Controlling Related to Nursing Management

Nursing Management

1. Controlling Shraboni Roy Teaching Assistant Department of Graduate Nursing

2. Introduction Controlling is an important element of the management process. In addition to pointing out the actions needed to accomplish the goals, it provides a record of actual performances. It is a process of verification and comparison that ascertains anticipated performance. Towards some predetermined goals control directs activities.

3. Introduction Controlling consists of the following activities - Control over policies of an enterprise Control over organization Control over personnel employed in a concern Control over wages and salaries paid to the employees Control over costs of material, labor, overheads Control over capital expenditure Control over production Overall control

4. What is control/controlling?? E.F.L. Brech : Control is checking current performance against predetermined standards contained in the plans with a view to ensuring adequate progress and satisfactory performance. George R. Terry: Controlling is determining what is being accomplished, that is, evaluate the performance and, if necessary, applying correctives so that the performance takes place according to plans.

5. What is control/controlling?? H. Fayol: In an undertaking, control consists in verifying whether everything occurs in conformity with the plans adopted, the instructions issued and the principles established. objective is to point out the weaknesses and errors in order to rectify them and prevent occurrence. It operates on everything, that is, things, people and actions.

6. Areas of Control Policies Wages and salary Production Materials and labor Capital expenditure Overall control Employee Organization

7. Essentials of effective control system 1 . Reflect organizational needs: The control system adopted should suit the needs of a concern. For instance, the control system used in the finance department will be different from that used in the sales department or the production department.

8. Essentials of effective control system 2. Promptness in reporting deviations: The control system should enable subordinates to inform their superiors in time about what they have achieved. This would help the managers in detecting deviations and also in taking prompt corrective actions.

9. Essentials of effective control system 3. Forward-looking control: A good control system is one that detects deviations early enough so as to enable the manager to take quick corrective action. 4. Objective control: Control should be objective. Objective control clarifies the expected results in clear and definite terms and also provides the control standards by which actual performance can be measured.

10. Essentials of effective control system 5. Flexible control: Plans and other predetermined standards or criteria need to be altered from time to time. 7. Simple control: To be effective, control must be simple and easily understandable by the manager as well as the subordinates. 8. Corrective action: The control system should not only detect deviations from the predetermined standards but should also provide solutions to the problems that are responsible for deviations.

11. Essentials of effective control system 9 . Acceptability 10. Reveal exceptions at strategic points 11. Motivation to high performance 12. Others: Control should be positive, constructive and helpful and should also provide guidance to the employees. Further, the manager should recognize the importance of human beings in the control system.

12. Characteristics of control Control is continuous process Control is forward looking Control process is universal Control involves measurement Control is an influence process

13. Type of control system Budgeting Internal auditing External auditing Reports Standing order and limitations Job descriptions Personal observation / supervision Program evaluation and review technique (PERT) Human resource accounting

14. Advantage of control Control prevents faulty operations and creates a good base for the future and help in taking sound decisions. Control systems ensure corrective measures in case the plan activity deviates from original designs. Control systems provide a good opportunity for decentralization of authority. Control brings about coordination in planned activity. A good control system acts as a disciplinary measure and brings about operational efficiency

15. Importance Facilitates decision making Facilitates decentralization Stimulates action Enhances employee morale Promotes efficiency of operation Promote coordination Psychological pressure

16. Role of nurse in charge in ward control 1. Carrying out the instructions of the medical officers regarding the treatment of patients, observing and recording the progress of treatment and generally assisting the medical officer to achieve his/her therapeutic aim. 2. Maintaining general cleanliness and cheerful environment for the patients.

17. Role of nurse in charge in ward control 3. Supervising care and maintenance of buildings, furniture, fittings, and arranging the reports through the CNO or medical officer. 4. Keeping the ward equipment in optimum state of readiness by prompt repairs and replacement through condemnation boards .

