Quantifying the benefits of staff participation in shared governance

  • Structures, in the form of councils and committees, provide forums where nurses participate and engage in work.
  • Processes are the bylaws and policies that define
    how the work and decisions will be made.
  • Outcomes involve such metrics as patient outcomes,
    nurse engagement, and nurse satisfaction.
  • Accountability and ownership are important principles
    of shared governance. Shared governance isn’t
    a new concept in health care, but several misconceptions
    exist about what it is and isn’t. One misconception
    is that it adds expenses to already burdened
    healthcare organizations. This article addresses this
    misconception by sharing our organization’s experience
    as well as several methods to demonstrate the
    financial impact of shared governance.

    Organizational overview

    Children’s Hospital Colorado (CHC) is a 500-bed pediatric
    hospital with a main campus in Aurora and 17
    additional sites. It has a long history of shared governance.
    Staff have participated in unit-based and hospital-
    wide committees since the 1980s. However, CHC
    had few division-level structures to support decisionmaking
    across the nursing division. Creating these
    structures was a priority for our new chief nursing
    officer (CNO). In 2009, we began to revise the structures
    and processes that support shared governance.

    Shifting the culture

    Developing shared-governance structures at the divisional
    level wasn’t as simple as scheduling the time
    and finding membership. We had to shift the organizational
    culture. Although staff were engaged in
    practice and decisions affecting their work, best
    practices rarely were shared and aligned across units
    and practice areas—mainly because we lacked the
    structures for this. So we created new councils and
    revised existing ones to meet our needs and provide
    links among unit-based structures.

    • The Executive Nursing Council, consisting of
      nursing directors, the CNO, and the associate
      CNO, is strategically focused.
    • The Nursing Operations Council, consisting solely
      of nursing managers and directors, is operationally
      focused.
    • The Advanced Practice Council engages nurse
      practitioners, certified registered nurse anesthe –
      tists, and physician assistants.
    • The Professional Development Council allows clinical
      specialists and nurse educators to align practice
      for staff education, training, and competency.
    • The Innovations and Outcomes Council focuses
      on research, evidence-based practice, and nursing
      quality and safety.
    • The Clinical Partners Council is an interdisciplinary
      venue that includes all clinical departments,
      both within and outside the nursing division.
    • The Clinical Nursing Practice Council (CNPC)
      and Nursing Governance Board (NGB) are described
      in the case studies below.

    Of course, developing new councils alone doesn’t
    create a culture change. Individuals participating in
    councils also must adopt the right attitude and behaviors.
    Each council educated its members on the council’s function and
    purpose, planning agendas and communicating with
    staff. An experienced nurse leader acted as a mentor
    for each council. Every council completed a charter to
    further define its purpose, essential functions, decisionmaking
    authority, membership and co-chair responsibilities,
    and communication structures. Bylaws outlined
    the overall structure of the entire division.


    Case studies

    The CNPC is a staff-nurse council with members representing
    all areas of the organization, including inpatient
    units, ambulatory clinics, procedural areas,
    emergency department, urgent care, psychiatry, and
    network-of-care sites. Although it existed before 2009,
    it was mostly an advisory group that rarely got involved
    in decision making. Slowly, through agenda
    management and mentoring of staff co-chairs, it has
    evolved into a decision-making body. Staff representatives
    meet monthly to discuss clinical nursing practice
    issues. Co-chairs can allot 8 to 10 hours of administrative
    time each month for council activities.

    Cost of the CNPC. The council has 56 members;
    55% are nonexempt employees. They hold 2-hour
    meetings each month at a cost of $32,856 per year.
    Co-chairs’ administrative time is $8,000 per year.
    This brings the total cost to $40,856 per year.

    The NGB formed in 2011 as the central oversight
    body over all councils in the nursing division. Initial
    membership included chairs of all practice-area
    (unit-based) councils. The purpose of such wide
    membership was to educate and train council chairs
    on their role, effective meeting management, agenda
    planning, communication, and conflict resolution.
    To promote this training, a retreat was held
    and relevant topics were discussed each month during
    regularly scheduled NGB meetings. In fall 2012,
    after 16 months of start-up, membership was cut to
    18 to make the council more focused and efficient.

