CONTROLLING

Definition

Controlling or evaluating is the process by which we attempt to see that actual activities conform to planned activities.

- is an on-going function of management which occurs during planning, organizing and directing activities.

- includes assessing & regulating performance in accordance with the plans that have been adopted, the instructions issued & the principles established.

Definition

Performance is evaluated and corrective measures are taken to ensure the accomplishment of original goals

Provides information about how well processes and people functions so they can be motivated to perform better

It leads nursing administrators to view the delivery of nursing care as the institutional control of process that bring sick patients back to good health.

The control measures which may be utilized by the Nursing Service:

Quality Assurance

Nursing Audit

Performance Appraisal

Records and Report

Budget

Control Process

1. Establish standards for all elements of management in terms of expected and measurable outcomes.

2. Apply the standards by collecting data and measuring the activities of nursing management comparing standards with actual care.

Control Process

3. Make any improvements deemed necessary from the feedback

4. Keep the process continues for all areas including :

4.1 Management of the nursing division and its subunit

4.2 Performance of personnel

4.3 Nursing process /product

This may be expressed as a Formula:

Ss+ Sa + F+ C= I

Standard set Standards applied Feedback+ Correction=Improvement

Essence of Manager’s Control Function

To keep things in line and make sure plans are attained.

To make sure that subordinates are working on time, materials and resources are maximized and at the same time secured.

To ensure that certain authorities are not abused.

Manager’s Role in Control Process

1. Assessor

The manager observes what is happening (or what has occurred) during the transaction and compares his observation with the sets standards.

These standards are derived from the goals which set as part of the planning process

Manager’s Role in Control Process

2. Problem Solving and Decision making

Manager does not only determine the reason behind performance deviations but must also be able to institute necessary corrective action.

Reasons for Conducting Evaluation

Evaluation ensures that quality nursing care is provided It allows for the setting of the sensible objectives and ensures compliance

with them It provides visibility and a means for employees to monitor their own

performance Reasons for Conducting Evaluation It highlights problems related to quality care and determines the areas that

require priority attention It provides an indication of the cost of poor quality It justifies the use of resources It provides feedbacks for improvement

Evaluation Principles

Evaluation must be based on the behavioral standards of performance which the position requires.

In evaluating performance, there should be enough time to observe employees behavior.

The employee should be given a copy of the job description, performance standards and evaluation form before the scheduled evaluation conference.

The employee’s performance appraisal should include both satisfactory and unsatisfactory result to which specific behavioral instances exemplify the evaluative comment.

Areas needing improvement must be prioritized to help the worker upgrade her performance.

The evaluation conference should be scheduled and conducted at the convenient time for the rater and the employee under evaluation, in a pleasant environment and with ample time for discussion

The evaluation report and conference should be structured in such a way that it is perceived and accepted positively as a means of improving job performance

Characteristic of an Evaluation Tool

OBJECTIVE : is free from bias

RELIABLE : refers to the accuracy or precision of the tool such as it will produce the same result if administered twice

VALIDITY: refers to the relevance of measurement of the performance of the employee

SENSITIVE: the instrument can measure fine lines of difference among the criteria being measured

Basic Component of Control Process

Establishment of the standards, objectives, and methods of measuring performance.

Measurement of actual performance. Comparison of result of performance with standards and objectives and

identifying strengths and areas for correction and/or improvement. Action to reinforce strength for success. Implementation of corrective action, if necessary.

Types of Performance Standards

STANDARDS are desirable set of condition and performance necessary to ensure the quality of nursing, care services which are acceptable to those instrumental to or responsible to or maintaining them.

Structure standards are those that focus on the structure or management system use by the agency to deliver care.

Process Standards refer to the decisions and actions of the nurse relative to the nursing process which is necessary to provide good nursing care

Outcome Standards are design to measure the results of care provided in terms of changes in the health status of client serve, changes in the level of their knowledge, skills and attitude and satisfaction of those served including the members of the nursing and health team

Types of Control

1. According to Approach

Control by Inspection =done when the manager sees and checks the work himself though direct observation

Control by Exception = allowing the subordinate to evaluate his or her work output based on the set of standards set by the manager

2. According to time element

Preventive control= done on the onset before the implementing process

Focus: resources which include manpower

Objective: to ensure that only resources of desired specification and/qualities enter the process.

Types of Control

Concurrent control= controls that are taking place during the implementation process.

Focus: Operating conditions

Objective: To ensure that the desired conditions are maintained and problems are corrected before they come out of the process

Corrective control= takes place at the end of the implementation stage (after the product is finished or after the service had been delivered.