18. Role of nurse in charge in ward control 5. Assigning of duties for patient care to the staff working in the ward, taking into consideration the capabilities of each. 6. Indenting the collection of various items of medical, QM and other stores.

19. Role of nurse in charge in ward control 7. Ensuring that all specimens are sent to the laboratory in time and results collected when due. 8. Maintaining strict control over accounting and distribution of controlled and dangerous drugs. 9. Ensuring requisition of diet as per the instructions of the medical officer and making sure that the diets and extras are distributed to patients as per the requisition.

20. Role of nurse in charge in ward control 10. Ensuring that sufficient linen is available in the ward. 11. Maintaining all the registers and documents required in the ward. 12. Supervising all that is happening in the ward, to ensure that the patient's treatment an recovery are as smooth and pleasant as possible. 13. Training of nursing and other personnel working in the ward.

21. What is Quality? Quality is defined as 'the degree to which the patient care services increase the probability of desired outcomes and reduce the probability of undesired outcomes given the current state of knowledge. - Joint Commission for Accreditation of Health Care Organization

22. Purposes of Quality To meet the needs and expectation of the customers, both external and internal To meet increased demand for effective and appropriate care To minimize the errors and further eliminated to attain excellence in care To bring improvement in care and services To bring efficiency in the use of health care resources and effectiveness in the delivery of care and services

23. Purposes of Quality To reduce the failure and appraisal costs To fit into the pressure of competition and to enhance marketing To complete accreditation, certification and regulation To fulfill the ethical code to provide the best and most appropriate care accessible to the patient To fulfill the desire for recognition and to strive for excellence To attract recognition in the field and will encourage other individual, organizations or systems to emulate and follow

24. Quality control It is defined as "the process by which actual performance is measure, the performance is compared with goals, and the difference is acted upon. The statistical methods are used to measure the quality.

25. Quality Assurance (QA) " Quality assurance is a judgment concerning the process of care, based on the extents to which that care contributes to valued outcomes". -Donabedian, 1982 Bull 1985 defined "quality assurance as the monitoring of the activities of client care to determine the degree of excellence attained to the implementation of the activities".

26. Quality Assurance (QA) According to the Joint Commission, QA was initially defined as: "The process for objectively and systematically monitoring and evaluating the quality and appropriateness of patient care, and for resolving identified problems.“ Whereas 'appropriateness' referred to the extent to which a particular procedure or treatment is efficient, is clearly indicated, is neither excessive nor deficient, and is provided in a setting best suited to the patient's needs.

27. Standard of Nursing Care Standards can be defined as a benchmark of achievement, which is based on a desired level of excellence. Donabedian defines that standards are professionally developed expressions of a range of acceptable variations from a norm or criterion. Whereas criteria are defined as predetermined elements against which aspects of quality of medical service may be compared and norms as 'measures' of usual observed performance.

28. Standard of Nursing Care A standard is a descriptive statement of desired level of performance against which the quality of structure, process or outcomes can be judged. Thus applying this concept, the nursing care standard can be defined as 'a descriptive statement of desired quality against which nursing care given to a patient is evaluated'.

29. Characteristics of standard Standards must be: Specific Measurable Appropriate Reliable Timely implemented

30. Taxonomy of standard Viewed into two dimensions. Dimension one - Specifies the type of standards Dimension two – Specifies the context of standards

31. Dimension one Structure standards : Structural standards establish guidelines for organizational patterns and support structures for providing health care. It defines the rules under which the services must be delivered. These outline the legal parameters that govern performance expectations. These are non-negotiable and cannot be situation ally modified.

32. Dimension one Structure standards : They include mission, philosophy, goals, policies and job descriptions of the organization/ department. The physical plant, equipment, number of personnel, their educational backgrounds. and job assignments are also considered for the structure standards. Standard for physical facilities include heating and ventilation and infection control capabilities.

33. Dimension one Process standards: Process standards define how the service is to be carried out. It also referred to as performance standards. These are modifiable based on individual practitioner's analysis of the situation and their decisions. It translates the organizational values into actions. It defines in writing those processes for which the organization will be held accountable. It is negotiable and flexible.

