Chapter 08

CONTROLLING

Author
Prof. Dr. Rohini T
 Learning Objectives
After studying this chapter students will be able to
• define controlling
• discuss the components of controlling
• describe implementing standards, policies, procedures, protocols and
practices
• explain nursing performance audit, patient satisfaction
• discuss nursing rounds
• explain documentation including records and reports
• describe total quality management
• elaborate on quality assurance
• discuss quality and safety
 Learning Objectives
After studying this chapter students will be able to
• narrate on performance appraisal
• explain Program evaluation and review technique (PERT)
• describe benchmarking
• explain activity plan (gantt chart)
• describe critical path analysis
 Chapter Outline
• Definition and components of controlling
• Implementing standards, policies, procedures, protocols and practices
• Nursing performance audit, patient satisfaction
• Nursing rounds
• Documentation including records and reports
• Total quality management
• Quality assurance
• Quality and safety
• Performance appraisal
• Program evaluation and review technique (pert)
• Benchmarking
• Activity plan (gantt chart)
• Critical path analysis
 INTRODUCTION

Controlling is the measurement and correction of the performance in

order to make sure that enterprise objectives and the plans devised to
attain them are accomplished.
The various components of controlling/evaluation include nursing
rounds, nursing protocols, nursing manuals, quality assurance model,
documentation - records and reports and performance appraisal.
 Implementing standards, policies, procedures,
protocols and practices
Standards are mandatory practices or guidelines that provide official
policies with direction and assistance. Every standard of practice offers
guidance on the skills, judgement, knowledge, and attitudes required for
safe practice.
Policies: High-level statements of an organization's objectives,
principles, and standards are called policies.
Procedures: These are comprehensive, step-by-step instructions that
specify how particular jobs or activities are to be completed.
POLICIES TO BASELINES

Policy
(General Management statement)

Standards (specific mandatory

controls)

Procedures (step by step

instructions)

Guidelines (Recommendations/best
practices)

Baselines (uniform ways for

safeguard implementation)
 Steps for Successful Implementation of
standards, Policies and Procedures

Develop
Comprehensive
Establish Policies and Monitor and
Specific Goals Procedures Review

Identify Communicate
Stakeholders and Train
 Measures to overcome resistance to change
Resistance to change Measures to overcome

Communicate the Need It's essential to make clear the reasons for the suggested
modifications as well as their advantages for the
organisation as a whole. Staff members will
comprehend the necessity of change if it is emphasised
to them how important it is to adjust to the evolving
workplace and the possible benefits.

Provide Training and Support: Offering comprehensive training programs will help
educate employees about the changes and guide them in
navigating the new policies and procedures. Ongoing
support should also be provided to assist employees in
understanding and adapting to these changes.

Engage and Involve Employees Employees will feel more invested in the changes if
they are included in the decision-making process and
their opinions are encouraged.
 Measures to overcome resistance to change
Resistance to change Measures to overcome

Address Concerns It is crucial to actively listen to employees’ concerns

and address them in a transparent and empathetic
manner. By providing reassurance and clarification, any
fears or uncertainties can be alleviated.

Lead by Example By actively participating in the changes and following

the new policies and procedures, leaders may
demonstrate their commitment to the reforms.

Celebrate Achievements It's critical to acknowledge and celebrate significant

dates or accomplishments brought about by the
changes. This increases acceptance of the new policies
and processes and shapes a positive mindset.
 NURSING PERFORMANCE AUDIT

An independent evaluation of an organization's operations to ascertain if

particular programmes or functions are carrying out as intended to meet
predetermined objectives is known as a performance audit.
 PATIENT SATISFACTION

• Patient satisfaction is a balance between expectations and perceptions

of the nursing care received.
• It is measured by comparing the perception of care received with the
expected nursing care. In this way, patients assess both the healthcare
personnel and the services from their own subjective perspective.
FACTORS INFLUENCING PATIENT SATISFACTION

