Empowerment, A Prescription For Success |
Cynthia R Copp, MSN, APRN, CPNP; Christine Agpaoa, CMA; Sandra Carvalho;
William F Pfeiffer, MD
empowerment enables employees to make independent autonomous decisions
in almost any situation. This empowerment would necessitate guidelines
for the conduct of whatever role staff members occupy. Dunlap et al1
found that by empowering employees, managers create a nurturing environment
in which staff can learn, grow, improve, and function effectively. Staff
empowerment gives employees a sense of trust, importance, and capability,
thus creating a positive work environment.
et al2 stated that empowerment occurs when organizational
leaders engage staff in ways that promote personal and professional
growth: Leaders help employees to extend their capabilities and thus
to make progress toward realizing the staff's full potential. We found
that involving each staff member in clinical processes and operations
creates a more committed staff. Thus, during the evolution of our health
care team, we invited all the staff to participate in bringing order
and contentment to the chaos and frustration existing in the clinic.
This mission would necessitate a more functional system, empowered employees,
and an increased sense of customer service.
large organizations, the workforce often feels frustrated and stifled
by not being permitted to have any input into their work. This situation
leads to unnecessary stress and lack of productivity (Figures 1,2).
At the Kaiser Permanente (KP) Honolulu Pediatric Clinic, staff members
(see Table 2, page 35) are invited to be a part of their own operations:
They are encouraged not only to identify and "own" the problem
but also, in turn, to "own" its solution so that a positive
working environment can be created and maintained.
Figure 1. Anti-stress kit for maintaining status quo in dysfunctional
workplace. This humorous-but-true image reflects the observation that
employees who are not empowered to contribute fully have no productive
outlet for their job-induced stress.
2. Anti-stress kit for changing the status quo (ie, solving problems
that induce stress) in a dysfunctional workplace.
of our pediatric clinic includes five physicians, each of whom is assigned
a medical assistant; two nurse practitioners, who share the services
of one medical assistant; four registered nurses; one licensed practical
nurse in the injection clinic and one "virtual" injection
nurse (who may be paged from the nurses' station to administer immunizations
in the patient's room); and several receptionists. Because several medical
assistants in the clinic are pursuing a nursing degree, the staff must
use a principled, flexible scheduling scheme. This scheme involves self-scheduling,
a process in which the medical assistants state their availability to
a scheduler (another medical assistant). The scheduler considers each
medical assistant's preferences and needs while assuring that each physician
has adequate medical assistant coverage daily. The medical assistants
in the clinic are content because they have input into their schedules
and thus support their goals for family life.
identified a need among clinic employees for consistent operations,
medical assistant Mary Domingo founded our Medical Assistant (MA) Playbook,
a 300-page compilation of principles, procedures, protocols, phone numbers,
and other important information. In the course of our operations, when
any new protocols or changes were to be implemented, clinic employees
were invited to add to the Playbook to ensure that clinic functions
were consistent and standardized. The Playbook is both an excellent
resource for clinic employees and an outstanding training manual for
newly hired employees.
about clinical management, Mass3 stated that regardless of
the structure and technology of an organization, its most potent leverage
for exceptional performance and quality assurance lies within the workforce.
ago, when our health care team was formed, the clinic manager and the
health care team leader sought to invest in its people by sending everyone
involved with direct patient care to Teamworks, a six-day workshop conducted
by Glenn Furuya, a consultant to the KP Hawaii Region. The Teamworks
workshop is designed to enhance the experience of being a contributing
team member. The program provides skills in group process facilitation,
team building, conflict management, problem solving, and quality management.
The workshop also helps employees to understand leadership styles, techniques,
and systems as well as employee optimization, facilitation, and empowerment.
We find that sending employees to this workshop has facilitated cooperation,
collaboration, and cohesion within our team.
us who grew up in Hawaii or who have come to call Hawaii our home have
had some introduction to traditional Hawaiian values. Eight of these
values--and their approximate translation--include aloha (a collection
of desirable social, emotional, and spiritual traits which lead to reciprocal,
joyous, sharing relationships between people), ohana (family), kuleana
(responsibility), kôkua (helpfulness), laulima (cooperativeness),
ike (recognition, vision), ho`oponopono (setting things right; correcting
problems and conflicts by openly discussing them with forgiveness),
and lôkahi (peace, balance, unity, harmony) (Figure 3). These
values are vitally important to a fulfilling lifestyle. Our team has
adopted these values, which have been accepted into each team member's
inner being and have provided both a common vision and ground rules
for creating and maintaining a highly satisfying, enjoyable workplace.
relationship to flourish, it must include a vital component: communication.
To disseminate information to the staff, two special communication avenues
were set up in our clinic: our daily "morning huddle" and
our semimonthly team meetings.
huddle," as we call it, is the informal daily meeting of medical
assistants, registered nurses, and nurse practitioners who are working
in the clinic that day. They meet at the nurses' station from about
8:45 am until about 9:00 am to share any new forms, equipment, protocols,
or pertinent information that may affect the workflow. Someone reads
aloud the names of the physicians staffing the clinic that day, the
medical assistants assigned to work for those practitioners, and the
role of each registered nurse on the team. At the end of each morning
huddle, a motivational quote is read to create a positive tone for the
rest of the day.
