Shared Governance


Implementing Shared Governance in Rehabilitation Services

Rose Fowler, MS, OTR; Mike McAvoy, MS; Barbara Haag-Heitman, PhD, APRN, BC; Carol DiRaimondo-Decker, MPT; and John Zuleger, PT, LAT

Rehabilitation Departments, as with other healthcare services, face continuous challenges to find more efficient and effective ways of adapting to our rapidly changing environments. Competition in the marketplace for rehabilitation services and the demands for quality, cost-effective outcomes from consumers, payors, and regulatory agencies are also on the rise. Collaborating with professional staff in a formal shared governance/shared decision-making model is one innovative management approach shown to effective means to help meet these demands. For the past nine years, our hospital-affiliated Rehabilitation Department has been working within a formal professional shared governance model. Our model integrates six distinct professional practice disciplines, working in five distinct geographic locations, into one dynamic professional practice model. This article presents the background, key steps, and outcomes achieved by moving to a shared decision making model.

Shared Governance Foundation

Over the last decade, organizational change leaders have identified that organizations with flattened hierarchical management structures and empowered workers at the point of service are more flexible and adaptive to change.(1,2,3) Flattened hierarchies create new conditions for professional staff to exercise more autonomy, authority, and influence around practice decisions. In healthcare, shared governance is the most commonly implemented organizational framework used to enhance the decision-making partnership between staff and management. Shared governance has shown its effectiveness in healthcare for creating highly functioning professional practice environments that can demonstrate quality outcomes, enhance collaborative relationships, and positively affect staff retention and recruitment.(2,4) The Magnet recognition program criteria requires flat organizational structures and shared decisions, further supporting its essential role of shared decision in achieving excellent levels of quality care.(3)

Shared governance models build from the point of service outwards. This point of service focus promotes integrated leadership and supports the interdependence of organizational members and work processes. Shared governance recognizes and supports the primary relationships needed for effective care delivery. Within a Rehabilitation department, the primary relationships are between the professional therapist, the client, and the referring healthcare provider. Supporting these primary relationships demands organization of all the departmental structures and systems to ensure clinical care and customer service of the highest quality. The role of the manager changes significantly in shared governance. There is a shift from controlling and directing practice to supporting the practice environment by focusing on human, fiscal, and resource management. The department’s original shared governance preamble (Figure 1) summarizes the key concepts and organizational structures that create the working context for shared governance principles.

Bringing About the Change

The former Director of Rehabilitation took the first step in the department’s reorganization. Having worked in a hospital where the nursing division practiced within a shared governance framework, he had experienced it to be an effective model for professional practice. He gained support for this change in organizational structure from senior administration. Starting with this top-down administrative approach was critical to successful implementation.

The Director rolled out his plan to move to a shared governance model at his employee staff meetings. During the meetings, he shared that from his experience, shared governance practice decisions are “better decisions because they are made by people who are more informed.” He related that the traditional hierarchical bureaucracy management model, found in most hospitals, assumes that the leader knows the answers to all of the problems and concerns related to the department, including practice issues. In addition, he reported that therapists and administrative staff routinely sought clinical guidance and direction from him even though he had not done “hands-on practice” for many years. He went on to discuss how the management career path focus is on improving administrative skills and his skills were strongest in human resources and financial topics. By the end of the discussion it seemed clear that a shared decision-making model was needed to advance clinical practice and that staff, not management, should be the ones to decide practice issues, such as if a therapist should use ultrasound over a 16-year-old’s knee joint. The presentations also encouraged and addressed staff’s questions and concerns. One session was video taped to ensure that all staff would be able to learn about this substantial change in operations. A consultant, with over 15 years of experience working in shared governance, assisted with the model’s creation and implementation.