Communication with healthcare providers

Access to care and wait times

Quality of care

Cleanliness and comfort of

healthcare facilities

Availability of information and education about care and treatment options

Cultural competency and sensitivity to patients' needs and preferences

 CALCULATING PATIENT SATISFACTION

1. Average satisfaction score

The average satisfaction score is the result of patients answering all
survey items with the same number. This gives a general indicator of the
satisfaction of patients.
2. NPS or Net Promoter Score
This indicator gauges how likely it is for patients to suggest a healthcare
professional to others.
3. Top-box satisfaction
The proportion of patients who answer "excellent" or "very good" to all survey
items is measured by this metric. This offers a more focused way to gauge how
satisfied patients are with particular elements of their healthcare experience
 IMPROVING PATIENT SATISFACTION
Strategies . Description

Enhance Communication Ensuring patient satisfaction requires effective communication. By providing personnel with
training in active listening, empathy, and effective communication techniques, healthcare
facilities can enhance communication. Employees should be motivated to speak with patients
in a straightforward and intelligible manner.

Reduce Wait Times For patients, lengthy wait times can be a major cause of discomfort. By employing strategies
to shorten wait times, such as enhancing scheduling procedures, hiring more personnel, and
streamlining workflow, healthcare facilities can enhance patient satisfaction.
Provide Patient Education Patients are more likely to be happy with their care if they are knowledgeable about their
medical issues and available treatments. To assist patients in understanding their medical
issues and available treatments, healthcare facilities might offer patient education materials
including booklets and internet resources.
Improve Facility Environment Patient satisfaction may also be impacted by the physical layout of a medical facility.
Healthcare facilities can boost patient satisfaction by ensuring that their facilities are clean,
comfortable, and well-maintained.
Encourage Patient Feedback Patients should be encouraged to share their experiences with healthcare institutions.
Suggestion boxes, online feedback forms, and patient satisfaction questionnaires can all be
used to gather feedback. Additionally, hospitals ought to use these comments to push for
enhancements to the patient experience.
 NURSING ROUNDS
Nursing round presents an overview of certain aspects of
the nursing or medical care of all patients in the ward or
of selected patients
- Gaberson
Usually nursing rounds are
conducted by the nurse
manager/head nurse or the nursing teacher with active
participation of staff nursesand nursing
students in the ward.
 NURSING ROUNDS - Purposes
To observe the physical and mental condition of the patient and the progress he/she
has made from day to day.
To make specific observations on the patient.
To demonstrate therapeutic procedures on or for the patients.
To demonstrate the effect of drugs used in the treatment.
To illustrate successful improvisation and to give opportunity for the use of different
application.
To make a judgement of the treatment received
To teach nurses or nursing students regarding specific disease condition, pattern of
care and treatment
To suggest modifications in nursing action
To demonstrate symptoms important in nursing
NURSING ROUNDS - Classification
Information
giving
rounds

Problem
Instructional
solving
rounds
rounds
 NURSING ROUNDS – Role of Head nurse

The head nurse selects the patients in advance according to time available.
Rounds usually last less than an hour.
The head nurse needs to read the patients histories, know the plan for their
treatment and results, the patients progress, prognosis, their nursing care and its
effectiveness
Rounds for staff nurse should be held separately from those of junior students.
Natural patients' response

Clarify issues

Develop skills and proper

attitude

Team Spirit
and
professionalis
m
Learn in depth
NURSING ROUNDS – Advantages
 NURSING ROUNDS – Disadvantages
The patient may overhear the discussion
Other patients in the same ward may overhear the discussion
There may be distractions in the ward
It cannot be organized for large group
It is time consuming
It is difficult to conduct nursing rounds when there is an unexpected
emergency or busy schedule
 BEDSIDE CLINIC

Bedside clinic is an informal or formal discussion regarding patient’s

problems and sharing of knowledge and experience about the same or
identifying management strategies using problem solving techniques.
 BEDSIDE CLINIC - Purposes

Provides an opportunity to understand the condition of each patient

in real life situation
Improve the ability of nursing staff to solve patient care problems in
an organized way
Improve nurses’ ability to collect information about patient -
assessment of needs and problems of patients
Improve the ability to implement nursing care appropriately
 BEDSIDE CLINIC – Site and duration

