CONTROLLING

Reported by:
Ricare, Mary Claire Ida B. Lumintac, Lenie Gwenn Andam, Salahuddin Quiling, Rose Ann Naif, Farhanie H. Daud, Rayhannah

CONTROLLING The head or president of any organization is responsible for its overall direction. Since she cannot perform all these functions, she has to delegate to her subordinates the responsibility and authority to perform certain tasks for which she is still responsible. Thus, she has to use some systems of control to enable her to appraise the performance of each and every one of her subordinates. Unsatisfactory performance may be corrected before it causes serious damage. A good control system encourages each employee to exercise self-control. Selfcontrol would be possible when standards or criteria for performance exist to the point where an employee knows the specific level of performance expected of her. DEFINITION OF CONTROLLING: Controlling is the use of formal authority to assure the achievement of goals and objectives. Here, performance is measured and corrective action is taken to ensure the accomplishment of organizational goals. It also involves assisting, regulating, monitoring, and evaluating individual and group performance. Some people react strongly against the phrase management control. The word itself can have a negative connotation, e.g., it can sound dominating, coercive and heavy-handed. It is now preferred to use the term coordinating rather than controlling. But, for all intents and purposes, coordinating is controlling. TYPES OF CONTROL 1. Feedforward Controls- focus on operations before they begin. Their goal is to prevent anticipated problems. An example is preparing all supplies and equipment for scheduled wound dressing, or bedside lumbar tap, intravenous insertion, in order to determine what is lacking and other things to be done. 2. Concurrent Controls- apply to processes as they are happening. It enacted while work is being performed include any type of materials or supplies for therapeutic care which require direct supervision or the use of automated systems such as computers programmed to inform the user when they have issued the wrong command, and organizational quality programs and resources. 3. Feedback Controls- focus on the results of operations. They guide future planning, inputs, and process designs. Examples include timely ( weekly, monthly, quarterly, annual) reports so that almost instantaneous adjustments can be made.

CONTROL PROCESS
Is a continuous flow between measuring, comparing and action Control is a regulation of organization activities so that some targeted element of performance remains within acceptable limits. Without this regulation, organizations have no indication of how well they perform in relation to their goals. CHARACTERISTICS OF CONTROL PROCESS

C5: Cyclic

Changes in the behavior of employee is expected Control is both anticipatory and retrospective Control is viewed by each person of health care delivery system as responsibility Controlling builds on planning, organizing, leading

The Control Process

Step 1. Establish Standards serve as the criteria against which performance is measured, and give an idea of the level of performance that managers can expect of a person Involving employees in setting standards >Commits the employees to achieving the standards >Results in more appropriate standards This consists of the following: (F.R.O.S.T.S.) F- Financial Controls

facilitate achieving the organizations profit motive

R- Resource controls (B.E.C. M.E.T) Budgets control cost- expense related standards which identify the quantity of materials used and units to be produced Employee performance controls- focus on actions and behaviors of individuals and groups of employees. Cost controls- help ensure cost standards are met Material controls- relate to inventory and material- yield controls Equipment controls- built into the machinery, imposed on the operator to protect the equipment or the process Time controls- relate to deadlines and time constraints O- Operations control assess how efficiently and effectively transformation processes create goods and services S- Standards created when objectives are set during the planning process Standard- any guideline established as the basis for measurement and organizations

T- The Just- in- Time (JIT) System timely application of medication for the illness of a patient, and purchased materials just in time to be transformed into parts communication, coordination, and cooperation are required from supervisors and employees to deliver the smallest possible quantities at the latest possible date at all stages of the transformation process in order to minimize inventory costs S- Statistical Process Control use of statistical or mathematical methods and procedures to determine whether production operations are being performed correctly, to detect any deviations, and to find and eliminate their causes

Step 2. Monitoring and Measuring performance Techniques for monitoring and measuring service (N.Q.N) Nursing Rounds- pay particular attention to issues of patient care and nursing practice. This will also satisfy needs and problems met or unmet. Quality assurance- monitors compliance with established standards

