Karen Zwickel, Senior Analyst

We recently hosted a webconference with Liz Cambier, MSN, RN-BC. Liz currently serves as a professional development specialist for the Emergency Department and plays a key role in facilitating the shared governance committees.

Below you will find Liz’s answers to frequently asked questions about how Holland Hospital overcame challenges to improve its shared governance structure.

Can you describe Holland Hospital’s shared governance structure?

While shared governance structures can vary significantly from organization to organization, they typically consist of unit-level committees and a committee with organization-wide oversight made up of leaders from the unit-level. Holland Hospital’s shared governance structure consists of:

• Unit Practice Teams (UPTs), which are our unit-level shared governance committees.
• Clinical Practice Leadership Team (CPLT), which is our organization-wide committee consisting of the chairs and co-chairs of all the UPTs in the organization. Each quarter, chairs and co-chairs attend CPLT meetings, which also include the CNO, the nursing QI manager, and me.

Why did Holland Hospital decide to transform its shared governance structure?

We determined that transforming our shared governance structure would be a worthwhile investment to improve both quality of care and staff engagement. On the reference page of the presentation you can find research that demonstrates the positive impact of shared governance on both retention and outcomes. Leaders at Holland Hospital can confirm that these improvements have more than paid for our significant investment in time and resources.

How did you determine the areas that needed improvement and who made those determinations?

In 2013-2014, our CNO and nursing PI coordinator performed a gap analysis of our shared governance structure. They asked all UPT chairs and managers several questions to determine how the shared governance committees were functioning and where there were problems. These questions included: What is the function of UPTs? What are your current goals? What projects are you working on? How often do you meet? What do you need to meet your goals?

What problems did you identify from the gap analysis?

We found that the shared governance structure varied significantly between units. Some units didn’t have any UPTs. Where UPTs did exist, they often weren’t functioning well because both managers and UPT chairs did not have a clear understanding of their purpose. For example, UPT meetings should be focused on clinical and practice issues, but they often dealt with operational and performance issues that should be handled by managers. Because of this lack of clarity, many UPT meetings either became staff meetings (led by managers) or gripe sessions instead of facilitating meaningful quality and performance improvements.

We organized our findings into six categories in order to pinpoint our opportunities for improvement. These categories are summarized below. You can also see a detailed diagram of our gap analysis in the slides.

1. UPT chairs: UPT chairs lacked prior leadership experience and knowledge of quality and safety improvement processes. We were asking UPT chairs to handle problems before providing them with proper skills.
2. Managers: Because UPT chairs were not leading effectively, managers viewed UPTs as ineffective and were hesitant to relinquish control.
3. Training: UPT chairs needed training to fill knowledge and skill gaps and managers needed training to understand how to effectively support UPT chairs.
4. Communication: Organizational quality goals and outcomes were not consistently communicated to staff.
5. Resources: Staff did not have readily available tools to implement quality and safety improvement initiatives or ongoing leadership support.
6. Environment: Because departments were working in silos, they did not effectively resolve interdepartmental issues.

How did you use the information from the gap analysis to make improvements?

We determined the reasons why UPTs were not effectively resolving quality, safety, and practice issues. They were struggling with the basics of structure, leadership, and communication, so loftier goals were out of reach. We created a leadership development program to close these gaps and provide UPT chairs with the knowledge, skills, and resources they needed to be effective leaders.

How did you secure support for the UPT leadership development program?

1. Secured leadership buy-in: Our CNO was very supportive and helped communicate key information to leaders across the organization.
2. Sought support from managers: We spoke with each unit manager to ensure they all understood their role in supporting the leadership development program. This included creating a UPT if a unit did not have one, identifying a chair and co-chair for the UPT, recruiting members to join the UPT, and supporting program participation and attendance.

How do you incentivize staff to become UPT chairs and participate in the leadership development program?

While staff do not receive a higher salary for assuming this role, UPT chairs are paid for the extra time they spend doing meeting prep, trainings, and projects. In addition, we discuss the benefits of leadership training for the chairs’ long-term professional growth and development. This includes the opportunity to form relationships with administration and organizational leaders.

How do you budget for this training and who pays for it?

We budget for 14 hours of training per year for each chair and co-chair, and 8 hours a year for attendance at CPLT meetings. The cost comes out of each department’s education and development budget. The cost of materials and the Everything DiSC Workplace program comes out of our central Nursing In-Service Budget.

Did HR play a role in developing the program?

Yes, HR led one of our sessions on communication and collaboration. In addition, our HR education and development staff helped me create some resources that were used in several of the sessions.

What is the structure and content of the leadership development program?

We have four sessions that occur each quarter throughout the year, with our first session starting in February. Our final session on communication and collaboration is broken up into two parts, which are two weeks apart. The leadership development program is taken during the co-chair year. After co-chairs complete their training, they assume the position of chair and a new co-chair is chosen. If a new UPT is forming, the chair and co-chair often participate in the program together. We chose quarterly sessions to give co-chairs time to take in the information and apply what they learn during UPT meetings.

Below, you can see the length of each session, an overview of the content, and supporting resources.

Session 1: Basic Leadership Principles (Length: 3 hours)
In our first session participants get an overview of what Shared Governance is and the history of UPTs. We also discuss technical and leadership skills.