Bedside clinic is conducted at the bed side of the patient or the patient
can be brought to the clinical examination room which is attached to the
ward.
The usual duration of bedside clinic is 20-30 minutes
 BEDSIDE CLINIC – Phases
Phase Description

Preparation phase  During the preparation phase the ward in-charge or the nursing
supervisor explains the purpose of conducting the clinic to the group
 Select the patient and get consent from patient or relatives
 The nurse assigned to the patient collect the details of personal
characteristics of patients - demographic data, past and present
medical history, personal history and family history
 The students who are assigned to the patient can also contribute their
observations
 BEDSIDE CLINIC – Phases
Phase Description
Conduction phase  Conduction phase occurs at the bedside of the patient (or in the clinical
examination room)
 Then nurse in-charge of the patient describes the details of the patients
 Patients conditions, signs and symptoms, relevant history, treatment
and nursing management are explained during this phase
 The patient is allowed to verbalize his needs or problems
 Students are allowed to clarify their doubts and to interact with the patients
 The group can also interact with the patients for further clarification about the
disease aspects, needs and problems
 Total number of participants in the group can be limited from 10 to 15

Conclusion phase  In this phase the group comes to a conclusion about the management of
patients and prepare a summary of the clinic
 BEDSIDE CLINIC – Advantages

Bedside clinics provides opportunity for critical thinking and enhance

the problem solving skills
It helps to recognize the practical aspects of care
Provides learning of patients with different disease conditions
Improves skill in providing nursing care
Enhance the confidence of nurses and students in providing nursing care
Provides opportunity to evaluate patient care
 BEDSIDE CLINIC – Disadvantages

It is time consuming
Participants in bedside clinic are limited to 10 to 15
Bedside clinic may be difficult to conduct if the number of participants
exceed more than 20
 NURSING CARE CONFERENCE

Nursing care conference is a formal meeting of a group of nurses to

discuss the problems and issues related to nursing care and services.

In nursing care conference experts from other specialty areas of care

such as doctors, physiotherapists, occupational therapists etc. can also
be involved.
 NURSING CARE CONFERENCE - Purposes

Provide good learning experience to nurses and nursing students

Discuss innovative ideas and exchange new information among the

experts
To arrive at possible solutions related to patient care or nursing needs

Develop creative potential and problem solving skills

Identify common nursing care problems/issues and suggest measures to

solve the problems
 NURSING CARE CONFERENCE - Characteristics

It is a two-way process in which teaching and learning occurs

simultaneously
It consists of a group discussion with problem solving
technique
A group of people (mainly nurses) meet together to discuss a particular
topic
There is an informal discussion of problems and free exchange of ideas
and experiences about the problem in nursing care conference
 NURSING CARE CONFERENCE

Advantages
Nursing care conference provides opportunity to formulate possible
solutions to a problem in a creative way
It enhances the critical thinking and the judgement capacity of the staff
nurses
Disadvantages
Nursing care conference is time-consuming
It may be difficult to arrange a group of participants and experts during
the busy schedule of the hospital
 NURSING CARE CONFERENCE

Role of nurse in charge/ for nurse administrator in conducting the

conference
Plans the nursing care conference
Inform the venue and time of the conference to the participants
Collects information regarding the issue or concerned problems with the
help of subordinates
Student nurses may also be involved in conference
The charge nurse should direct and control the discussion
 DOCUMENTATION
Documentation is anything written or printed which is relied on as a
record of proof for authorized person.
- Webster's dictionary
Nursing documentation is the process of making
an entry on a record, data which is pertinent to patient
care or services provided to the patient.
 DOCUMENTATION - Purposes

Facilitate Coordination of Continuity of

communication care care

Meet
Quality nursing professional and Accountability
care legal standards

Evidence based
practice
 NURSING RECORDS - Importance
Provide baseline data for the plan of action and to evaluate the care given
Nursing records are used for diagnostic purposes. Example: Temperature
graphic record, intake output record etc. can be used for diagnosis.
Evaluate the workload and calculation of manpower required in a
particular setting
Evaluate the quality of care
It can be used for research purposes
It is a valuable document used for legal purposes
QUALITY ASSURANCE MODEL
 QUALITY ASSURANCE

