Part 3: Case management capability and capacity

Accident Compensation Corporation: Using a case management approach to rehabilitation.
Each day you will be faced with the challenge of utilising your knowledge and networks to produce the best possible outcomes, while working within your core guidelines … We offer full training and value staff through ongoing development and support.
(ACC Case Manager position advertisement, July 2014)

In this Part, we set out our assessment of ACC's case management capability and capacity – its staff and systems.

Capability refers to having the right staff with the right skills and behaviour, equipped with the appropriate tools and knowledge.

Capacity refers to having enough of the appropriate capability in the right place at the right time.

Summary of our findings

ACC has the capability and capacity in place to manage cases. However, its systems and processes need to better support the delivery of a fair service that focuses on claimants.

ACC knows what competencies, skills, and experience case managers need to have. However, specialist training in case management is limited. ACC has begun a project to make specialist case management training available to case managers.

In general, case managers are passionate about their jobs and strongly committed to serving claimants. However, they see some systems and processes as barriers to delivering good service. Case managers also have to do a lot of administrative work.

Case managers often ask colleagues for advice about processes instead of consulting ACC's policies, procedures, and reference material. Some staff find the material difficult to access.

Communication problems are at the centre of many complaints about ACC. ACC is working to improve its forms, letters, and information sheets and provide case managers with more guidance about talking with claimants.

Case managers' caseloads vary widely. ACC has pragmatic practices in place to manage caseload peaks, but heavy caseloads can negatively affect the customer experience.

Staff skills and training

ACC knows what skills and experience case managers need. However, specialist training in case management has been limited. ACC has introduced a programme to provide specialist training to case managers.

Case managers have to use good judgement to make decisions that are appropriate to each person's needs and circumstances. Technical skills can be taught, but it is also important to have the necessary "softer" skills, such as empathy and the ability to communicate. As one staff member told us, a good case manager is "someone who wants to do the job for the right reasons".

ACC expects case managers to focus on claimants and to reach a customer focus competency of level 2, with level 4 being the highest competency. Gaining this competency means:

  • establishing and maintaining effective relationships with claimants and gaining their trust and respect;
  • being available, especially when claimants are going through a difficult period;
  • being dedicated to meeting claimants' expectations and requirements;
  • giving detailed reasons for providing or declining services in a way that maintains positive relationships;
  • handling difficult customers tactfully and with respect;
  • taking proactive steps to ensure the privacy of claimants' information; and
  • making suggestions for process improvements.

ACC has an organisation-wide induction process for new staff, which is a mix of e-learning modules, "buddying", self-study, and training workshops. Workshops cover specific topics, such as introductions to weekly compensation and best practice. There is a corporate orientation day.

Six trainers deliver specific training to frontline staff.

Staff turnover rates in some offices affects the delivery of training. The frequent change in staff increases the demand for training.

ACC has partnered with Auckland University of Technology to develop undergraduate and postgraduate qualifications in case management tailored to ACC's needs. The undergraduate qualification includes papers in rehabilitation management, dispute resolution and advocacy, and dealing with complex case management. Postgraduate papers are offered in vocational rehabilitation and advanced case management practice.

Offering specialist training is a positive step in ensuring that case managers have the right knowledge and skills.

A new manager's induction programme and qualifications in leadership and management are also planned.

Support available to staff

A variety of support is available to case managers to make good decisions. However, case managers use and access specialist advice and support to varying extents. Evidence could be better integrated into case management tools and systems to help case managers to follow evidence-based treatment and rehabilitation pathways. Tools for coaching staff are not used consistently. ACC needs to strengthen its case management quality review tools to help staff to deliver the highest practicable standard of service and fairness.

To perform well, staff need to have good systems, knowledge, information, advice, and guidance.

Advice and guidance

Case managers have access to internal specialist advice, policies, guidelines, and peer and managerial support, to help them make good decisions.

We found inconsistencies in how teams and offices use specialist advice. Some case managers appear to use these resources more than others. This use depends in part on the case manager's own experience and a claimant's particular needs and circumstances.