Focus: Problems that occur after the process

Objectives: To avoid problems of the same nature in the future

Performance Appraisal

Performance Appraisal is a control process in which employee's performance is evaluated against standards.

most valuable tool in controlling human resources & productivity.

reflects how well the nursing personnel have performed during a specific period of time.

Each employee should be evaluated by line supervisor.

Purpose of Performance Appraisal

To determine job competence

To select qualified employees for advancement and salary increase

To identify unsatisfactory employees for demotion and termination

Make inventory of talents within institution and re-assess assignment

To determine training and developmental needs of employees

To improve the performance work groups by examining and encouraging better relationship among them

To improve communication between supervisors and employees and reach an understanding on the objective of the job

To establish standards of supervisory performance and to aid the managers counseling and coaching ability

To discover the aspirations of employees and recognize their accomplishment and inform them “ where they stand”

Factors Contributing to an Effective Performance Appraisal

Compatibility between the criteria for individual and organizational goals.

Direct application of the rated performance to performance standards and objectives expected of the worker.

Development of behavioral expectation which have been mutually agreed by both the rater and the worker.

Understanding the process and effective procedure by the rater.

Rating of each individual by immediate supervisor.

Concentration on the strength and weakness to improve individual performance.

Encouragement of feedback from the rated employees about their performance needs and interest.

Provision for imitating preventive and corrective action and making adjustment to improve performance.

Types of Evaluation Devices

Performance Checklist

Consist of a list of performance criteria (task in JD) with corresponding blanks wherein an evaluator is asked to indicate for each criterion whether the nurse has exhibited the desired behavior.

Graphic Rating Scale

- Evaluator is asked to indicate the quality of the nurse’s performance for each activity by checking the appropriate point on a numerical scale

-Ex. Degree of nurse’s proficiency where each corresponding number means:

4 - Excellent

3 - High Proficiency

2 - Moderate Proficiency

1 - No proficiency yet

Free response report

Evaluator is asked to submit written report on the quality of the nurse’s performance in a particular position over a given period of time. No direction on which performance is to evaluated assessment is not comprehensive

Simple Ranking

- Evaluator ranked the employee according to how he fared with his co-workers with respect to certain aspects of performance

- Maybe ranked with regard quality of performance, to patient care measures, quality of contribution to a project

Forced- choice Comparison

- Evaluator is asked to choose from a group of weighted descriptive statement those that best describe the nurse being evaluated and those that least described her.

Ex. Select from the following statement the one which best describe …

1.1 enjoys the respect of co- workers

1.2 Tends to complain about the assignment

1.3 Prompt in reporting the changes in patient condition.

Behaviorally Anchored Rating Scale (BARS)

- New type of evaluation tool

- In BARS technique a separate rating instrument is developed for each job to develop each tool, staff help the manager to identify key dimension and determine the relative weight of each dimension for total job performance

Frequency of Evaluation

1st evaluation end of orientation

2nd eval. -3rd month Bi- annual -q 6 mo.

3rd eval. -6th month Annually-use PPMCC

Evaluation Principles

Evaluation must be based on behavioral standards of performance which the position requires. (JD and Performance Standards)

There should be enough time to evaluate an employee's performance; evaluate usual consistent behavior; observe an adequate and representative sampling of the nurse’s behavior

The employee must be given a copy of the job description, performance standards and evaluation form before the scheduled evaluation conference.

The employee’s performance appraisal should include both satisfactory and unsatisfactory results with specific behavioral instances to exemplify these evaluative comments.

Areas needing improvement must be prioritized to help upgrade his performance.

Evaluation conference shall be scheduled and conducted at a convenient time for the rater and the employee under evaluation with ample time for discussion

Evaluation report and conference should be viewed and perceived positively as a means for improving job performance.

Common Errors in Evaluation

Halo Error – allowing one trait to influence the evaluation of other traits or of rating all traits on the basis of a general impression.

Examples:

An employee with pleasing personality or strong social skills is likely to receive a higher performance rating than work quality warrants.

When a subordinate has performed well in the past, but not well recently observed.

An employee whose performance has been mediocre during the previous year but recently made a single spectacular performance.

An employee who shares the manager’s area of critical expertise or research interest.

Logical Error – rating a nurse high on one characteristic because the nurse possesses another characteristics that is logically related.

Horns Error – opposite of the halo effect and the evaluator is hypercritical a recent mistake may offset a year’s good work

Common Errors in Evaluation

Contrast Error – the tendency of the managers to rate the nurse opposite from the way they perceive their own ability and trust. A perfectionist manager may rate personnel lower than they should.

