Managing a Team When the Stakes Are High Mary is the director of case management and has six managers who report to her. In Mary's hospital and healthcare system, case management has a direct interface with the financial department, and Mary reports directly to the chief financial officer (CFO). She also interfaces with the payer side of the business, which includes contract negotiations with various state and federal payers, HMOs, insurers, self-insured employer groups, and the hospital's own self-insured/managed care group. In interfacing with these various groups over the years, Mary has improved her competencies in interprofessional collaboration and negotiation. It hasn't always been easy balancing the needs of the patients with the financial demands of the payer groups, but Mary has astute business skills that position her well in hard-nosed discussions related to cost, profits, quality, and more demand than the system can supply. The skills of the managers who report to Mary are quite varied. Two of the six have earned their master's degree in nursing and are relatively new to their roles and case management. One of the other direct reports has an MBA and came from the payer side of the business. The other three have been in their roles for a number of years, and although they perform well, they rarely show the initiative to "think outside the box" or advocate for patients when the patient need is not strictly within the prescribed guidelines. These three individuals work well together, but they do not seem to interface well with the other members of their team. When Mary meets with them individually, she hears stories of how they do not trust the other three, who have more education than they do but less experience in case management. In the meetings Mary observes these three and notices that they rarely speak up or contribute unless they are directly asked a question. Their body language and eye contact clearly indicate that they are disengaged from the rest of the group. On the other hand, the three members of the team with more advanced education and less experience have many questions and need reassurance about their decisions with patients who need special considerations. Although they are eager to make patient-centered decisions, they are uncertain how far they can push the limits in negotiating with payers for additional coverage or equipment for patients. The manager with the MBA is very confident in his skills and is highly regarded by Mary's boss, the CFO. The manager speaks the "financial language" with ease, which impresses the CFO. The two of them often joke and laugh with one another, and clearly a strong relationship has formed. Mary not only observes her manager's very confident demeanor, she also recognizes that he demonstrates a very superior attitude when working with the others on her team. Because of his financial background, he often acts as the devil's advocate when innovative ideas are brought forward for discussion within the group. He has absolutely no tolerance for the three more senior individuals, whom he regards as being unprepared for their roles because of their lack of a master's degree and specifically their lack of financial knowledge. For the most part it seems as if he disregards much of what they say when they occasionally speak up in the team meetings. He often laughs when others are speaking or becomes engaged in other activities such as reading his emails or texts on his mobile phone. One of the less experienced managers is very sensitive emotionally, and when pushed, it almost seems as if she is ready to cry in the team meetings. Of course, it doesn't take long for the MBA manager to take advantage of her vulnerability and relate to her in ways that increase her level of discomfort. He nitpicks every presentation she makes to the point that it drives her to tears, which appears to be very entertaining to him. Mary has assessed that the sensitive manager has the competencies and knowledge necessary to be successful in the role, but her inability to keep her emotions in control seems to detract from how others perceive her competencies. The CFO has frequently made comments to Mary about how this sensitive manager is the weakest member of the team, which requires Mary to advocate for her on several occasions. The CFO has put subtle pressure on Mary to terminate this individual because he perceives her to be very weak and incompetent. Mary has coached the manager frequently in their individual meetings about her need to develop a stronger "business face" and has tried to determine the underlying cause of the manager's lack of self-confidence because she has significant knowledge and understanding of case management. She has asked the manager to engage in some self-assessment and self-reflection related to her emotional intelligence and to work with the hospital's Employee Resource Center to develop ways to improve her self-confidence and to adapt her behavior in ways that would make her less vulnerable in group situations. With new requirements and stricter guidelines in place with the hospital's designation as an accountable care organization, Mary's department is pressured to achieve better financial outcomes while also improving patient satisfaction levels. Her department is also held responsible for preventing 30-day readmissions that will penalize the hospital's reimbursement from Medicare. Mary realizes that her only hope for success is to improve the individual functioning of each of her direct reports and to improve the team's ability to work as a high-performing team. It is clear that every member of the team is at a different level of knowledge and experience in case management and at very different levels of emotional intelligence. When Mary assesses her team, she recognizes that she has one bully in the group who is overconfident about his own skills, completely unaware of how he comes across to others, but highly skilled in his financial understanding and case management. At the other end of the continuum, she has an individual who has the knowledge and skills of case management but who lacks self-confidence and is highly sensitive to any criticism or questioning of her knowledge base. The three less educated case managers have formed a subgroup that refuses to engage with the other members of the team because they do not trust the others. It appears that Mary only has one strong manager, who is less experienced in case management, but who demonstrates a high level of emotional intelligence, desire to learn the role, and willingness to engage with all members of the team including the bully. It's clear to Mary that the team is completely dysfunctional and that she needs to develop a strategy to help this group either develop as a highly functioning team or replace some of its members with new individuals who are more willing to work as a team to meet the organization's goals.

1. How do you feel about Mary's assessment of her direct reports' job competencies and emotional competencies and their ability to work together as a team?

2. If you were Mary, what steps would you take to improve the team's level of functioning?

3. How should Mary manage the bully on her team given that he has the most expert knowledge of the financial side of case management and is highly regarded by Mary's boss, the chief financial officer?

4. If you were Mary, how would you manage the three more experienced individuals who have opted out of the team's membership and who are boycotting any participation in the team meetings?