IMPAQ's Thoughts on Shared Governance

Much of our current client work at IMPAQ is focused on moving organizations from "silo" thinking to true cross-functional, accountable structures. In the healthcare field this is necessary in "shared governance", an innovative approach which expands the control, decision making and influence of specific groups (most often nursing) within the hospital over areas that are classically controlled only by management. Clients frequently want to know what they can do to assure a more successful implementation of that model. As many in healthcare know, the concept of shared governance is not a new one, having been first introduced in nursing more than twenty five years ago. Shared governance can offer an innovative opportunity to move decision-making closest to those in a position to effect greater change. In addition, shared governance may:

• Enhance employee engagement through more ownership of the organizational outcomes
   
• Support communication between employees and management in meaningful ways
   
• Improve clinical practice and quality outcomes, potentially providing a model for breaking down the silos that often exist in organizational settings

In the past, more than 1000 healthcare institutions have successfully applied principles of shared governance. The level of implementation of shared governance can range from full-blown initiatives to modified participatory management change efforts often focusing on decentralized structures. While a large number of these programs disappeared through the frenzy of managed care, mergers or administrative changes, some are still going strong. However, as you probably know, many others attempting implementations were unsuccessful.

Presently, there is a renewed interest in shared governance, fueled by a desire to enhance engagement, particularly in attempts to deal with professional workplace shortages or to achieve nursing magnet status designation. Staffs, who have been part of shared governance, claim more satisfaction because they are able to participate in decision making that impacts them, clinical practices and their patients. Researchers have studied shared governance and its connection to everything from employee retention to organizational culture. While quantifying the statistical significance of the positive relationships has not always been easy to prove, proponents of shared governance still feel strongly about its potential for positive impact on organizational outcomes. It has also been shown that the road to implementation can be long and difficult, and one thing most studies agree on is that implementing shared governance has a financial cost in both time and energy.

One nursing administrator defended potential costs this way: "I am dealing with a nursing shortage that is national in scope, and it can cost me upwards of $60-$70,000 to replace a staff nurse. If shared governance can impact nurse retention in even a moderate way, then it is probably worth it."

Given the potential for positive impact as well as the cost and complexity of implementation, organizations desiring successful implementation would do well to assess and then focus on critical success criteria. They will also want to know where shared governance can break down so that actions are taken to avoid potential problems.

So, where do breakdowns in a well intentioned shared governance implementation occur? Breakdowns can occur if outcomes and organizational priorities are not clearly understood and consistently addressed by all individuals, groups and/or teams. Those with newly assigned delegated authority often take action based on their own understanding of the direction and priorities. However, upon final approval and implementation, these actions frequently clash with the direction and priorities of leadership. Decisions are vetoed and individuals feel betrayed or dismissed. If this happens enough, individuals and teams will lose trust and enthusiasm for the overall process. Organizations sometimes make the error of thinking that they have addressed this by simply informing or stating outcomes and priorities. They will often miss the point that a clear understanding of what it takes to accomplish the outcomes and knowing ‘how do I specifically contribute’ is imperative for success.

Without healthy group dynamics, committees assigned important decision making and management of practice can fail if the individuals do not keep agreements, are not direct and honest in communication or do not follow through on commitments necessary for success. Group members lose trust with each other as well as losing interest in initiatives because they are unable to accomplish the tasks or duties assigned to them. Leaders lose trust in the implementation groups and then question the ability of the new model to work. It hardly needs to be noted that when this cycle of negativity takes hold, it is extremely expensive as well as demoralizing.

Leaders unsure of how to manage in a situation of shared and delegated authority may not provide oversight, coaching and facilitation appropriate to the new situations. When the implementation becomes problematic and unforeseen obstacles arise, both leaders and teams can lose sight of the desired outcome if the vision and criteria for success have not been carefully defined and planned for. This latter breakdown can lead to the cynicism that is so often heard in the lament of "the flavor of the month."

It is necessary to both identify and apply an organizational structure that matches the particular model of shared governance. Breakdowns can occur when the new structure is not implemented with enough attention to the impact on individuals and processes involved. Organizations can be left where no one really knows how to play or interact in the new structure. Linkages necessary for effective information sharing and communication must be established. Concepts of authority, responsibility and accountability must be understood, applied and assigned appropriately at all levels involved.

Breakdowns will also occur if there has not been enough attention to the preparation of the individual contributors who will now participate in a more expanded manner. Nurses and other staff members in a shared governance setting will need specific new skill sets, e.g. knowledge of patient management, decision making, conflict resolution skills, etc.. Nurses in this environment would be asked to share and discuss clinical best practices, work with governing committees to come to agreement when there are dissenting views, apply appropriate decision making and implementation criteria in the clinical setting, etc.

Above all, if there is unwillingness to change organizational culture or to even realize that the organizational culture must change as needed to succeed; implementation of shared governance will not be successful and may end up as a costly, once-promising project that never accomplished its outcomes.

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