Central Tendency Error -

6. Recency Error- the tendency to have the appraisal on recent rather than their performance over the entire evaluation period.

Examples:

An employee who has performed at above average level throughout the previous year but committed a serious error a few days before the annual performance evaluation.

An employee whose work has been consistently above average but disagrees openly with the manager.

An employee who’s performing average but with poor performing peers.

Developing Performance Standards

Performance standard is the work a manager performs to establish criteria by which work and results can be measured and evaluated (How much we require), derived from JD, JA and job evaluation

Measures =are the yardsticks use to judge how well you have done each accomplishment (what to evaluate)

General Measures= Tell what is important, in general, about each accomplishment. They are used when you have difficulty identifying specific measures for a particular accomplishment

General Measures

Quantity :how many ,rate or volume

Quality :how well accuracy, completeness originality

Cost : how much, cost limits the employee has to work within

Timeliness : when deadline by which the accomplishments will be completed

Specific Measures = use words to evaluate the accomplishment you want to track. They define how will you know whether the quantity ,quality, cost, or timeliness standards have been met

Types of measures

Numeric measures- use numbers to evaluate accomplishment

Descriptive measures- use of words to evaluate ;list the factors that defines what exceeds expectation

Cost measures-

Timeliness measure- state the date, time, day, or amount of time needed to meet the expectation

Discipline

Discipline is a part of the controlling process in management. It is a constructive and effective means by which employees take personal responsibility for their own performance and behavior, this is termed as self-discipline.

Factors that influence self-discipline

A strong commitment to the vision, philosophy, goals and objectives of the institution.

- Strong commitment results in cohesion and teamwork which in turn encourage greater conformity to expected norms of conduct within the organization.

Laws that govern the practice of all professionals and their respective Codes of Conduct.

- All government employees must comply to the Civil Service Rules & Regulation as provided for in PD807 and the Code of Conduct for Public Officials, RA 6713.

Understanding the rules and regulations of the agency.

- During orientation, managers should give their employees a handbook containing rules and regulation and the possible sanctions for their infractions.

- Lack of knowledge of policies and procedures is a major cause of the need for disciplinary action.

4. An atmosphere of mutual trust and confidence.

- Self-discipline thrives best in an atmosphere of trust and confidence between superiors & subordinates

Principles of Discipline

Have a positive attitude.

If personnel are to treated as suspects, they are more likely to provide trouble.

2. Investigate carefully.

3. Be prompt.

The longer the delay the more likely, they are to feel that the discipline is not deserved.

4. Protect privacy.

5. Focus on the act.

6. Enforce rules consistency.

7. Be flexible. Consider mitigating factors.

8. Advice the employee.

9. Take corrective and constructive actions.

10. Follow-up.

Correcting Performance

COACHING-continuous reinforcing task that are well done and extending assistance to areas where improvement is necessary.

Correcting Performance

Counseling =assisting and giving advise to an individual or group for the purpose of helping them grow and develop self direction, self discipline and self responsibility

When to do counseling?

Getting to work is a problem ,real or imagined.

Off-jobs pressures are too strong that they weaken the employees resolve to work.

The employee is imitative, easily led or misled.

The work appears boring, disagreeable and/or unattractive

Working relationship are unpleasant

There are in fact off- job problems –child care, serious illness ,court appearances

Absence or tardiness has become a habit

Counseling Guidelines:

Listen carefully and with empathy

Convey genuine counsel

Describe what you can and cannot do

Keep the responsibility for solving the problem with the employee

Agree on action plan to solve the problem

Manager’s Role in Correcting Performance

Employee Counseling – to facilitate where she/ he listen more then talk

Non -Directive Approach - allowing the employee to have maximum freedom in determining the course of interview

Rewarding Good Performance:

One minute praising

Catch them doing the right thing

Praise openly

Be sincere

Do it immediately

Disciplinary action should be progressive in nature preceded by counseling.

Counseling

Verbal reprimand

Written reprimand

Preventive suspension

Penalty suspension

Discharge/Dismissal

QUALITY ASSURANCE

Assurance

Achieving a sense of accomplishment and implies a guarantee of excellence

A formal guarantee of a degree of excellence

Quality

The degree of excellence

Gives people with different functions in the organization a common language for improvement.

QUALITY OF CARE

The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with the current professional knowledge.

It is the balance of benefits and harms to a client of effectiveness and efficiency and appropriateness of care.

QUALITY ASSURANCE

A process of evaluation that is applied to the healthcare system and the provision of health care services by health workers.

