Nursing Management , CONTROLLING

Nursing management

What is Controlling ?
–    Controlling is one of the basic functions of managers.
–    It is the measurement and correction of performance.
–    Its purpose is to make sure that plans succeed.
Who Controls?
–    Control activities are essential parts of the responsibilities of managers at all levels in the organization (first-line managers, department heads, and top management).
Basic Steps of the Control Process
–    The basic control process, wherever it is found, and whatever it controls, consist of three steps as follows:

–    setting control standards.
–    measuring performance against these standards (monitoring).
–    correcting deviations from standards.

–    Example 1: controlling blood pressure
–    Control standard: systolic blood pressure not more than 140 mmHg.

–    Measurement: measurement of BP every month.

–    Corrective action: medication administration

    Relationship between controlling and planning:
    They are know as the Siamese twins of management.
–    Standards can be quantitative or qualitative
–    Quantitative: Physical units: thermometers in each examination room in health centre
–    Qualitative: clean sheets of examination beds.
–    It is important to differentiate between practice standards and control standards
–    Practice standards
–    Are the organization’s detailed definition of the desired level for resources, the delivery processes and procedures, and the desired outcome of these processes.

–    Control standards:
–    Are indicators selected to monitor compliance with practice standards.
–    Are measurable variables (characteristics).
–    Are less detailed than practice standards.
Sources of Standards
1) Official documents.

2) Historical analysis of institution’s own data.
3) Comparative standards (benchmarking)
4) Scientific.
5) Expert opinion:
Levels of Standards

Minimum standards:
–    Represent the lowest level of acceptable performance.
–    Appropriate only in health systems and facilities where the general level of care is average so that those below minimum standards are suspected to constitute a significant problem.
Minimum standards don’t.:
–    Under such situations, the presence of minimum standards is expected to encourage health care institutions to reach and even exceed them with the ultimate result of improving the quality of health services the patients receive.
–    Optimum Standards
–    The best level of performance under the best possible circumstances.

–    They represent the ultimate goals toward which a health service program would direct its efforts and continuity try to achieve.

–    Optimum Standards don’t.:
–    They are suitable mainly for health facilities which have achieved a reasonable high level of development concerning their resources, organization and operational systems and processes, and which have well established successful control programs.

Empirical / average standards:
–    Empirical standards are usually averages that are based on actual practice.
–    They may be based on institutional, regional or national averages within a certain time frame.
–    Examples of these standards may include:
–    The average number of investigations by diagnosis.
–    The average hospital stay by diagnosis.
–    The caesarean section rate.
Empirical / average standards don’t.:
–    Empirical standards are preferred by many people because they represent actual performance and therefore, provide a realistic target, which has been achieved by some institutions and exceeded by others.
–    Empirical standards also have some limitations. The most important limitation is that they may conceal actual poor performance even though the standards have been achieved.
–    Criteria for Setting Good Standards:
–    1)Good standards should focus on critical elements, i.e., elements known by their demonstrated relationship to the outcome of service (validity).
–    High volume: affecting large number, e.g., diabetes mellitus.
–    High risk: serious consequences, e.g., pneumonia.
–    High cost: e.g., MRI examination.
–    Problem-Prone: problem specific to the facility or department.
2)Current: standards should be reviewed and revised or changed as necessary so that they reflect the changes in medical sciences and technology, as well as changes in the socio-economic condition of the community and in the values and expectations of the people.
3)Good standards should be specific, objective, and preferably expressed in quantitative terms, thus to leading to reliability of measurement.
4)Standards should be reasonably attainable (realistic) considering resources and environment:
–    Too high either cause anxiety or tend to be treated with contempt.
–    Too low tend to breed premature satisfaction and complacency.
–    Participation of all levels involved in the process in setting standards:
–    Ensures that they are realistic.
–    Promotes compliance with standards.
–    Promotes self-control.
Examples of Hospital Control Standards
Input standards:
– Hospital care should be provided at a level of 4 hospital beds per 1000 population
Activity / process standards :
– Except in extreme emergency, all patients undergoing surgery shall have a signed consent.

