LISTEN-SORT-EMPOWERFind and Act on Local Opportunities for Improvement to Create Your Ideal Practice

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

1. LISTEN to the Team to Uncover LOFIs Unique to Your Practice

2. SORT the LOFIs to Prioritize Them for Resolution

3. EMPOWER Team Members to Make Changes and Resolve Issues

4. 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.

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.

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.

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

Table 1. LOFIs Frequently Involve Dysfunctional Processes, Relationships, or Policies that Frustrate Professionals and Degrade or Interfere with the Best Patient Care

LOFI Category	Real-World Example	Real-World Solution
Team culture issues	Annual staff survey showed team culture issues in a work unit	Culture is the combination of all the words, actions, standards, and values of a work unit. These aspects reflect how each care team member interacts with each other, with leadership, and with patients. The annual staff survey shed light on unit discontent with teamwork, which was categorized as a unit culture LOFI subsequently brought to the attention of the leadership. Under the unit's guidance the leader and the care team discussed the issues and behaviors that were troublesome. They prioritized issues and behaviors to improve one at a time. Confidential responses on the next annual survey confirmed that team culture improved substantially over a 9-month period. The unit members now meet once a month over lunch to discuss nothing other than the “pebbles in their shoes” and to review the whiteboard that tracks their “pebble removal” progress.
Inefficiency of practice	To reach their desired productivity level, a physician requests an additional examination room and support nurse	Leaders were sympathetic. The organizational mantra for requests like this is “no new resources to an unexamined process,” so first they gained a better understanding of the challenge. With the assistance of a process improvement expert, the workflow, handoffs, teamwork, team documentation, and communication were examined and refined. No incremental resources were needed to improve productivity and asset utilization. In addition, enough wasted effort was removed that the impact on the team seemed even greater—in effect, it felt as if the practice had added more team members. Both the physicians and leaders were satisfied with the results. Because the clinicians were involved in the solution and because the new workflow reduced most of the frustrations, morale improved substantially.
Clerical burden	Family physician team overwhelmed by the clerical burden	Over a period of 18 months, the practice leader and manager worked with the team to identify all non-patient-facing work. Together, they looked for the best way to perform each task and engaged the best person on the team to be responsible for it. The tasks included pre-visit planning, documenting visit notes, entering orders, scheduling referrals, and preparing prescriptions. The role of the medical assistant (MA) substantially expanded and the morale of the whole team improved. Because the LISTEN-SORT-EMPOWER process worked so well, the team started to include a LOFI agenda item at every meeting.
Work outside of work	Physicians logging many “work outside of work” hours in EHR	Challenges related to the electronic environment are common. This clinic segmented EHR LOFI and chose to address “work outside of work” first. They identified and partnered with EHR superusers. The superusers codified their best practices to share with the physicians with the most work-after-work hours. Then the superusers met these physicians to help them improve EHR workflow habits (eg, minimizing interruptions, charting immediately after the patient encounter), mouse-click efficiency (eg, with improved otitis media orders), and teach them that multi-tasking actually lowers productivity. Improvement was monitored by an EHR function and dramatic reductions in work after work were realized. This LISTEN-SORT-EMPOWER episode was so successful, it was spread to other primary care settings in the organization.
Physicians or other providers performing tasks that should be performed by other team members	Physician team leader was performing tasks involving EHR on behalf of team members	A newly instituted daily huddle led to the discovery of this LOFI. The team moved the discussions from the huddle to a staff meeting setting and used LISTEN-SORT-EMPOWER. They all came to understand that the physician leader was performing EHR tasks on behalf of the team that individual team members could have been doing themselves. Over the course of several sessions they determined who on the team was best suited to perform each task. The team culture evolved to one where everyone worked together to care for patients. The MAs on the physician's team adjusted to cover wherever patients needed them most that day, for example with rooming or answering calls and inbox messages. MAs now routinely enter chief complaint, history and physical information, and family and social history as well. As colleagues found new ways for all to contribute at the top of their training and licensing, teamwork and morale skyrocketed.
