By Susan R. Allen, PhD, RN-BC; Nicole Kneflin, MSN, RN, CNP; Heather Morath, BSN, RN-BC; Tammy Casper, DNP, Med
Editor’s Note: This is an excerpt from Shared Governance: A Practical Approach to Transforming Interprofessional Healthcare, Fourth Edition by Diana Swihart, PhD, DMin, MSN, APN CS, RN-BC, FAAN and Robert G. Hess, Jr., RN, PhD, FAAN.
Cincinnati Children’s Hospital is one of the oldest and most distinguished pediatric hospitals in the United States, with more than 600 registered beds. We believe that our interprofessional shared governance (ISG) structure is an effective, evolving, viable decision-making structure. However, this was not always the case.
Our shared governance history
Cincinnati Children’s has had a nursing shared governance structure in place since 1989. Following the integration of allied health professions with the Division of Nursing in 1995 to become the Department of Patient Services, a second interdisciplinary structure for allied health professionals was developed and implemented in 1999. We chose the word “interprofessional” rather than “multidisciplinary” because we believed that multidisciplinary indicated that there were multiple co-existing disciplines but did not convey the sense of the interaction we desired between professions. Our two governance structures operated in parallel, with few occasions for interface and with little collaboration.
By spring 2005, the increase in collaborative practice precipitated discussions during which the purpose and efficiency of the two separate structures were considered. As interprofessional collaboration grew, so did the need for interprofessional decision-making. Questions arose about the purpose, effectiveness, and viability of maintaining two governance structures. Our Patient Services and shared governance leadership began the work to merge the structures to better reflect our new interprofessional reality (Hoying & Allen, 2011).
Our Interdisciplinary Coordinating Council (ICC) and the Nursing Executive Council (NEC) joined forces in 2006 to start integrating the shared governance structure. Over the next two years, this team met regularly to create an integrated and efficient decision-making structure. In February 2007, a research study was conducted—using Dr. Robert Hess’s 1998 2.0 Index of Professional Governance (IPG) tool—to determine the nursing and allied health professionals’ current perceptions of shared decision-making. (See Chapter 6 for a detailed description of the IPG tool (Hess, 2013).) Baseline data was collected on the then-current perceptions of shared governance in Patient Services. Six hundred and thirty-one individuals (32% of the eligible staff) completed this survey. In 2007, the total sample mean score of 170.0 (SD 59) indicated that registered nurses and allied health professionals felt that there was room for improvement in shared decision-making. IPG values indicating shared governance ranged from 177–352.
With these results, the team worked diligently to create an integrated governance structure that promoted efficient decision-making around issues relating to interprofessional and profession-specific practice for optimal patient outcomes. Consensus was reached on eight critical elements of an effective interprofessional shared governance structure:
1. An integrated structure—no silos.
2. Shared governance is a “hub” of decision-making—shared governance is connected and is a player in the work of the organization.
3. Shared governance work has defined, visible, measurable outcomes.
4. Meaningful work is done in shared governance councils and committees.
5. Managers create the environment for shared governance.
6. The shared governance structure is easily articulated: it is streamlined, efficient, and effective.
7. There is representation of all Patient Services members in the shared governance structure.
8. Shared governance is integrated deeply into our culture; there is excitement about shared governance.
Using these guiding principles, a proposed model revision was developed and shared with Patient Services direct-care providers and managers for input and feedback. Consultative assistance was sought from nationally recognized shared governance leaders Timothy Porter-O’Grady, DM, EdD, ScD(h), FAAN, and Vicki George, RN, PhD, FAAN. Their recommendations included the following:
• Streamline the current interdisciplinary divisional structure into one interprofessional council for decision-making about systems issues that cross professions; interprofessional practice, education, and research issues would be on this agenda
• Ensure that each profession with representation on the interprofessional council has a profession-specific governance structure
• Design the structure to promote decision-making closest to points of service
Council structures were established for decision-making about broad interprofessional issues that affected multiple disciplines centrally, profession-specific practice decision-making within each discipline, and decision-making by the interprofessional teams that practiced at the points of service. Our enhanced Interprofessional Shared Governance structure was launched in July 2008.
Evaluation: Nurse and allied health perceptions
In November 2010 two years after the 2008 enhancement launch, the IPG study was repeated to gather data to look at how perceptions of shared governance had changed since 2007. The goal of the 2010 study was to use the data to guide the continued enhancements to Cincinnati Children’s shared governance interprofessional structure.
Multivariate analysis of variance was conducted to simultaneously test whether IPG sub-scale scores changed from 2007 to 2010 and whether there were differences between nursing and allied health responses. In 2010, 947 individuals completed the tool, which translates to a response rate of 33.5%.