34. Dimension One Process standards: Procedures, protocols, practice guidelines, plans and documentation are the examples of process standards. A process standard might specify that the initial nursing care plan be established within 24 hours of admission. These standards are receiving increasing attention as a way to systematize care and eliminate the inappropriate deviation from what have been identified as best practices.

35. Dimension one Outcome standards: These are part and parcel of every process and define both desirable results that to be achieved and undesirable results that to be avoided. These might be patient outcomes.

36. Dimension one Outcome standards: Outcomes are attached to all process standards and are written for every procedure, practice, guidelines and plan. The Institute of Medicine (IOM) has identified that process and outcome must go hand in hand. Effective processes increase the likelihood of appropriate outcomes. However if outcomes are not met, it may mean that processes need to be changed (IOM, 1999).

37. Dimension Two Nursing service standards Standards of nursing practice Standards of governance

38. Nursing service standards from the accreditation manual for hospitals There is an organized nursing department/service The nursing department/service is directed by a qualified nurse administrator and is appropriately integrated with the medical staff and with other hospital staffs that provide and contribute to patient care The nursing department/service is organized to meet nursing care needs of patients and to maintain established standards of nursing practice Care are commensurate with the qualifications of nursing personnel and are designed to meet the nursing care needs of patients

39. Nursing service standards from the accreditation manual for hospitals 5. Individualized, goal-directed nursing care is provided to the patients through the use of nursing process. personnel are prepared through 6. The nursing department/service appropriate education and training programs for their responsibilities in the provision of nursing care 7. Written policies and procedures that reflect optimal standards of nursing care practice guide the provision of nursing care 8. As part of hospital's quality assurance program, the quality and appropriateness of the patient care provided by the nursing department/ service are monitored and evaluated, and identified problems are resolved

40. American Nurses Association Standards The nursing department has the responsibility and authority for the practice of nursing in the health care facility. The nursing department is allocated the finance necessary to carry out the departmental program. The nursing department promotes safe and therapeutically effective nursing care through implementation of established standards of nursing care. It has clearly delineated responsibilities in the health facility's disaster plan. It has written personnel policies, which can be expected to attract, qualified nursing programmes and opportunities for staff development.

41. American Nurses Association Standards It develops a written agreement with the educational institution for the use of the clinical facilities by nursing students, which ensures the safety and welfare of the patients. It initiates and promotes studies of and where feasible, research on administrative, supervisory and nursing cares practices. It ensures and provides the physical facilities, supplies and equipments needed to carry out the objectives and standards of nursing department. It continuously evaluates its administrative, supervisory and nursing cares practices.(ANA Standards of Professional Nursing Practice (Source: American Nurses Association (ANA) Scope and Standards of Nursing Practice, 2022).

42. Models of quality assurance American nurses' association model Donabedian model Wilson's model Quality health outcome model Quality management model

43. Models of quality assurance Focus-PDCA Model (Quality Management Model) Joint commission 10 Step process model Performance management system paradigm Quality caring model Marker's umbrella model

44. What is six sigma?? Six-Sigma stands for Six Standard Deviations from mean. Sigma is the Greek letter of the alphabet used to describe variability or in mathematical or statistics term, Standard Deviation. Standard deviation, a measure of dispersion (spread), indicates how far away a measured result is from the average (the center of data).

45. What is six sigma?? Six-Sigma is a rigorous and a systematic methodology that utilizes facts and statistical analysis to measure and improve organizational operational performance, practices and systems by identifying and preventing 'defects' in service-related processes in order to accomplish effectiveness (Craig Tonner).

