1. Shared Governance Theresa Presley MSN, RN, CNL Associate Chief Nurse, Outpatient Specialty Care VA Boston Healthcare System Joan Clifford DNP, RN, NEA-BC, FACHE Deputy Nurse Executive VA Boston Healthcare System

2. Objectives Define shared governance Explain the principles of a shared governance practice model Describe leadership in relation to shared governance Discuss the processes used to implement a shared governance model at one facility Illustrate successes and challenges at the unit level

3. Shared Governance Share: Participate, partake, implies having or taking part in an undertaking or activity Governance: exertion of a determining of guiding influence over; government; direct control; having the authority to determine basic policy Source Webster's English dictionary

4. Shared Governance Defined “An evidence- based management process model of shared decision making based on the principles of partnership, equity, accountability, and ownership at the point of service”

5. History of Shared Governance Began in business and management – Organizations began to design formal structures and relationships around their leaders and employees. – Positive outcomes emphasized movement from point of service outward. – This differed from the more traditional, hierarchical method of moving from the organization downward approach previously used. In the late 1970s and early 1980s, shared governance found its way into the healthcare and nursing arenas as a form of participative management. – It engaged self-managed work teams and grew out of the dissatisfaction nurses were experiencing with the institutions in which they practiced.

6. Primary Principles of Shared Governance Partnership Equity Accountability Ownership

7. Decentralized management structure Employee partnership, equity, accountability, and ownership occur at the point of service where at least 90% of the decisions need to be made 10% of the decisions at the unit level belong to management

8. Partnership Partnership links health care providers along all points in the system Collaborative relationship among stakeholders and nursing required for professional empowerment Essential to building relationships Involves all staff members in decisions and processes Each member has a key role in fulfilling the mission and purpose of the organization and is instrumental in the effectiveness of the health care system

9. Shared Decision making Empowers all members of the health care team to have a voice in decision making Ownership at the point of service Makes every employee a “Part manager” with a personal stake in the success of the organization This concept leads to longevity of employment, increased employee satisfaction, better safety and healthcare, greater patient satisfaction and shorter lengths of stay

10. Equity Method for integrating staff roles and relationships into structures and processes to achieve positive patient outcomes Focus is on services, patients and staff No role more important than another Each team member is essential in providing safe and effective care

12. The willingness to invest in decision making and express ownership in those decisions Accountability is the core of shared governance Used interchangeably with responsibility and allows for evaluation of role performance Facilitates partnerships for sharing decisions and is secured in the roles by staff producing positive outcomes

13. Recognition and acceptance of the importance of everyone's work Designates where the work will be done and by whom to enable participation by all team members Commitment is required

14. Shared governance activities Participatory scheduling Joint staffing decisions Can you think of any others??

15. Self Governance VS shared Governance Centralized Interactions Position based Distant from the POC Hierarchical communication Limited staff input Separates responsibilities managers are responsible Divided goals Decentralized Interactions Knowledge- based Occurs at the POC Direct communication High staff input Cohesive goals Collegiality, collaboration Partnership

16. Shared decision making Occurs best in a decentralized organizational structure where those at the point of service are granted the autonomy and the authority to make and determine the appropriateness of their decisions

17. Benefits of Shared Governance Increased nurse satisfaction Increased professional autonomy Patient satisfaction Improved patient care outcomes Cost reduction

18. Transformational leadership transformational leadership can be seen when "leaders and followers make each other to advance to a higher level of moral and motivation." Through the strength of their vision and personality, transformational leaders are able to inspire followers to change expectations, perceptions, and motivations to work towards common goals. James MacGregor Burns

20. VA Boston

21. How do the Committee fall under the Council Structure? Nurse Professional Development Council Grand Rounds Skills Workshop Educational Programs Competency Development/Training Nursing Quality and Safety Council Safety Performance Improvement BCMA/Pharmacy Nursing Workforce Planning Council Retention, Recognition and Recruitment Expert Panel for Staffing Methodology Nursing Professional Practice Council Clinical Practice/EBP Nursing Advanced Practice Sub- Council Supply

22. Unit Council Team Roles Front Line Staff Identify issues, problems, ideas for improvement at the unit level Participate in planning, implementation and evaluation of changes Share first-hand knowledge and experience with peers Unit Council Ensuring all staff input Set priorities Develop unit based measures Gather data and information Review available data Support staff Hold others accountable Nurse Managers Inspire the team Remove barriers Support the members, leader and process

23. Unit Level Shared Governance Empowers front line staff to make autonomous, evidence-based decisions at the unit/area level within their scope that lead to excellent customer service and improved patient satisfaction. People who DO the work must TRANSFORM the work!

24. Who’s On the Team? Front Line Staff Supervisor Unit Council Working together to move improvements and changes forward

25. Shared Governance – Unit Council The structures and processes by which staff participate fully in all activities that have an impact on their work. Shared decision-making based on the principles of partnership, equity, accountability, and ownership at the point of service. Provides the opportunity for all members of the workforce to have a voice.

26. Shared Governance structure Nursing staff are responsible, accountable, and have authority over all decisions related to professional nursing practice at the microsystem level Direct care nurses are elected to the positions thy hold by their peers rather than appointed by management Direct care nurses drive the structuring of the shared governance process Management is in the servant leader role; provides support encouragement and resources

27. How do the Nurse Manager and Assistant Nurse Manager fit? Evaluate outcomes Coach staff Set expectations Provides the nursing staff with tools and resources Accountable for patient care delivery

28. Implementation Methods Rules of Trust Education for front line staff Unit/area meetings Formal and informal Huddles Communication Minutes – send email to staff Dynamic Priority Boards Virtual through use of e-mail or discussion boards Consensus building

29. Reporting Mechanisms Unit Council report to staff via email/minutes to include brief statements on: Issue – what is being looked at Actions – what is being done Results - (supported with data)

30. Communication chain within Nursing Service Quality and Safety – for quality issues; results of unit based activities Professional Practice via Clinical Practice Committee for changes in policies/procedures Professional Development – for educational needs of staff Workforce Planning – to insure resource are available

31. Positive Outcomes Empowers staff Shifts accountability Teamwork Staff satisfaction Productivity Working together to make decisions that affect nursing practice and patient care. Working with other disciplines for the good of the patient. It is collaborating to improve nursing practice.

33. Leadership Support

34. Unit Council Report

35. Early Ambulation in the ICU Problem: No clear measurement or consistent documentation is taking place on a routine basis encouraging follow through with early ambulation. Many patients first ambulate at the time of transfer or in some cases discharge. Resulted in increased length of stay, increased readmission rates and increased complications.

36. Patient Satisfaction Problem: Actual procedure time runs over anticipated procedure time resulting in long wait times. Endoscopy suite working on improved Veteran Experience.

37. Management of Medical Emergencies in an Outpatient Setting Problem: The outpatient clinic setting faces specific challenges in emergency response. The largest challenge is that infrequency of occurrence of these events can cause panic and disarray in staff when these emergent clinical events present. Often times emergency’s in the outpatient settings are falls bringing unneeded resources to areas.

38. Staff Education Problem: Specialty Clinic staff identified need for education when cross covering clinics. Staff education day initiated in Sim lab including skills workshop.

39. Collaboration between RN and NA Problem : Engagement of non licensed staff. Nursing Assistant of the day program developed in the CLC to improve communication and empower the Non licensed staff.

40. Challenges Culture Change. Preparation of staff for their roles on the council. Levels of Knowledge with the basics of Process Improvement.