Staff have access to a range of specialist advisors at a local, regional, and national level. This range includes, but is not limited to:

  • local medical advisors;
  • local psychological advisors;
  • cultural advice teams;
  • technical claims managers;
  • serious injury regional advisors; and
  • the serious injury national panel.

ACC has raised questions about the quality of its clinical advice. The clinical advice model is fragmented, which can lead to inconsistent decision-making. We were told that delays in getting specialist clinical advice can make case management services less timely.

ACC has created a central pool of specialist advice that it can call on to improve the consistency and availability of clinical advice to its staff. In our view, moving to manage specialist advisors (such as medical and psychological advisors) as a collective – rather than local – resource is a sensible approach. This should help to improve case managers' access to specialist advice and potentially improve the timeliness and consistency of advice.

Systems and processes

Case managers rely heavily on Eos, ACC's case management system. As in many work places, relying heavily on an information system means that work is disrupted when the system stops working, including for system upgrades. We experienced system disruptions during our review of claims files in Eos.

Because case managers enter tasks manually in Eos, an evidence-based framework within Eos does not guide their decisions. Case managers are expected to consult policies, procedures, and reference material stored in CHIPS to work out the appropriate tasks and to use the relevant ACC form or letter for those tasks.

The information in CHIPS is comprehensive – and, in our view, good quality – but there is a lot of it, and it could be made easier to search. Many staff we spoke to found it difficult to access and find the information in CHIPS. 9

Because of practical challenges using CHIPS, case managers often draw on their experience or advice from peers instead of referring to ACC's policies or best practice guidance. This risks having inconsistent decision-making and variable claimant experiences, which is something claimants have told us that they experience. This variability in experience is consistent with our audit evidence, as well as the information gathered from interviews with claimants. We describe claimants' experiences further in Parts 4 and 5.

Recommendation 1
We recommend that the Accident Compensation Corporation set out the possible standard treatment and rehabilitation steps for a given injury, based on scientific evidence, in the information systems that its case managers use – to ensure that all claimants in similar circumstances receive consistent and effective treatment and rehabilitation, based on proven treatment and rehabilitation pathways.

If ACC addresses this recommendation well, case managers' approaches to claimants in similar circumstances should vary less. It is important, though, that the treatment and rehabilitation pathways built into any existing or new information systems do not become formulaic but are flexible enough to adapt to a person's needs and circumstances. Some flexibility is an important feature of an effective case management approach.

ACC plans to better integrate treatment and rehabilitation pathways into its case management systems as part of Shaping Our Future.

ACC is working to further enhance the CHIPS search functions to help case managers to more easily access its procedural and practice information. This is to reduce the risk of case managers doing what they or their colleagues have always done instead of using ACC's relatively good quality procedural and practice information.

Quality management and coaching tool

Using a set of best practice principles, ACC regularly assesses how well case managers engage customers. This is referred to as a Customer Engagement Appraisal. For ACC, customers include claimants, employers, and providers. In 2013/14, Customer Engagement Appraisals replaced ACC's existing case management quality review tools.

Customer Engagement Appraisals are used to measure how well case managers interact and engage with claimants, and plan and arrange rehabilitation for those claimants. Managers use Customer Engagement Appraisals as a coaching tool to encourage case managers to view case management from a claimant's perspective. Customer Engagement Appraisals are in line with aspects of the Code.

A Customer Engagement Appraisal results in the case manager being assigned to one of three outcome bands:

  • expert;
  • competent; or
  • developing.

In the Customer Engagement Appraisal process, managers review a file and, where possible, seek comments from the claimant, employer, or provider associated with that case. In 2013/14, ACC expected a Customer Engagement Appraisal to be carried out once a fortnight for each case manager. In our analysis of a sample of 36 Customer Engagement Appraisal reviews, we found that the majority had no record of feedback from claimants, employers, or providers.

One of four performance advisors – who are independent of the local office and experienced in case management practice – later assesses some of the Customer Engagement Appraisals (between 2% and 4% in the offices we visited). In our view, performance advisors could have a more consistent approach to their reviews of Customer Engagement Appraisals.