• Technical skills: Creating an agenda, facilitating meetings, making minutes that matter, managing workgroups, and delegating effectively.
• Leadership skills: Making effective decisions according to organizational goals and values, taking ownership of goals, and supporting decisions made by others. We also provide tools for peer accountability.

Session 2: Quality & Safety (Length: 3 hours)
Our second session provide an overview of the quality improvement process, drivers of quality in health care, and patient safety.

• Quality improvement: How to identify QI projects, choosing measurement indicators, and the PDSA cycle (plan, do, study act). Once a project is identified, our Nursing QI Manager and I work with the team on the data collection, analysis, intervention planning and implementation.
• Drivers of quality: Brief discussion of quality indicators, how they affect the organization, and how nursing care can impact outcomes.
• Patient safety: Use curriculum for new RNs, evidence based practice information, and the Why5 Care Review Process. We also conduct a safety survey activity and develop several UPT quality and process improvement projects from this activity.

Session 3: Leading Change (Length: 3 hours)
In our third session we provide a brief overview of Lewin’s Theory of Planned Change. We spend the rest of the session working on a change planning activity, where small groups come up with an idea for change and outline a plan to implement that change using the change planning tool. At the end of the session, our CNO leads a discussion on how to approach decision making and overcome barriers to change.

Session 4: Communication and Collaboration Part 1 (Length: 3-4 hours)
In the first part of this two part session, participants complete the Everything DiSC Workplace assessment before the session. During the session, an HR representative leads the DiSC training to explore different work styles and improve collaboration

Communication and Collaboration Part 2 (Length: 1.5 hours)
In the second part of this session, UPT co-chairs from each department discuss goals, challenges, and improving collaboration with managers and/or educators using a DiSC style comparison report and conversation cards.

• Supporting Resource 1: Use Holland Hospital’s shared governance crash course slides to understand the history of shared governance and how shared governance can be beneficial to your organization.
• Supporting Resource 2: Access Holland Hospital’s UPT Agenda Template to see standing agenda items discussed at each meeting.
• Supporting Resource 3: Access Holland Hospital’s UPT Meeting Minutes Template to see the standard template used to record discussion topics and action items at each meeting.
• Supporting Resource 4: Access Holland Hospital’s UPT Why5 Care Review Process Template which is used determine why an adverse event occurred and how to prevent the event from occurring in the future.
• Supporting Resource 5: Use Holland Hospital’s Change Planning Tool to lead an activity where small groups come up with an idea for change and outline a plan to implement that change.
• Supporting Resource 6: Use Holland Hospital’s deck of Conversation Cards to facilitate conversations with UPT chairs about improving collaboration with managers and/or educators.

How often do UPTs meet?

Most UPTs meet once a month, but some meet every other month. Each department chooses its own meeting dates and times. We encourage UPTs that don’t meet as often to have active communication between meetings (either in person or by e-mail) to make sure projects are moving forward.

Do you document your shared governance meetings on standardized forms?

Yes, we have two standard templates which are listed below:

• Standing agenda: Our agenda topics include: performance data, organizational performance improvement, and other issues we would like UPT chairs to discuss.
• Meeting minutes: We provide a standard template to record the minutes of the meetings.

How do you include and support colleagues who work in ambulatory settings?

We have UPTs in several ambulatory areas, both on and off-site: our Ambulatory Treatment Unit, Wound Care Clinic, Urgent Care, Outpatient Rehab, Home Health, and Breast and Bone Center. We ensure that they feel included in discussions by using information and examples that pertain to ambulatory settings, rather than limiting ourselves to acute care. We also encourage conversations between acute care and ambulatory groups to improve care transitions. In addition, we support ambulatory initiatives and projects; we often go off-site for their UPT meetings, and they attend the CPLT meetings on a quarterly basis.

You mentioned that one of your current goals is to encourage the use of the UPT case review process. Can you explain this process?

Cases for review come from a few different places–they may come from managers, staff who had a particularly difficult or interesting situation, or from quality or risk departments (from occurrence reports or patient relations concerns).

The case review process is peer protected as quality review. Each case review is facilitated by a trained facilitator (a UPT Mentor or myself), who understands the peer review process and HIPAA requirements. The facilitator assists the UPT Chair in preparing information prior to the meeting (essentially a timeline of what happened with the patient). Whenever possible, those involved in the patient’s care attend as well.

The facilitator and UPT chair lead the team members through the case review process using the Why5 Care Review template. The UPTs use this information to formulate action plans, which the UPTs then have the responsibility to carry out (with manager assistance as needed).

What have you accomplished with respect to your UPT process and what do you still hope to accomplish?

We recently started the third year of our UPT leadership development program and we currently have 28 UPTs across the organization. Our UPTs have successfully tackled several projects including reducing falls, creating patient education videos, and improving patient satisfaction in semi-private rooms. You can see more examples of our accomplishments in the presentation. We have also improved interdepartmental collaboration through structured shadowing experiences, our CPLT meetings, and even some interdepartmental Why5 Care Reviews. Finally, we have recently started a mentorship program using former UPT chairs to mentor new chairs.

We hope to continue expanding—UPTs have already expanded to several other clinical areas outside of nursing. We also hope to increase the number of mentors and involve mentors in leadership development classes. We continue to work with managers, educators, and organizational leaders to ensure UPTs have true autonomy.