CONTROLLING

The Final Element of management defined by Fayol was control, which he defined as:

Verifying whether everything occurs in conformity with the plan adopted, the instructions
issued and principles established. It has for its object to point out weaknesses and error in order
to rectify them and prevent recurrence.

It is important that controlling be done on a factual basis. When issues arise, people should be
made to meet with each other and settle them through direct contact. To stimulate cooperation,
they need to participate from the beginning. Nurse managers can teach people to cooperate
across departmental lines and to let reason and common sense prevail.

Basic Components of the Control Process

1. Establish standards for all elements of management in terms of expected and measurable
outcomes. These are the yardsticks of which achievement of objectives are measure.
2. Apply the standards by collecting data and measuring the activities of nursing management,
comparing standards with actual care.
3. Make any improvements deemed necessary from the feedback.
4. Keep the process continuous for all areas including
a) management of the nursing division and each subunit.
b) Performance of personnel.
c) Nursing process/product

Controlling as A Function of Nursing Management

Control is “the sum of the findings of the means in use to determine whether the goal is being
achieved.” Control includes coordination of numerous activities – decision making related to
planning and organizing activities and information from directing and evaluating each worker’s
performance. Control is also viewed as being concerned with records, reports, organizational
process toward aims, and effective use of resource. Control uses evaluation and regulation;
controlling is identical to evaluation. Koont and Weihrich defined controlling as “the
measurement and correction of the performance in order to make sure that enterprise objectives
and the plans devised to attain them are accomplished.”

CONTROLS AS MANAGEMENT TOOLS

In the process of measuring the degree to which predetermined goals are achieved and of
applying necessary corrective actions to improve performance, policies and procedures are used
as standards. Also, observations, questions, patient charts, patients, and health care team
members serve as sources of data. Corrective actions can be corroborative, disciplinary, or
educational. In the process of feedback, a positive experience will stimulate motivation and
contribute to the growth of employees.

Controls are management tools for improving performance. Among the controls are rules
to let people know what is expected of them and how functions are to be coordinated.
Communication of information is essential to control. Self-control includes being up-to-date in
knowledge, giving clear orders, being flexible, understanding reasons for behavior, helping
others improve, increasing problem-solving skills, standing calm under pressure, and planning
ahead. People should be told the facts in language that they understand and words that have the
intended meaning. Effective nursing managers set limits and make them known to their
employees. Then, when the line is crossed, the appropriate disciplinary action should be taken.
The latter is achieved by corrective action that is consistently applied by checking the facts.
 Controls can be separated into 2 elements: mechanical and sociological. There are three
stages of control, the two being the mechanical elements: (1) a predetermined definition of
standards for a level of performance, and (2) measurement of current performance against the
standards. The third, taking corrective action if it is indicated, is the sociological element. Nurse
managers will avoid the unintended consequence of control, that is, noncompliance. Because
control can be perceived as a threat from unwanted power and authority, it can trigger defense
mechanisms such as aggression and repression. Lemin advocated the following approaches to
control: time, a high degree of mutual support, open and authentic communications, clear
understanding of objectives, respect for differences, use of member resources, and a supportive
environment. These approaches will lead to conflict resolution, changed beliefs and attitudes,
genuine innovation, genuine commitment, strengthened management, and prevention of
unintended consequences of a control.

In a good control system, controls should do the following:

1. Reflect the nature of the activity. 6. Be flexible.

2. Report errors promptly 7. Reflect the organizational pattern.
3. Be forward-looking. 8. Be economical.
4. Point out exceptions at critical points. 9. Be understanding.
5. Be objective 10.Indicate corrective action.

Nurses activate the processes of control. This function involves the use of power and should be
used by nurse managers to promote openness, honesty, trust, competence, and even
confrontation. This function also involves value system, ethical decision making, self-control,
professional self-regulation, and control by aggregate of professionals. Quality management
programs excel in quality of care, processes of care, and self-regulation. Audits and budgets are
the major techniques of control.

