Controlling

CONTROLLING

• One of the important functions of a manager.

• As ensuring that activities in an organization are performed as per the plans.
• Ensures that an organization’s resources are being used effectively & efficiently for the
achievement of predetermined goals.

EVALUATION MECHANISM

1. QUALITY ASSURANCE (QA)

• Is a way of preventing mistakes and defects in manufactured products and avoiding

problems when delivering products or services to customers, which ISO 9000 defines as
"part of quality management focused on providing confidence that quality requirements
will be fulfilled".

• Standards
o Are professionally developed expressions of the range of acceptable variations
from a norm or criterion"-Avedis Donabedian.
o Defined as "Benchmark of achievement which is based on a desired level of
excellence.
o Criteria are pre-determined elements against which aspects of the quality of
medical service may be compared.

What are Nursing Standards?

▪ All standards of practice provide a guide to the knowledge, skills, judgment &
attitudes that are needed to practice safely.
▪ They reflect a desired and achievable level of performance against which actual
performance can be compared. Their main purpose is to promote, guide and
direct professional nursing practice.
 Why are Standards Important?

▪ Outlines what the profession expects of its members.

▪ Promotes guides and directs professional nursing practice – important for self-
assessment and evaluation of practice by employers, clients and other
stakeholders.
▪ Provides nurses with a framework for developing competencies.
▪ Aids in developing a better understanding & respect for the various &
complimentary roles that nurses have.

2. CONTINUOUS QUALITY IMPROVEMENT

• Or CQI, is a management philosophy that organizations use to reduce waste, increase

efficiency, and increase internal (meaning, employees) and external (meaning,
customer) satisfaction.

• It is an ongoing process that evaluates how an organization works and ways to improve
its processes.

• Continuous Quality Improvement (CQI) is:

o A theory-based management system that looks at processes/outcomes.

o Culture change.
o Client-centered philosophy.
o Tools to help quantify what we do.
o A search for common causes of variation.
o Driven by data.
o System, process and client feedback.
o Shared success.
o Long-term approach.

• Key elements of Continuous Quality Improvement

o Accountability.
o Driven by good management...not crisis.
o Driven by input from all levels of staff and stakeholders.
o Teamwork.
o Continuous review of progress.
 • Internal and external benefits of Continuous Quality Improvement

o Improved accountability.
o Improved staff morale.
o Refined service delivery process.
o Flexibility to meet service need changes.
o Enhances information management, client tracking & documentation.
o Means to determine & track program integrity and effectiveness.
o Lends itself to design of new programs & program components.
o Allows creative/innovative solutions.

• Goals of Continuous Quality Improvement

o Guide quality operations.

o Ensure safe environment & high quality of services.
o Meet external standards and regulations.
o Assist agency programs and services to meet annual goals & objectives.

• Involved in Continuous Quality Improvement

o Persons & families served.
o Employees, volunteers & consultants.
o Members of advisory boards.
o Consumer advocates.
o All levels of agency staff.

3. PERFORMANCE EVALUATION

• Is the process of evaluating how effectively employees are fulfilling their job
responsibilities and contributing to the accomplishment of organizational goals?

• 7-Steps Performance Evaluation

o Job Analysis.
o Establishing performance standards.
o Communicating the standards.
o Determining the actual performance.
 o Matching the actual with the desired performance.
o Discussing results.
o Decision making.

4. 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 programs.

• Nursing audit is a detailed review and evaluation of selected clinical records by qualified
professional personnel for evaluating quality of nursing care.

• 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.

• Audit as a Tool for Quality Control.

• An audit is a systematic and official examination of a record, process or account to

evaluate performance. 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 patient's 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.

Advantages of Nursing Audit:

- Can be used as a method of measurement in all areas of nursing.
- Seven functions are easily understood.
- Scoring system is fairly simple.
- Results easily understood.
- Assesses the work of all those involved in recording care.
- May be a useful tool as part of a quality assurance program in areas were accurate
records of care are kept.

Disadvantages of the Nursing Audit:

- Appraises the outcomes of the nursing process, so it is not so useful in areas where the
nursing process has not been implemented.
- Many of the components overlap making analysis difficult.
- Time consuming.
- Requires a team of trained auditors.
- Deals with a large amount of information.
- Only evaluates record keeping. It only serves to improve documentation.
- Not nursing care

5. NURSING ROUNDS
• A procedure in nursing education and in later practice in which one or more visits to a
hospital patient are scheduled by two or more nurses to coordinate care, troubleshoot,
respond to patient needs, and share insights.
6. VARIANCE REPORT
• Variances, or deviations from practice, that lead to a quality defect or problem are
reported.