It promotes collegial and sharing relationships among workers instead of a feeling of threat when observed and evaluated.

It focuses on the care and the service the patient receives.

TOTAL QUALITY MANAGEMENT

A way to ensure customer satisfaction by involving all employees in the improvement of the quality of every product or service. All systems are evaluated and improved.

It aims to reduce waste and cost of poor quality.

It is a structured system for involving an entire organization in a continuous quality improvement process targeted to meet and exceed customer expectations.

PRINCIPLES UNDERLYING QUALITY ASSURANCE EFFORTS

All health professionals should collaborate in the effort to measure and improve care.

Coordination is essential in planning a comprehensive quality assurance program.

Resource expenditure for quality assurance activities is appropriate.

There should be focus on critical factors such as functions and activities that promise to yield the greatest health and financial benefit to reveal significant findings.

Quality patient care is accurately evaluated through adequate documentation.

The ability to achieve nursing objectives depends upon the optimal functioning of the entire nursing process and its effective monitoring.

Feedback to practitioners is essential to improve practice. It perpetuates good performance and replaces unsatisfactory interventions with more effective methods.

Peer pressure provides the impetus to effect prescribed changes based on the results of assessment and needed improvements on the quality of care.

Reorganization on the formal organizational structure may be required if assessment reveals the need for a different pattern of health care.

Collection and analysis of data should be utilized to motivate remedial action.

QUALITY ASSURANCE METHODS

The primary purpose of quality assurance programs in nursing is to measure and improve the quality of nursing delivered in the agency.

Several methods used are:

concurrent patient care audits

retrospective patient care audits

patient care profile analysis

peer review

quality circles

DEVELOPING QUALITY ASSURANCE CRITERIA

Structure Approach

– includes physical setting, instrumentalities and conditions through which nursing care is given such as the philosophy and objectives, the building, organizational structure, financial resources and equipment.

Process Approach

– includes the steps in the nursing process in compliance with established standards of nursing practice.

Outcome Approach

- Identifies desirable changes in the patient’s health status such as modification of symptoms, signs, knowledge, attitudes, satisfaction, skill level, and compliance with the treatment regimen.

Reports

Oral, taped or written exchanges of information between nurses and/or members of health team.

A. Change-of-shift-reports

- system of communication aimed at transferring essential information and holistic care for patients.

Oral Report – pre-conference made at Nurses’ station prior to the nursing rounds

- should be done quickly and efficiently.

Reports

2. Audio-tape report – made by the outgoing nurse and is replayed by the incoming nurse.

3. Nursing Rounds – made at the patient’s bedside. The patient’s care plan is discussed.

B. Telephone Reports and Orders

- should be accurately transcribed by the receiving nurse in written form.

- such order should be sign by the physician on his next visit on the hospital.

Reports

Telephone Reports and Orders

- nurse should note the date time when the order was made, when he wrote the order, the name of the physician making the order, then sign his own name including designation.

C. Transfer Reports

- patients may be transferred from one unit to another as their conditions or case warrants it.

Transfer Report

- it contains the summary of the medical progress up to the time of transfer, current health status, current nursing diagnosis or health problems and care plan or critical assessments or interventions to be completed after transfer and the special equipment necessary.

- oral report is usually made by the accompanying nurse so that additional information can be made or clarified.

Records

Printed or written that can be as record or proof for authorization.

Documentation of nursing care should be pertinent and concise and should reflect the patient’s status.

Nursing documentation shall address the patient’s needs, problems, capabilities and limitations.

Nursing interventions provided and the patient’s responses should be noted.

FORMS

Nursing Health History and Assessment Worksheet

- contains basic biographical data, his present illness, past health history, family health history, emotional profile, environmental history and physical assessment, including the nursing diagnosis on admission.

B. Graphic Flow sheets

- forms that allow nurses to record specific measurements of observation on a repeated basis.

Medicine and Treatment Record

- contains all medications and treatment given on repeated basis.

Nursing Kardex

- flip-over card that has two parts: an activity and treatment section and a nursing care plan section.

- it contains the basic demographic data, primary medical diagnosis, current physician’s orders to be carried out by the nurse, a written nursing care plan, nursing orders, scheduled tests and procedures, safety precautions to be used in client care & factors related to activities of daily living.

Discharge Summary

- a special progress report that helps ensure that a client’s discharge results in desirable outcomes

- this includes the following:

Teaching and counseling to prepare the patient discharge

Current medications and treatments to be continued and the precautions to observe and report

Activities of daily living and self-care activities

Support system

Mode of discharge

Person who will accompany patient on discharge

destination

Nurses Progress Notes

- narrative descriptions of patient’s progress toward goal achievement.