The 2010 total sample mean score of 178.6 (SD 61) showed that the nurses and allied health professionals now perceived shared decision-making to be occurring. The changes were significant in the nursing and allied health professionals’ total governance scores and in the Participation and Goals scale scores. No other significant changes or interactions were noted (Hoying & Allen, 2011).
Interprofessional Shared Governance (ISG): 2016 Redesign
At Cincinnati Children’s, we are always striving “to be the best at getting better.” Our robust shared governance structure served us well, gaining national attention and recognition. As with all systems, inherent challenges and opportunities for improvement exist. Our structure grew to more than 100 operating councils with marginal alignment, reducing our ability to be responsive, communicate well, and sustain us in our constantly evolving environment. As a result, an Interprofessional Shared Governance redesign was initiated in 2016 to better actualize our Shared Leadership model.
Our redesign objectives
In alignment with the eight critical elements of an effective shared governance structure, as described earlier, the redesign steering team set the following objectives:
• Effectiveness and efficiency: Reduce the number of councils and streamline processes to allow us to better move issues/items through shared governance, thus reducing duplication and improving performance.
• Alignment: Ensure that work is aligned with the current strategic plan, our Interprofessional Practice Model (IPM) (see F. interprofessional practice model, IPM), and Sources of Evidence from the MRP.
• Accountability: Increase our ability to be efficient and effective and in line with institutional priorities to support us in collaborative work. We will achieve 90% of decision-making closest to the point of care and achieve empirical outcomes.
At our annual IPM retreat, clinicians shared with the group an innovative interprofessional eight-hour Shared Governance Day meeting structure that they learned about at the 2015 ANCC Magnet Conference. Multiple iterations with direct care and leadership feedback informed the redesign of our shared governance structure from more than 100 varied councils to a systemwide interprofessional structure. These enhancements reflect the IPM tenets and enable alignment, authority, accountability, and advocacy for the interprofessional team.
Cincinnati Children’s current interprofessional structure and responsibilities
Our interprofessional shared governance (ISG) structure was designed to include house-wide councils that explicitly reflect the tenets of our IPM (Safety Tenet Council, Best Practice Tenet Council, Collaborative Relationships Tenet Council, Comprehensive Coordinated Care Tenet Council, Professionalism Tenet Council, and Innovation and Research Tenet Council). The structure is a strategically aligned, shared decision-making forum, facilitating bi-directional communication and collaboration between PoC and house-wide councils; affecting optimal and empirical outcomes for patients, families, and staff; and developing leaders within the organization. All councils include direct-care clinicians, leadership, and other key stakeholders essential in contributing to informed shared decision-making. For example, the Director of Employee Safety is a member of the Safety Tenet Council, in which goals are focused on decreasing patient and employee harm. All of the co-chairs of the councils are direct care providers.
The key take-aways include the following:
• The house-wide tenet councils align with our IPM tenets.
• House-wide councils focus on systemwide interprofessional work, supporting identified organizational priorities.
• Each house-wide tenet council has a dyad chair model, led by a clinical nurse and an allied health clinician.
• To ensure bidirectional communication, membership of each house-wide tenet council includes a member from each PoC Interprofessional Council and other key stakeholders as indicated.
• Outcomes are reported by council members to constituents and by council chairs to Patient Services Leadership.
• Every council in this structure meets on a single eight-hour day, once a month. During this eight-hour day, all members receive skills and leadership development, as well as coaching and mentoring.
• Work related specifically to a single profession is completed in a profession-specific shared decision-making forum and shared within the context of our IPM.
Breaking down silos: Demonstrable benefits to our interprofessional governance structure
Building a culture of interprofessional team-based collaboration means that we must break down long-established silos. Those silos have deep roots that foster mistrust through misunderstanding associated with our profession-specific training and socialization. Interprofessional shared governance is worth doing because through the process and structure, professions learn from each other. We spread best practice and stretch perceived boundaries using the examples of others who have already crossed them. Synergies emerge. We have recognized opportunities for interprofessional collaboration in professional practice, education, research, and development.
The fundamental premise of our shared governance structure is that care areas affected by decisions regarding practice, education, and research must be directly involved in the decision-making process. By actualizing true shared leadership, professionals from all settings and roles are empowered to participate actively in all levels of organizational decision-making groups at Cincinnati Children’s. We anticipate continuing the spread of our improved integrated governance structure. It is profound when existing decision-making structures seek out partnerships with leaders of interprofessional shared governance, and the work is continuing on our journey to enhance interprofessional shared governance at Cincinnati Children’s.