• The purpose of this reporting is to give the health care facility and the health care
professionals the opportunity to address the issue and prevent the occurrence of future
incidents, events, irregular occurrences, and variances.

• The data collected on these reports is analyzed, tracked and trended over time in a
blame free environment that is consistent with the health care facility's culture of
safety.

• Nurses must immediately report all client care issue, concern or problem to the
supervising nurse, the charge nurse and/or the performance improvement or risk
management department according to the reporting policies and procedures of the
particular facility.

CLASSIFICATION OF VARIANCES

Practitioner variance
▪ Is an irregularity that is associated with the care and/or service provided by a
health care provider.
▪ For example, an untimely medical assessment upon admission is considered a
practitioner variance.

System/institutional variance
▪ Is an irregularity that is associated with the care and/or service given by the
facility.
▪ For example, the lack of necessary supplies and equipment to adequately and
safely care for patients and the lack of staff education and competency
validation are considered system/institutional variances.

Patient variance
▪ Is an irregularity that is associated with the patient themselves and not the
health care provider or the facility.
▪ For example, the development of a pressure ulcer secondary to the patient's
immobility and poor nutritional status is an example of a patient related
variance.
Benchmarking
▪ Benchmarking is a comparison and measurement of a healthcare organization's
services against other national healthcare organizations.
▪ It provides leaders with insight to help them understand how their organization
compares with similar organizations that provide the same services.
▪ It also allows for the sharing of best practices and evidence-based practice (EBP)
clinical research outcomes between healthcare facilities at a national level.
Benchmarks can be tailored to specific areas of nursing, such as acute- and long-
term-care hospitals, hospice, and home health facilities.

The four core principles of clinical practice benchmarking are

- Maintaining quality.
- Improving customer satisfaction.
- Improving patient safety.
- And continuous improvement.

Accreditation
▪ Is a process of review that allows healthcare organizations to demonstrate their
ability to meet regulatory requirements and standards established by a
recognized accreditation organization?
▪ Reflects an agency’s dedication and commitment to meeting standards that
demonstrate a higher level of performance and patient care.
▪ An external evaluation mechanism which assesses the performance of HCOs
through investigating their compliance with a series of pre-defined, explicitly
written standards.
▪ Its aim is to encourage continuous improvement of quality rather than simply
maintaining minimal levels of performance.
▪ It is also described as the public recognition emanating from the achievement of
specific standards by a Health Care Organization, which is demonstrated after an
independent external assessment of the organization's performance.

Benefits of accreditation
- Benefits all stake holders.
- Patients are the biggest beneficiary.
- Accreditation results in high quality of care and patient safety.
- The patients get services by credential medical staff.
- Rights of patients are respected and protected.
- Patient satisfaction
- Regularly evaluated.

Local Accreditors

- DOH
- Phil health

International Accreditors

- Joint Commission (formerly the Joint Commission on Accreditation of

Healthcare Organizations [JCAHO]).
- Joint Commission International (JCI) works to improve patient safety and
quality of health care in the international community by offering education,
publications, advisory services, and international accreditation and
certification.

- Four Philippine hospitals have been cited by Joint Commission International

(JCI) for rendering the best service to Filipino patients.

1. Makati Medical Center.

2. The Medical City in Pasig City.
3. St. Luke’s Medical Center (SLMC) in Quezon City.
4. Chong Hua Hospital in Cebu.

- ISO 9001 Is a universally used quality management standard, adopted by

organizations all over the world to standardize and improve the service given
to customers.

Magnet Accreditation
- The designation of “Magnet Hospital” is awarded by the American Nurses
Credentialing Center (ANCC). This coveted honor helps hospitals attract
patients, nurses, and other medical staff.
- Before achieving Magnet status, a hospital must demonstrate excellence in
nursing and patient care as well as innovation in professional nursing
practice.
Employee Discipline
▪ Is defined as the regulations or conditions that are imposed on employees by
management in order to either correct or prevent behaviors that are detrimental
to an organization.
▪ The purpose of employee discipline is not to embarrass or degrade an employee.
▪ The purpose is to ensure that an employee performs in a manner that is deemed
acceptable by the organization.
▪ Fayol believed that a disciplined employee was one that not only was sincere
about his work, but also had faith in the policies and procedures of an
organization.
▪ He also believed that a disciplined employee would fulfill the orders given to him
and respect management.

▪ Misconduct
- Is generally the more serious problem as it is often deliberate, exhibited by
acts of defiance.

