Shared Governance
Shared governance in large healthcare organizations–future or fantasy?
Our large organization (over 20K employees with over 1500 faculty MDs) is attempting to transition from a more ‘typical’ top down structure to one of shared governance. This has been loosely defined, however is believed to represent a concept where input is gathered from a wide range of providers and staff who then actively participate in institution level decision making. My question is around the practical application of such a system.
Currently I oversee a Division within the organization comprised of 1000 employees and roughly 165 faculty. Many faculty feel disenfranchised, uninformed and subject to top-down leadership. As leaders, we have made attempts to include faculty though various mechanisms–matrix cross functional committees which govern the large majority of faculty and operational issues, regular meetings with faculty representatives, open town hall meetings with all faculty, an open door policy , email/ digital communications and the like.
Frankly, I am concerned that many would rather sit in the stands and throw fruit, than get in the arena and solve problems. Does anyone have suggestions to better engage faculty in organizational leadership in an academic medical center where most faculty believe faculty value is defined by publications, amount of grant funding and wRVUs generated… not contribution to the mission through active participation and leadership?
This is a very interesting challenge and one one which I imagine some of our participants from large clinic models might be able to offer some insight. We will also be discussing Mayo Clinic in the third module. Mayo has tried to pair clinical leaders with administrative counterparts to try to push initiatives forward. Do any participants have experience with similar models?
Our organization has taken the tactic of pairing a physician with an administrator to create dyad relationship, I assume similar to Rob’s mention of Mayo. the two work closely together to really bridge the gap that is often found between administration and providers/staff. I think this model, when choosing the right provider/faculty/clinical leader can be very successful in engaging those in the stands that want to throw the fruit. Providers/faculty are more likely to respect one of their own and if that person can really explain the ‘why’ of what the mission is we have found that to be moderately successful in moving forward. I have been in a dyad model for years and am currently shadowing the physician leader that I will be replacing at the next level and seeing how he works with his dyad partner.
At one stage we had a closed group online sort of social media application that was open to all employees to post their ideas and thoughts (identified or anonymous). I found this positive if the terms of use are clear and the site is properly controlled to prevent deviation from the main goal. Considerable number of brilliant ideas came from junior staff and because they were publicly posted gain the support of everyone and have taken place. In my opinion such an exercise helps to identify talents in the organisation who would otherwise remain dormant behind some old fashioned chains of command and with accumulating evidence of effectiveness this would lead to changing the whole governance system.
I believe that the shared governance model is great in theory but agree with jrsjr that there are so many that would rather “sit in the stands and throw fruit than get in the arena and solve problems” (great saying by the way). We have a model where we have department chair meetings and they have a say in how the organization works; however, ultimately, there is a business to run and that can’t always be done by concensus.
I think that I am in the same situation now, and I am not so happy to take the responsibilty for problem areas. The problems are bigger when the economical knowledge at the central administration “have delay” to response to the changing world. I think that the divisions should have more power to decide their operational movements and investments in wide range. Also you must have risk-investments. So I think that you should have more financial and law knowledging people at you own administration, or at least good consulting opportunities. The decision power should be concentrated more on you and your own division. This is because there really are so many people waiting for ready-made solutions.
Speaking about workplace experience with shared governance at my Organization,where the nursing department took the team involvement gradually into several steps or milestones, as the value of shared governance was not clear by that time to frontline nurses as well as many middle managers and educators.
In my origination we adapted the SG since 2011, at that time the first nursing council started as the fllowing:
• Select the highly motivated and influential staff to set in the councils, by that time no elections or even bylaws were present, nevertheless there were no council evaluation criteria as the main goal was to get the councils the initiation spark
• Involving the education staff in EBP appraisal for new ideas introduced to the council, and mandate staff to consult the assigned faculty to their unit or division before the idea submission
• Shaped by drawing the fine lines for the manager’s involvement in the unit council as well as the quality and education facilitators by setting the bylaws and forms linked to each council according to ranking of decision making and influence
• Education department involvement with the councils is remarkable and defined in the bylaws at different levels in nursing
In Nursing, each staff role in shared governance is in staff performance appraisal as technical competency which should be understood by each staff member according to the document of SG bylaws.
Currently, our shared governance system is well formed and structured where everyone knows his/her roles and responsibilities and adheres to those as they will be reflected in staff annual appraisal with supporting evidences
There are strong support of the nursing executive leaders to the whole process of shared governance as it requires staff dedication and enthusiasm to keep it going which was understood and appreciated by the top executives and rolled down to leaders and mangers to sustain enculturation of the Magnet Concept as SG is the soul of the Magnet Journey.
The Board of Directors initiated dialogue with 4 other hospitals within our region to explore opportunities for collaborative governance. Collaborative governance is an emerging model and set of practices that Boards are deploying to accelerate change in an increasingly complex health services environment – it asks that we recognize that many of the challenges faced by health service providers cannot be solved independently.
The first step was to conduct a joint environmental scan which was completed in December 2016. The scan identified potential opportunities for collaboration. At our Board Retreat last week Board Chairs and CEOs from each hospital attended the retreat and agreed on the following partnership guidelines:
Collaborative Governance – Shared accountability and service delivery where it makes sense
Open Dialogue – A true partnership develops slowly and shall be nurtured, without fettering the organizations. All efforts will be made to continue ongoing dialogue between parties
Proactive Engagement -The Board and Senior Management a proactive role in engaging potential partners in discussion of partnership opportunities
Alignment -The Board and Senior Management will be kept current with all communications and direction from the LHIN and MOHLTC.
Focus on Quality -Integration and partnership opportunities will endeavor to promote patient experience, quality of care and improved value to the system
We are still in the exploratory phase of the initiative and another facilitated meeting will be scheduled in the near future.
We have a variety of shared governance models with our partners that present various challenges and opportunities. When we partner with community hospitals in a joint operating agreement both institutions retain their board structures and have a combined joint operating board. The joint board serves to make strategic decisions on behalf of the total partnership while some reserve powers concerning these decisions rest with the individual boards. One key issue we encounter is who employs the partner CEO, CFO and CMO. It is challenging when the CEO is employed at the local hospital level and doesn’t represent the full partnership across the market. It is also challenging if the community hospital is a public entity.
Shared governance also brings to bear employment considerations, specifically as it relates to who employs which employees, shared employment models and comp and benefit alignment. System integration is also a key consideration in making these partnerships work – specifically, whose systems, EMR, rev cycle, IS, accounting, etc. will be utilized the manage the operations.