D159: Shared Governance Implementation in Home Care Programs

Student Name

Western Governors University 

D159 Evidence-Based Measures for Evaluating Healthcare Improvements

Prof. Name

Date

D159: Shared Governance Implementation in Home Care Programs

The focus of this health improvement project is the integration of a shared governance framework within the Home & Community-Based Care (HCBC) department at the Iron Mountain Veterans Affairs (VA) facility. Shared governance aims to strengthen staff engagement, professional responsibility, and collaborative decision-making by actively involving frontline employees in organizational processes. The ultimate objective is to empower staff members through comprehensive education and participation in performance improvement efforts.

To determine the impact of this initiative, the project team established three critical data elements. These metrics assess frontline staff knowledge regarding shared governance before and after educational sessions and track the number of staff-initiated performance improvement projects. These combined measures offer both quantitative data and qualitative insights into knowledge acquisition and practical application.

The first data element is a pre-education survey conducted among frontline staff to establish their baseline understanding of shared governance. Given the diversity in staff backgrounds, prior leadership experience, and professional expertise, capturing this baseline is crucial for identifying knowledge gaps. The second data element is a post-education survey designed to evaluate the effectiveness of the training and determine whether staff can clearly explain and apply shared governance principles in their routine work. The third element monitors the initiation and progress of staff-led performance improvement initiatives, serving as a concrete demonstration of shared governance principles being put into practice.

Employee feedback tools like surveys are essential in driving organizational growth. Huebner and Zacher (2021) highlight that the true benefit of employee surveys extends beyond data collection to the subsequent planning and action phases that transform feedback into meaningful organizational advancements.

Data Management Plan

What is the source of data for the project?

The primary data originates from digital surveys distributed to frontline HCBC staff before and after the shared governance education sessions. The pre-education survey captures the initial knowledge and attitudes towards shared governance, while the post-education survey measures the gains in knowledge and the perceived relevance of the concepts introduced.

According to the Agency for Healthcare Research and Quality (AHRQ, 2020), well-structured data is vital in healthcare for workflow optimization, quality reporting, and incentivizing improvements. Aggregated data at the practice level facilitates continuous quality enhancement, standardization of processes, and better patient outcomes. However, data must be rigorously analyzed and embedded within a quality improvement framework to yield actionable insights.

To protect confidentiality and ensure data security, all surveys will be conducted through encrypted digital platforms accessible exclusively via VA-issued computers. The data will be securely stored on VA systems and available only to the project team and authorized stakeholders.

Key Performance Indicators (KPIs) and Deliverables

The project’s effectiveness will be assessed through KPIs directly linked to the objectives of shared governance. These indicators address both educational outcomes and behavioral changes among staff.

Deliverables tied to these KPIs include measurable improvements in knowledge test scores and an increase in staff-led problem-solving and performance improvement projects. These outcomes embody the foundational principles of shared governance such as empowerment, accountability, and professional ownership.

An internal target was set to achieve a 30% increase in staff knowledge of shared governance by July 31, 2025. This benchmark ensures the ongoing relevance and effectiveness of the educational efforts tailored to departmental needs.

Data Collection and Analysis Methods

How will the data be collected and analyzed?

Data collection will occur through digital surveys featuring multiple-choice questions that assess fundamental shared governance concepts. The pre-education survey will also invite staff to provide input on how shared governance could be applied in their roles and their preferred formats for learning. This feedback will allow customization of educational content and delivery methods.

Participation rates in surveys will be closely monitored to ensure sufficient representation. Pre-education survey results will guide modifications to the training to address identified knowledge gaps effectively.

Data analysis will utilize descriptive statistics such as percentages of correct responses, completion rates, and comparisons between pre- and post-education knowledge scores. Visual tools like bar graphs and pie charts will illustrate knowledge gains and common themes in staff improvement projects.

Houser (2023) emphasizes that effective data analysis enhances informed decision-making and may encompass descriptive, diagnostic, predictive, or prescriptive approaches. For this project, descriptive analytics are most suitable to assess knowledge acquisition and participation trends.

Potential Challenges and Mitigation Strategies

What barriers might impact the project’s success?

One anticipated challenge is the potential for low survey response rates, which could undermine data validity and introduce bias. Moreover, maintaining ongoing support from both leadership and frontline staff may be challenging, especially during periods of organizational change and uncertainty within the VA system.

To address these risks, leadership endorsement will be actively sought, and the importance of shared governance will be clearly communicated to all staff. Educational sessions will emphasize the benefits of shared governance, including increased professional autonomy, improved communication, and support for staff-driven improvements. Demonstrating the practical relevance of shared governance is expected to boost engagement and participation.

Despite these obstacles, this initiative offers significant organizational value by fostering staff ownership of professional growth and departmental improvements.

Dissemination of Results

After completing data collection and analysis, the findings will be shared with the Pathway to Excellence team to explore opportunities for extending early shared governance education to other departments. Additionally, the High Reliability Organization (HRO) lead will be informed to promote staff involvement in advanced training programs such as Yellow Belt and Green Belt process improvement initiatives.

If the project yields positive results, the shared governance implementation model will be proposed to other departmental leaders to encourage facility-wide adoption.

Project Closure and Sustainability

How will the project conclude and be sustained?

Upon project completion, frontline staff will receive small tokens of appreciation acknowledging their participation in surveys and educational sessions. Personalized thank-you messages will be sent to stakeholders and project team members to recognize their contributions.

Sustaining the initiative long-term will rely on continued shared governance activities championed by the Pathway to Excellence team. Ongoing education for new employees and encouragement for staff to engage in councils and improvement initiatives will be essential. The Nurse Practice Council will act as a core structure supporting sustained engagement, shared decision-making, and professional accountability.

Brennan and Wendt (2021) emphasize that shared governance fosters continuous practice excellence by promoting ownership, empowerment, leadership growth, and innovation—all critical factors in enhancing staff satisfaction and patient outcomes.

References

Agency for Healthcare Research and Quality. (2020). Collect and use data for quality improvement. https://integrationacademy.ahrq.gov/products/playbooks/behavioral-health-and-primary-care/implementing-plan/collect-and-use-data-quality-improvement

Brennan, D., & Wendt, L. (2021). Increasing quality and patient outcomes with staff engagement and shared governance. OJIN: The Online Journal of Issues in Nursing, 26(2). https://ojin.nursingworld.org/table-of-contents/volume-26-2021/number-2-may-2021/articles-on-previously-published-topics/increasingquality-and-patient-outcomes/

Houser, S. (2023, October 9). Data analytics concepts for health information professionals. Journal of AHIMA. https://journal.ahima.org/page/data-analytics-concepts-for-health-information-professionals

Huebner, L.-A., & Zacher, H. (2021). Following up on employee surveys: A conceptual framework and systematic review. Frontiers in Psychology, 12, 696732. https://pmc.ncbi.nlm.nih.gov/articles/PMC8696015/