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Department: Shared Governance Spotlight

Shared governance transformation

Lockhart, Kaija MSN, CCRN

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Nursing Management (Springhouse): September 2021 - Volume 52 - Issue 9 - p 11-14
doi: 10.1097/01.NUMA.0000771760.54720.c8
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Nestled in rural Northwest Montana, Logan Health Medical Center has grown from a small-town community hospital to a multihospital and regional system. The facility supports 219 beds, with approximately 900 nurses working within our comprehensive cancer program accredited by the American College of Surgeons Commission on Cancer; a wide range of orthopedic services; an expansive neuroscience and spine program; gynecologic surgery, including advanced laparoscopic and robotic procedures; a comprehensive cardiovascular program, including cardiac catheterization, electrophysiology, and heart surgery; a pediatric ICU; and a neonatal ICU.1

Shared governance (SG) has been part of our organizational history since 2010. Originally, all the councils developed their own set of bylaws to guide the work of the specific council, resulting in each council being unique in structure and operations. Some councils appeared to do well and had made practice changes, whereas others continuously struggled. The councils discussed care issues or unit issues, yet it was difficult to make the connection between their work and outcome changes to validate the need for council activities. Without leadership at the table, the councils were independently managing change initiatives and prioritize issues, while the leadership teams had their own strategic plans.

Understanding clinical data and how to use data are keys to improving outcomes.2 Without a connection to the data elements, the councils had a hard time quantifying their work, demonstrating improvements, and linking outcomes to their initiatives. Nurse leaders created a strategic plan; however, without a structured way to track it, there was continuous rework and lack of sustainment that left the initiatives unsupported and provoked disengagement.

In fall 2018, our organization held an all-employee engagement survey and an SG assessment survey. The engagement survey was disheartening and highlighted challenges with three organization themes: communication, transparency, and trust. The SG assessment survey showed frustration among staff members and unclear directions or understanding of what their role was and how to go about doing it. The councils felt unsupported and spinning their wheels without a voice or only a small voice in what mattered to them.

SG has been shown to improve patient experience, elevate quality, and increase nurse retention.3 To improve patient outcomes and nurse engagement and provide support for staff professional development within our growing healthcare system, the decision was made to restructure the SG program. Ultimately, the restructure needed to align the councils with organizational initiatives while offering additional support and structure for council work and reducing inconsistencies in council activities and expectations.

Redesigning the SG program

To ensure that both leadership and clinical staff members were part of the SG redesign, an SG steering committee comprised of a small handful of leaders and clinical nurses was created.4 The SG restructuring announcement wasn't clearly understood or supported by the nursing staff. With the lack of understanding among other issues, over the next few months a few things happened: the leadership team was restructured, a union was voted in, and large amounts of staff turned over.

Throughout the transition, the SG steering committee was determined to bring a meaningful voice to the bedside and continued redesigning the SG program. The committee partnered with an SG expert to ensure that the new structure embraced best practices.5 The committee gained an understanding of the purpose behind SG and set out to design a structure to provide a voice at the bedside and support from the leadership team. Meeting every 2 weeks with standard agenda topics, including success stories, take-aways, and a communication plan, the committee established one set of bylaws to govern the SG program and defined membership roles, responsibility, accountability, and authority.5 They ensured that the decision-making process was clearly defined, and a new idea of consensus decision-making emerged.5 Consensus decision-making eliminated voting and allowed a way for council members to feel heard.4 Standard, simple-to-use tools and templates were also created to help councils stay focused on data and patient outcomes to drive goals.

An SG council day was developed as a single day of council activity starting at 0730 and ending at 1900 to allow activities to flow from one council to another.6 The council day was designed to streamline intercouncil communication/networking and improve scheduling opportunities while providing protected time for council members to attend the meetings. The councils were also designed to be multidisciplinary in nature, allowing key stakeholders to be present at the council meetings.

For example, our ICU council includes a pharmacist, a respiratory therapist, an intensivist, a physical therapist, a clinical educator, and clinical nursing staff and leaders. The leadership council includes dietary, pharmacy, supply distribution, education, therapy services, the electronic health record supervisor, and clinical leaders across the organization and the system. Expanding the councils from nursing only to a multidisciplinary team eliminates the time of rework. The multidisciplinary members are “in the know” about issues affecting the clinical areas, streamlining process changes across the organization.

New SG structure

The redesigned SG structure recognizes the councils' need for ongoing support, direction, and a direct connection to the strategic plan.3 Each of our councils is supported by an SG mentor, an evidence-based practice (EBP) mentor, and a leadership sponsor. (See Table 1.) Each of these roles is actively engaged within the new SG model and participates in a structured SG council day. (See Table 2.) Two educational workshops were held for both leaders and frontline staff.

Table 1: - Unique roles in SG
Role Description
SG mentor SG mentors provide coaching and mentorship to the leadership sponsors, chairs, co-chairs, and councils. They help ensure that the program continues to function as intended, addressing data-driven issues, breaking down barriers, and connecting the bedside to the strategic plan. The SG mentor meets with the chairs, co-chairs, and leadership sponsors annually and as needed to review documents, engage in action planning, and act as a connector/facilitator in council workings.
EBP mentor EBP mentors are individuals who have done extensive work in EBP. They're also members of the evidence, innovation, and research council. Their goal is to ask questions, cultivating a spirit of inquiry among council members. The EBP mentor encourages council members to use the steps of EBP when implementing a practice change and serves as the council's designated subject matter expert for the EBP process.
Leadership sponsor Leadership sponsors include individuals within the organization holding formal leadership roles. They're responsible for the budget and allocating resources, including staff, finances, space, and protected time for council work. They meet with council chairs before and after council meetings to help set the agenda, articulate guard rails and level of authority, and eliminate barriers, all while coaching and mentoring. The leadership sponsor fosters a culture of accountability by tracking council action items or projects to make sure they're moving forward and completed; reviewing and providing feedback on reports; and ensuring that multidirectional communication is occurring.

