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(Written by Allison Sturm*) Consultants, Chris DeRose and Noel M. Tichy, are authors of Judgment on the Front Line: How Smart Companies Win By Trusting Their People shows how to build a front line-focused organization. This is the little L leader concept.

• How many times have you heard a leader say, “People are our most important asset!” Have you ever been told by your manager to share your ideas and to suggest new ways of doing things? Have you ever felt that these gestures were sincere? Hopefully you have, but experience has shown Chris DeRose and Noel Tichy that there are not many leaders who tap into more than a tiny fraction of the knowledge, creativity, and judgment of their frontline employees. They found most organizations function as a hierarchy and people reflexively bow to the “highest-paid person’s opinion” (HiPPO) or forsake their own opinion.
• The authors provide an anecdote from the inventor of Amazon’s personalized shopping cart, Greg Linden. Greg came up with the idea as he reflected on supermarkets’ success with increasing sales by strategically placing candy, potato chips, and other “impulse buys” on the racks next to the checkout lines. He suggested Amazon personalize recommendations for similar impulse buys based on the items in the customer’s virtual shopping cart. As a software engineer, he was prohibited by his senior manager to move forward with the project. Despite that senior manager’s arguments against it, the rest of the leadership team allowed Greg to test his idea. It was a huge success and the CEO gave the green light immediately. This is an excellent example of how important it is to create a culture where experimentation and innovation is welcomed and even expected from all members of the team. HiPPO, highest-paid person’s opinions, is not a limiting factor at Amazon. Amazon leadership does not assume intelligence and capability are related to a person’s job title.
• DeRose and Tichy suggest 5-steps for creating this type of culture within your work place.

1. Connect the front line to the customer (in pharmacy’s case nurses, physicians, patients and families)
   • Authors’ Case Example: Yum! Brands’ focus on empowering frontline employees
     • Yum! CEO’s philosophy is “people capability first…satisfied customers and profitability follow.” Yum! senior managers titles have been changed to “coaches” instead of “bosses.” Yum! gives every employee the ability to spend up to $10 to resolve any conflict or service issue.
   • Pharmacy Applicability: Remember that individual pharmacists and technicians  are the ones who have the greatest impact on the customer/patient experience and represent the department externally. Provide extensive training for employees to empower them to intervene for customers/patients when necessary. Encouraging these employees to take ownership in patient care creates an accountable and one-for-all culture within the department.
   • Pharmacy Applicability: Frontline staff will have to make judgment calls and apply black and white guidelines to gray areas. It is leadership’s responsibility to make sure that employees are given continuous coaching as well as resources to make the best decisions in practice and feel confident when doing so.
   • Pharmacy Applicability: Instead of just asking for suggestions, encourage suggestions by organizing meetings focused on brainstorming to innovate. Clearly define areas where frontline innovation is desired (e.g., ADC fills, antibiotic monitoring), create teams and facilitate their work, and then provide methodology for experimentation and measurement.
   • Pharmacy Applicability: There are many ways to do this. Departments could definitely consider implementing a similar safety philosophy like The Mayo Clinic’s. Administration could watch the queue while pharmacists attend staff meetings or lectures. Reporting relationships could be restructured to allow supervisors to spend legitimate time coaching and working with their direct reports.
   • Pharmacy Applicability: Research has shown that the most likely reason an employee will leave the company or, worse, remain but be disgruntled is the relationship with their immediate supervisor. Encourage management to embrace the “four Cs” model when building relationships with employees.
2. Teach people to think for themselves
   • Authors’ Case Example: Navy SEALs’ “Hell Week”
     • SEALs are trained to operate semi autonomously. Their training ends with Hell Week – candidates must function on a maximum of five hours of sleep in a week. This affords SEALs opportunities to practice making decisions under stress and instills confidence and courage.
3. Experiment to implement
   • Authors’ Case Example: Hackathons
     • Hackathons are 24- to 48-hour around-the-clock programming fests aimed at taking ideas and turning them into prototypes. Facebook chat and video messaging all started as hackathon projects. Hackathons embody this principle because they require boldness and creativity from all employees.
4. Break down the hierarchy
   • Authors’ Case Example: The Mayo Clinic’s “Plus One” philosophy
     • Plus One is a protocol that enables nurses to add one person to the patient-doctor-nurse relationship at any time. The risk-adjusted mortality rate has declined significantly faster than the U.S. average.
5. Invest in frontline capability
   • Authors’ Case Example: Zappos’ “four Cs” model shown to impact an employee’s sense of empowerment. Zappos addresses each element as it brings new employees on board:
     1. Context – Employees desire to connect their work to larger goals. Screen against the hospital/department values and test whether behaviors associated with these values play a meaningful role in the candidate’s prior experience.
     2. Control – Provide training to allow employees to make autonomous decisions and take action.
     3. Care – Invest time and energy in both recruiting and training.
     4. Creativity ­– Foster a deep respect for each individual’s uniqueness and enable candidates to express their personality.
6. The last piece of advice that the authors offer is recommending opportunities to promote “corporate citizenship on the front line.” Corporate citizenship involves organizing community service activities for employees. They have seen tremendous benefits with corporate citizenship, which gives frontline employees an opportunity to partner directly with community members, who are often their customers. Whether delivering food with an automobile factory employee or painting a halfway house with an oil industry engineer, the authors found that each time they worked with a frontline associate in the community they were amazed at how profoundly such work impacts the employee and the positive effect it has on their relationships with their coworkers and employers

Application. Technician turnover in your department is very high and you also notice an increase of medication delivery errors reported over the past few months. When you ask technicians about their job satisfaction, they smile and tell you things are great. You reassure them that you want to hear about ways to improve work flow to ensure they are not overwhelmed or have too much on their plates. They tell you that they only feel like this sometimes when someone calls off or it gets abnormally busy. You say, “Great! Keep up the good work. My door is always open.” You check in with another technician and instead ask if they feel satisfied with their professional development. The technician asks to be trained on TPN so that they can have more variety during the work week. The technician also tells you that the other technicians often complain of being bored and underappreciated. You reply, “That’s too bad. I will make a note to bring this up at the next staff meeting at the end of the month.”

• How did the manager do? What would you have done differently?
• Are staff meetings and similarly structured forums the best way to assess employee satisfaction and address concerns? What about annual reviews?
• How could the manager have used the 5-steps to address the obvious issues happening on the frontline?
• What is the “low hanging fruit” in this scenario? How can the manager get a “quick win” by addressing the low technician morale?

 *Allison Sturm, PharmD

PGY1/PGY2 Health-System Pharmacy Administration Resident
Nationwide Children's Hospital
M.S. Health-System Pharmacy Administration Candidate 2016
The Ohio State University College of Pharmacy
Email: Sturm.42@osu.edu