Figure 3. Traditional Hawaiian values have been integrated into the
KP Honolulu pediatric clinic to provide a common vision and ground rules
for creating a highly satisfying, enjoyable workplace.
when our health care team started, we found that meeting weekly was
important so as to maintain our momentum and vigilance in formulating
our principles. Then, as our team moved forward and much of the groundwork
was completed, the members decided that such frequent meetings were
no longer necessary but that having regular meetings at least twice
monthly was important.
alluded to chaos previously existing in the clinic: If you had interviewed
staff members working in the pediatric clinic before we implemented
our clinical renovations, you would have seen a lot of headshaking and
frustrated looks on people's faces. As one of our receptionists, Sandy
Carvalho, could tell you firsthand the system of scheduling patients
for visits to the pediatric clinic was not working well. Now that we
have implemented what we call "demand-based scheduling," access
to primary care practitioners has increased tremendously for patients.
In addition, clinicians' schedules have become more manageable.
of demand-based scheduling is a simple approach based on principles
of patient care; within these patient-based principles, the system is
flexible for patients and employees (Figure 4). The fundamental idea
of demand-based scheduling is to redistribute supply to meet demand
(Figure 5). Demand is characterized by priority level so that patients
who are sick or who have other urgent medical problems are seen on a
same-day basis, and patients with nonurgent needs receive appointments
to fill existing capacity throughout the month. In this system, appointments
are readily available, and patients choose the day and time convenient
for them. We believe that this patient-centered aspect of the system
is an integral part of why it is successful.
scheduling model has had positive results:
for appointments has become reasonably predictable (Figure 6);
to clinicians is appropriate, timely, and convenient for patients;
by an easy-to-use tool, the "fuel gauge" (Figure 7), receptionists
can give patients what they need or request;
are not backlogged or rushed;
clinic runs smoothly and expediently;
is increased for everyone involved--patients, receptionists, and physicians
as well as nonphysician medical staff.
The Associate Clinician
past, nurse practitioners working in the KP Honolulu Pediatrics Clinic
were required to prepare paperwork, initially interview the patient,
and see the patient for an appointment. Despite these nurse practitioners'
advanced degree--a master's degree from an institution of higher learning--this
scenario paid nurse practitioners for performing clerical duties and
failed to use them to their highest capacity.
role of the pediatric nurse practitioner is to perform physical examinations
and treat minor acute illness in children. In a functional system that
includes a dedicated medical assistant for clerical support, the nurse
practitioner has more opportunity to practice a niche specialty in which
they serve as expert and as consultant to the physician. Nurse practitioners
at our clinic see patients for asthma education, adolescent gynecology,
lactation consultation, tuberculosis follow-up, and weight management.
When nurse practitioners are supported in this way, they sense that
they have a value-added role within the team. Nurse practitioners are
thus empowered and become even more committed to their work, to the
team, and to the organization.
Figure 4. Principles adopted by receptionists in the KP Honolulu pediatric
clinic for "treating Hawaii's people like family." Patients
who call the clinic for an appointment are given the same consideration
as though they were the receptionist's own beloved Auntie.
Figure 5. Diagram illustrates demand-based scheduling approach for increasing
efficiency as well as patient and staff satisfaction in the KP Honolulu
Figure 6. Graph of predicted versus actual demand for same-day, urgent
appointments in the KP Honolulu pediatric clinic during February 2003
shows that demand is predictable.
practitioner's relationship with team members and with other clinicians
should be one of interdependence. In the health care industry, no person
can--or should--stand alone. A group of people with different and special
talents working together toward the same principles can only bring about
greater and more innovative results. Thus, in Steven Covey's The
Seven Habits of Highly Effective People,4 interdependence
is defined as people combining talents and abilities to create something
greater together. Ultimately, this philosophy allows us to tap into
the best of each of us and consequently to provide high-quality patient
care as well as high staff satisfaction.
happy, well-functioning adults and contributing members of society,
children must be allowed to grow and mature independently while constantly
receiving parental messages about values. Parents must also communicate
to their children reasonable and known limits and provide a structure
to allow this communication to occur naturally. Obedient children obey.
They do what they are told--no more, no less. Disciplined children are
disciples, willingly behaving in accordance with the values communicated
7. The "fuel gauge," a tool used by receptionists in the KP
Honolulu pediatric clinic to direct nonurgent appointments to days on
which available capacity exceeds predicted demand for urgent appointments.
is like good parenting. We want our employees to be happy, contributing
members of our health care team. Our values are stated outright but--even
more importantly--they are implied in our many processes and standards.
We have regular meetings so that we can review, emphasize, and sometimes
even "ventilate" to ensure that we stay on track.
the unique contributions that each person brings to the team, and we
try to nurture their strengths to meet our patients' needs. We are not
all equal, and we cannot make equal contributions in all areas of our
fields; but by allowing all team members to emphasize their own unique
strengths, our team has become more than the sum of its individual parts.
entered our respective fields because of our desire to contribute. A
leader's job is simply to facilitate that desire and to guide that energy.
Understanding and accepting this principle, the leaders of the Honolulu
pediatrics team developed and implemented the following steps to improve
pediatric clinic operations:
enthusiastic people and clearly delineate their--and your own--tasks
your own principles and priorities.
processes and optimize them--as well as the flow of patients through
the clinic--by ensuring that all staff focus on the patient.
staff sufficient opportunities to advance their professional skills
beyond "putting out fires."
the service delivered to patients so that staff can be proud of this
service instead of having to defend or apologize for it.
these basic steps, a clinic functioning at a suboptimal level of performance
can be reengineered into a high-functioning workplace run by an empowered
staff who use an effective, patient-focused system.
is probably the most important aspect of any business or operation.
By recognizing the value brought to the organization by productive,
committed employees, regular communication, and patient-focused systems,
leaders enable workplace operations to run smoothly and successfully.
By empowering the staff and by equipping them with effective, reliable
tools, leaders can give all members of the team an opportunity to realize
their full potential.
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