Use of a Steering Committee

An important first step included the formation of an ad hoc steering committee to design and implement the new shared governance model. The charge of this committee was to define the guiding principles of the model and identify each council’s membership and responsibilities. They also established an implementation plan, including a department-wide election for shared governance participation. Staff interested in participating submitted a profile of their interests, skills, and abilities in guiding this change. The participants’ comments illustrate their expressed curiosity about the proposed changes and a desire to act collaboratively:

“To see a greater staff involvement in how we operate as a system, as we are very fragmented at this point in time.”- O.T./P.T. Coordinator – 12 years’ experience

“I believe this is the/my opportunity to help create and shape a new leadership structure in our department.” – P.T. – 5 years’ experience

“To have the opportunity for greater involvement in operations and clinical decisions related to our services and practices.” – Voc. Rehab. – 10 years’ experience

“To see cohesiveness between the staff at all sites and define common goals for all therapies – not this is O.T., this is P.T., etc.”- O.T. – 5 years’ experience

“I feel shared governance would be a great benefit for the Physical Medicine Department as we have many sites and a large mix of people – this would be a good way to pull everyone together.” – P.T. – 26 years’ experience

“To promote best practice within the clinical arena” – P.T. – 15 years’ experience

Of note was the desire to transcend the artificial boundaries of their site locations and discipline-specific labels. The steering committee consisted of 23 members: 16 staff, four site coordinators, the manager, and the director. Collectively, the steering committee membership represented five practice sites and six rehabilitation disciplines. While the steering committee was large in number, the intent was to be inclusive and stimulate interest in providing council leadership for the new model. The consultant worked with the steering committee to define the guiding principles found in Figure 1. Initial and current council membership and accountabilities are defined and presented in Table 1.

Moving Forward

A nominating committee was formed from the steering committee members to help organize and implement the nomination and election process for the new councils. Candidates were required to provide a biography that listed their name, practice discipline, and interest in shared governance. The election ballot included this information. The election took place two months after the steering committee’s first meeting. A governance newsletter, The Governance Gazette, helps facilitate communication among all department members.

Measuring Change and Outcomes

The easy part of implementing shared governance is creating the model or structure.(6) The more challenging part is working with professional staff to alter their behaviors and attitudes about their roles in patient care and unit operations. Brooks(6) indicated that implementation is more difficult in organizations entrenched in bureaucratic traditions and those with a strong medical model orientation. The diversity of professionals and geographic locations within the department added to the challenge.

Since shared governance was new both to the organization and unique in its application outside of nursing, a pre-implementation measurement of the current professional practice environment was conducted using The Index of Professional Governance (IPG), developed by Dr. Robert Hess.(5) Measurement of professional governance, using the IPG, encompasses both the structure and process through which professional staff controls their professional practice and influences their organizational context.(7) The IPG was designed to measure staff’s perceptions of professional governance on a continuum ranging from traditional management to shared governance. The tool’s subscales measure six dimensions of governance: personnel, information, resources, participation, practice, and goals. The pre-implementation survey, completed by 87 multidisciplinary staff, indicated that staff had a very traditional view of the department’s governance structure, with the majority of decisions being made by management.

A re-measurement of staff’s perceptions of governance, using the same IPG tool, one year after implementation showed a significant change towards shared governance. Hess(7) provided a comparison of these scores with those from 15 other organizations. Our organization ranked among the highest in the mean overall scores and second highest on all the subscales. During this second measurement phase, the Rehabilitation Department’s staff satisfaction scores were significantly higher than other areas within the healthcare system. This correlated with the high mean for job satisfaction reported in the IPG survey.

Results of the most recent IPG survey indicate maintenance of a shared governance culture. The dimension of “resources” consistently rose during the three periods of measurement. This indicates staff’s perception of autonomy and control over resource for professional practice. A decline occurred in the two subscales measuring operational dimensions: control over personnel and setting of goals and negotiating resolution of conflict at various organizational levels. Both dimensions are associated with and reflect traditional managerial responsibilities in organizations.

Is the Journey Worth the Price?

