Realigning Shared Governance With MagnetA and the Organization"s Operating System to Achieve Clinical Excellence

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T H E J O U R N A L O F N U R S I N G A D M I N I S T R A T I O N

Janette V. Moreno, DNP, RN, CCRN-K, NEA-BC

Anita S. Girard, DNP, RN, CNL, CPHQ, NEA-BC

Wendy Foad, MS, BSN, RN, NEA-BC

In 2012, an academic medical center successfully overhauled a 15-year-old shared governance to align 6 house-wide and 30 unit-based councils with the new Magnet Recognition ProgramA and the organiza- tion"s operating system, using the processes of LEAN methodology. The redesign improved cross-council communication structures, facilitated effective shared decision-making processes, increased staff engagement, and improved clinical outcomes. The innovative struc- tural and process elements of the new model are repli- cable in other health institutions.

In the clinical setting, engagement of the frontline staff to develop a structure enabling shared decision making is often done through shared governance (SG).1

Even before the introduction of SG, models of stake- holder engagement had been explored in the business setting. R. Edward Freeman,2 a philosopher and pro- fessor of business administration known for his work on stakeholder theory, proposed that a Bstakeholder in an organization is (by definition) any group or individual who can affect or is affected by the achieve-

ment of the organization"s objectives.[2(p46) This article describes the assessment, planning, and execution phases of developing innovative structures, processes, and outcomes of the SG program redesign in a large aca- demic medical center. We describe how the structural redesign was aligned with the Magnet Recognition ProgramA (MRP).

3 We also discuss how the processes

of shared decision making and council goal setting are aligned with the organization"s operating system. Aligning SG with the MRP and the operating system has led to achieving the triad of clinical excellence: staff satisfaction, patient satisfaction, and patient outcomes.

Redesign Process

Assessment

Shared governance has existed at Stanford Health Care (SHC) for almost 2 decades. A gap analysis revealed inconsistent application of SG across hospital units and departments. There were communication lapses be- tween unit-based and house-wide councils, lack of clarity on how unit-level issues were handled, and a lack of process in the referral of unit issues to the house-wide councils. The 2012 National Database of Nursing Quality IndicatorsA (NDNQI) survey on practice environment validated SHC nurses not feel- ing engaged in the decision-making process concern- ing nursing practice. Meeting minutes and agendas revealed mostly informational topics and insufficient clarity of the goals in each council. An extensive re- view of meeting attendance records and a staff survey revealed 11 house-wide councils and 88 unit-based councils and committees constituting 1250 members, with only 25% regular attendance.

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Author Affiliations: Director of Professional Development and Clinical Education (Dr Moreno), Center of Professional Excellence and Inquiry, Stanford Children"s Health/Lucille Packard Children"s Hospital, Menlo Park; and Magnet Program Director (Dr Girard) and Associate Chief Nursing Officer (Ms Foad), Patient Care Services, Stanford Health Care, Stanford, California.

The authors declare no conflicts of interest. Correspondence: Dr Moreno, Stanford Children"s Health,

725 Welch Rd, MC 5895, Palo Alto, CA 94305 (JVMoreno@ stanfordchildrens.org).

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal"s Web site (www.jonajournal.com).

DOI: 10.1097/NNA.0000000000000591

mailto:[email protected]

http://www.jonajournal.com

Planning

The planning phase included forming a strategy team, engaging stakeholders through an SG retreat, and the formation of redesign workgroups. Patient care services (PCSs) formed a strategy team to provide guidance and direction to the SG redesign. The strat- egy team includes the SG coordinator, assistant chief nursing officer, director of practice and education, MagnetA program director, director of nursing research, chair of the Coordinating Council (clinical nurse), chair- elect of the Coordinating Council (clinical nurse), nurse manager, chair of the Magnet council (clinical nurse), chair-elect of the Magnet council (clinical nurse), and clinical nurse specialist.

To ensure participation and engagement in the redesign, the PCS leadership sponsored a full-day retreat for 55 staff members from the SG councils. The retreat attendees chosen from the existing SG structure included nurses from all levels of care, respi- ratory therapists, case managers, dieticians, phar- macists, rehabilitation therapists, quality specialists, and patient advisors from the community. The retreat activities focused on organizational assessment, liter- ature review, and best practices. Discussions were focused on how the current SG structure had grown considerably and failed to support effective commu- nication at the micro, meso, and macro levels. The current structure being unsupportive of shared decision

making became apparent through these discussions, and by a unanimous vote, the attendees agreed and deter- mined to restructure and overhaul the SG framework.

