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11/22/2002

Shared Governance Builds Leaders, Aids Patient Care

Donna Young

Health-system pharmacists participating in decision-making processes gain opportunities to increase their knowledge, responsibilities, and leadership experience, said Thomas W. Woller, pharmaceutical services director for Aurora Health Care—Metro Region in Milwaukee, Wisconsin.

Many health-system nurses, Woller noted, have been involved in decision-making programs, known as shared governance, for more than a decade.

"The general premise of shared governance is, that within a profession, the decision making for functions ought to be in the hands of those practitioners who are performing those functions," Woller said.

Last year, the American Nurses Association, citing a successful shared governance program, bestowed its highest honor on the nursing departments at Aurora Health Care—Metro Region’s five Milwaukee-area hospitals.

The pharmacy departments at those five hospitals, Woller said, have modeled their program after the one used by the health-system’s nurses.

The structure. Pharmacists elect nonmanagement peers to a decision-making body known as the practice council. The practice council meets once a month to discuss and make decisions about clinical issues, Woller said. A member of the management team and a clinical coordinator also attend the meetings.

"Management brings to the table understanding and experience of legal and regulatory compliance," he said, "but they act as advisers only and are not there to influence decisions."

A manager may place items on the practice council’s agenda, he added, when a decision has been determined to be in the council’s realm.

The council, with concurrence of Aurora’s health-system management, set the bylaws that guide the types of decisions that may be made, Woller noted. Some decisions, such as budget-related issues or anything involving the hiring of new staff members, are not in the realm of the practice council and must be made by the management team, he said.

Many issues of concern to pharmacists, Woller added, overlap between the practice council and management and must be resolved by both teams working together.

For the purpose of organizational structure, the council has a chairperson and secretary, he noted. One to three pharmacists represent each pharmacy department, depending on the hospital’s total number of pharmacists.

While shared governance has many benefits, he confessed that there are some drawbacks.

"Traditional management," Woller said, "often wants to push to get things done quickly."

But issues brought before a practice council, he admitted, can often take weeks or months to resolve.

"Sometimes you have to wait for everyone to get up to speed on something," he said.

However, he added, the time spent on those issues is usually time spent making sound decisions.

Management steps in, he said, only when a swift decision must be made, such as a crisis that necessitates a change from usual procedure.

A voice in patient care. Shared governance gives pharmacists a voice in making everyday decisions that affect the quality of a patient’s care, said Todd Armbruster, staff pharmacist at Aurora’s West Allis Memorial Hospital in suburban Milwaukee.

"It helps you feel like you are more than just ‘Joe Pharmacist’ and that you are not just taking orders from above," he said. "We want our pharmacists to take the practice council opportunity seriously and realize that they do have a voice."

Before joining West Allis’s pharmacy department, Armbruster had participated in a similar shared governance program at Northwest Community Hospital, a 563-bed independent facility in the Chicago suburb of Arlington Heights, Illinois.

"But here at Aurora," he said, "the decisions we make affect five facilities, and so we have to make sure that everything that is agreed upon is doable and that it is something that we can make work at all facilities. And that is a little bit tougher because there is a wide variance of opinions."

Shared governance, Armbruster said, helps the pharmacy and other departments standardize their practices, which aids in patient safety.

One issue brought to the practice council, he explained, was the lack of a standardized concentration of hydromorphone for use in patient-controlled analgesia (PCA).

West Allis had been contracting with Baxter Pharmaceuticals of Deerfield, Illinois, for prefilled syringes containing 50 mL of hydromorphone 1 mg/mL. Aurora’s other Metro Region pharmacy departments had been compounding the hydromorphone solution at a concentration of 0.2 mg/mL in 30-mL syringes.

When Aurora pharmacists or nurses covered shifts at another Metro Region facility, they sometimes encountered a concentration of hydromorphone and type of PCA pump with which they were unfamiliar, Armbruster said.

"It created a lot of confusion for everyone, especially the nurses," he said. "The potential for error was high."

To resolve the issue, Armbruster said, the pharmacy practice council recognized that it must involve the nurses’ shared governance council before any decisions could be made.

"The nurses had to come onboard with this because it involved the way they practiced and their patients, too," he said.

Former practice council chairman Bruce Yale, now pharmacy supervisor for Aurora’s St. Luke’s South Shore Hospital in Cudahy, said Metro Region nurses and pharmacists agreed to standardize the hydromorphone concentration at 1 mg/mL.

"It’s a patient safety issue that, through communication and cooperation, we were able to resolve," he said.

The hospitals are in the process of standardizing the type of PCA pump used, Yale said.

Practitioners can move about a health care organization more easily, covering shifts at various facilities, when they know that training and clinical practices have been standardized systemwide, noted Yale, who served one year on the practice council before being elected as chairman.

That experience, he said, helped him develop leadership skills that led him to his supervisory role at Aurora’s St. Luke’s South Shore.

"As a member of the council, I learned a better appreciation of how and why decisions are made and that there are consequences to those decisions," he said. "It gave me more insight into management."

A decision made by a practice council, he said, is often easier for staff to accept "because it’s peers telling other peers that this is what is expected of them. These are decisions that staff can live with because they don’t see it as something that came down from the management level."

Staff retention. According to a report released in May 2001 by the Nursing Institute at the University of Illinois at Chicago, shared governance programs help create a more desirable working environment for practitioners by emphasizing teamwork and communication.

In Who Will Care for Each of Us? America’s Coming Health Care Labor Crisis the authors, which included former U.S. Secretary of Labor Lynn Martin, urged health systems to adopt shared governance programs as a way to recruit and retain staff.

"This type of program works well in the pharmacy environment because it breaks down barriers between management and practicing pharmacists," Yale said. "In our practice councils, we have the opportunity to get to know people throughout the organization."

Participation in a shared governance program, he added, is a valuable learning experience that made him a better practitioner.

Yale suggested that health systems considering adoption of a shared governance program should begin by having a human resources official instruct participants in how to create an agenda and lead a meeting.

"We had to learn all of that from scratch, and it was difficult in the beginning," he said. "We struggled for a while, and it would have helped had we had some basic leadership classes before we started."