Moving forward: Strengthening our collaborative practices
Throughout 2017 and 2018, multiple resources informed the ISG program of opportunities to strengthen the integration of interprofessional shared decision-making. The following are essential elements and processes we continue to refine:
• Onboarding new council members
• Leadership and development sessions
• Communication plans
The shared governance program leader aligned the new fiscal year organizational priorities to tenet councils based on their defined purpose. Through shared decision-making, council members decide how their council will contribute to these priorities and develop additional priorities as desired. This novel approach allows for intentional connections across the system for hospital leaders and members to gain perspectives from multiple professions and care areas.
In the new fiscal year, new mentors joined councils aligned with their assigned strategic priorities. In our efforts to formalize the role of the mentor, key aspects were defined. They were identified as optimizing bidirectional communication, eliminating systemwide barriers, and minimizing redundant efforts. They also include assisting with robust council member discussions, identifying SMART (specific, measurable, attainable, realistic, and timely) goals, and facilitating implementation strategies to reach yearly goals.
Onboarding new members
In our redesign, we are using a preceptor model to support the incoming chairs over the course of three months. The following is the schedule for the incoming council chairs:
• April: Observe the council chair’s responsibilities and deliverables within and outside of the council meeting
• May: Assist the council chair in meeting preparations, meeting discussions, and post-meeting needs
• June: Lead efforts for meeting preparation, meeting discussions, and post-meeting needs supported by the previous council chair
Additionally, support is provided by the Shared Governance Program Manager who facilitates the assessment of needed resources and development. For example, through collaboration with council members, a digital tool kit was created. It includes items such as meeting agenda templates, job aides for consensus decision-making, minute-taking strategies, and communication tools.
Leadership and development sessions
Leadership and development sessions were integrated into the redesigned eight-hour, single-day structure. These opportunities in shared governance allow organizations to develop and retain top talent. The challenge lies in offering curriculum and learning objectives with enough breadth for individual learning needs across the organization; the need to develop an annual needs assessment for ISG members has since been identified. Based on these results, curriculum objectives will be adjusted to address and influence leadership competencies for the council membership. Additionally, we will continue to offer sessions that include Shared Governance 101, strategic planning, and annual goal setting.
Effective and meaningful communication across the organization is crucial to the success of a shared governance structure. A study done at the organization found that our clinicians preferred digital communication related to shared governance work and decisions (Giambra et al., 2018). This finding influenced the development of council-specific PowerPoint slides, highlighting decisions made, actions taken, and takeaways. The collection of slides from each house-wide council is electronically distributed shortly following the house-wide council meetings to assist with communication in the afternoon PoC council meetings. Further considerations include outlining an organizationwide communication plan to use multiple platforms, such as newsletters, electronic resources, and streamed webinars, to reach and inform all clinicians.
Creating an environment in which governance is truly shared is not easy to do and requires the ongoing commitment and attention of all members of the organization. Sharing governance requires significant changes in an organization’s culture and in the behaviors, beliefs, and values of its members. A few false assumptions such as the following may challenge your progress:
• If we have shared governance councils, we have shared governance.
• If we have multi-professional councils, we have interprofessional decision-making.
• If shared governance is interprofessional, nursing will lose its voice.
These concerns must receive focused time and ongoing attention throughout interprofessional shared governance design, development, training, implementation, and cycled evaluation. Interprofessional shared governance has immeasurable benefits for an organization, its members, and all internal and external stakeholders. Consider these words from a nursing shared governance council chair—who did not lose her voice—as she describes her experiences with interprofessional shared governance:
“All the right people are at the table from bedside nurses to pharmacists, to physicians, to educators, to … everybody coming together for the mutual purpose of seeing if this idea is feasible and beneficial and productive. … I see so much more of an emphasis on the team, and on the understanding that it is the team that makes the difference. It’s not the individual components thereof. That’s what shared leadership is; it’s the engagement of everybody.” (Allen, 2013)
We have illustrated how interprofessional shared governance came to be and how it is in place and thriving at Cincinnati Children’s Hospital. We are proudly committed to the delivery of safe, quality care through an interprofessional approach to shared governance. This interprofessional philosophy is embedded throughout the organization. Our principal supportive structure for the participation of nurses, allied health professionals, care providers, and leaders from all roles and settings in decision-making is the interprofessional shared governance structure. We strongly believe that including people impacted by decisions in making those decisions will result in better ones, in actions more widely supported across services, and in empirical outcomes sustained over time. The “why” of what needs to be accomplished is communicated to and realized by everyone involved in the work of the organization. Interprofessional shared governance gives direct-care providers’ ownership of their practice at every point of service across the organization.