During the SG retreat, workgroups were formed to develop innovative structures and robust processes and achieve outcomes of clinical excellence. Swihart"s4

definition of SG as Ban innovative management model which provides the structure and processes of shared decision making to achieve the outcomes of shared leadership[4(p2) provided a shared vision for redesigning and rebranding SG as Shared Leadership Council (SLC).

Execution

Structural Alignment With the Magnet Recognition Program Model Components

The new SLC structure"s key elements included aligning councils with the MRP model, council member selec- tion, and structured council meetings. The 11 existing house-wide councils were consolidated and restructured to align with the 5 components of the MRP model.3

Each council"s functions and responsibilities were con- sidered, linked with appropriate Magnet account- abilities, and incorporated into the bylaws. This led to forming 6 SLCs appropriately aligned with the 5 Magnet components (Figure 1). To emphasize front- line staff"s importance, the individual unit councils are depicted on the top of the new SLC structure

Figure 1. Shared Leadership Council alignment with MRP model components.

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(Supplemental Digital Content 1, http://links.lww. com/JONA/A610). The goal was not to recreate an SG structure but to develop an SLC program that provided staff with autonomy and support to guar- antee maximal engagement and workplace fulfillment.

Membership Application and Future Leaders Selection

To ensure active participation in council work, a council member selection process was developed, consisting of application, r2sum2 submission, and exemplar of innovative solutions at the unit level, which was highly successful in developing a sense of pride and ownership among the participating nurses and interprofessionals. Each clinical unit is represented at the 5 house-wide councils by at least 1 member, who then forms the unit council for unit-level council projects. A strong collaboration with the Patient Family Advisory Council enabled patient partners to be represented at every house-wide council and join the unit-based councils on an as-needed basis.

Eight-Hour Council Day and Structural Empowerment

Two of the reasons cited for the low attendance in previous council meetings were the inconvenience of driving to the meeting location and the insufficient time for undertaking council projects. At one point, teleconferencing was provided for staff to join the

(online) meeting, which enabled participation but was not sustainable for active staff engagement with council work. Consequently, a robust 8-hour council day was developed to allow time for council work, networking, idea exchanges, and support leadership development sessions.

The 8-hour council day structure (Figure 2) was guided by Kanter"s5 structural empowerment concept of access to information, support, resources, and opportunities to learn and grow. With equal represen- tation from all nursing units, including ambulatory care and interprofessional groups, the 2-hour house-wide council meetings in the morning provided members the access to resources and support for developing action plans for the outcome-driven council agenda. While the house-wide council meetings progressed, the unit-based council chairs met to improve knowl- edge and leadership skills, discuss unit-based council meeting issues and updates, and share best practices. Another feature of the morning session was the infor- mation booth exhibit, which enables staff to provide direct feedback to the teams working on issues con- cerning the clinical bedside workflow, such as selecting new workstations on wheels or new medication scan- ners. These booths can also promote nursing updates, such as the NDNQI Registered Nurse Satisfaction Survey or the rollout of a new house-wide program.

Figure 2. Eight-hour SLC day at SHC.

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Collaboration, communication, coordination, and celebration were the focus of the Coordinating Council meetings. While the council chairs and advisors met for the Coordinating Council, the members attended leadership development sessions, where they learned leadership skills such as evidence-based practice (EBP), continuous process improvement, active daily man- agement of issues, and communication skills, thereby providing professional growth and development opportunities to prepare them as leaders at all levels of care. As Pennington-Caraviello6 suggests, being part of the SLC allowed bedside clinicians to observe nurse leader interactions, and provided a different perspec- tive of organizational needs.

After a lunch break, the council members returned to their respective units to complete the last 4 hours of the day. The 5 council members from each unit gathered with their council advisors, clinical nurse specialist, and unit educator to report on house-wide council updates, prioritize the issues brought forward via action requests from the clinical bedside, and work on their unit council"s goals. The bulk of work and decisions are made by point-of-care frontline staff.