Two measurement methods are used to assess achievement of nursing goals: task analysis and
quality control. In task analysis, the nurse manager inspects the motions, actions, and
procedures laid out in written guidelines, schedules, rules, records, and budgets. Task analysis is
the study of the process of giving nursing care. It measures physical support only; a few tools
have been developed to do task analysis in nursing. In quality control, the nurse manager is
concerned with measurement of quality and effects of nursing care. The ANA and JCAHO and
other organizations have developed mechanisms or models for measuring nursing care. Many
quality management techniques are referred to as audits.

STANDARDS

A prime element of the management of nursing services is a system for evaluating the total
effort including evaluation of the management process as well as the practice of nursing and all
nursing care services. Evaluation requires standards that can be used as yardsticks for gauging
the quality and quantity of services.

Standards are established criteria of performance, planning goals, strategic plans, physical or
quantitative measurements of products, units, of service, labor hours, speed, cost, capital,
revenue, program and intangible standards. They have also been defined as “an acknowledged
measure of comparison for quantitative or qualitative value, criterion, or norm…a standard or
rule or test on which a judgment or decision can be based.” Nursing managers develop, in
collaboration with clinical nurses, the “clinical nursing criteria against which to measure patient
outcomes and the nursing process.”

Eight categories of standards are:

 1. Physical Standards. An example would be using patient acuity ratings to establish nursing
hours per patient day.
2. Cost Standards. Cost per patient day for supplies would be an example.
3. Capital standards. A new program of monetary investment, such as patient teaching staff,
would be included here.
4. Revenue standards, Include the revenue per hour of nursing care received by patients.
5. Program standards. For example, one designed to develop a new nursing service for
changing people’s behavior regarding exercise, eating, or other health activity.
6. Intangible standards. Staff development costs in nursing are one example.
7. Goals are frequently used as standards in nursing management. Intangible standards are
being replaced by goals, including those for qualitative measurements.
8. Strategic plans, as control points for strategic control, are also used as standards. As nurse
managers increase their involvement in strategic planning they will need to perform
strategic control.

CONTROLLING TECHNIQUES

Although evaluation operational plans are controlling techniques, other specific controlling
techniques can be developed, including planned nursing rounds by nurse managers from all
levels, checklists from ANA Standards of Nursing Administration, Practice ANA Standards of
Clinical Nursing Practice, JCAHO Accreditation Manual for Hospitals, and other published
standards of third-party payers such as those put forth by the Centers for Medicare and Medicaid
Services (CMS).

1. Nursing Rounds
An effective controlling for nursing managers is planned nursing rounds, which can be
placed on a schedule and can include all nursing personnel. Rounds cover issues such as patient
care, nursing practice, and unit management. To be effective the results should be discussed
with appropriate nursing personnel in a follow-up conference. Part of the evaluation progress
takes place as a result of the communication occurring during the rounds.

Protocol for Planned Monthly Nursing Rounds

1. The chair, assistant chair, and other 4. All unit nursing personnel are
appropriate nursing personnel will make welcome to attend these rounds with
nursing rounds monthly. their head nurse. Patient care needs
come first. The following areas will
2. Time is 10:00 to 11:00 a.m. unless be covered as rounds are made to
otherwise indicated. each patient’s bedside:
a. Nursing histories
3. Schedule b. Nursing care plans
c. Nursing notes
Unit Day d. Nurses’ signatures on
necessary documents.
1F 1st Tuesday
2A 1st Wednesday 5. Other management areas of note
2B 1st Thursday will be discussed after bed side
2F 2nd Tuesday rounds.
ICU 2nd Wednesday a. Equipment and supplies
4A 2nd Thursday b. Staffing and assignments
3A 2nd Friday c. Narcotic registers
3-OB 3rd Tuesday, 10:30-
11:30 a.m.
3F 3rd Wednesday
4B 3rd Thursday, 11:00 a.m.
 to noon
5A, CCU 4th Tuesday

2. Nursing Operating Instructions

Nursing Operating Instructions or policies become standards for evaluation and controlling
techniques.