Nursing Audit- consists of documentation of the quality of nursing care in relation to the standards established by the nursing department Step 3. Compare performance against standard the actual accomplishment is matched with the acceptance standard to check if there are delays or deviations from the standard Techniques for corrections and improvements of performance: Program Evaluation and Review Technique (PERT)

- model for project management designed to analyze and represent the tasks involved in completing a given project -employs a matrix that uses network of activities represented in a chart, including the goals or product desired, time management, budget and estimation of critical paths Benchmarking

-seeks out the best so as to improve its performance Step 4. Evaluate results and take any necessary corrective action - Correction of deviations or errors- may be made by modifying the plan either by changing the number of personnel, or by better selection and training of subordinates, or by changing the other factors of production or by adding more materials or resources to minimize or eliminate errors or any deviations - Master Control Plan- may be used by Managers depicting its functions, goals and objectives to be accomplished and its specific activities to ensure quality of performance and products - Take necessary action- the supervisor must find the cause of deviation from standard. Then, he or she takes action to remove or minimize the cause

Control Strategies
Managers can use one or a combination of four (4) control strategies or styles. 1. Market Control It relies primarily on budgets and rules Involves the use of price competition to evaluate output In using this, there must be a reasonable level of competition in the service area and it must be possible to specify requirements clearly. It is non-appropriate in controlling functional departments, unless the price for services is set through competition and its representative of the true value of provided services. 2. Bureaucratic Control It is the use of rules, policies, hierarchy of authority, written documentation, reward systems, and other formal mechanisms to influence employee behaviour and assess performance. It can be used when behaviour can be controlled with market or price mechanisms. 3. Clan Control It represents cultural values almost the opposite of bureaucratic control. It relies on values, beliefs, corporate culture, shared norms, and informal relationships to regulate employee behaviours and facilitate the reaching of organizational goals. Organizations that use this control style require trust among their employees. 4. Self-control It is sometimes called adhocracy control, is complementary to market, bureaucratic and clan control. It is essential to managerial control, as it is the highest form of control. It includes being up-to-date in knowledge, giving clear orders being flexible, understanding reasons for behaviour, helping others improve,

increasing problem-solving skills, standing calm under pressure, and planning ahead. By training and encouraging the individuals to take initiative in addressing problems on their own, there can be a resulting sense of individual empowerment, which plays out as self-control. Benefits the organization and increases the sense of worth to the business and individual.

PERFORMANCE APPRAISAL
Definitions: A method of acquiring and processing information needed to improve the individual employees performance and accomplishments. It is the individual evaluations of work performance. A tool that can use to help enhance the efficiency of the work unit. It consists of setting standard and objectives; ongoing feedback between the appraiser and employee; reviewing progress; and planning for reinforcement, deletion or correction of identified behavior as necessary.

Purposes: A - Assess the: Appropriateness, Adequacy, Effectiveness and Efficiency of services E - Explain the general evaluation process for employees E - Exchange ideas and feelings G - Guide employees toward highly effective service by identifying areas of their job performance that need improvement

P - Provide legal protection against lawsuits for wrongful termination

E - Encourage improvement (employees and team leaders)

PERFORMACE EVALUATION TOOLS

The effectiveness of a performance appraisal system is only as good as the tools used to create the assessments made. An effective competence assessment tool (Decker and Strader, 1998) should allow the manager to focus on priority measures and specifically define competencies such as costumer focus and cost consciousness so hat training and giving performance feedback are easier

1. Trait Rating Scales - A method of rating a person against a set standard, which may be the job description, desired behaviors, or personal traits - It locates the behavior at a point on a continuum and notes quantitative and qualitative abilities Advantages: Does more than just note the absence and presence of desirable behavior Disadvantages: They are subject to central tendency and halo and horns effect errors and thus are not used as often today Interpersonal bias

2. Job Dimension Scales - It also uses rating scales but focuses on the job description and the quality work performance preventing ambiguous terms such as quantity of work Advantages: Focused on job description Disadvantages: They face the same disadvantage as with the trait scale

3. Behaviorally Anchored Rating Scale (BARS) - A separate rating form be developed for each job classification and employees in specific positions work with management to delineate key areas of responsibility