Innovative Process Design

Management and Continuous Improvement Systems

The innovative processes of SLC were based on the LEAN methodology principles of the management and improvement systems, which support the overall organization operating system.7 The management system in the SOS refers to active daily management, a key principle in LEAN methodology pertaining to leadership visibility at the gemba (where the work is), accessibility, and responsiveness to the frontline staff. In a LEAN organization, frontline staff is expected to proactively present innovative solutions to identified priority issues in their microsystem. In a LEAN environ- ment, employees are empowered to voice their con- cerns and are encouraged to partner with management and collaborate with the interprofessional group in developing action plans for addressing issues.

Another key principle in LEAN methodology sup- porting the SLC processes is the improvement system. Clinical excellence outcomes are achieved by aligning council work and the improvement system, which pertains to the organization"s values and beliefs regard- ing continuous process improvement. Both house-wide and unit-based SLCs support the improvement system by setting annual goals to achieve clinical excellence.

Process of Shared Decision Making and Management System

To ensure a robust process of shared decision making, the workgroup developed a workflow process that

encouraged and facilitated staff to request and express their issues and concerns regarding professional practice, service quality, and competency in practice. The redesign aims to strengthen the communication of action plans or outcomes on issues from the unit- based to house-wide councils. An online action request form (ARF) was developed for any employee to submit requests online; the staff states the request, recom- mends solutions, and indicates any specific action taken. The staff is encouraged to attach any supporting documents to facilitate the request.

Action request forms submitted to both unit-based and house-wide councils are prioritized for the council meeting discussions. An ARF tracker report is posted online and at the monthly council meetings, and it can be generated anytime. Council chairs and advisors can view all existing ARFs to determine any similar issues with action plans in other units or departments. The ARFs" accessibility has allowed sharing best practice across the organization and improved cross- council communication.

Principles of Shared Leadership in Action

Partnership The ARF review and communication process exem- plifies the principles of shared leadership: partnership, accountability, ownership, and equity.4 Partnership between the council chair and advisor at the unit and house-wide level is vital to shared decision making and timely resolution of ARFs. The unit council advisor and council chair regularly meet to review and prioritize in their council agenda for action planning. An ARF requiring feedback, review, or approval at the house- wide level is assigned to Coordinating Council. The Coordinating Council advisor (associate chief nursing officer) and the Coordinating Council chair (clinical nurse) review all ARFs routed to them and determine appropriate referral to other councils.

Equity The principle of equity in shared leadership pertains to prioritizing ARFs, collaboration, coordination, and communication. Some action requests require coor- dination and collaboration with other nursing units, departments, services lines, or interprofessional depart- ments. The ARF status and progress are documented online, regularly updating the requestor. The process provides information access, support, and resources to everyone involved.

Accountabilities All ARFs are analyzed and categorized according to the accountabilities of shared decision making (Figure 3).8

The model defines 2 major decision-making categories: clinical practice and management accountabilities.

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Clinical-practice accountabilities include shared deci- sions around standards of practice, care delivery model, professional development, quality, peer review, and interprofessional relationships. Frontline staffs are held accountable for making decisions around the standards of care to ensure patient safety and improved patient outcomes.9 Management accountabilities in- clude decision-making domains on resource allocation (fiscal, human, or material), structures, systems and processes, and rewards and recognition. The manage- ment team collaborates with frontline staff and other healthcare providers to address system and workflow issues and identify, manage, and use resources.9

Ownership Determining whether an ARF is unit-based or house- wide defines the ownership of the process, although every role has a stake in the shared decision making. A 90/10 rule is set, where 90% of decision making occurs at the unit-based council level.8 The 10% referred to the house-wide councils are reviewed and analyzed according to each house-wide council"s function and responsibility that are aligned with the Magnet Model components. The house-wide councils to which ARFs are referred to include the following:

� Coordinating CouncilVsystem-wide structure, systems, processes requiring resource allocation (fiscal, human, material) � Quality and Practice CouncilVnew clinical prac-

tice implementation, practice changes, nursing- sensitive indicators, core measures � Research and Innovation CouncilVnew knowl-

edge, EBP, innovations � Education and Informatics Cou ncilV

documentation, patient education, staff edu- cation needs � Magnet, Professional Growth, and Develop-

ment CouncilVrewards, recognition, certifi- cation, professional development, community involvement

Continuous Process Improvement System

The LEAN management principles of continuous process improvement guided the annual unit-level and house-wide council goals to ensure council work alignment with the triad of clinical excellence such as preventing falls, infection, and pressure ulcer and increasing patient and staff satisfaction. Through the improvement system, utilizing tools, such as A3

Figure 3. Clinical practice and management accountabilities guided shared decision making at SHC.

