In health care, "Agency" refers to the capacity of an individual or team to make decisions and take actions that positively affect their situation or events. I recall seeing this in action in the late 1990’s when a seasoned Director of Nursing (DON), new to our area, took over this position at a skilled nursing facility (SNF) where I was the Medical Director. She had an “Open Door” policy that encouraged employees to enter and approach her with their concerns. Our employees quickly learned she was a good listener and would listen even to personal concerns that were affecting the employees’ work. She had the ability to coach an employee or a group of employees with a similar problem and then develop with them potential innovative actions that might improve the problem(s). During her time as our DON, the facility developed and sponsored scholarships for certified nursing assistants (CNAs) to go to nursing school. Our employees listened well to our patients and their families and helped them take action during the rehab process to facilitate their recovery. In a brief period, our state and federal surveys improved to the point of back-to-back deficiency-free annual surveys. Unfortunately, her husband took a job out of the area, ending her time as our model “DON.”

Early in the COVID pandemic, the CMA (California Medical Association) sponsored training for potential “coaches” to help medical providers develop and utilize their “agency” during this crisis. At its heart, a coach helps someone recognize and constructively approach an important problem that seems irremediable. The coach’s role is to be part of conversations that look for deeper causes and then encourage self-directed actions that empower constructive change. As a newly retired physician, I took that training. 

Over the last year, I have resumed clinical practice as a part-time post-acute rehab physician, which is less demanding than when I had a full-time practice. I have intentionally kept the door open to my small office on the unit. In doing so, I have had unexpected encounters with patients, families, and staff that have often become the context for mini-coaching opportunities and for becoming more aware of gaps in our delivery of patient care. Besides the “open door,” I found that a “clipboard” approach to patient care enhances my ability to sit at the bedside, learn what matters to this patient and their family, and then jot potential actions. These notes become the basis for improving their “agency” during their rehab. Often, the agency-facilitating process involves the rest of our rehab team. 

What does success look like? We recently had a patient who came to our facility for continued postoperative rehab, after relapsing from another SNF to an acute hospital for a serious complication. Our care was not perfect, but when asked by an outside physician about our facility, he said it was like living in a “Luxury Hotel.”   

Our facility’s role as a facilitator of “Agency” is still in its infancy, but the initial results have been amazing. I encourage others to consider an “Open Door” approach to health care.