Dysfunctional processes	Care team was frustrated with processes for patient care in an ambulatory setting	Using the LISTEN-SORT-EMPOWER Model, the care team identified several LOFIs. They worked with the unit manager to institute pre-visit planning and medication management processes. These two standardized processes saved 1.5 hours of professional time every day. The standard work was diffused to other practices in the medical center. And the care team embedded LISTEN-SORT-EMPOWER into their standard unit work.
Challenges with work–life integration caused by scheduling issues	An organization experienced triage mistakes and the loss of flexibility for physicians in scheduling their other professional responsibilities and family commitments	The organization believed that central scheduling of appointments was most efficient, but it wasn't working for the team. LOFIs were identified with a LISTEN-SORT-EMPOWER session. The work unit leader expressed frustration and presented LOFIs to the senior leaders who made the decision to use central scheduling. Together, they worked out an outcomes-based program where the local unit schedulers who worked directly with the physicians took responsibility for their schedules and committed to the patient experience and productivity outcome metrics that the organization needed for the practice. Work satisfaction improved substantially on surveys and now the team has a formal LOFI discussion once a month.
Teamwork and communication issues	Staff surveys pointed out that the outpatient clinical unit was struggling with teamwork and communication.	A series of LISTEN-SORT-EMPOWER meetings in a safe setting identified pain points of teamwork and communication. The staff addressed each issue in their sphere of control. The team came up with 3 actions that dramatically improved communication and teamwork: 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. The satisfaction, professional fulfillment, and burnout characteristics of the work unit improved substantially on the annual staff survey nine months later.
Management style that did not engage team members	Identification and problem-solving of LOFIs using a participative management style	During daily care team huddles, team members are asked to identify any ongoing issues that are adversely affecting their daily work, such as inefficient patient rooming practices, difficulties consistently collecting copays, or delays in obtaining diagnostic test results. Once a problem is identified the discussion is moved from the daily huddle to a weekly staff meeting where there is more time to discuss and funnel the issue into the rolling wave of improvement work using LISTEN-SORT-EMPOWER. Team members suggest potential solutions to test. They appoint an individual responsible for leading and then move forward. Once a satisfactory remediation is identified, the new process or policy is implemented, and then evaluated. These staff-initiated solutions have resulted in rapid improvements to problems that contributed to delays for patients and frustration among the care team. If a problem cannot be solved by the team and local leaders, it is escalated to the clinic leaders, who address the problem or bring it to the attention of medical center leaders. The survey measure of professional fulfillment improved as this collaborative work became embedded.
Excessive clerical work being done by physicians	Medical assistants undervalued and not able to work at the top of their license	In a LISTEN-SORT-EMPOWER session, the team leader heard from physicians that their MAs were being under-utilized and under-appreciated. So together they worked to address this LOFI. The goal was to have their MA professionals serve as cornerstones in their team-based care model. The solution involved assigning each MA their own panel of patients for which they could refill medications, acquire authorizations and facilitate referrals, and perform routine chronic disease and health maintenance communication. MAs also monitor tests, address and/or triage patient phone calls and emails, and act as a scribe at patient visits. The small group of MAs works with 2 to 3 physicians. This way, they can cross-cover as needed to ensure continuity when someone is on vacation or there is an unexpected absence. By transferring these important responsibilities to MAs within the bounds of state law, the physicians can utilize their time more efficiently and effectively. By sharing important aspects of the workload, MAs feel like valued, appreciated, and respected members of the care team.
Lack of recognition for team members	Team leader found LOFI to appreciate colleagues	A LISTEN-SORT-EMPOWER session brought the lack of meaningful recognition to the attention of the team leader. She understood that weekly staff meetings and daily huddles can serve as opportune venues to appreciate and recognize members for their positive contributions to the care team. The unit supervisor starts each meeting with a positive reflection on a specific event that happened recently. She encourages team members to do the same (eg, read positive comments and letters from patients and families that the supervisor receives or retrieves from ongoing patient experience surveys). Once a month the supervisor starts each staff meeting with a round table response to this request: “Please tell us something at work or at home for which you are grateful.”

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.

• Camaraderie:

  • 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.