rehabilitation outcomes.

Complaints, Reviews, and Appeals

Complaints (paragraphs 6.23-6.30 on pages 93-94)

ACC has clear and appropriate procedures for receiving and responding to complaints made by dissatisfied claimants. Additionally, the Act establishes detailed review and appeal rights. The rights to complain, to seek a review, or to appeal, provide important checks and balances on case management in individual cases.

While ACC records the number and nature of the complaints it receives, we were told that it has been difficult to gather accurate qualitative information about trends. ACC has indicated that it plans to do more to collect and analyse overall information about the types of complaints it receives, and how the nature of complaints has changed over time. This work is valuable; otherwise, lessons learned from complaints may not always lead to organisational improvements.

We recommend that ACC prioritise the collection and analysis of qualitative information about the types of complaints that it receives and how the nature of those complaints has changed over time.

We recommend that ACC use qualitative information about complaints to help identify areas where changes to policies or practices may be necessary.

Reviews and Appeals (paragraphs 6.31-6.47 on pages 94-97)

A claimant can challenge an ACC decision by filing an application for review, which is determined at a formal hearing before an independent reviewer.

The ACC representative at the formal review hearing is usually the original decision-maker, and their presentation is often a mixture of advocacy and evidence. In cases where the relationship with the claimant has deteriorated and the case manager’s credibility and evidence is being challenged, the case manager’s ability to act effectively as an advocate and representative may be undermined. In our view, when a case manager is required to provide evidence that is likely to be disputed, it may also be necessary for ACC to be represented by an advocate who is not personally connected to the factual disputes in the case.

We recommend that ACC consider whether, in contentious review hearings, the role of the case manager should be limited to that of a witness, with another staff member acting as ACC’s advocate.

ACC’s decisions are upheld in a majority of review and appeal proceedings. However, in those proceedings where its decisions are overturned and it elects not to appeal, we consider that ACC needs to quickly remedy the situation where it has been found at fault. Additionally, ACC needs to formalise a process by which it can learn from overturned decisions, so that mistakes are not repeated.

We recommend that ACC prioritise action to implement a reviewer’s decision as quickly as possible in cases where ACC’s decisions are overturned and it elects not to appeal.

We recommend that ACC formalise its processes and timetables for considering issues arising out of review and appeal decisions, and implementing any subsequent changes to policies or practices.

Claimant Satisfaction Surveys (paragraphs 6.48-6.62 on pages 98-101)

ACC commissions and widely promotes the results of seven claimant satisfaction surveys. We reviewed the quarterly Network Management Survey because of its focus on claimant satisfaction with branch performance, and to provide assurance that the results were based on sound methodology. In our view, the methodology was sound and the surveys produce reliable information on which to base statements in ACC’s accountability publications.

ACC’s Annual Report for 2002-03 describes claimant satisfaction rates for both short-term and long-term claimants. However, the report does not show the difference between them on the corresponding graph, instead showing only short-term claimant satisfaction. In our view, both short-term and long-term claimant satisfaction data should be presented in a consistent manner when using a graph or text.

We recommend that ACC report both short-term and long-term claimant satisfaction rates in a consistent manner in its accountability publications.

In our review of the surveys we also found a number of minor discrepancies between the survey findings and the information shown in ACC’s Annual Report for 2001-02.

We recommend that ACC implement a process to ensure that claimant satisfaction survey results are accurately reported in published material.

1: Te Puni Kōkiri, Follow up Review of the Accident Compensation Corporation’s Service Delivery to Māori, 2001.

2: Te Puni Kōkiri, Review of the Adequacy of ACC’s Service Delivery to Māori, January 1998.