Managers can choose which claims to appraise. This raises a risk of bias because managers could be inclined to assess a claim that has been managed well. A review of a sample of each manager's completed Customer Engagement Appraisals reduces this risk.

There is evidence of the results of Customer Engagement Appraisal reviews being relayed to the managers carrying out the Customer Engagement Appraisals. However, some staff felt that it was not a valuable process because getting good assessments told them nothing new about the claimant or about how to improve their own practices.

As well as Customer Engagement Appraisal reviews, a risk-based compliance check is also carried out. ACC considers this administration checklist, which has been in place since October 2013, to be part of its "Network's First Line of Defence activity". The checklist includes items about weekly compensation, social rehabilitation, and documents. Six claims reviewers carry out these checks.

ACC is working to improve the Customer Engagement Appraisal and compliance check processes. This could include a more random selection of claims, regularly completing the stakeholder contact component of Customer Engagement Appraisals, more consistent reviewing of completed Customer Engagement Appraisals, and continuing efforts to introduce a risk basis to the frequency of Customer Engagement Appraisals and compliance checks. In our view, it is sensible for ACC to improve quality assurance.

We are aware that ACC is working on a wider case management quality review framework. The framework is intended to cover the end-to-end case management process and support quality measurement, including the stages involving case management. The framework was not finalised when we did our audit work.

Recommendation 2
We recommend that the Accident Compensation Corporation strengthen the overall approach and tools that it uses to guide, monitor, review, and manage the quality of its case management services – to ensure that people consistently receive treatment and rehabilitation services of the highest practicable standard and fairness in line with the requirements of the Code of ACC Claimants' Rights.

If ACC addresses this recommendation well, claimants should experience improved services that are more in keeping with the Code. Better quality management should give ACC earlier and more accurate information on those aspects of its case management service delivery that might prevent claimants from receiving a consistent service that is fair and of the highest practicable standard.

Pastoral care

At times, case management can be challenging because of the amount of contact with claimants and because the decisions case managers make can affect claimants' lives in important ways. These are in addition to the normal stressors that people experience in their workplaces and private lives.

Case managers have access to an employee assistance programme and, on request, can access psychological support in the form of professional supervision. Flexible working arrangements are also available to staff.

Allocating work and caseloads

Case managers' caseloads vary widely. ACC has pragmatic practices in place to manage caseload peaks, but sometimes caseloads can negatively affect the claimant experience.

Combined caseloads are different between case management streams, reflecting the different intensities of case management. Figure 3 shows the average number of cases by case management stream for the local offices we visited. Caseloads varied significantly between the offices we visited, even within a case management stream. In some serious injury teams, caseloads were grouped into several types: employment, child and youth, and building independence.

Figure 3
Average number of cases for each case manager, by case management stream, in local offices we visited

Front-endRecover Independence ServiceSerious Injury Service
Christchurch 60.0 48.8 55.3
Counties Manukau 64.6 69.6 47.7
North Harbour 61.1 48.1 43.7
Whangarei 84.8 48.2 44.9
Porirua 44.6 N/A 37.2
Henderson 66.7 N/A 41.8
Greymouth 47.4 N/A N/A

Note: We have calculated caseloads using the combination of active and inactive claims at the local offices we visited. Although some claims are considered to be inactive, they can involve a lot of work for a case manager – for example, preparing for a review hearing.
N/A indicates that stream is not managed in that office – other offices manage the claims.

Although we saw no single approach to allocating caseloads to case managers, work was generally allocated on the basis of staff experience and workload.

From our visits to local offices, it was clear that newer staff generally receive fewer cases to begin with, with caseloads increasing as they gain experience.

Local office managers and team managers have used practical ways to manage peaks in workloads. For example, teams share work. In at least one region, staff "float" between offices to help ease workload peaks. Some team managers carry a small caseload.

Despite these approaches, sometimes high workloads mean that case managers have to focus on ensuring that weekly compensation is paid. Being proactive with claimants is a lower priority, and there can be less attention to detail when recording notes. In this sense, workload peaks can negatively affect a claimant's experience of ACC.