Quality Assurance refers to making sure that the services provided by the
hospital are the best possible in a given existing resources and current
medical knowledge.
- World Health Organization
Quality Assurance is the process of evaluating patient care in a particular
setting by developing standards of care and implementing mechanism for
ensuring that the standards are met

Coyne C, Killien M
 QUALITY ASSURANCE - Types

External quality Internal quality

assurance assurance

Quality Assurance is Quality Assurance is

evaluated by evaluated by local
independent assessors or assessors or senior
people from outside the personnel from the same
institution or Hospital Institution or hospital
 QUALITY ASSURANCE – Factors influencing

Lack of resources Personnel related

• lack of infrastructure problems
Unreasonable Actions of accreditation
equipments and supplies • Lack of trained, skill and Expectations of patients
etc. motivated employees laws
and their caregivers
may decrease the quality
of care

Miscellaneous factors
• Lack of good
supervision, policy and
Lack of goodmanuals,
administrative Hospital Lack of patient
information
procedure system
manual, satisfaction surveys
evaluation tools and
techniques, written job
descriptions, continuing
education programs etc.
 Providing quality care

 Provide risk-reduction strategies for safe healthcare that include preventing avoidable
injuries and medical blunders.
 Deliver efficient services grounded in scientific understanding and evidence-
based protocols.
 To cut down on delays, promptly deliver and receive medical care.
 Provide effective medical treatment in a way that minimises waste and makes the most
use of available resources.
 Provide healthcare to all patients equally, regardless of their personal
attributes,
including gender, race, ethnicity, geographical location, or socioeconomic position.
 Adopt a people-centered strategy that takes into account the inclinations and goals of
each individual service user as well as the culture of their community.
QUALITY OF CARE - COMPONENTS

Effective
communication

Competent and
Community motivated
engagement healthcare
professionals
QUALITY AND SAFETY MANAGEMENT – BEST PRACTICES

Quality and safety management systems

SMART goal

QHSE Automation
 PERFORMANCE APPRAISAL
Performance appraisal is the systematic evaluation of the individual with
regard to his or her performance on the job and his or her potential for
development
-Beach DS Performance appraisal is the systematic, periodic and an
impartial rating of an employee's excellence in matters pertaining to his
present job and his potential for a better job
-Flippo
PERFORMANCE APPRAISAL - Goals

Improve the performance of the

employees

To let the employee, know where they

stand

Give performance feedback

PERFORMANCE APPRAISAL - Characteristics

Realistic

Time bound Measurable

and written and verifiable

Stable Practical

Non-
Relevant
discriminatory
 PERFORMANCE APPRAISAL – Pre-requisites

The staff and management should develop and agree upon the
desired outcomes that needs to be evaluated.

The minimum level of expectation must be clearly defined

The staff and the management should be clear on the criteria for
unsatisfactory, average and excellent performance

Standards of care should be defined against which a professional

employees conduct is compared
PERFORMANCE APPRAISAL PROCESS

Follow up Establish
meetings and criteria for
corrective performance
actions standards

Communicate
Discuss formulated
evaluation standards to
employees

Compare
actual
Measure
performan ce
performance
against
standards
 PERT
PERT is a method of analyzing the tasks involved in completing a given
project, especially the time needed to complete each task, and to identify
the minimum time needed to complete the total project. It is a procedure
through which activities of a project are represented in its appropriate
sequence and timing.
 PERT - History
PERT charts were first created by the U.S. Navy's Special Projects Office
in 1957 to guide the Polaris nuclear submarine project

Since then, project managers have used the Program Evaluation and
Review Technique in all manner of industries
 PERT - Purposes

Allow better
Minimise the Minimise any communication
Minimise idle Identify any
total time to delay in the between the
potential
complete resources implementatio various levels
problems
project n of the plan of
Management
 PERT chart

It is a graphical representation of the activities of a project showing the

sequence that has to be performed continuously. It has a critical path of
the task that has to be finished in time.
 APPLICATION
OF PERT

