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The practice of LISTEN-SORT-EMPOWER is a simple, effective team-based approach to eradicating the root causes of professional burnout. LISTEN-SORT-EMPOWER is a broadly applicable model adapted from the Listen-Act-Develop approach for physician engagement, used for decades by Mayo Clinic.1 The LISTEN-SORT-EMPOWER model begins with the assumption that systems and behaviors—not people—are the source of many practice problems. Using a collaborative problem-solving technique like that found in LISTEN-SORT-EMPOWER results in a friendlier work environment for clinicians and a cohesive team that is able to meet the daily challenges that arise. Through this improvement process, care teams identify local opportunities for improvement (LOFI). Fundamentally, addressing LOFIs is about trusting and respecting clinicians to improve their work environment. LISTEN-SORT-EMPOWER engages care teams in daily improvement and problem-solving, while demonstrating that leaders have confidence in the team's abilities to be trusted partners. It is a participative way of managing, not an autocratic initiative.
Quiz Ref IDQuiz Ref IDLISTEN-SORT-EMPOWER works in teams of physicians as well as with integrated care teams to identify and eliminate sources of frustration and inefficiency.2 Fundamental to the success of LISTEN-SORT-EMPOWER is participative management that engages physicians and other clinicians as partners rather than employees, thereby transforming their roles from “carpenters” to “architects” who can directly improve dysfunctional units.1,3 This leadership style encourages individuals to partner together to analyze problems, make decisions, and implement solutions for issues that directly affect them. It is the opposite of an autocratic management style, which does not work as well (or create the best team dynamics) because an individual repairs the work environment for a team.
Team-based quality improvement work is an important part of reducing burnout and cultivating professional fulfillment. Point-of-care leaders with their teams can improve efficiency of practice and workflows and remove frustrating conditions while simultaneously promoting morale, resulting in better care for patients and a more robust organization.4 Using the LISTEN-SORT-EMPOWER technique to identify and remove LOFIs reduces burnout and improves team morale and satisfaction.
The LISTEN-SORT-EMPOWER model is ideal for improving local work systems and relationships. It is intended to1:
Identify drivers of burnout
Foster healthy clinician–leadership relationships
Engender teamwork and camaraderie
Support development of clinician leaders
Alleviate burnout by improving team dynamics, processes, and systems of care
LISTEN to the Team to Uncover LOFIs Unique to Your Practice
SORT the LOFIs to Prioritize Them for Resolution
EMPOWER Team Members to Make Changes and Resolve Issues
REPEAT to Revisit or Replenish Your List of LOFIs
Rather than coming in with a predetermined plan for improvement, it is essential to listen and understand the challenges your team is currently facing. The majority of LOFIs are unique to local work units. It is important to remember that if you have seen one unit, you have just seen one unit.
The process of identifying and removing sources of frustration and inefficiency starts with a comfortable, safe conversation with the clinicians of a given work unit. Emphasize to clinicians that their responses will not lead to reprimand or backlash. This dialogue should focus on asking the right questions and listening to and accurately recording all responses. The interviewer should maintain a disposition that demonstrates they are looking for ways to increase the positivity of the workplace; appreciative inquiry is a useful approach.
Use these questions to lead and facilitate discussion.
The discussion is about identifying what contributes to or detracts from clinicians' professional fulfillment. Only by understanding what really matters to everyone will the team be able to recognize, categorize, and then remove drivers of professional burnout. The output of the LISTEN session should be a long list of LOFIs that you will then categorize in the next STEP.
The ideal group size for an effective LISTEN session is 6 to 8 members with a scribe and a designated leader to facilitate the meeting. The leader can be any team member, or even a facilitator from outside the work area. It is best to create groups that share common interests, but there should be diverse representation of multi-disciplinary (clinicians, leadership, administrators, etc.) or mono-disciplinary care team members (groups of physicians or nurses) to employ LISTEN-SORT-EMPOWER. Some LOFIs may be more specific to different groups of professionals, therefore some improvements will not affect others. That's why it is critical to have diverse representation in a LISTEN-SORT-EMPOWER session or series of sessions.
You can hold LISTEN sessions as often as you like, but after the first round of LISTEN-SORT-EMPOWER, this aspect of participative management should be embedded into the regular workings of team meetings. An hour is a reasonable length for each session. You may want to hold sessions over the lunch hour or provide snacks.
In preparation for the next step, the facilitator should distribute the LISTEN meeting notes to all team members. The end-to-end process should be transparent as long as the LOFIs are respectfully worded and anonymous.
How can we train session leaders?
No formal training is necessary. The leader should record and acknowledge all ideas for LOFIs. They should not be defensive or attempt to try to solve problems. The goal is to record as many ideas for LOFIs as possible and to make sure that everyone is comfortable suggesting ideas.
Are participants compensated for their time during a LISTEN session?
Compensation depends on the culture and arrangements in each organization. In general though, it is far preferable to expect this citizenship behavior as part of the compact (written or unwritten) we all have with each other and with our organizations.
How do you prevent this from becoming a “gripe” session?
The facilitator should take responsibility for keeping the discussion on track and maintaining a positive, constructive tone. That is why the first questions suggested seek input on what is going well. Keeping the conversation positive is one of the ground rules each leader should establish at the beginning of the LISTEN session, along with reinforcing the confidentiality and anonymity of each comment and LOFIs.
Will I need to secure budget and time upfront to address LOFIs?