The difference is that many specific examples are defined for each area of responsibility that are given by various degrees of importance by ranking them. Advantages: Applies to physically observable skills Focuses on specific behaviors Allows employees to know exactly what is expected of them Reduces rating errors Allows the rater to look at more than one dimension of work performance, eliminating bias Disadvantages: Time and expense Poor in the evaluation in conceptual skills

4. Checklist - It is composed of behavioral statements that represent desirable behavior - There are 3 types: o Weighted Scale the most frequently used checklist, is composed of many behavioral statements that represent desirable job behaviors with a weight attached on each o Forced checklist requires that the supervisor select an undesirable and a desirable behavior for each employee o Simple Checklist composed of numerous words or phrases describing various employee behaviors or traits Advantages: Focus on a variety of job-related behaviors Avoid bias that is inherent in the trait rating scales Disadvantages: There are no set performance standards Specific components of behavior are not addressed

5. Peer Review - It is a collegial evaluation of the performance done to promote excellence in practice and offer information, support, guidance, criticism and direction to one another - This is monitoring and assessing work performance being carried out by peers rather than supervisors - The review will never be shared only to the employees supervisor

Advantages: when implemented properly, provides the employee with valuable feedback that can promote growth Provide learning opportunities Peers provide a level of insight into each others clinical practice Opportunity to receive better feedback about self improvement Has the potential to increase accuracy of performance appraisal Opportunities for increased professionalism and learning Disadvantages: Viewed as very threatening when inadequate time is spent orienting the employees to the process and when necessary support in not provided throughout the process Peers feel uncomfortable sharing feedback with people whom they work closely at some point making the review more like an advocacy than an evaluation Time-consuming Because socialization takes place in the workplace, friendships often result in inflated evaluations, or interpersonal conflict may result in unfair appraisals Shifts authority away from management making the manager feel threatened Risk taking Requires a great deal of energy

6. Self Appraisal - This tool allows the employee to evaluate his own performance. Employees are being asked to submit written summaries or portfolios of their work-related accomplishments and productivity as part of self-appraisal process Advantages: Result in growth when the person is self-aware An opportunity for the employees to receive positive feedback from their supervisor Disadvantages: Even mature people require external feedback and performance validation Subjectivity is an issue making it more negative Some employees undervalue their accomplishments or may feel uncomfortable giving themselves high marks in many areas It is not congruent with other date available, the manager may wish to pursue the reasons for this discrepancy

QUALITY MANAGEMENT I.

INTRODUCTION Quality refers to excellence of a product or a service, including its attractiveness, lack of defects, reliability, and long-term durability. Florence Nightingale introduced the concept of quality in nursing care in 1855 while attending the soldiers in the hospital during the Crimean war. Quality assurance provides the mechanisms to effectively monitor patient care provided by health care professionals using cost-effective resources. Nursing programmes of quality assurance are concerned with the quantitative assessment of nursing care as measured by proven standards of nursing practice. Quality assurance system motivates nurses to strive for excellence in delivering quality care and to be more open and flexible in experimenting with innovative ways to change outmoded systems.

II. QUALITY MANAGEMENT THEORIES 1. Maxwell (1984)

Maxwell recognized that, in a society where resources are limited, self assessment by health care professionals is not satisfactory in

demonstrating the efficiency or effectiveness of a service. The dimensions of quality he proposed are:

Access to service Relevance to need Effectiveness Equity Social acceptance Efficiency and economy

2. Wilson (1987) Wilson considers there to be four essential components to a QA programme. These are:

Setting objectives Quality promotion Activity monitoring Performance assessment

III.

AUDIT: a tool for quality assurance Nursing audit may be defined as a detailed review and evaluation of selected clinical records in order to evaluate the quality of nursing care and performance by comparing it with accepted standards. Nursing audit, is a review of the patient record designed to identify, examine, or verify the performance of certain specified aspects of nursing care by using established criteria.