46. Six sigma management system Set client focused high objectives Prioritize resources for projects Mobilize teams to attack high impact projects Collect and analyze data to take decisions Accelerate improved service results Direct efforts to ensure improvements

47. Benefits of six sigma Increased cost savings Decrease levels of variations/negligence Improved service quality Maintains consistent quality of output Better customer/client service Enhanced employees morale and satisfaction

48. Nursing Audit The term audit means an official examination of activities or financial records to see that they are true and correct. It is also an official examination of quality or standard of something. 'Nursing audit refers to assessment of the quality of clinical nursing’ - Elison

49. Nursing Audit Nursing audit is a formal detailed systematic review of records or observation of nursing actions in order to evaluate quality of nursing care by comparing the documented evidence with accepted standards and criteria. It is the examination of a patient record to determine the degree to which nursing care was satisfactory according to prescribed standards and to collect data as a base for corrective action.

50. Bases of Nursing Audit Debit items Credit items Nursing auditors Quality Development of nursing standards Activities Resources

51. Bases of Nursing Audit Debit items: death of the patient complication of disease hospital infections errors in treatment patients left against medical advice, untoward reactions etc

52. Bases of Nursing Audit Credit items: number of recovered patients expansion of health knowledge in patient population shorter stay of patients

53. Bases of Nursing Audit Nursing Auditors: Nursing auditors required are of two types: internal and external. These should be trained auditors. Quality: It is a degree of excellence that needs to be defined and predetermined on the basis.

54. Bases of Nursing Audit Nursing Standards: These should be valid and explicit statements about the quality of facts of nursing care. These are classified as: structure, process and outcome. The structure relates to the characteristics of health care institution and men, money, material, methods required for the nursing organization, process is the performance of nursing care delivered by the care providers, and outcome indicates the end results in relation to objectives of nursing organization and that of health care institution.

55. Bases of Nursing Audit Activities: These are the goal oriented transactions required to carry out for auditing. Resources There are in relation to human and material required for auditing and desired health care.

56. Types of Nursing Audit Retrospective: This means looking back at what has happened in the past. This type of audit takes place by the use of records maintained by the nurses for the care of patients and for doing other administrative or managerial work.

57. Types of Nursing Audit Concurrent: Other name for concurrent is prospective. The information is gathered at the time care is given or this type of audit takes place while the patient is receiving care in the hospital. They may be observed directly for the care. Sometimes, the nurse may be interviewed for the care rendered to the patient. Observation check list or the interview guide, rating scales, Opinionnaire will be used for audit.

58. Types of Nursing Audit Retrospective and Concurrent: Both methods are used for auditing the care received by patients. Observation, interviewing, and questionnaires are the techniques used for this purpose.

59. Clinical Audit Cycle Usually clinical audit cycle has six stages that must be undertaken to ensure an audit is systematic and successful. The stages are: Identify a topic Set criteria or standard Collect data Compare results with criteria and standard Implementing change Re-audit

60. Golden tips to practice nursing audit Appoint an audit committee with approval from appropriate authority Select committee members keeping in mind unidisciplinary or multidisciplinary type of committee Conduct regular meetings with members Make a priority list of problems and issues Have a grand round by the audit committee Develop standardized tools and should be available with the with the committee members

61. Golden tips to practice nursing audit Orient the auditors for data collection and data analysis Be honest while gathering information Be sensitive to the attitude and feelings of subjects Make realistic recommendation for improvement or change if required Ready with the action plan- Implement the change and monitor the progress

62. Golden tips to practice nursing audit Make the audit a continuous process by implementing and re-auditing Use guiding approach rather than fault finding Keep a record of all the information and remedial action taken

63. Performance appraisal Performance appraisal is the process of evaluating the performance and qualifications of the employees in terms of requirements of the job for which he/she is employed, for the purposes of administration including placement, selection for promotion, providing financial rewards and other actions which require differential treatment among the members of a group as distinguished from actions affecting all members equally.