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problem analysis and the plan-do-check-act (PDCA) cycle, facilitates standard work and continual solution finding. Continuous process improvement ensures that both frontline staff and management collaborate in evaluating new improvement efforts. An A3 is a single- page worksheet named for the paper size (A3, 11 � 17 inches). In LEAN methodology, the A3 provides the team with a single view of the data and countermea- sures for moving the change process forward.10 It is used as a draft document and continuously modified as the project moves forward. Supplemental Digital Content 2 (http://links.lww.com/JONA/A611) illus- trates the A3 tool and logical problem-solving steps reflecting the PDCA process. The steps are depicted on the A3 paper to summarize and visualize the under- standing of the current state, future state, implemen- tation, measurement, and sustainability plan.

Both house-wide and unit-based councils set goals to achieve the clinical excellence triad. Each house- wide and unit-based council brainstormed to formu- late goals aligned with the strategic plan. Each council cycles through the steps of the PDCA process (Supple- mental Digital Content 2, http://links.lww.com/JONA/ A611) regularly and continuously monitors their prog- ress. On a quarterly basis, council chairs and advisors report on their council goals" progress using the A3 format. To sustain the process, small wins are cele- brated at the Coordinating Council. A3 reports are displayed on the unit"s visibility walls, communicated throughout the organization via the newsletter, and posted on the intranet.

Results

The overhauling of SG to shared leadership resulted in implementing of a structure-aligned council func- tion and responsibilities with the MRP. The innova- tive processes of shared decision making through the management and improvement system rendered outcome-driven council goals. Shared decision mak- ing through active daily management established a standard work that streamlined and prioritized council agenda items, enabling more targeted and efficient action planning. The online ARF submission allows monitoring and trending progress and results. Two years after the introduction of SLC, 814 ARFs had been reported. The overall ARF closure rate is 88% (average time of closure, 58 days). Of the 563 ARFs (69%) at the unit-based level, 475 have been closed, and 8 ARFs are in progress. Of the 251 ARFs (31%) referred to the house-wide councils, 243 have been closed, and 8 are in progress. Coordinating council, Education and Informatics Council, and Quality and Practice Council received most of the ARF referrals (88, 73, and 66 ARFs, respectively).

Thematic Analysis Based on the Shared Decision-Making Domains

Based on the Accountabilities of Shared Decision- Making Model,8 ARFs are categorized according to the clinical-practice and management accountabil- ity domains. Several steps have been taken to ensure the validity and reliability of categorizing ARFs. Upon initial review, the council chairs and advisors cate- gorized the ARFs according to the decision-making domains. For example, Supplemental Digital Content 3, http://links.lww.com/JONA/A612, shows an ARF gen- erated from a clinical nurse requesting to develop a nurse-driven standardized procedure on lidocaine jelly application prior to nasogastric tube insertion. The ARF was categorized under the decision-making domain of clinical-practice accountability (subcategory: standard of practice) and was referred by Coordinating Council to the Quality and Practice Council. On a weekly basis, the Coordinating Council chair and shared leadership coordinator review the ARFs to validate the domain categories. The ARF outcomes by the decision-making domains are regularly monitored.

Two years after introducing shared leadership, distribution trends revealed 72% (583) of ARFs under management accountabilities and 28% (231) under clinical-practice accountabilities. A study of Magnet organizations showed that nursing SG is dominated by administration/management with some staff input,11

which is congruent with the ARF trend of primarily management accountabilities. It is therefore critical for frontline staff and managers or nurse leaders to partner in developing innovative solutions to current issues. The 583 ARFs under the management account- ability category were further subcategorized. The top 3 subcategories were (a) resource allocation (35%), (b) systems/processes (23%), and (c) electronic docu- mentation build requests (32%; Figure 4), whereas 186 (80%) of the 231 ARFs classified as clinical-practice accountabilities emerged under the subcategory of standards of practice. Most of these 231 ARFs prompted frontline staff involvement in the policy and procedure revisions, development of nursing-driven protocols, ini- tiation of standardized nursing procedures, interprofes- sional collaboration, and reeducation on care standards.

