NUR 462 Principles of Nursing Administration Directing and Controlling (Leibler: Chapter 7) Dr. Ibtihal Almakhzoomy March 2007 Dr. Ibtihal Almakhzoomy Directing and Controlling Define the management function of controlling Relate controlling to directing Quality control Characteristics of Control Control Process Standards Measuring performance Clinical Audits Total Quality Management Six Sigma strategies Benchmarking Tools for control Dr. ibtihal Almakhzoomy 2 1
Directing Directing is influencing people's behavior through motivation, communication, group dynamics, leadership and discipline. The purpose of directing is to channel the behavior of all personnel to accomplish the organization's mission and objectives simultaneously helping them accomplish their own career objectives labels: leading, influencing, coaching, motivating, interpersonal relations, and human relations motivation, communication, performance appraisal, discipline and conflict management (to be covered the last four weeks) Dr. ibtihal Almakhzoomy 3 Controlling Controlling is the management function in which actual performance of the organization is measured against predetermined standards corrective action is taken to ensure the accomplishment of organizational goals a nurse s performance can be measured only when it can be compared with a preexisting standard Productivity, innovation, and quality outcomes Not a means of determining success or failure, but as a way to learn and grow.improve It is the policing operation in management. create a positive climate so that the process of control is accepted as part of routine activity Controlling is also a forward- looking process in that the manager seeks to anticipate deviation and prevent it. Dr. ibtihal Almakhzoomy 4 2
Controlling Because the management process, like the nursing process, is cyclic, controlling is not an end in itself; it is implemented throughout all phases of management. periodic evaluation of unit philosophy, mission, goals, and objectives; the measurement of individual and group performance against preestablished standards; the monitoring of expenses and use of supplies; and the auditing of patient goals and outcomes Dr. ibtihal Almakhzoomy 5 Quality Control activities that are used to evaluate, monitor, or regulate services rendered to consumers. In nursing, the goal of quality care would be to ensure quality while meeting intended goals. For any quality control program to be effective, certain components need to be in place Support from top level administration (fiscal and human resources) Commitment by the organization in terms of fiscal and human resources Quality goals reflect search for excellence (optimum levels) rather than minimums (minimally accepted levels) Process is ongoing (continuous): must reflect a belief that the search for improvement in quality outcomes is continuous and that care can always be improved Dr. ibtihal Almakhzoomy 6 3
Control Phases Beginning: Manager initiates the control function during the planning phase when possible deviation is anticipated and policies are developed to help ensure uniformity of practice. Organizing phase Manager may introduce - close supervision and tight leadership style as a control factor Through rewards and positive sanctions the manager seeks to motivate workers to conform =thus limiting the amount of control that must be imposed. Final Stage The manager develops specific control tools, such as: Inspections Visible control charts Work counts Special reports Audits Dr. ibtihal Almakhzoomy 7 The Basic Control Process The control process involves three phases that are cyclic: Establishing criteria or standards For example, hospital nurses should provide postoperative patient care that meets standards specific to their institution Measuring performance Information is collected to determine if the standard has been met. Correcting deviation if the criteria is not met Dr. ibtihal Almakhzoomy 8 4
Establishing Standards A standard is a predetermined level of excellence that serves as a guide for practice. specific units of measure that delineate acceptable work policy and procedures manual that outlines its specific standards Clinical practice guidelines: step-by-step interventions to control resource utilization and cost Standards have distinguishing characteristics; they are predetermined, established by an authority, and communicated to and accepted by the people affected by them. Because standards are used as measurement tools, they must be: objective, measurable, and achievable. Basic standards may be stated as: Staff hours allowed per activity Speed and time limits Quantity that must be produced Number of errors permitted Dr. ibtihal Almakhzoomy 9 Types of Standards Standards may be of a physical nature-both in terms of quantity and quality pounds of laundry that are clean and without stains or the number of charts processed according to the required regulations. Such standards make it easy to develop inspection processes, because such information can be recorded simply on: Control charts Work logs Standards may also be set in terms of cost: A monetary value is attached to an operation or the delivery cost of a service The cost per square foot per employee The cost per patient per visit The cost per object in a factory Intangible costs: Competence or Loyalty in an employee Ability in a trainee =wherever possible though it should be quantifiable Dr. ibtihal Almakhzoomy 10 5