The cost effectiveness of shared governance is an important question for organizations to address. The opportunity for our organization to implement shared governance naturally presented itself when one of the department managers resigned. The monies designated for this manager’s full-time position were re-allocated to support shared governance activities. The reduction in this management position has continued to offset the cost of shared governance activities. Annually, there is a budget set for each council. The council chair is required to perform a formal accounting of his or her council’s expenses, activities, and key decisions.

The cost effectiveness of shared governance for the organization has been demonstrated by reduced turnover rates and associated reductions in recruitment and orientation costs, an increase in staff efficiencies, an increase in staff satisfaction, and high patient satisfaction. As an example, the department turnover rate is 5.6%, far less than the organization’s turnover rate of 10%. The financial impact of turnover is significant. Using nursing as an example, estimates of cost to replace one clinical staff member ranges from $50,000 to $64,000.(8) Decreased turnover alone can provide a substantial reason for supporting shared governance. Another positive outcome resulted in the area of staff efficiency, measured by the use of time, labor, and equipment in the treatment of patients. The current measure of staff efficiency is at or below the national benchmarks.

The relocation of practice into the hands of the providers, where it rightfully resides, yielded results not possible in traditional management structures. Many innovative solutions and significant practice changes resulted from structurally positioning the authority and accountability for practice in the hands of the professionals at the point of service through shared governance. Each council creates an annual report of their major goals and accomplishments. Table 2 highlights the key council decisions and activities during the first year of implementation alone.

Key outcomes and changes beyond the initial implementation phase include:

  • Explicit expectation for shared governance participation of all staff integrated into job descriptions and measured in the essential job duties section of the annual performance/merit review.
  • Integration of RN role
  • Alignment of shared governance activities with organizational strategic plans and initiatives.

The move to a shared decision-making environment is a journey and a process that is continually evolving. Its success requires that leaders are willing to shift their roles, power, and relationships with staff for clinical decision making. The rewards for doing so are plentiful, as described by the current Director of Rehabilitation Services:

“The biggest shift I have seen in the councils is the move from a discipline-centered focus for decision making to a patient perspective. It has been an eye-opening transformation for both staff and leadership. I know that this change has been difficult for some. I have found that having shared governance definitely gives us a recruiting advantage, and I discuss shared-decision making in interviews with prospective new employees. In fact, many new hires run for council and are elected in their first years of employment. Our seasoned staff report that participation in shared governance is rewarding and they find becoming the council chair to be a developmental opportunity. Managers report that their shared governance model is very appealing to potential new hires, assisting with recruitment.”

At the time of this project, Rose Fowler, MS, OTR, was Vice President of Clinical and Patient Support Services, Wheaton Franciscan Healthcare – All Saints; Mike McAvoy, MS, PT, was Vice President of Operations, St. Mary’s Duluth Clinic; Barbara Haag-Heitman, PhD, APRN, BC, was the Independent Consultant; Carol DiRaimondo-Decker, MPT, was Inpatient Rehabilitation Services Manager, Wheaton Franciscan Healthcare – All Saints; and John Zuleger, PT, LAT, was Outpatient Rehabilitation Services Manager, Wheaton Franciscan Healthcare – All Saints.

Corresponding Author: Barb Haag-Heitman, 551 E Lake Hill Ct, Whitefish Bay, WI 53217, bhaagheitman@yahoo.com

References

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  3. American Nurses Credentialing Center. The Magnet recognition program application manual. Silver Spring, MD: 2005.
  4. Ladewig N, Raaum, J. Vision to reality: a historical perspective. In: Haag-Heitman, BJ, ed. Clinical practice development using novice to expert theory. Gaithersburg, MD: Aspen. 1999: 1-16.
  5. Hess RG. Measuring nursing governance. Nurs Res. 1998; 47:35-43.
  6. Brooks, BA. Measuring the impact of shared governance. Online J Issues Nurs [serial online]. 2004: issue 9.
  7. Hess RG. The measurement of professional governance survey results. Personal Communication. 2000.
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