Chapter 2. Design a Structure to Support Shared Governance After reading this chapter, the participant should be able to:
Discuss the basic guidelines for forming the governance bodies in shared governance
Compare and contrast four structural process models of shared governance The loftier the building, the deeper must the foundation be laid. - Thomas Kempis Healthcare providers work closely with an ever-widening network of internal and external stakeholders and systems to meet the challenges of today's practice settings and provide safe, effective, quality care. They pull information from multiple sources to facilitate the interrelationships and collaborations among professionals and settings, and for care delivery within the larger organization and communities of practice. Every model, structure, or process of shared governance looks different when appropriately implemented at each of these levels of the organization. The unique character of the organization, its mission, and its staff will yield a foundational organization process model reflective of the depth and importance of their practice and leadership contributions. For example, when moving patients from a service or unit (microsystem) through the organization and into the community (macrosystems), providers might collaborate with several departments and disciplines for related services (
e.g., mesosystems such as pharmacy and social services) prior to discharge, especially if the patient is homeless. (See an illustration of a sample model in
Figure 2.1 and a description of these systems in
Table 2.1.)
Figure 2.1. Sample health system model
Table 2.1. Systems descriptions
ORGANIZATION LEVEL DESCRIPTION TEAMS Health system macrosystem Whole organization; communities of practice; teams focus on systems, strategic planning, resources allocations (human, material, and fiscal), professional governance, and relationships within the whole organization and communities of practice at local, national, and global levels Health services; senior leaders: CEO, chief operations officer, chief financial officer, chief marketing officer, chief nursing officer, chief medical officer, chief information officer; internal and external stakeholders
Facility (departments or divisions) mesosystem Major divisions and systems; teams focus on systems and relationships, the structure, framework, and context that support the team's activities (
e.g., shared governance, risk management, quality systems, human resources, fiscal services); teams build and sustain professional relationships, interactions, and connections among team members, other teams, and the services they provide to achieve clinical and service-related outcomes Nursing, medicine, pharmacy, social services, dietetics, laboratory services, environmental management services, radiology, physical and occupational health, speech-language pathology, rehabilitation, surgery, critical care, informatics, women's health, nursery, pediatrics, and other clinical and departmental service lines
Clinical (unit council) microsystem Frontline service units; smaller functional units and teams that focus on specific functions and activities that are the work of the organization at the points of service or care; work collaboratively to facilitate, improve, and advance relationships and services provided by the multidisciplinary team members and interprofessional partners Nurses, managers and supervisors, social services and social workers, pharmacists, physicians, clinical nurse leaders, case managers, clinical specialists, educators and staff development specialists, chaplains and clinical spiritual leaders and pastors, risk managers, and others, including patients and families
SOURCE: Adapted from Monaghan, H. M., & Swihart, D. L. (2010). Clinical Nurse Leader: Transforming Practice, Transforming Care. A Model for the Clinician at the Point of Care. Sarasota, FL: Visioning Healthcare, Inc. Many features of shared governance are similar enough to provide guidance in designing a structure to support shared governance in practice (see
Figure 2.3, Porter-O'Grady, 2004, 2009b; used in Swihart & Hess, 2018, with permission.). See Expanded Bibliography for many other excellent resources for designing and implementing a shared governance organization management process model.
Figure 2.3. Interdisciplinary shared governance model
Common Characteristics of Shared Governance Structures All shared governance structures have the following characteristics in common (see
Table 2.2 for a detailed comparison of features):
There is no one way to design or structure a shared governance management process model. Your model will be unique to the opportunities and constraints of your organization.
Shared governance is grounded in practice at the practice or unit (microsystem) level.
Staff members are responsible, accountable, and have authority over all decisions related to professional practice (practice, quality, and competence).
Staff members may have some influence over the resources that support practice.
Frontline staff members are elected to the positions they hold in the shared governance structure by their peers rather than appointed by management.
Management cannot remove an elected staff representative except as an official action against the employee (
e.g., substandard work performance, unethical conduct, failure to perform assigned duties related to job description).
Shared governance needs to be implemented service - or department-wide at the mesosystem level rather than unit by unit or practice at the microsystem level, thereby avoiding the inadvertent creation of silos.
Practice- or unit-level operational processes are defined by frontline staff.
Direct-care providers drive the structuring of the shared governance process.
Management, in the servant leader role, provides the support, encouragement, resources (financial, human, material), training, and boundaries (organizational and management).
A coordinating group composed of staff and management provide s guidance about issues affecting the department or discipline, communicating the organization's strategic plan, developing shared governance bylaws or charter, approving departmental or service expenditures or budgets, and helping determine accountabilities for appropriate groups and members within the shared governance structure.
Shared governance is driven by bylaws or rules. Some practices or units will use project charters (or charters) instead of bylaws. In current usage among many healthcare organizations, a
charter is a description of the scope, purpose and objectives, and participation guidelines for a committee or council. It identifies and provides a preliminary delineation of roles and responsibilities of participants and stakeholders, defines the authority and duties of the leadership, and serves as a reference of authority for the committee or council. Though similar to bylaws in many ways, a charter is usually considered to be a more flexible, less formal set of rules, with voting often by consensus, and rarely incorporates parliamentary procedure.
Shared governance is responsibility- and accountability-based, defined by what employees do, how they do it, and the outcomes expected from practice at point of service (see
Table 2.3 for the characteristics of accountability and responsibility). Shared governance has a primary focus. It is a process with core principles. Effective shared governance engages constant assessment and evaluation to be flexible and adaptive to:
Transform the organization to a practice model of shared decision-making in a decentralized relational partnership with individual professional responsibility, accountability, and authority over practice decisions at points of service;
Empower the staff in unexpected ways, such as nontraditional involvement in operations and decision-making; and,
Shift some of the accountability historically or traditionally part of the management or supervisory role or owned by the organization to direct-care providers.
Involve many participants who, through shared decision-making, undertake multiple essential roles that are mutual in their exercise and on which each partner depends.
When implemented effectively, shared governance affects the organization as a whole, division-wide and at practice and unit levels.
Table 2.2. Comparing features of shared...