The Intangible Nature of Service Health care organizations face a special difficulty: =primary activities = service =do not always lend themselves to quantifiable measurement =difficult to monitor the delivery of service Patient privacy is a major concern Dilemma: attempts to delineate service in terms of cost =difficult. Many services must remain available even if the patient census has dropped in a given period. An emergency service must provide adequate cover no matter how many patients come for service at a particular time Dr. ibtihal Almakhzoomy 11 Measuring Performance Involves comparing the work (e.g.the goods produced or the service provided) against the standard. identifying information relevant to the criteria. What information is needed to measure the criteria? In the example of postoperative patient care, this information might include the frequency of vital signs, dressing checks, and neurological or sensory checks. determining ways to collect information. As in all data gathering, the manager must be sure to use all appropriate sources. assessing quality control of postoperative patient, information in the patient chart. Postoperative flowsheets the physician orders, and the nursing notes Talking to the patient or nurse also could yield information Dr. ibtihal Almakhzoomy 12 6
Clinical Audits Audits are measurement tools. An audit is a systematic and official examination of a record, process, structure, environment, or account to evaluate performance. Auditing in healthcare organizations provides managers with a means of applying the control process to determine the quality of services rendered. Auditing can occur retrospectively, concurrently, or prospectively. Retrospective audits are performed after the patient receives the service. Concurrent audits are performed while the patient is receiving the service. Prospective audits attempt to identify how future performance will be affected by current interventions. Dr. ibtihal Almakhzoomy 13 Clinical Audits The audits most frequently used in quality control include the outcome, process, and structure audits. Outcomes can be defined as the end result of care, or how the patient s health status changed as a result of the intervention. Outcome audits determine what results, if any, occurred as a result of specific nursing interventions for patients. These audits assume that the outcome accurately demonstrates the quality of care that was provided. outcome measures considered most valid indicators of quality care, but most evaluations of hospital care have focused on structure and process. Dr. ibtihal Almakhzoomy 14 7
Clinical Audits Process audits are used to measure the process of care or how the care was carried out and assume that a relationship exists between the process used by the nurse and the quality of care provided. Critical pathways and standardized clinical guidelines examples of efforts to standardize the process of care. provide a tool to measure deviations from accepted best-practice process standards. Process audits tend to be task-oriented and focus on whether practice standards are being fulfilled. Process standards may be documented in patient care plans, procedure manuals, or nursing protocol statements. For example, a process audit might be used to establish whether fetal heart tones or blood pressures were checked according to an established policy. In a community health agency, a process audit could be used to determine if newborn teaching had been carried out during the first postpartum visit. Dr. ibtihal Almakhzoomy 15 Clinical Audits Structure audits assume that a relationship exists between quality care and appropriate structure. A structure audit includes resource inputs such as the environment in which health care is delivered. It also includes all those elements that exist prior to and separate from the interaction between the patient and the healthcare worker. For example, staffing ratios, staffing mix, emergency department wait times, and the availability of fire extinguishers in patient care areas would all be structure measures of quality of care. Structural standards, which are often set by licensing and accrediting bodies, ensure a safe and effective environment but do not address the actual care provided. Structural audit: checking to see if patient call lights are in place or if patients can reach their water pitchers. staffing patterns to ensure that adequate resources are available to meet changing patient needs. Dr. ibtihal Almakhzoomy 16 8
Measuring Performance Auditing quality control is collecting and analyzing information. For example, if the standards specify that postoperative vital signs are to be checked every 30 minutes for 2 hours and every hour thereafter for 8 hours, it is necessary to look at how often vital signs were taken the first 10 hours after surgery. The frequency of vital signs listed on the postoperative flowsheet is then compared with the standard set by the unit. The resulting discrepancy or congruency gives managers information with which they can make a judgment about the quality or appropriateness of the nursing care. If vital signs were not taken frequently enough to satisfy the standard, the manager would need to obtain further information regarding why the standard was not met and counsel employees as needed. Likewise, the manager should reward employees who provide nursing care that exceeds organizational standards Dr. ibtihal Almakhzoomy 17 Final Stage: Re-evaluation If standards are consistently unmet or met only partially, frequent reevaluation is indicated. Remedial action is taken Retraining employees Reviewing standards If quality control is measured on 20 postoperative charts and a high rate of compliance with established standards is found, the need for short-term re-evaluation is low. Quality control is not reactive (implemented as a reaction to a problem). Quality control is proactive (pushing standards to maximal levels and by eliminating problems in early stages, before productivity or quality is compromised). Dr. ibtihal Almakhzoomy 18 9
