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 health improvement project centers on the implementation of a shared governance framework within the Home & Community-Based Care (HCBC) department at the Iron Mountain Veterans Affairs (VA) facility. Shared governance is designed to enhance staff engagement, professional accountability, and collaborative decision-making by involving frontline staff directly in organizational processes. The primary goal of this initiative is to empower staff through education and active participation in performance improvement activities.
To evaluate the effectiveness of the shared governance initiative, the project team identified three essential data elements. These include assessing frontline staff knowledge of shared governance before and after educational interventions and monitoring the number of performance improvement projects initiated by staff. Together, these metrics provide both quantitative and qualitative insight into knowledge acquisition and practical application.
The first data element involves a pre-education survey administered to frontline staff to establish baseline knowledge. Because staff backgrounds, prior leadership exposure, and professional experiences vary, baseline data are necessary to identify gaps in understanding shared governance principles. The second data element is a post-education survey, which evaluates the effectiveness of the educational intervention and determines whether staff can articulate and apply shared governance concepts in their daily practice. The third data element tracks the initiation and execution of staff-led performance improvement projects, serving as a tangible indicator of shared governance integration into practice.
Employee feedback mechanisms, such as surveys, are critical tools in organizational development. Huebner and Zacher (2021) emphasize that the true value of employee surveys lies not only in data collection but also in the follow-up actions and planning that translate feedback into meaningful improvement.
Data Management Plan
What is the source of data for the project?
The primary data source for this project consists of digitally administered surveys distributed to frontline HCBC staff before and after the shared governance educational sessions. The pre-education survey captures baseline knowledge and perceptions, while the post-education survey measures knowledge gains and perceived applicability of shared governance concepts.
The Agency for Healthcare Research and Quality (AHRQ, 2020) underscores the importance of structured data in healthcare settings, noting that data support workflow development, quality reporting, and improvement incentives. Aggregated, practice-level data facilitate continuous quality improvement, process standardization, and enhanced patient outcomes. However, data must be systematically analyzed and incorporated into a quality improvement framework to produce actionable results.
To ensure confidentiality and data integrity, all surveys will be conducted through an encrypted digital platform accessible only via VA-issued computers. Survey data will be stored and reviewed on secure VA systems and accessed solely by the project team and designated stakeholders.
Key Performance Indicators (KPIs) and Deliverables
The project’s success will be evaluated using clearly defined KPIs aligned with shared governance objectives. These indicators focus on both educational outcomes and behavioral change among staff.
| KPI Number | Description | Intended Outcome |
|---|---|---|
| KPI #1 | Development and delivery of shared governance educational materials | Increased staff knowledge, confidence, and engagement in shared governance activities such as councils, committees, and improvement initiatives |
| KPI #2 | Strengthening collaborative relationships between leadership and frontline staff | Enhanced shared decision-making, critical thinking, and communication demonstrated through staff participation in leadership forums |
The primary deliverables associated with these KPIs include measurable improvement in staff knowledge scores and an increase in staff-initiated problem-solving and performance improvement activities. These outcomes reflect key principles of shared governance, including empowerment, accountability, and professional ownership.
To measure success, the project team established an internal benchmark of a 30% increase in shared governance knowledge by July 31, 2025. This benchmark ensures that educational interventions remain effective, relevant, and aligned with departmental needs.
Data Collection and Analysis Methods
How will the data be collected and analyzed?
Data will be collected through digitally administered surveys containing multiple-choice questions focused on foundational shared governance concepts. The pre-education survey will also solicit staff input regarding potential applications of shared governance in their roles and preferred educational formats, allowing the project team to tailor educational delivery methods.
Survey participation rates will be closely monitored to ensure adequate representation. Results from the pre-education survey will guide refinements to educational content, ensuring that identified knowledge gaps are addressed effectively.
Data analysis will rely on descriptive statistics, including calculation of correct response percentages, overall completion rates, and comparison of pre- and post-education results. Visual data representations will include bar graphs comparing knowledge scores before and after education and pie charts summarizing staff-identified improvement project themes.
Houser (2023) notes that effective data analysis supports informed decision-making and may include descriptive, diagnostic, predictive, or prescriptive analytics depending on project goals. In this project, descriptive analytics are most appropriate for evaluating knowledge acquisition and participation trends.
Potential Challenges and Mitigation Strategies
What barriers might impact the project’s success?
One anticipated challenge is low survey participation, which could limit data validity and introduce response bias. Additionally, securing sustained buy-in from both leadership and frontline staff may be difficult during periods of organizational change and federal-level uncertainty within the VA system.
To mitigate these risks, leadership support will be emphasized, and the value of shared governance will be clearly communicated to staff. Educational sessions will highlight how shared governance enhances professional autonomy, improves communication, and supports staff-driven change. By demonstrating relevance to daily practice, the project aims to increase engagement and participation.
Despite potential barriers, the initiative offers substantial organizational value by promoting staff ownership of professional development and departmental improvement efforts.
Dissemination of Results
Upon completion of data collection and analysis, findings will be shared with the Pathway to Excellence team to evaluate the feasibility of expanding early shared governance education across departments. The High Reliability Organization (HRO) lead will also be informed to encourage staff participation in advanced training opportunities, including Yellow Belt and Green Belt process improvement programs.
If the initiative demonstrates positive outcomes, the shared governance implementation strategy will be presented to additional department leaders to support replication throughout the facility.
Project Closure and Sustainability
How will the project conclude and be sustained?
At project completion, frontline staff will receive small tokens of appreciation in recognition of their participation in surveys and educational activities. Personalized thank-you communications will be distributed to stakeholders and project team members to acknowledge their contributions and support.
Long-term sustainability will depend on continued shared governance development led by the Pathway to Excellence team. Ongoing education for new staff and continued encouragement of participation in councils and improvement initiatives will be essential. The Nurse Practice Council will serve as a foundational structure for maintaining engagement, shared decision-making, and professional accountability.
Brennan and Wendt (2021) emphasize that shared governance supports sustained practice excellence by fostering ownership, empowerment, leadership development, and innovation—key drivers of improved 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
D159: Shared Governance Implementation in Home Care Programs
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/