Operating Instructions

1. Special care units will maintain policies and procedures relative to their mission.
These procedures will be reviewed, updated, and signed at least annually.
a. Intensive care unit
b. Critical care unit
c. Newborn/intensive care unit nursery
d. Renal dialysis
2. Special care units will maintain a list of equipment needed to achieve their
mission.
3. Supplies and equipment:
a. Blount resuscitator will have percent adaptor to increase oxygen
concentration.
b. Ambu resuscitator will have tail on to increase oxygen concentration.
c. Humidification will not be used with oxygen with Ambu resuscitator.
d. Trays from Central Sterile Supply will be returned as soon as used so that
instruments will not be lost or misplaced.

3. Gantt Chart

A Gantt chart is a horizontal bar chart developed as a production control tool in 1917 by Henry L.
Gantt, an American engineer and social scientist. Frequently used in project management, a
Gantt chart provides a graphical illustration of a schedule that helps to plan, coordinate, and
track specific tasks in a project. Gantt charts are useful tools for planning and scheduling
projects. They allow you to assess how long a project should take, determine the resources
needed, and lay out the order in which tasks need to be carried out. They are useful in managing
the dependencies between tasks. When a project is under way, Gantt charts are useful for
monitoring its progress. You can immediately see what should have been achieved at a point in
time, and can therefore take remedial action to bring the project back on course. This can be
essential for the successful and profitable implementation of the project. To draw up a Gantt
chart, it must follow these steps:

Step 1 - List all activities in the plan. For each task, show the earliest start date, estimated
length of time it will take, and whether it is parallel or sequential. If tasks are sequential, show
which stages they depend on.

Step 2 - Head up graph paper with the days or weeks through to task completion.

Step 3 - Plot the tasks onto the graph paper. Next draw up a rough draft of the Gantt Chart. Plot
each task on the graph paper, showing it starting on the earliest possible date. Draw it as a bar,
with the length of the bar being the length of the task. Above the task bars, mark the time taken
to complete them.
Step 4 - Schedule activities. Now take the draft Gantt Chart, and use it to schedule actions.
Schedule them in such a way that sequential actions are carried out in the required sequence.
Ensure that dependent activities do not start until the activities they depend on have been
completed. While scheduling, ensure that you make best use of the resources you have
available, and do not over-commit resource.

Step 5 - Presenting the analysis. The final stage in this process is to prepare a final version of
the Gantt Chart. This should combine the draft analysis (see above) with your scheduling and
analysis of resources. This chart will show when you anticipate that jobs should start and finish.
In constructing a Gantt chart, keep the tasks to a manageable number (no more than 15 or 20)
so that the chart fits on a single page. More complex projects may require subordinate charts
which detail the timing of all the subtasks which make up one of the main tasks. For team
projects, it often helps to have an additional column containing numbers or initials which identify
which one in the team is responsible for that task6. Gantt charts don't indicate task
dependencies - you cannot tell how one task falling behind schedule affects other tasks. The
PERT chart, another popular project management charting method, is designed to do this.

BENEFITS
1  Gives a clear illustration of project status.
2  May be adjusted frequently to reflect the actual status of project tasks.
3  Helps manage the temporal dependencies between tasks.

PREREQUISITES
1  Gantt chart forces group members to think clearly about what must be done to
accomplish their goal.
2  Computer software can simplify constructing and updating a chart.

The Gantt chart is useful for planning and scheduling projects. It allows the manager to assess
how long a project should take, determine the resources needed, and lay out the order in which
tasks need to be carried out. Gantt charts help the manager monitor the project’s progress and
stay on track.

Gantt charts help the manager plan out the tasks that need to be completed by scheduling times
that the tasks will be carried out and allocating resources. The chart is also useful when working
with multiple projects. An advantage of the chart is the ability to review projects that are
progressing in a timely fashion. The nurse manager’s goal is to complete each activity or phase
on or before the projected date.

GANTT CHART
Week
1 2 3 4 5 6 7 8 9 10
Recruit Hire Assess Train Train Install Install Prepare Hold Admit
staff staff staff’s staff staff furniture informati patient open patients
Market strengt Order and on medical house
center hs furniture equipme system records
and nt
equipme
nt

4. Program Evaluation and Review Technique (PERT)

The program evaluation and review technique was developed by the Special Projects Office of
the U.S. Navy and applied to the planning and control of the Polaris system in 1958. It worked
then; it still works; and it has been widely applied as a controlling process in business and
industry.
PERT uses a network of activities. Each activity is represented as a step on a chart.