▪ The pre-disciplinary procedure

- The pre-disciplinary procedure informal counselling should be carried out to
ensure the employee knows the standards expected and should be carried
out by a supervisor/manager.

▪ The employee should be:

- Told what needs improvement (eg., timekeeping, attendance, conduct, work
standards).
- Given the opportunity to explain.
- Given an action plan to bring about the required improvement.
- Given a written note, signed by both supervisor/manager and employee, of
the agreed action to be taken.

STEPS IN DISCIPLINE PROCESS

Step 1: Verbal counselling

• Verbal counselling is usually the initial step. Verbal counselling sessions

are used to bring a problem to the attention of the employee before it
becomes so serious that it has to become part of a written warning and
placed in the employee’s file.
 • The purpose of the initial discussion is to alleviate misunderstandings and
clarify the direction for necessary and successful correction. Most
discipline problems can be solved at this stage if the matter is
approached constructively and if the employee can be engaged in seeking
solutions. This is usually effective because most people don’t want the
disciplinary process to escalate.

Step 2: Written warning

• If the problem is not resolved, you will need to prepare the written
warning. Include in the warning information, responses, and
commitments already made in the verbal counselling session.

• The written warning has three parts:

a. A statement that the verbal discussion has occurred, which reviewed the
employee’s history with respect to the problem. Be sure to include the
date the verbal discussion took place.
b. A statement about the present, including a description of the current
situation and including the employee’s explanation or response. Use the
“who, what, when” model to be sure you include all necessary details.
c. A statement of the future, describing your expectations and the
consequences of continued failure to correct the problem. This step may
be repeated in the future with stronger consequence statements, so be
clear on what the next step is. For example, this statement might state
that the situation “may lead to further disciplinary action” or, in a later
warning, “this is a final warning and failure to correct the problem will
lead to discharge.” By documenting these conversations, you cover
yourself in legal disputes that may arise from terminations. Here are
some guidelines for documenting written warnings:

1. Clearly identify the performance issue that needs to be resolved.

2. Give the employee the opportunity to propose a solution to the issue
with you.
3. Agree on the solution, and document what is going to change. -Include
a section on how the employer will help the employee change the
behavior.
4. If appropriate, agree on a date when you will review the situation
together, and ensure that the performance issue has changed for the
better.
 5. Ensure that the employee understands the repercussions if the
behavior does not change. This must also be documented on the
progressive discipline form.
6. Both the employee and the employer should sign this written record of
the conversation that outlines the issue, the solution, and the timeline for
the change.
7. Give the employee a copy of the written documentation for his or her
own records.
8. Follow-up on the agreed-upon date.

Step 3: Suspension without pay

• Depending on the situation there are times when it is appropriate to
suspend an employee and times when it is not. The rules on suspending
employees without pay may depend on the specific situation, and,
therefore, it is advised that employers review the BC Employment
Standards Act (or other provincial employment standards legislation)
before carrying out a suspension without pay.

Step 4: Termination
• If a problem is not resolved after appropriate warning, you may have to
terminate an employee. As well, there may be cases when you want to
terminate an employee immediately before going through steps 1 to 3.
• Employment standards legislation in most provinces establishes a three-
month probationary period during which an employee can be terminated
for any reason, without notice. The only exceptions to termination within
the probation period are any reason deemed discriminatory under
human rights legislation, such as religious beliefs or nationality.
• After the probationary period, the employer must have just cause for
termination or otherwise provide sufficient notice or severance. It is
recommended that you consult with your provincial labor regulations to
confirm what is deemed “just cause.” Poor work performance is not
normally considered just cause unless the progressive discipline process
has been followed and the employee has been given sufficient time to
improve. Just cause normally includes any of the following as grounds for
immediate dismissal:

a. Theft, fraud, or embezzlement.

b. Fighting.
c. Working while under the influence of drugs or alcohol.
d. Any conduct that threatens the safety of others.
e. Gross insubordination.
f. Appropriate level of discipline.
g. It is important to determine the proper level of discipline in each
situation. In other words, “the punishment must fit the crime”.

• Consistency in discipline is important. How others have been treated for

similar infractions should provide the primary basis for determining
appropriate action, but there are several factors that may justify
increasing or decreasing the level of discipline:

a. The employee’s length of service.

b. Previous record of performance and conduct.
c. Whether the employee was provoked.
d. Whether the misconduct was premeditated or a spur-of-the-moment lack
of judgment (i.e., was it with or without intent?).
e. Whether the employee knew the rules and those rules have been
consistently enforced on others
f. Whether the employee acknowledges the mistake and shows remorse.