Table 2: - SG council day
0730 to 0900 0915 to 1045 1100 to 1230 1230 to 1330 1330 to 1500 1515 to 1645
Quality councils Practice councils Development council Open time with SG mentor Evidence, innovation, and research council Advisory council

In spring 2020, amidst the COVID-19 pandemic, our SG membership drive began, which led to the formation of 27 partnership councils, six house councils, and two support councils. (See Figure 1.)

Figure 1:
Figure 1::
SG model

Each council is comprised of a chair, co-chair, and multidisciplinary team members who review data; bring practice or quality issues to the council; and actively participate in council discussions, projects, subcommittees, and workgroups. They maintain records related to the council's business, such as the charter, minutes, correspondence, lists of ongoing projects, membership rosters, and the communication network that connects council members with nonmembers. They set annual goals based on their data and the strategic plan, focusing the council's efforts on these goals. Although nonmembers aren't on the council themselves, each employee has a responsibility to support the SG program and use their voice by communicating with their council representative and participating in the implementation of council projects.

The clinical leadership council serves as the leadership collaboration for our SG program. This council is comprised of multidisciplinary leaders across the organization and represents the leadership sponsors for all councils. The multidisciplinary approach helps identify barriers early while engaging stakeholders and increasing awareness and understanding of the “why” behind initiatives. The council is responsible for tracking progress of the clinical strategic plan while removing barriers, providing support, and determining guardrails for the SG councils. Leadership sponsors report the work of the house councils during the clinical leadership council meeting. Identified council barriers are discussed, addressed, and tracked within the strategic plan.

The advisory council is comprised of the chairs/co-chairs of each council. This council is responsible for the oversight and direction of SG, including bylaws, charters, and tools. The chairs/co-chairs report on council work, collaborate with other chairs, and identify and provide solutions to barriers the councils are facing. The CNO is the leadership sponsor and attends the advisory council.

Our house councils include practice; quality; development; and evidence, innovation, and research. The practice and quality councils are further divided into inpatient and outpatient, designed to come together quarterly to bridge the inpatient/outpatient gaps. The practice councils oversee the scope and standards of clinical practice in accordance with our practice model, emphasizing national, state, and local regulatory requirements, specialty guidelines, ethics, and evidence. The quality councils foster an environment of continuous improvement and quality patient care by reviewing and responding to patient data. They track, trend, and ensure data are being used in practice-related changes. The development council promotes individual, unit, and organizational professional growth throughout the system and community. Their current focus is a “we care about your career” program and creating career tracks for our workforce. The evidence, innovation, and research council supports research and EBP implementation throughout the system. They're responsible for the EBP mentors, teaching EBP workshops, and tracking clinical research projects.

The transition from unit-based councils to partnership councils highlights the essential connection between the leadership team and the clinical staff in creating and sustaining meaningful change, shared decision-making, and professional growth.5 The partnership councils address complex clinical issues through comprehensive workgroups, engaging in a multidisciplinary change management approach. They provide a forum of shared decision-making and resolution by frontline staff in the environment they're closest to. The councils' focus is using data to track, trend, and improve area-specific practice issues, patient care outcomes, standards of care, and employee engagement.6 For example, our oncology unit's partnership council investigated their pressure injury data, identified special populations and gaps in care, and reviewed the literature. Using consensus decision-making, they discussed, designed, and implemented a turn team that has decreased their pressure injury rate from an average of 1.77/1,000 patient days to 0/1,000 patient days for 3 months running.

Lessons learned

Regardless of the size, restructuring can be challenging. Remember to start with where you are and keep moving forward. Seek out expert consultations and communicate clearly, early, and often, reiterating a continuous process improvement mindset. We were truly amazed at the innovative problem-solving strategies of our staff, and watching the councils successfully implement their action plans further engaged their colleagues. Healthcare may continue to be complex but knowing that our teams are equipped and have a supportive structure in place, we can meet the demands of our ever-changing work environment.

REFERENCES

1. Logan Health. About. www.logan.org/krhc/about.
2. McNett M. Data for Nurses: Understanding and Using Data to Optimize Care Delivery in Hospitals and Health Systems. San Diego, CA: Elsevier; 2020.
3. Kutney-Lee A, Germack H, Hatfield L, et al. Nurse engagement in shared governance and patient and nurse outcomes. J Nurs Adm. 2016;46(11):605–612.
4. Guanci G, Medeiros M. Shared Governance that Works. Bloomington, MN: Creative Health Care Management; 2018.
5. Guanci G. Feel the Pull: Creating a Culture of Nursing Excellence. 3rd ed. Bloomington, MN: Creative Health Care Management; 2016.
6. Moreno JV, Girard AS, Foad W. Realigning shared governance with Magnet® and the organization's operating system to achieve clinical excellence. J Nurs Adm. 2018;48(3):160–167.
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