 Nursing audit is the process of collecting information from nursing reports and other documented evidence about patient care and assessing the quality of care by the use of quality assurance programmes. A concurrent nursing audit is performed during ongoing nursing care. A retrospective nursing audit is performed after discharge from the care facility, using the patient's record. Purposes of Nursing Audit 1. Evaluating Nursing care given, 2. Achieves deserved and feasible quality of nursing care, 3. Stimulant to better records, 4. Focuses on care provided and not on care provider, 5. Contributes to research. Methods of Nursing Audit There are two methods: a. Retrospective view - this refers to an in-depth assessment of the quality after the patient has been discharged, have the patients chart to the source of data. Retrospective audit is a method for evaluating the quality of nursing care by examining the nursing care as it is reflected in the patient care records for discharged patients. In this type of audit specific behaviors are described then they are converted into questions and the examiner looks for answers in the record. For example the examiner looks through the patient's records and asks: a. Was the problem solving process used in planning nursing care?

b. Whether patient data collected in a systematic manner? c. Was a description of patient's pre-hospital routines included? d. Laboratory test results used in planning care? e. Did the nurse information used? perform physical assessment? How was

f. Were nursing diagnosis stated? g. Did nurse write nursing orders? And so on. b. The concurrent review - this refers to the evaluations conducted on behalf of patients who are still undergoing care. It includes assessing the patient at the bedside in relation to predetermined criteria, interviewing the staff responsible for this care and reviewing the patients record and care plan. Components of Nursing Audit: Auditing in health care organization provide managers with a means of applying control process to determine the quality of service rendered. Nursing audit is the process of analyzing data about the nursing process of patient outcomes to evaluate the effectiveness of nursing interventions. The audits most frequently used in quality control include outcome, process and structure audits. 1. Outcome audit Outcomes are the end results of care; the changes in the patients health status and can be attributed to delivery of health care services. Outcome audits determine what results if any occurred as result of specific nursing intervention for clients. These audits assume the outcome accurately and demonstrate the quality of care that was provided. Example of outcomes traditionally used to measure quality of hospital care include mortality, its morbidity, and length of hospital stay.

2. Process audit Process audits are used to measure the process of care or how the care was carried out. Process audit is task oriented and focus on whether or not practice standards are being fulfilled. These audits assumed that a relationship exists between the quality of the nurse and quality of care provided. 3. Structure audit Structure audit monitors the structure or setting in which patient care occurs, such as the finances, nursing service, medical records and environment. This audit assumes that a relationship exists between quality care and appropriate structure. These above audits can occur retrospectively, concurrently and prospectively. For the effective quality control, the nurse manager has to play following roles and functions. Advantages of Nursing Audit : 1. Can be used as a method of measurement in all areas of nursing. 2. Seven functions are easily understood, 3. Scoring system is fairly simple, 4. Results easily understood, 5. Assesses the work of all those involved in recording care, 6. May be a useful tool as part of a quality assurance programme in areas where accurate records of care are kept. Disadvantages of the Nursing Audit : 1. appraises the outcomes of the nursing process, so it is not so useful in areas where the nursing process has not been implemented,

2. many of the components overlap making analysis difficult, 3. is time consuming, 4. requires a team of trained auditors, 5. deals with a large amount of information, 6. only evaluates record keeping. It only serves to improve documentation, not nursing care Audit Committee : Before carrying out an audit, an audit committee should be formed, comprising of a minimum of five members who are interested in quality assurance, are clinically competent and able to work together in a group. It is recommended that each member should review not more than 10 patients each month and that the auditor should have the ability to carry out an audit in about 15 minutes. If there are less than 50 discharges per month, then all the records may be audited, if there are large number of records to be audited, then an auditor may select 10 per cent of discharges. Conclusion A profession concerns for the quality of its service constitutes the heart of its responsibility to the public. An audit helps to ensure that the quality of nursing care desired and feasible is achieved. This concept is often referred to as quality assurance.

Monitoring and Feedback

The quality management process is cyclic and requires monitoring of clinical and managerial performance and feedback to ensure that problems stay solved. Followup can be expensive and difficult. Its breadth should determine what should be covered. Problems of a multidisciplinary in nature, such as those involving

occupational therapy, physical therapy, speech pathology, and nursing, can be one consideration. The cyclic process will continue to set standards of care, take measurements according to those standards, evaluate care from multiple sources, recommend improvements, and above all, ensure that improvement are carried out.