Examples of Hospital Control Standards


Input standards:
–    Hospital care should be provided at a level of 4 hospital beds per 1000 population
Activity / process standards :
–    Except in extreme emergency, all patients undergoing surgery shall have a signed consent.
Output Standards:
–    The postoperative wound infection rate should not exceed 2% of clean surgical cases.
–    What is Measurement ?
–    Measuring is the process of assigning a value to some objects, events, or phenomena, according to predetermined rules.
–    The assigned value is usually numerical (quantitative), but sometimes it is nominal (qualitative).
–    The use of the word rules is very critical. It means that the method of assigning value must explicitly (spelled out) and clearly state what is exactly to be measured, when, and where. This is important for standardization, which means that similar results should be obtained when the same measuring instrument is used by the same person or by different persons.
–    Importance of measuring performance:
–    Provides measures of achievement, so that each member of the organization knows not only his/her performance, but also that of relevant other members.
–    To provide an objective basis for rewarding members of the organization.
–    To provide data useful in setting new expectations (objectives).
–    For controlling (to identify correctable deviations from the plan).

Characteristics of Good Measures

–    1. Accuracy of collected data
–    2. Reliability of measurement


1- Performance meets standards (In-control loop):

–    No change is required.
–    Continue monitoring.
2- Performance below standards:
Determine the cause of the deviation.
–    a. If the deviation is acceptable, or its cause is uncontrollable, activities continue with no intervention (Acceptance control loop).
–    Examples of acceptance deviation:
–    The size of the waiting list increases because one of the theatres is being renewed.
–    B- If deviation is unacceptable and the cause is controllable, intervention should occur (Required change control loop):
–    Examples:
–    Average stay higher than standard due to unacceptable reasons:
–    Physicians do not discharge patients in time.
–    3. Actual performance exceeds standard (positive control loop):
–    a. If desirable (e.g., % of pregnant women attending antenatal care clinic exceeding standard in one rural health unit of the district):
–    Reinforce.
–    Freeze in place.
–    Replicate elsewhere (change standard in other units of the district).
–    If undesirable, the cause should be determined and either “acceptance” or “required change” control loops should be used.
–    For example, physical plant maintenance expenditures may be below budget, yet this may be undesirable if preventive maintenance is postponed.
–    Steps of Corrective Action:
–    Identify the root cause of the problem.
–    Develop a plan for corrective action that includes:
–    The changes required.
–    The appropriate actions needed to overcome the problem.
–    The person or group responsible for implementing and overseeing the actions (adequate authority).
–    The time frame within which the actions should occur.
–    Implement corrective action.
–    Monitor and evaluate performance.
–    Most Common Causes of Problems Are:

–    Insufficient knowledge.
–    Behavioral problems.
–    Defects in systems (usually responsible for around 70% of problems).
–    Appropriate corrective action:
–    Insufficient knowledge may be corrected by:
–    Training and continuing education.
– Providing reference source, e.g., books, periodicals, internet
Behavior or performance deficiencies may be corrected by:
–    Counseling.
–    Emphasizing supervision and motivation.
–    Changing duties.
–    Transferring.
–    Withdrawing certain privileges.
–    Discipline.
Defects in systems may be corrected by: 
–    Changing policies and procedures.
–    Changing lines of authority.
–    Changing span of control.
–    Redistribution of staff.

Characteristics of Effective Control Systems

–    Control systems should be extensions of the planning process.
–    Actual performance should be compared to planned performance.
–    Feedback from controlling to planning, which may lead to changing of strategies or objectives.
–    Effective control systems should coordinate standards of different units with one another and with objectives of the organization: Sometimes standards are not coordinated

–    Effective control systems should be based on good control standards (critical elements, current, objective, realistic, participation). These standards should be explicit (predetermined, written and formalized.
–    Effective control systems should be based on appropriate information. If information is not appropriate, the whole control process will fail.
–    Either too little or too much information is undesirable. Too much information may cause important indicators to be lost. Too little information may be missing critical elements.
–    Effective control systems should be designed to give the manager sufficient valid (measures what it is supposed to measure), reliable, accurate and sensitive detects changes) information at the right time in a usable format.
–    Participation of all levels involved in a process should be involved in all steps of the control process:
–    Ensures that standards are realistic.
–    Improves compliance with standards.
–    Promotes self-control.
–    Improves problem solving and corrective action.
–    When possible control should be forward looking (input and process control) as well as feed backward (output control). Neither of three approaches to control is a substitute for the two others.
–    Leads to corrective action:
–    An effective control system must lead to corrective action; merely uncovering deviations is not enough. Therefore, the system should be able to disclose:
–    Where the problem areas are.
–    The magnitude of the problems.
–    Who is responsible for them.
–    What should be done about them.

