Shared Governance
Shared Governance is based on the principles of partnership, equity, accountability,
and ownership, supporting the autonomy of practicing nurses and leading to empowerment.
Shared Governance
Shared Governance is based on the principles of partnership, equity, accountability,
and ownership, supporting the autonomy of practicing nurses and leading to empowerment.
Overview
AU Health's Revitilization Journey
In late 2018, shared governance leaders recognized an opportunity to restructure shared
governance and refine some of the existing processes to better empower our nurses
to own their practice and to advance our organizational pursuit of nursing excellence.
We were fortunate to have Tim Porter O’Grady, a national expert in shared governance,
as the guest speaker at the Professional Governance Forum held Friday, May 10, 2019
during Nurses Week. He shared a wealth of knowledge about shared governance and spoke
on leadership essentials, all while entertaining a captive audience of shared governance
members and leaders.
Key takeaways from his presentation regarding professional accountabilities and the
core principles of shared governance were used to inform and guide the restructure
and revitalization of shared governance at AU.
So why the need to Revitalize?
Periodically it is beneficial to review the effectiveness of the current structure
to be sure both internal and external concerns of the profession are being addressed.
It is also critical to analyze whether responses based on protocols and policy are
appropriate based on the most recent evidence-based guidelines.
Reflection also leads to personal and professional growth. It is important to understand
that meeting the standards does not indicate excellence. Standards are the foundation
of good practice, reaching above the standard is excellence.
Professional Accountabilities
As a member of the nursing profession, you are accountable for:
- PRACTICE: Delivering nursing care consistent with customary standards and expected procedures
- QUALITY: The outcomes of the care you deliver
- COMPETENCE: Ensuring you have the education, training and skills necessary to provide quality
care
- KNOWLEDGE: Contributing to the base of nursing knowledge including generation of new knowledge
and application of current EBP
Committee Members
Members included representatives across the organization with a variety of experience
in shared governance and spanned roles to include direct care nurses, ANMs, NMs and
Directors. The Shared Governance revitalization steering committee:
- Nadria Alicea, BSN, RN, CCRN, CPN Senior Staff Nurse, Pediatric ICU
- Carla Allen, MSN, RN, RNC-OB Interim Nurse Manager, Perinatal Services
- Carol Brody, MSN, RN, CNL, NE-BC Director Nursing Excellence, Nursing Administration
- Sandra Clay, BSN, RN Nurse Manager, Medical ICU & 6 South Intermediate Care
- Carrie Dellinger, MSN, RN, CMSRN, RN-BC Senior Staff Nurse, Shock Trauma
- Jennifer Gillooly, BSN, RN, RNC-OBCharge Nurse, Perinatal Services
- Debra Marranci, BS, ADN, RN, CAPA, CNOR Assistant Nurse Manager
- Perianesthesia Shanna McBride, BSN, RN, CPN Senior Staff Nurse, Emergency Services
- Kathryn Mathis, BSN, RN, CMSRN Assistant Nurse Manager, 4 West & 5 West
- Damian Priessman, BSN, RN Nurse Manager, Shock Trauma & Surgical ICU
- Noah Rees, MBA, PMP Operations Manager, Nursing Administration
- Kim Sharkey, DNP, MBA, RN, NEA-BC Director, Cerner Magnet Advisory Program
- Michael Somma, BSN, RN Staff Nurse, PACU
- Lynne Wallom, DSN, RN-BC, NEA-BC Director Professional Practice, Quality & Education, Center for Nursing Education.
Councils
To address professional accountabilities the house-wide councils were designed as follows:
- Practice Council- responsible for defining and controlling issues related to clinical practice. They
are also responsible for monitoring the appropriateness and efficacy of care provided
by the nursing staff while assessing and ensuring compliance with established standards
of care and practice.
- Quality Council- responsible for administering quality improvement plans for nursing through reviewing
the Patient Care Services scorecard and identifying, prioritizing, and monitoring
performance improvement initiatives.
- Education Council- responsible for providing a forum to ensure educational standards are defined, implemented
and maintained to promote professional growth, development and ongoing clinical competency.
- Research Council- responsible for supporting the implementation of evidence-based practice through
the generation, utilization and advancement of empirical knowledge while ensuring
opportunities for staff to be mentored in their understanding, evaluation and conduct
of research.
- Operations Council- responsible for addressing the management and optimization of fiscal resources,
material resources, human resources, staff support and organizational systems required
to deliver quality patient care.
Achievements
Practice Council
- Developed and recruited members for two additional subcommittees, including: Nurse
Peer Review Committee and Policy Committee
- Refined Practice Council charter and developed new charters for the Policy Committee,
the Nurse Peer Review Committee, and the Clinical Ladder Committee
- Organized and launched Nurse Peer Review program for nurses at AUMC in collaboration
with Clinical Quality Excellence
- Restructured policy review process to ensure policies, protocols and guidelines are
reviewed in a standardized, efficient process, ensuring current evidenced-based practices
are incorporated before documents are routed to senior leadership for approval
- Integrated shared governance participation into the job description for nursing positions
- Enhanced and streamlined several nursing processes:
- Piloted a new Fall Prevention Program on several units and then adopted in the adult hospital and integrated into Powerchart
- Amended catheter management policy to support specifically trained nurses in the Urology
Clinic to remove specialized catheters
- Updated multiple aspects of Powerchart to more accurately reflect nursing processes
- Augmented I & O documentation to allow nurses to record percentage of meal consumed
- Expanded perinatal charting to include fields for various types of inductions
- Enhanced iView for easier charting
- Improved specimen collection process and associated documentation to provide an easier
way to sign off labs at the bedside.