Many case managers told us that they felt they were busy. They gave several reasons for this:

  • Their roles include a lot of administrative work. (We agree.) For example, when a new case manager takes over a claimant's file, they put together a file summary, which is a manual process. One of the summaries we saw was a 33-page document.
  • Checking that information sent to and from providers refers only to the relevant claimant takes a lot of time, especially for large files of several hundred pages.
  • Unplanned staff leave and staff turnover can affect productivity. We were often told it takes at least one year for a new case manager to get up to speed with the role.

In offices with high staff turnover, experienced staff might also suffer from "buddy fatigue" because of the need to keep "buddying" new staff as well as maintain heavier-than-normal caseloads.

Workloads and stress can affect staff morale, which can lead to staff turnover, which also affects morale. As at 1 July 2013, staff turnover at ACC's local offices ranged from 0% to 50%. Although the average staff turnover rate in ACC's local offices has been falling since 2011, one of the offices we visited had an annual turnover rate of 25%. (These staff turnover rates include all staff in the local offices.)

ACC continues to improve its local and regional case management work capacity and work allocation planning, to reduce the risks of isolated peaks of workloads that could negatively affect customer experience and to ensure that enough resources are available to cover routine commitments, such as training, leave, induction, and case management.

We discussed with ACC its overall approach to working out the total number of case managers required. It was not clear to us whether ACC used an organisation-wide model to inform this decision, beyond historical practice. We were told about individual offices needing to present business cases for extra case management resources, rather than relying on any established resourcing metric or comparison with other offices.

Communicating with claimants

ACC has recognised the need to improve its communication with claimants – in particular, the need to improve the tone of its written communications and use less jargon.

Communication is an integral part of providing good customer service, and it greatly affects the claimant experience. A case manager has to communicate effectively with a person, including that person's family, whānau, employer, assessors, service providers, and colleagues.

The Code encourages a positive relationship between ACC and its claimants that is built on mutual trust, respect, understanding, and participation. Achieving a positive relationship on these bases requires good communication. The following extract from a Research New Zealand report reinforces this message (we have added the emphasis):

Frontline staff who stand out establish trusting relationships with their clients. They are described as compassionate, respectful and great communicators. They are thought to do their jobs well; looking after the best interests of both their clients and ACC.10

Frontline staff are expected to:

  • set up and maintain effective relationships with claimants;
  • gain claimants' trust and respect;
  • do what they said they would do;
  • explain their reasons for providing or declining services in a way that maintains positive relationships; and
  • handle difficult customers tactfully and respectfully.

One of the main reasons for claimants being dissatisfied with ACC is poor communication. Most of the complaints that ACC receives under the Code are about communication.

ACC has known for some time that it needs to improve its communication with claimants. Our evidence confirms this. This evidence includes:

  • our reviews of ACC files;
  • ACC's client satisfaction survey results;
  • complaints that ACC received;
  • ACC's identifying the need for its Forms, Letters, and Information Sheets project to reduce the jargon used in, and improve the tone of, many ACC documents; and
  • comments from the claimants we interviewed.

ACC relies heavily on template letters and forms as its main way of communicating with claimants. Because of their style, these may not always encourage effective communication.

When we reviewed files, we saw examples of ACC sending several letters to one claimant on the same day and a set of letters over a few days. All the letters were about different aspects of the same claim.

We observed that ACC could much better link the information in its written communication to aspects of a person's individual rehabilitation plan.

When responding to ACC's client surveys, some claimants said that case managers did not always explain the reasons for their decisions and that case managers were sometimes impersonal and rude. Our interviews with ACC claimants are consistent with these comments.

Appendix 2 lists the improvements in communication that claimants told us they wanted.

Serving claimants

ACC and its staff generally have a strong commitment to serving claimants, but ACC has identified the need for a stronger focus on the needs of claimants.

ACC has identified the need to focus more on the needs of claimants. ACC's information about complaints shows considerable room for ACC to increase the proportion of complaints about fairness and service quality that are resolved in favour of ACC. We discussed ACC's focus on clients in paragraphs 2.20-2.24.

9: Case managers have to be familiar with about 80 provider contracts, as well as ACC's policies and procedures.

10: Research New Zealand (2012), Understanding Clients' Expectations of ACC.

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