Most LOFIs identified by teams do not require any budget. The primary resources required are the support and attention of leadership and time for teams to find and implement effective solutions. When LOFIs are identified that need a budget or a substantial amount of time to address, the case will need to be made to the appropriate entity and supported by leadership in a way consistent with local culture and practice.
You probably have a long list of LOFIs from listening to your team. Now, the group discusses and makes decisions about what to do with all the exciting opportunities for improvement. This next STEP, the SORT process, is probably best done on a whiteboard or with another collaborative approach so the team can discuss and organize in real time. This module's tool kit contains a sample Rank Order template for attendees to rank LOFIs on their own before your next meeting.
There are 3 parts to the SORT process:
Part 1: Determine who has control of each local opportunity for improvement (LOFI).
Part 2: Prioritize the “local control to remedy” LOFI into one of three categories based on impact and feasibility.
Part 3: Create a Rank Order List of priority 1 and 2 LOFIs based on preferences, cultural readiness, difficulty, and estimated time to complete.
Once you've sorted and prioritized the issues, communicate or defer issues that fall into “shared control” or “no local control” to the appropriate members of your organization.
Use this as a guide to help you prioritize your LOFIs.
What if the most important LOFI has insufficient resources and support available today?
The leadership of the work unit should petition the appropriate organizational leader to communicate the gravity of the LOFI and the need for senior leadership to support it. In the meantime, the team should start work on the top-ranking LOFI from the Rank Order List.
Now that the team has a Rank List of LOFIs for which the unit has complete control, with sufficient resources and support available today, you are ready to start resolving issues. At this point, the remaining LOFIs will have been communicated to other leaders in your organization or deferred for later consideration after resources and/or partnerships have been secured.
Begin with your Rank #1 LOFIs by asking the involved team members to commit to supporting the improvement and change management process. Then, appoint a local clinician to lead this effort in partnership with local administrators or managers. An important aspect of the process is for the improvement to be done together, not “for you” or “to you” by someone else. Collaborate with clinicians to develop and implement solutions to address the prioritized issue. This partnership creates the ecosystem for clinician empowerment and professional fulfillment. You can also assemble a task force of team members interested in helping develop a better set of solutions. In all situations, allow the team to find a solution or refined process rather than turning to an individual to accomplish this.
Once the team has developed an intervention or improvement, conduct a pilot or trial of this new approach. Then, evaluate outcomes:
Assess whether the intervention achieved the desired results, and whether further refinements are needed
Communicate all results (successes and failures) to all staff members
Establish new practices, protocols, and systems as needed
Communicate plans to the care team and senior leadership
Recognize the group's accomplishments and celebrate
They created a team compact so that each member knew what was expected of them and what they can expect from their leaders.
They established opportunities for team communication at their weekly staff meetings with designated time to bring up LOFIs related to any frustration, including team dynamics.
They scheduled a monthly social luncheon with no agenda. They choose a topic and then have a round table discussion during the meal.
What if we don't have the time?
Local and senior leaders should understand the moral imperative and the business case for growing professional fulfilment and reducing burnout. The improvement work of LISTEN-SORT-EMPOWER should be a shared responsibility of clinicians and administrators. The partnership should minimize clinician time, but the results will be suboptimal if all the LOFI are fixed by one individual. For more substantial LOFIs, it may be appropriate to support clinicians for the time involved in a manner consistent with the organizational culture and arrangements, such as by providing protected time for employed clinicians or monetary compensation for affiliated or contracted clinicians.
What are some examples of ways to celebrate and communicate successes?
It is helpful to have full transparency of the LISTEN-SORT-EMPOWER model. Many teams use a whiteboard in a high-traffic area to communicate. The LISTEN-SORT-EMPOWER work should be embedded into standard work so that there are updates at every staff meeting. At each milestone, including completion, it is important for leaders to communicate to all and to recognize those involved in the work whether it ultimately resulted in a constructive change or not.
What are some ways to communicate about failures?
Failures are always a part of the best-intended changes. Not every LISTEN-SORT-EMPOWER LOFI ends up with a fabulous practice advance or innovation. But every LISTEN-SORT-EMPOWER episode should build community and mutual respect—and each episode should result in greater levels of engagement as all colleagues are co-creating their ideal workplace.
LISTEN-SORT-EMPOWER can guide a cycle of continuous improvement. Repeat the previous STEPS to co-create the ideal work environment one element at a time. Revisit or replenish your Rank List to identify the next round of LISTEN-SORT-EMPOWER LOFIs.
LISTEN-SORT-EMPOWER is a participative management approach that is well suited for long-term wellbeing of teams and work units. It should be the way clinicians lead colleagues. There will always be issues that need to be addressed in pursuit of the ideal work environment.
The LISTEN-SORT-EMPOWER Model engages the frontline care team to identify and solve local sources of frustration and root causes of professional burnout. Participative management with collaborative action-planning is an authentic gesture of confidence by leadership in the point-of-care team's abilities to be true partners in improving daily operations to better serve the needs of patients and the care team.
In addition to removing sources of inefficiency and frustration, the dividends of using a team-based approach based on LISTEN-SORT-EMPOWER for improvement include:
An important message from leadership:
We are listening.
We trust and respect you.
Self-discovery among team members:
We know what the problems are.
We can develop solutions together.
We care about each other.
We are not helpless.
Meaning and purpose in work:
We are improving the practice environment to allow us to better serve our patients.
We can make a difference.
Focus on the Positive.
Always start with a positive appreciative inquiry approach.
Establish what works well and explore opportunities to expand on that.
Look at the long game—“Think Big,” then “Start Small” with a highly feasible and impactful opportunity.
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