Achieving Council Goal Outcomes

At the fiscal year end, council goals and outcomes were reported at the annual retreat. The NDNQI survey results were above the Magnet mean in all categories 2 years after shared leadership implementation. Certification has increased from 42% in 2014 to 56% in 2016. The overall rate of staff with a bachelor"s or higher degree increased from 80% to 86%. Participation in the Professional Nurse Development Program (clinical ladder program) increased from 22 council members

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(clinical nurse 3 and 4) to 45 (21 clinical nurse 3 and 4). Catheter-associated urinary tract infection rates decreased to 0 in 3 nursing units. Patient satisfaction scores on the overall likelihood to recommend increased from the 90th to 93rd percentile.

Discussion

One of the most important outcomes achieved with the innovative SLC program is the impact on structural empowerment. Moore and Hutchison12 reported that implementing a program to support the structural empowerment of the clinical voice in decision making increases employee engagement and commitment and thus creating accountable leaders at all organizational levels. Through this process, aspiring leaders with innovative, creative ideas who are early adopters of

innovation emerge within the organization. Through structural changes, 200 nurses have been provided a 5-fold increase in time (1.5-8 hours) for dynamic net- working, collaboration, problem solving, and council work. The alignment of shared decision making with the LEAN methodology principles embedded in the operating system has supported a robust and struc- tured cross-council communication process leading to partnership, accountability, ownership, and equity. Autonomy and control over practice improved through the innovative structures and processes. The staffs now feel that they have the tools to seek solutions for themselves and are empowered to do so.

Leadership Support

A thematic analysis of the shared decision-making process provided the organization with clearly defined

Figure 4. Action request progress based on thematic analysis of decision-making domain accountabilities.

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ownership and thorough analysis of decision-making accountabilities. With a 91% ARF closure rate under the management decision-making domain, data supported the importance of the nurse leader and manager roles in partnering with frontline staff to implement innovative solutions. The success of shared leadership is attributable to the accessibility and visibility of the nursing and interprofessional lead- ership in the Coordinating Council. Frontline staffs continue engaging and being actively involved in seeking leadership support and resolution to system, process, and resource allocation ARFs. Nursing directors (house-wide advisors) provide mentorship, coaching, and guidance in council decision making. Nurse managers (unit-based council advisors) main- tain shared leadership principles by engaging frontline staff in shared decision making. Leadership support is pivotal to the success of SG, where managers dele- gate decision-making authorities, facilitate frontline staff"s involvement in decision making, clear obstacles, and provide feedback when unable to move forward with decisions.

Likewise, the clinical nurse specialist and nurse educators provide frontline staff with clinical expert coaching and guidance on all ARFs under the clinical- practice accountability decision domain. With 81% ARF closure rate under this domain, frontline staffs are involved in reviewing and approving practice changes, developing nurse-driven protocols and stand- ardized procedures, and implementing new workflows to improve the professional practice environment. The Coordinating Council has developed a practice change checklist to standardize changes in the organization (Supplemental Digital Content 4, http://links.lww.

com/JONA/A613). Interprofessional groups have been integrated into the shared leadership structure and provide expert coaching, guidance, collaboration, and coordination to achieve the clinical excellence goals.

Lessons Learned

Overhauling SG to achieve shared leadership outcomes was successful because of leadership support, robust cross-council communication, interprofessional collab- oration, and enterprise-wide coordination. The trans- parency of shared decision-making process enables leadership and frontline staff to operationalize shared leadership. The councils continue disseminating the progress and results within and outside the organiza- tion. Replication of the same structure and processes in the outpatient and ambulatory care clinics is in progress. One of the future goals of the Coordinating Council is further strengthening interprofessional collaboration. Succession planning is a byproduct of shared leadership. Working through these councils has fostered members" professional development and career advancement. Organizations that have had structures of SG in place over time may benefit, as SHC did, with a thorough evaluation of the processes and outcomes and an openness to redesign.

Acknowledgment

This project would not have been a success without the support of nursing leadership. The authors appreciate the SLC members, advisors, and chairs, nurses from all levels of care, and interprofessionals for their hard work and dedication to achieving and sustaining clinical excellence.

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