–    Timeliness:
Control should detect, report and correct deviations quickly. Late feedback may result in a problem being attacked after it has already cured itself, or worse, it may allow a problem to get so out of control that more drastic means of intervention must be employed. The consideration of when feedback is “late” depends on the process being controlled and the speed with which intervention can be successfully employed. The control system that is not timely is not only useless, but also costly.
–    Flexibility:
–    Blind and inflexible use of numerical measures causes distortions. Changes and unforeseen circumstances require that judgment, common sense, and flexibility be used in control systems.
–    To help managers concentrate on significant deviations, control standards (UCL & LCL) should be defined in terms of upper and lower acceptable limits. These are termed (tolerance limits). This is particularly important in the field of hospital care because most of the work in hospitals is stochastic (subject to random variation)>
–    Economical:
–    The cost of implementation of the control system (mainly cost of data collection and analysis) should not exceed its benefits.
–    The practical difficulty is that most managers, particularly in the field of hospital care, find difficulties in estimating the cost of control and the expected value or benefits to be achieved out of it.

–    Understandability:
–    Reports should be simple; those that are too complicated will not be used.
–    Problem-Solving Capacity:
–    The manager should have the knowledge, skill, resources, and authority to intervene. Therefore, effective control systems should consider training managers who are going to implement and use them.

–    Responsibility:
Control systems should reflect the authority-responsibly relationship. As far as possible, the worker and the immediate supervisor should be involved in the monitoring and correction processes.
–    Backup Support:
–    There should be an organizational structure behind the manager, which reinforces the manager’s authority both to control the process and to step in when circumstances beyond the manager’s control cause the process to step to get out of control.
–    This support structure can be regarded as a “super” control system over the control system itself. The super control system is asked to intervene only when the manager calls for help, or when the whole process (including the manager and the control system) appears not to be functioning properly.

–    Respect for the control system:
–    All people involved – from those in the process to the manager – should regard the control system as a serious and essential part of the organization. This includes respect for the need to have control, belief in the standards of the performance, a feeling of responsibility for maintaining control, and a feeling that they do have the ability to intervene when necessary.
–    Effective control system should emphasize rewards as well as sanctions.
–    Concentration on sanctions and negative corrective actions will eventually lead to dissatisfaction, frustration and failure.
–    Sanctions and negative corrective action when needed must be used promptly, fairly, and equitable.

Performance appraisal

    It is a periodic formal evaluation of how well personnel have performed their duties during a specific period.
–    Purposes of performance appraisal:
–    Improve performance (main purpose).
–    To determine job competence.
–    To enhance staff development and motivate personnel toward higher achievement.
–    To discover the employees aspirations and to recognize accomplishment
–    To improve communications between managers and staff associates and to reach an understanding about the objectives of the job and agency.
–    To determine training and development needs.
–    To select qualified nurses for advancement and salary increases.
–    Identify unsatisfactory employees for demotion or termination.
–    Reinforce standards of job performance.
–    Select quality individuals for promotion
–    Discover aspirations of employees and reconcile them with goals of heir organization.
–    Determine salary standards.


