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A Focus on Patient-Centered Care and Office Practice Management:
••Fall 2003/Vol. 7, No. 4

Editorial CommentsComments from the Journal EditorsAbstracts from articles published in other journals
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Poetry, Art, Musings from Permanente clinicians
Articles from a Systems perspective
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Health Systems

Staff Empowerment, A Prescription For Success | pdf >>
By Cynthia R Copp, MSN, APRN, CPNP; Christine Agpaoa, CMA; Sandra Carvalho; William F Pfeiffer, MD


Staff 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.

Erikson 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.

Staff Empowerment

In many 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.

Figure 2. Anti-stress kit for changing the status quo (ie, solving problems that induce stress) in a dysfunctional workplace.


The staff 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.

Having 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.


Writing 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.

Five years 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.

Most of 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.


For any 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.

The "morning 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.


Initially, 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.

Demand-Based Scheduling

I have 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.

Our system 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.

Our demand-based scheduling model has had positive results:

  • Demand for appointments has become reasonably predictable (Figure 6);
  • Access to clinicians is appropriate, timely, and convenient for patients;
  • Assisted by an easy-to-use tool, the "fuel gauge" (Figure 7), receptionists can give patients what they need or request;
  • Physicians are not backlogged or rushed;
  • The clinic runs smoothly and expediently;
  • Satisfaction is increased for everyone involved--patients, receptionists, and physicians as well as nonphysician medical staff.

The Associate Clinician Role

In the 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.

The primary 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 pediatric clinic.

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.


A nurse 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.


To become 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 to them.

Figure 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.

Good leadership 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.

We value 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.

We all 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:

  • Hire enthusiastic people and clearly delineate their--and your own--tasks and goals.
  • Determine your own principles and priorities.
  • Evaluate processes and optimize them--as well as the flow of patients through the clinic--by ensuring that all staff focus on the patient.
  • Give staff sufficient opportunities to advance their professional skills beyond "putting out fires."
  • Improve the service delivered to patients so that staff can be proud of this service instead of having to defend or apologize for it.

By following 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.


Its workforce 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.


  1. Pfeiffer IL, Dunlap JB. Empowered employees--a good personnel investment. Clin Lab Manage Rev 1992 Mar-Apr;6(2):154-6, 160-1.
  2. Erickson JI, Hamilton GA, Jones DE, Ditomassi M. The value of collaborative governance/staff empowerment.
    J Nurs Admin 2003 Feb;33(2):96-104.
  3. Mass D. Staff retention and empowerment: functions of leadership. Clin Leadersh Manag Rev 2002 Nov-Dec;16(6):391-8.
  4. Covey SR. The seven habits of highly effective people: restoring the character ethic. New York:Simon and Schuster, 1989.



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