- Clinical Ladder Committee
- Revised Clinical Ladder Program requirements
- Managed the application, submission and review process for biannual clinical ladder
cycles
Quality Council
- Improved the pain assessment documentation process which included pain reassessment
documentation.
- Collaborated with Nursing Informatics to address an issue regarding patient weight
documentation and the process for nurses to have documentation corrected when entered
in error.
- Addressed opportunities for HAPI improvements and reinforced consistent use of the
skin risk assessment upon admission and the subsequent use of Mepilex foam bordered
dressings when indicated.
- Assisted the Hospital Falls Prevention Committee with a trial of a Lap Belt in the
ER and the use of the Falls Patient Agreement throughout the hospital.
Education Council
- Collaborated with Dr. Brandy Gunsolus from the lab to address lab labeling errors.
Developed a reference poster and distributed for use in units throughout the hospital
to aid in decreasing specimen collection and lab labeling errors.
- Partnered with Clinical Quality Excellence and reviewed SOS trends with Kim McGahee
to identify education needs.
- Applied for and received approval for the No Pass Zone class which was awarded 3 continuing
education nursing contact hours.
- Formed a Skills Fair subcommittee that recommended each unit develop their own skills
fair catered to unit-specific needs.
- Added a representative from the Education Council to the Patient Value Team to keep
abreast of new products and product changes.
- Reviewed and approved patient discharge instructions and uploaded to patient education
section with EHR for easy access by nursing staff, including: atrial fibrillation,
heart failure, and ENT surgery.
- Administered annual nursing education needs assessment survey to inform annual nursing
education plan.
- Surveyed nursing staff to identify nurse certification review course to be offered
in 2021.
- Developed Coude catheter protocol and competency assessment and forwarded to the CAUTI
Committee for approval.
- Evaluated education resource needs at the unit-level. Developed a position description
for unit-based educator and submitted recommendations for locations and FTEs.
- Identified and communicated a need to revive the Preceptor Class. The Nursing Education
department responded by scheduling Preceptor Training Classes
Research Council
- Challenged all council members to complete CITI training
- Reviewed and evaluated EBP models and voted to adopt the Johns Hopkins EBP model
- Voted to also support use of the Iowa model by providing access to resources for nurses
already familiar with and preferring use of Iowa
- Sponsored multiple training sessions for hospital staff, each with 1.0 nursing education
contact hour:
- What is the Difference between EBP, Quality Improvement and Research? [two sessions
offered: 2/10/2020 and 2/11/2020]
- IRB Part 1 – Differentiation of Research and Review Types [11/16/2020]
- IRB Part 2 – IRB Application Process from A to Z [11/23/2020]
- Facilitation of the EMR for Research [11/18/2020]
- Research: The Basics for Bedside Nurses [two sessions offered: 11/30/2020 and 12/4/2020]
- Distributed communication about Center of Nursing Research monthly lunch seminar training
sessions
- Monitored and provided updates of IRB submissions with AUMC RNs as either PI or co-I
- Published first quarterly Research Council newsletter November 2020
- Developed Research & Innovations Scholars (RISP) fellowship program with plans to
launch first cohort Spring/Summer 2021
Operations Council
- Intrahospital Patient Transport Policy revised
- Promoted use of Travel Nurse Competency Assessment to ensure consistent practice of
travel nurses
- Recruitment and Retention Committee:
- Pulse Check Survey disseminated to Health System RNs
- ADN to BSN Recruitment and Educational Assistance program developed and launched
- Attendance Policy Revised
- PTO Buyout approved at a rate of 100% in 2020
- Collaborated with Human Resources to review pay for PCTs and Unit Clerks
- Holiday Pay approved Christmas Eve, Christmas Day, New Year’s Day 2020
- Special Events Committee
- Collected over 12,000 pounds of food for Golden Harvest Food Bank
- Delivered 900+ biscuits to nurses during Nurses Week for a pandemic-friendly celebration
- Raised thousands of dollars through fundraisers to pay for multiple activities
- Donated over $1,000 worth of toys/items for CHOG Child Life services
- Recognition Committee
- Revived DAISY Award winner presentations and nomination presentations; 21 DAISY Award
winners selected across 2019 and 2020
- DAISY Award nomination boxes added and/or replaced in several areas
- Collaborated with Division of Communications and Marketing to develop electronic nomination
and recognition campaign
- Managed Annual Nursing Specialty Awards nomination and selection process for 2020
Nurses Week
- Bee Award program developed for non-nurse team members
- Daisy and Bee Award QR codes made available to patients and families
- Communications Committee:
- Information collected and collated for Nursing Biennial report for distribution in
2021