–    Performance appraisal (evaluation):
–    Performance appraisal is an integral part of management control function.
–    It requires as a first step, careful gathering information on how employees at all levels in the organization are carrying out their duties.
–    The criteria and standards under which performance appraisal is carried out are of great importance and should be included in the employees job description.
–    The basic contents of job appraisal should include examination of:
–    The quality and quantity of work accomplished.
–    The employees attitude toward the organization and it’s goals.
–    The employees attitude toward other workers in the organization.
–    Interests in performance appraisal:
–    Administrative function:
–    It provides a method by which most likely fair decisions can be made with regard to promotion, demotion, and transfer of an employee or termination of employment.
–    Informational function:
–    It informs an employee as to how his supervisor judges their performance.
–    It indicates which area needs improvement.
–    It assesses the organization audit it’s human resources and specific skills.
–    Performance appraisal should also alerts the employer to strength and weakness in its recruitment and selection processes.
–    Motivational function:
–    Properly conducted performance appraisal should motivate employees to improve heir own performance, both in their behalf and with assistance of their employers.
–    Influence of hallo effect:
–    Hallo an effect obscures the true nature of the performance being apprised.
–    Performance appraisal process is described as having both evaluative and developmental components:
–    Evaluative components:
–    Focus on past performance and can be accomplished by using behavioral rating scales with narrative documents summarizing behavior in each category.
–    Developmental components:
–    Focus on future behavior and includes mutual goal projection by employee and supervisor.
Performance appraisal process includes:
1- Day-by-day supervisor-subordinate interaction.
2- Written documentation: (recording critical incidences – completing performance review form).
3- Formal performance interview.
4- Follow up with coaching  and or discipline as indicated.
–    It is essential to consider the concept that appraisal is an emotionally charged area, and that it is interpretation by the nurses being evaluated can have a strong impact on their self-esteem and subsequent performance.
–    The process of appraisal for employees should consider three behaviors demonstrated by the nurse:
–    Display of awareness of the rational for actions and self-confidence in performance.
–    Display of ability to communicate effectively.
–    Display of autonomy and responsibility for actions.
–    Guidelines to decrease the likelihood of discrimination when doing the performance appraisal:
–    The appraisal should be in writing and carried out at least once a year.
–    The performance appraisal information should be shared with the employee, and the employee should have the opportunity to respond in writing.
–    There should be a mechanism by which an employee can appeal the results of his performance appraisal.
–    The supervisor should have adequate opportunity to observe the employees job performance.
–    Notes (critical incidences) on the employees performance should be kept during the entire evaluation period.
–    The evaluators should be trained how to carry out the appraisal process.
–    The performance appraisal is preferred to be behaviorally based.
–    The nurse manager should rate on several different dimensions such as:
–    Initiative; including attitudes in dealing with patients and others.
–    Internal motivation.
–    Knowledge includes level of knowledge and skills in performing different nursing procedures/activities.
–    Ability to work with others.
–    Potential problems and Common errors in performance appraisal:
–    Leniency error: A = 90 – 100, B = 80 – 89, C = 70 – 79.
–    Recency error. The appraiser affected by recent events or incidences
–    Ambiguous evaluation standards.
–    Written comments.
–    Appraiser ability.
–    Appraiser motivation.
–    Criteria involving judgments are used for performance evaluation.
Hallo error:
     Is result of allowing one trait to influence the evaluation of other traits or of rating all traits on than basis of a  general impression.
A logical error:
    Is a rating a nurse possesses another chch or behaviors that is logically related.

–    Horns error:
    the evaluator is hyper perfectionist may rate personnel lower than they should.
–    Contrast error:
    Tendency of managers to rate the nurse opposite from the way they receive themselves.
–    Central tendency error:
    A small range of scores was applied in evaluation.

Methods of Performance Management

–    Anecdotal notes:
Are objective description of behavior recorded on plain paper or a form. The notation include who was observed, by whom, When, and where.
It comprises a description setting or background and the incident, and interpretation and recommendations may be included.
Value laden words such as good and bad should be avoided. It is advisable to make several brief observations over a time span to allow for  temporary Variables and to identify patterns of behaviors.
An advantage of anecdotal note readings is that not coerced into a rigid structure.

Check list:

`The manager categorically assess the presence or absence of desired chch or behaviors. Checklists are mostly for tangible variables, Such as inventory of supplies, and may be used to evaluate nursing skills also.

–    Rating scale:
     It does more than just note the presence or absence of desirable behavior. It locates the behavior at a point on a continuum and notes quantities and qualitative abilities. The numerical rating scale usually includes numbers against which a list which a list of Behaviors are evaluated.
–    Ranking:
    It forces managers to rank the staff in descending order from highest to lowest even if they do not think there is deference.

–    Key behaviors in performance review:
–    Put the person at ease.
–    Make it clear that the purpose of the performance review is to help the employee to do the best possible job.
–    Review the ratings with the employee, citing specific examples of behavior that resulted in a particular rating.
–    Ask for the employee’s feelings about the ratings and listen, accept and respond to them.
–    Together decide on specific ways in which weak areas can be strengthened.
–    Set a follow up date.
–    Express your confidence in the employee.
–    Remember:
–    Evaluation should be done day-by-day.
–    The nurse must be informed about his strong and weak areas.
–    The performance appraisal usually done annually and as needed.
–    The nurse must be informed about the results of appraisal.
–    According to the results, the employer can determine the staff needs for reward, development, updating.

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