In this article, we highlight how the cardiovascular procedural areas used a shared governance concept known to nursing to enhance staff engagement and provide opportunities for decision making by the staff at the point of service.
Lancaster General Hospital (LGH) is a 630-bed community hospital. LGH is an entity of LG Health/Penn Medicine and offers a full range of healthcare services, including inpatient and outpatient care, emergency care, and rehabilitative services.
The Heart & Vascular Institute (HVI) is comprised of cardiovascular procedural departments (cardiac cath lab, EP lab, interventional vascular unit [IVU], non-invasive cardiology [NIC]), two nursing units (pre/post procedure holding area [HA], and the medical outpatient unit [MOPU], and a cardiology practice [The Heart Group of LG Health]).
The HVI provides a wide range of cardiovascular procedures, including cardiac catheterization and percutaneous coronary intervention (PCI), diagnostic/interventional EP studies, pacemaker/ICD implants, echocardiograms, stress testing, nuclear imaging, peripheral arterial procedures, and pre/post procedure nursing care. The HVI employs approximately 400 physicians, nurses, technologists, and support staff who provide care across all HVI entities.
HVI departments are subject to many forces affecting healthcare delivery in the current and future environment. These forces include healthcare reform and the Affordable Care Act, advancing/new technology, rapid and constant change, the need for innovative strategies, financial constraints, and value-based purchasing. Historically, each HVI department addressed these issues individually, despite the fact that they care for the same patients (sometimes in the same day), and frequently encounter the same issues. In an effort to better coordinate and integrate care across the service line, the HVI management team (the managers of the previously mentioned HVI entities), decided in 2013 to explore the shared governance model. The team felt that shared governance would not only positively impact patient care, but could also increase employee satisfaction.
Shared governance incorporates the principles of partnership, equity, accountability, and ownership at the point of service. It provides employees with a mechanism for providing input regarding practice, education and leadership issues, and positively impacts employee satisfaction. Once the management team had committed to the idea of introducing the concept to the HVI, they looked to the nursing department for guidance. Nursing has successfully incorporated shared governance into their practice model for many years, so a validated model was readily available to serve as both a reference and a starting point for the HVI model.
The next step was to assemble a shared governance committee comprised of two representatives from each HVI department. Many of the committee members had previously worked together to introduce and implement the concepts of Relationship Based Care (the current LGH nursing model) in the cardiology department, and so had already proven their ability to effectively work together with each other and the management team. Other members either volunteered or agreed to serve on the recommendation of their managers. HVI management as a whole affirmed their support of the shared governance concept, and two managers volunteered to serve as the management liaisons for the committee.
The first HVI Governing Council (GC) meeting took place in April 2014. During the meeting, council members discussed the purpose of the GC and what they hoped it could accomplish. The first step was to create a mission statement for the council: “We will deliver superior cardiovascular care to our patients with an integrated and collaborative approach, across the continuum of care.”
GC members next addressed the council’s structure, using the nursing shared governance model as a template. Ultimately, the group decided that the GC would have a chair and co-chair to oversee the group as a whole, which would incorporate four subcouncils: Patient/Staff Education, Clinical Practice, Communication, and Patient/Staff Satisfaction. Each subcouncil would have a chair and co-chair chosen from GC members, with other subcouncil members drawn from the various HVI departments (ideally with one representative from each department on each subcouncil). The GC chair/co-chair and the subcouncil chairs/co-chairs would all serve two-year terms. The structure also addressed succession planning, as the GC and subcouncil co-chairs would be expected to become the chairs at the end of each term.
The second GC meeting occurred in June 2014. Council members elected GC and subcouncil chairs and co-chairs, and then spent the rest of the meeting creating the first draft of bylaws and discussing GC goals. The group decided to focus their efforts on two main goals: improving staff engagement and patient satisfaction.
Despite some growing pains, the group has accomplished a great deal in their first year of existence. Successful projects include:
- Interdepartmental shadowing to provide insight into what other members of the HVI team do, how they do it, and the problems/issues they encounter. This was especially effective when cardiologists’ office staff members shadowed in the hospital departments and vice versa. It didn’t take long for finger-pointing and blame to be replaced with cooperation and understanding.
- Revision and standardization of pre-procedure patient instructions so that all patients scheduled for a particular procedure receive the same information. The reading level was reduced to a fifth grade level, and the information was limited to what was most important to getting the procedure done in a timely manner (NPO status, what medications to take/not take, pre-procedure testing, etc.). The instructions also include information about procedure start time/length, possible procedure delays, and how long the patient can expect to be at the hospital. Misunderstandings regarding these issues often caused patient/family dissatisfaction.
- Creation of new “wayfinding” maps that include information and diagrams on where to park and where to go once inside the hospital. Maps are color, shape, and number coded to help patients figure out where they are supposed to go.
- Creation of a quarterly HVI newsletter to keep staff members up to date on GC initiatives and what is going on in the various departments.
- Implementation of AIDET®, (Acknowledge, Introduce, Duration, Explain, Thank You). AIDET® reminds staff members to practice basic customer service skills, such as calling the patient by name, introducing themselves, telling patients how long each step of the process will take, explaining what will happen and why, and thanking them for letting us take care of them. The team has achieved 100% AIDET® compliance for over a year. AIDET® implementation helped the HVI achieve a Press Ganey patient satisfaction score of 83%.
- Creation of the ACE (Acknowledging Consistent Excellence) Award. All HVI employees are eligible for the award. Anyone (peers, patients/families) can nominate an HVI employee (nurses, techs, physicians, or support staff) for the award. Award winners receive a commemorative pin designed by HVI staff, a banner to hang in their department for the quarter, and a celebration (including cake!) in their department.
- Implementation of daily manager rounding. Initially, managers rounded only in the cath/EP labs and pre/post procedure units, but eventually expanded it to include all the hospital-based HVI departments. Rounding has helped develop relationships between staff and management, and on more than one occasion has helped prevent the escalation of patient issues.
- A 15% increase in the Employee Engagement score from fiscal year (FY) 14 to FY 15.
Recently, however, both the GC chair and co-chair stepped down, and the timing seemed right to reconsider the GC structure and functioning. The GC Steering Committee (chair, co-chair, subcouncil chairs/co-chairs, and manager liaisons) met to discuss the options. One of the biggest issues the GC has had to deal with is getting people to quarterly GC meetings and weekly or biweekly subcouncil meetings. The steering committee also discussed whether the nursing model was a good fit for the HVI areas. Nursing units have time built into their staffing schedules for shared governance activities, but for the HVI’s procedural areas, busy schedules and lean staffing often do not allow for meeting attendance. Additionally, the group discussed concerns about burnout and how to get more people involved in the shared governance process.
After discussing several options and the pros and cons of each, the steering committee decided that complete restructuring was the best option. Moving forward, the GC will be comprised of a core group of people (one representative and an alternate from each department) who will meet quarterly, but otherwise operate on a task force basis. When issues arise, one or two core group members will pull together a group of people from the HVI department(s) affected by the issue, work to address/solve the issue, and then disband. This will eliminate too-frequent meetings and draw more non-GC people into the shared governance process.
Looking back over the past 18 months, shared governance in the HVI has accomplished much. Looking forward, there is undoubtedly more to do. We are confident that the new structure and format will be able to effectively and efficiently address issues that arise, improve HVI functioning, and continue to have a positive impact on patient and staff satisfaction.
Disclosures: The authors have no conflicts of interest to report regarding the content herein.