Why should nurse managers use the PERT system for controlling?
It forces planning and shows how pieces fit together. It does this for all nursing line
managers involved. It establishes a system for periodic evaluation and control at critical points in
the program. It reveals problems and is forward-looking. PERT is generally used for complicated
and extensive projects or programs.

BENCHMARKING

Benchmarking: A process used in performance improvement to compare oneself with best

practice.

Benchmarking is an offshoot of total quality management, and is a technique whereby and

organization seeks out the “best practices” in its industry so as to improve its performance. It is
a standard, or point of reference, for measuring or judging quality, values, costs, and other
factors. In doing so, organizations can also determined how and why their performance differs
from other exemplar organizations.

MASTER CONTROL PLAN

A master control or evaluation plan can be used by nurse managers to fulfill this important
management function. It can be a general plan for all, with each manager adding specific items
for her or his own management area.

Inspect and identify the presence of written, current, and practical statements of
mission, philosophy, vision, and objectives for the division of nursing and each of its
component units. They should reflect the purposes of the health care organization
and give direction to the nursing care program.
Actions
1. The written statements of mission, philosophy, and objectives were current
(reviewed or revised within the past year).
2. They existed for the division of nursing and for each department, ward, unit,
and clinic.
3. They were written by appropriate nursing personnel, representative of people
who will accomplish them.
4. The philosophy reflected the meaning of clinical practice.
5. The philosophy was developed in collaboration with consumers, employees,
and other health care workers.
6. The objectives were specified, written in behavioral terms, and achievable.
7. They guided the process of implementing the philosophy.
8. They were used for orientation of newly assigned personnel and were
otherwise widely distributed and interpreted.
9. They supported the mission, philosophy, and objectives of the institution.
10.Nursing personnel knew the rights of individuals and served as advocates for
these rights.
Objective 2
Inspect for and identify the presence of written operational or management
plans for accomplishment of the objectives of the division of nursing and each of its
component units.

Actions
1. The written operational or management plans were current (entries within
 past 30 days).
2. They existed for the division of nursing and for each department, ward, unit,
and clinic.
3. They included specific actions to be taken to achieve objective, target dates,
and names of personnel assigned responsibility for each action.
4. They were used to evaluate progress; accomplishments were listed.

Objective 3

Inspect and identify the presence of an organizational plan for the division of
nursing and each of its component units.

Actions
1. The organizational plan was current; it agreed with actual organization when
checked.
2. It existed for the division of nursing and for each department, ward, unit, and
clinic.
3. It showed the relationships among component parts, spelling out the major
functions of each, and it showed relationships with other services.
4. The organizational plan supported the mission assigned to personnel.
5. All nursing functions were managed by the nurse administrator.

Objective 4
Inspect for and identify the presence of adequate policies and procedures for
guidance of personnel of the division of nursing and each of its component units.

Actions
1. Policies and procedures of the division of nursing and of each department,
ward, unit, and clinic were current (reviewed within past year).
2. Policies and procedures did not duplicate those of higher echelons.
3. Policies and procedures were not obsolete, restrictive, or inappropriate in
context.
4. Context of location of policies and procedures was known by people who
needed this information.
5. Policies and procedures for special care units included:
a) Function and authority of unit director.
b) Admission and discharge criteria.
c) Criteria for performance of special procedures, including CPR,
tracheotomy, ordering of medications, administration of parenteral
fluids and other medication, and the obtaining of blood and other
laboratory specimens.
d) The use, location, and maintenance of equipment and supplies.
e) Respiratory care.
f) Infection control.
g) Priorities for orders for laboratory tests.
h) Standing orders, if any.
i) Regulations for visitors and traffic control.

6. The nursing annex to the disaster plan was current and included:
a) Recall procedures.
b) Assignment procedures.
c) Training plan.