Shared Governance Improves Patient Care

The Client

A multiple-Magnet, large metropolitan hospital.

The Challenge

Nurses were dissatisfied with the amount of input they were able to offer about patient care delivery.

Background

The 950-bed hospital provided patient care equal to or better than any comparable facility. Despite this clinical excellence, nurses believed that care could be improved if their ideas and input were considered.

Analysis of the employee attitude survey that was administered as part of the client’s Magnet recertification process indicated that a facility-wide shared governance process was needed to significantly increase nurse engagement, job satisfaction and satisfy such other Magnet criteria as:

  • Delivering excellent patient outcomes
  • Low nurse turnover rate
  • Appropriate grievance resolution
  • Involvement in data collection
  • Decision-making in patient care delivery
  • Open communication between nurses and other members of the health care team
  • An appropriate personnel mix to attain the best patient outcomes and staff work environment

As is true in many large hospitals, the client’s management system featured a top-down structure, with most decisions being made by organizational leaders and physicians, and with less than optimal input from bedside nurses.

IRI Consultants helped the client create a network of 46 Unit Practice Councils, the purpose of which was to promote quality patient care by providing a forum for improved decision-making at the point of service. The councils sought to foster the professional growth of bedside nurses and tap into their collective insight and experience in addressing issues of importance to staff, patients and physicians.

These councils, part of a larger shared-governance process designed with help from IRI, were intended to create an environment where nurses and other patient care providers could say, “I have an opportunity to make my voice heard in decisions that affect the care of my patients.”

The following illustration shows how unit practice councils interact with the other components of the client’s shared governance structure.i

The Unit Practice Councils have the latitude to advise and guide on such issues as:

  • Reviewing and revising clinical policies and procedures
  • Identifying and acting on system and process issues impairing work performance
  • Cultivating respectful communications and a positive team culture
  • Promoting a culture of accountability in which all members view their participation as critical to quality outcomes
  • Evaluating unit practices against established performance standards
  • Assessing training needs and introducing appropriate training

Essential to the success of the Unit Practice Councils was developing and measuring success benchmarks that nurses, physicians and the administration agreed were valid. The following four indicators of success were selected:

  • Staff members feel empowered and accountable to participate in the betterment of the unit. All members view themselves as having shared accountability for unit problem solving and improvement of outcomes.
  • Issues are heard, actions are taken. Issues of concern to staff receive proactive attention and resolution at the unit level.
  • Actions of the team are highly visible within the unit. Issues under consideration and actions taken are conspicuously posted and communicated to all staff.
  • The staff takes increased pride in the unit, teamwork grows stronger, communication improves, patient, physician and staff satisfaction increases, and newcomers are attracted by the positive spirit and energetic commitment evident within the unit.

Implementation

IRI helped the client establish the Unit Practice Councils’ guidelines and procedures, as well as train council members. Two councils were established initially; each consisted of approximately eight RNs, including the unit manager. All councils include employees from each shift. Meetings were held monthly or more often if necessary.

In true shared-governance fashion, the Council selected a chairperson; rarely was the chairperson the unit manager – which often caused confusion. Accustomed to being “in charge,” some managers exercised so much control that meetings became monologs, not a conversation among all eight members. Other managers viewed their council as a “staff group,” and were minimally – or not at all – involved. Calibration was needed, and IRI helped provide mentoring and additional training.

Unit Practice Council training, which takes one day, provides members with the skills and resources needed to maximize the group’s effectiveness. Training subjects included:

  • Membership selection
  • Agenda development
  • Taking minutes
  • Problem solving techniques
  • Case study in meeting management
  • Setting goals & measuring outcomes
  • Influencing others
  • Action planning

Because the shift to shared governance from a traditional command-and-control culture represented a top-to-bottom overhaul of how the hospital functioned, as well as the culture that dictated how thousands of employees interacted with one another and with patients, there was a great deal of uncertainty and apprehension at first. Spanning the breadth of the organization’s workforce, everyone in the hospital knew this wasn’t just another “flavor of the month.” Everyone also knew that it was a process, not an event; it was never going to be “done.”

Fine-tuning occurs continuously. Variations to accommodate specific unit needs are made within the system’s overall guidelines. Not surprisingly, the greatest need for ongoing mentoring and coaching has been among managers, supervisors and directors; culture change can be traumatic and slow, especially to those who have to relinquish some control.

Project Results

Shared governance has had highly positive affects on the client’s patient satisfaction and safety, as well as on team satisfaction and nurse turnover. The following charts illustrate.

Team development/staff satisfaction: Question #11
“I am part of an effective work team that continuously strive for excellence even when the conditions are less than optimal.”

Team development/staff satisfaction survey - Question #8
“I work within a supportive environment that nurtures my professional formation and development.”

i The seven divisional Clinical Practice Councils design and implement best practices of patient care. The Patient Care Council approves and integrates clinical practice and performance improvement for patient care safety, service and quality. The Nursing Research Council provides mechanisms for research and clinical investigation relevant to nursing care delivery, and disseminating and applying research outcomes. The Nursing Education Council implements education and career development programs. The Advanced Practice Council promotes professionalism and evidence-based practice, guidance for unit-based peer review, mentoring and strong clinical leadership. The Nurse Manager Council champions peer development and peer review processes, and facilitates interdepartmental communication and feedback. The Nursing Coordinating Council assures consistent nursing practice across the organization, monitors progress with organizational objectives and the hospital’s strategic plan, approves policy and nursing practice standards. With the exception of the Nurse Manager Council, all councils have staff nurses as full participants.

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