- includes assessment of the client’s mental and physical condition, client activities, nursing interventions and treatments performed by physicians that affect nursing care.

G. SOAP Charting

- includes subjective data, objective data, assessment, the plan, intervention, evaluation and revision

Guidelines for Good Reporting & Documentation

Factual - based on facts, objective not opinion

Accurate - reliable, timed, dated, correct spelling

Confidential- shared by members of health team

Complete -concise, described nsg. care rendered

Current -updated, omission avoided

Organized - logical format of repotting

Ethical -described what pt. did, refrain from using terms as “uncooperative", can use the word refuse

Purposes of Records

Communication -members of health team can keep track of pt’s progress

Legal evidence of care-description of what happen

Education-used for study to learn the case, disease

Financial Billing-finances reimbursement, HMO

Evaluation of quality of care rendered

Research & Statistical Information-client population, frequency of disorder, complication

Documentation

Nurses are expected to document fully, accurately legibly and promptly their observations and care they rendered from admission to discharge.

Patient’s response

Inaccurate document –cause unnecessary delay in the treatment ,basis for lawsuits

Rule “What was not written ,was not given or observed”

Documentation

Charting made by the nsg.students –CI to countersigned attesting that this was done under their supervision

NURSE as a MANAGER

Definition

Provides medication support services, psychiatric after-care and case management services for mentally ill and emotionally disturbed clients on an out-patient basis;

Collaborates with inter-disciplinary health treatment teams to plan treatment;

Assists in developing treatment plans

Performs related work as assigned.

Distinguishing Characteristics

Provides direct nursing, case management & continuing care services for designated clients in the out-patient program including those who have been discharged from the in-patient psychiatric facility.

Services are primarily provided in the home of the client or other community facility which requires the incumbent to work independently.

Examples of Duties (Illustrative Only)

Formulates and reviews with assigned client an individual plan of care; submits plan to nursing and medical staff for approval; coordinates plan with discharge staff; explains purpose of plan and the clients participate in the outreach services program.

Administers medications to clients in their homes or others sites in the community; assists clients to set u medication organizers and other established methods to enhance medication compliance

Provides on going medication education including medication side effects, potential interactions with foods, beverage, other medications and substances.

Conducts individual assessment including mental status, stability of illness, medication compliance, side effects and response to medications; evaluates the need for continuing services

Provides transportation to medical/psychiatric appointments, laboratory, pharmacy and other related appointments; coordinates with other staff for additional support service.

Monitors supports and assists client in developing & maintaining the skills required to achieve independent living status. Performs crisis intervention to provide support and assistance in problem resolution and to coordinate or arrange for the provision of needed services; is available for emergency situations as needed.

Maintains accurate records in compliance with state, local and maintain trust, observes overall living condition making referrals as needed.

Works closely & cooperatively with the Country Public Guardian; may appear in court as needed.

May serve as case coordinator for assigned patients

May administer medications to clients in a variety of mental health clinics.

Qualifications:

Knowledge of:

Principles & practices of general psychiatric nursing care

Techniques for dealing with disturbed individuals and their families

Principles and practices for providing nursing care in a home environment

Medical and psychiatric terminology and first aid methods and procedures

Principles and methods of mental health case management particularly as related to assessment and continuation of long term services

Psychiatric medicines, including narcotics and their side effects.

Standard medical recordkeeping, including patient charting and the processing and maintenance of required documentation.

Skill in:

Conducting psychiatric assessments and evaluating and reporting physical and mental condition findings to medial staff

Developing effective client care plans including medication maintenance monitoring plans.

Developing and marinating a supportive client relationship including fostering the client trusts.

INVENTORY

Inventory is an administrative tool designed to control supplies and equipment by listing the names, description, number and location of supplies.

Purposes of Inventory

To determine if standard are maintained

To serve as a basis for the revision of standards and systems

To recommend proper action on obsolete and surplus materials

4. To determine the operational status of equipment

5. To prepare plan for repairs and replacements

6. To determine the proper location of supplies, materials and equipment

7. To gather factual information to serve as basis for sound procurement planning.

Kinds of Inventory

Perpetual Inventory – recording is done as soon as supplies were used and replenished, thus indicating the number of supplies on hand at a time.

Physical Inventory – is he actual count made at designated intervals to correct accumulative errors resulting from loss, breakages or deterioration. Fixed equipment is usually inventoried annually; movable equipment, monthly; instruments, weekly; and narcotics, daily.