64. Characteristics of performance appraisal It is a formal systematic procedure involving usually three steps: setting work standards, assessing employee's actual performance against set standards, and provide feedback to the employees to improve deficiencies. It is to find out how well the employee is performing the job Employee knows that they are being evaluated

65. Characteristics of performance appraisal The focus of the performance appraisal is measuring and improving the actual performance of the employee and also the future potential of the employee Performance appraisal is not job evaluation It is a future oriented activity as it aims on employee development It is both formal or informal; but formal is more objective as well systematic

66. Performance appraisal process Establish performance standards Communicate the standards Measure actual performance Compare actual performance against standards and discuss the results Taking corrective action if required

67. Methods of performance appraisal Individual evaluation method Confidential reports Essay appraisal Critical incidences Checklists Graphic rating scale Behaviorally anchored rating scale Forced choice method Management by objective method

68. Methods of performance appraisal Multiple person evaluation methods Ranking method Paired comparison Forced distribution

69. Methods of performance appraisal Other methods Assessment center Group appraisal Field review method 360 degree appraisal

70. Discipline Discipline means voluntary and willing compliance of rules and regulations and instructions and also development of right habits of conduct in work with others at the work-place. It is the orderliness; the absence of chaos, irregularity and confusion in the behavior of employees.

71. Discipline It refers to a set of actions imposed by organization on its employees for failure to follow the organizational rules, standards and policies. Discipline implies confirming with the code of conduct established by the organization. In short, discipline implies obedience, orderliness and maintenance of proper subordination among employees.

72. Principles of Discipline There should be sound standard of conduct, codes and norms in the organization. Employees should be aware of standard of conduct, codes and norms. Conscious efforts should be made to create conditions for easy acceptance of the laid down norms. Standard of conduct, codes and norms should be implemented promptly and reviewed time to time. Disciplinary action, if required, should be taken promptly, privately, thoughtfully and consistently. Proper procedure should be adopted to take any disciplinary action. It should be progressive in nature and development approach should be used.

73. Role of Nurse Administrator in Maintaining Discipline Make your expectations clear to subordinates Develop a positive attitude towards employees Appreciate if subordinates take initiative and self disciplined Treat them as mature persons Have trust on your staff and accept their potentialities Spend time with them and have meetings with them Generate positive work culture in the department Make rules and policies available to all the employees

74. Role of Nurse Administrator in Maintaining Discipline Formulate friendly implementations of policies Carefully keep a record of employees disciplinary action Investigate carefully and be prompt if staff has any grievances Be empathetic to the grievances Avoid severe disciplinary procedures that may back fire Take corrective and constructive action Allow employees feedback in the disciplinary process

75. Supervision Supervision has been defined as 'overseeing', as higher vision. It refers to the direct and immediate guidance and control of subordinates in the performance of their tasks. It conveys different ideas to different people. It means directing, investigating, guiding, helping, and advising the subordinates in their performance with the purpose of achieving the established objectives. It is a teaching learning process which provides constant observation, monitoring, evaluation and guidance to subordinate to enable them to perform their activities effectively and efficiently.

76. Procedural Steps for Supervision Preparation Phase Actual supervision Follow-up supervision

77. Preparation Phase Have knowledge regarding relevant problem which may arise. Assess the performance of individual staff. Study the hospital policy, routine, rules, regulation, guidelines, procedure manuals, job specification, standard norms, targets, etc. Prioritize areas, activities and tasks related to nursing care which should be supervised. Prepare checklist for observation, prepare plan, schedule and content for supervision say work plan.

78. Actual supervision Establish contact with subordinates, clients and their relatives and with other team members. Review the objectives with subordinates . Review the job description. Observe nursing staff' motivation and interest towards work. Observe the performance of all tasks of the staff with regard to skill, attitude, organization of resources, and its utilization. Identify gaps and needs for the follow up action. Reporting to health team.

79. Follow up supervision Prepare a report of observations made during supervision. Plan for follow up actions on: Organizing in-service training programmes Reorganization of time table/work plan/duty roster Guidance and counseling of staff members Initiating action on staff welfare activities

80. THANK YOU ….