Controlling

What is controlling?

Controlling is one of the basic functions of managers.

(The other basic functions are planning, organizing, directing).

It is the measurement and correlation 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.

SETTING CONTROL STANDARDS

Standards can be quantitative or qualitative

Quantitative: Physical units: 2 thermometers in each examination room in health centre

Qualitative: clean sheets of examination beds.

CONTROL STANDARDS

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.

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.

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 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.

MEASURING PERFORMANCE (MONITORING)

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

CORRECTIVE ACTION Performance meets standards

(In-control loop): No change is required. Continue monitoring.

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.

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. Behavioural 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

Behaviour 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. a

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 judgement, 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. a

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.