    Cost of the NGB. This council has 49 members;
    71% are nonexempt employees. They meet for 2
    hours each month at a cost of $33,024 per year.
    Co-chair administrative time is $6,144. This brings
    the total cost to $39,168.

    During our journey to strengthen shared governance,
    it became apparent that duplicate work was
    occurring due to the large number of committees.
    To streamline and steer discussions to the correct
    council, CNPC absorbed the work of the laboratory/
    nursing committee and safety device committee,
    for a cost recovery of $13,804. Work continues on
    evaluating all committees and councils to further
    streamline and prevent duplication of work.

    Tracking performance and outcomes

    Three strategies can be used to track expenses and
    outcomes related to direct-care staff involvement in
    shared governance. (See Tracking shared-governance
    expenses and outcomes
    by clicking the PDf icon above.)

    Return on investment

    Cost of the organization’s investment in shared governance
    includes salary expenses for the hours that
    direct-care providers allocate to shared-governance
    work. Gain from the investment might be in the
    form of savings related to equipment and supply decisions,
    reduced lengths of stay for a certain patient
    population, or other quantifiable outcomes. To calculate
    return on investment (ROI), use this equation:

    ROI = gain from investment minus cost of the investment


    cost of investment

    Cost avoidance

    Cost avoidance refers to actions taken to reduce future
    costs. Initially, cost avoidance may incur higher
    costs but lead to lower final or lifecycle costs. For
    example, staff may be involved in purchasing or
    acquiring supplies and materials that in the long
    term may yield a reduction in expenses. This approach
    doesn’t include the cost of staff time to participate
    in decision making. It looks only at the future
    impact on expenses.

    Cost-benefit analysis

    Cost-benefit analysis includes salary expenses
    (time) of staff involved. Benefits may include savings
    from equipment, materials, and processes that
    can be quantified, as with the ROI example. The
    equation below shows how cost, benefits, and savings
    relate to one another:
    Cost – benefits = savings

    Examples

    As mentioned earlier, CNPC total annual cost is
    $40,856. In 2011and 2012, the council collaborated
    with the Nursing Operations Council and Executive
    Nursing Council to review and change two pay
    practices that reduced overall salary expenses by
    more than $500,000 annually. These pay practices
    were outdated and inconsistently implemented, so
    staff and leadership believed they needed to be
    eliminated.

    A second example involves the Save Our Skin
    (SOS) committee, which focuses on increasing
    awareness and improving education on skin care,
    with the goal of reducing skin breakdown and pressure
    injuries in patients. The SOS committee has
    representatives from all units; its annual salary expense
    was $11,520. During 2011, it decided to purchase
    rather than rent specialty beds and mattresses.
    Annual rental costs would have been $551,678.
    The committee recommended instead that we purchase
    a specific number of mattresses and beds;
    $250,000 was invested in these resources. Although
    we know we’ll have maintenance and labor costs
    for these new beds and mattresses, purchasing
    rather than renting will yield cost savings of at
    least $300,000 per year. The equipment has a 10-year lifespan, so savings will extend beyond the
    first year. We believe this was a good investment of
    our nursing staff’s committee time.

    Shared governance makes good sense

    With a little time and partnership with finance department
    colleagues, you can evaluate the costs of staff participation in shared governance.

    Selected references

    Porter-O’Grady T. Is shared governance still relevant? J Nurs Adm.
    2001;31(10):468-73.

    Scherb CA, Specht JK, Loes JL, Reed D. Decisional involvement: staff
    nurse and nurse manager perceptions. West J Nurs Res. 2011;33(2):161-79.

    Jeanine M. Rundquist is Director of the Magnet&#174 Program and of Performance,
    Practice, and Innovation at Children’s Hospital Colorado in Aurora, and Patricia L.
    Givens is associate chief nursing officer.

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