Management Develop and

development and Research and administer
organizational development various training
planning projects programs
 PERT chart software
PERT chart software is used to help project managers better estimate the
realistic duration of their project.
PERT charts can be built robustly using a dedicated PERT chart maker.
A PERT chart software allows to create PERT charts that are dynamic
and easily updated.
Microsoft Project is one of the most commonly used project management
software.
 Benchmarking - Definitions
Benchmarking is a technique in which an organization measures its
accomplishments against performance of the best organizations and according
to ASQ subjects that can be benchmarked include strategies, operations and
processes.
-American Society for Quality (ASQ)
Benchmarking is a measurement tool for monitoring the impact of governance,
management, clinical and logical functions.
-Braillon
 Benchmarking - Purposes
To learn how the best in class organizations achieved excellence and then
setting out to match and even surpass it
To identify potential areas of improvement by analyzing the standards, best
practices, and evidence-based practices
To identify new idea of improving the process in order to meet the customer
expectations
To develop true measures of productivity
To improve efficiency, quality of care, patient safety and patient satisfaction
 Benchmarking - Types

Internal Functional Global

benchmarking benchmarking benchmarking

External Competitive
benchmarking benchmarking
 Benchmarking process

1. Planning 2. Analysis 3. Integration 4. Action

phase phase phase phase
 Planning phase of Benchmarking

What to Benchmark?

Whom to Benchmark?

Studying the Superior Process

 Analytic phase of Benchmarking

Finding Reasons and Devising

Improved Processes

Goal Setting for Improved

Processes
 Integration phase of Benchmarking

Communicate Findings and Gain Acceptance

Establish New Functional Goals

 Action phase of Benchmarking

Develop Action Plan for Implementation

Implement Specific Actions and

Monitor Progress

Keep the Process Continuous

Advantages of Benchmarking

Quality

Understand
strength and Continuous
weakness improvement

Cost
Confidence
effective
Disadvantages of Benchmarking

Time Inaccessible
consuming data

Reduce Confidentia
motivation lity risk
Core principles in clinical practice BenchmarkingBenchmarking

Maintainin Improving
customer
g quality
satisfaction

Continuous Improving
improveme Patient
nt Safety
 GANTT CHART (ACTIVITY PLAN)

Gantt chart is a bar chart that provides a visual view of tasks scheduled
over time
A Gantt chart is a type of bar chart that illustrates a project schedule and
shows the dependency relationships between activities and current
schedule status
-Wikipedia
 GANTT CHART – Information available

The start date of the project

The project tasks
Who is working on each task
When tasks start and finish
Duration of each task
How tasks group together, overlap and link with each other
The finish date of the project
 GANTT CHART – Steps to create

Step 1
Identify the task involved in completing a project. The list of tasks must
be thorough and complete to be effective.
Step 2
Calculate the expected time required to complete each task. It is possible
and even likely that some tasks will be performed at the same time but by
different team members.
Step 3
Organize the sequence of each of the activities identified. Determine
which tasks are dependent on one another.
 GANTT CHART – Steps to create

Steps 4
Draw a horizontal time axis along the top or bottom of the page. Mark it in an
appropriate scale for the length of task (days/ weeks)
Step 5
On the left side of the page, write each task and milestones of the project in
order.
For the activities that occur over a period of time draw a bar that represents
appropriate items on the timeline.
Align the left end of the bar with the time when the activity begins and align
the right end with the time when the activity concludes. Decide who will be
responsible for each task and delegate to the team.
 GANTT CHART – Advantages

It provides easy graphical representation of progression of activities

Creates a sense of accountability

It helps to visualize how the task are connected

Ensures clean communication and team cohesion among all those involved in the project

Simple to create

It allows planning, monitoring and control

Helps in better time management

 GANTT CHART – Disadvantages

Some consider Gantt chart as too complicated to prepare, comprehend

and update
It does not explain the reason behind the duration of each activity
It does not indicate the relationship between separate activities
 CRITICAL PATH ANALYSIS - DEFINITION

• Critical path analysis is a project-management technique that lays out

all of the activities needed to complete a task, the time it will
take to complete each activity and the relationships between the
activities.
THANK YOU

Textbook of Nursing Management and Leadership