Total Quality Management Quality Assurance (QA) to Quality Improvement (QI) QA models seek to assure that quality currently exists QI models assume that the process is ongoing and that quality can always be improved. Total Quality Management model emphasizes the ongoing nature of QI also referred to as Continuous Quality Improvement (CQI), a philosophy developed by Dr. W. Edward Deming. Considered the hallmark of highly successful Japanese management systems, TQM is based on the premises that the individual is the focal element on which production and service depend (i.e., it must be a customer-responsive environment) and that the quest for quality in an ongoing process. identifying and doing the right things, the right way, the first time, and problem-prevention planning not inspection and reactive problem solving lead to quality outcomes. preventive or proactive mode so crisis management becomes unnecessary Dr. ibtihal Almakhzoomy 19 Total Quality Management Another critical component of TQM is the empowerment of employees positive feedback & reinforcing attitudes and behaviors that support quality and productivity Based on the premise that employees have an in-depth understanding of their jobs, believe they are valued, and feel encouraged to improve product or service quality through risk taking and creativity, TQM trusts the employees to be knowledgeable, accountable, and responsible and provides education and training for employees at all levels. philosophy of TQM emphasizes that quality is placed before profit Dr. ibtihal Almakhzoomy 20 10
Characteristics of Adequate Control Processes and Tools Several features are necessary to ensure the adequacy of control processes and tools: Timeliness Economy Comprehensiveness Specificity and appropriateness Objectivity Responsibility Understandability Dr. ibtihal Almakhzoomy 21 Characteristics: Control Processes and Tools Timeliness: reflects deviation from standard, at an early stage, so there is only a small time lag between detection and the beginning of corrective action Economy: involves routine, normal processes rather than special inspection routines at additional expense. The control devices must be worth their cost. Comprehensiveness: directed at the basic phases of the work rather than later levels or steps in the process; e.g. a defective part is best inspected and eliminated before it has been assembled with other parts. Dr. ibtihal Almakhzoomy 22 11
Characteristics: Control Processes and Tools Specificity and appropriateness: reflects the nature of the activity. Proper laboratory inspection methods, for example, differ from the financial audit and machine inspection process. Objectivity: the processes should be grounded in fact, and standards should be known and verifiable. Responsibility: reflect the authority-responsibility pattern. As far as probable, the worker and the immediate supervisor should be involved in the monitoring and correction process. Understandability: control devices, charts, graphs, and reports that are complicated or cumbersome. Dr. ibtihal Almakhzoomy 23 The Six Sigma Strategies Six Sigma is an approach to TQM and continuous performance improvement based on statistical analysis of variations in performance measures. In the SS approach process improvement teams seek to minimize variations from the desired norm. The target is six sigma or less from this desired level of performance. The emphasis is on: Prevention of error Reduction of variance Zero defects Continuously improving customer satisfaction Dr. ibtihal Almakhzoomy 24 12
Characteristics of Six Sigma Strategies Streamlining processes Reengineering total systems Focusing on cost reductions Increasing productivity Increasing quality Dr. ibtihal Almakhzoomy 25 The Six Sigma Strategies Measurement and statistical analysis are central. Process variation Rapid response to correct undesirable variations DMAIC Dr. ibtihal Almakhzoomy 26 13
DMAIC D=Define the project goals and customers/clients (both internal and external) M=Measure the process to determine current performance A=Analyze and determine root cause(s) of the defect I = Improve the process by eliminating defects C=Control future process performance Dr. ibtihal Almakhzoomy 27 DMAIC Health Care organizations have a long history of monitoring performance and seeking continuous improvement. Examples for ongoing quality reviews suitable for SS application Risk management reviews Infection control monitoring Clinical audit studies Patient safety analysis Coding error rates Accuracy of filing Dr. ibtihal Almakhzoomy 28 14
Benchmarking a tool for identifying desired standards of organizational performance. Benchmarking is the process of measuring products, practices, and services against best-performing organizations. In doing so, organizations can determine how and why their performance differs from these exemplar organizations and use them as role models for standard development and performance improvement. best practices programs healthcare institutions submit a description of a program or protocol relating to improvements in quality of life, quality of care, staff development, or cost-effectiveness practices. Experts review the submissions, examine outcomes, and then designate a best practice. Dr. ibtihal Almakhzoomy 29 Benchmarking Benchmarking is simply comparison of one s own activity or result with the level of activity or results of another department or organization. This involves as a benchmark, the experience of some other entity, the operating results of which appear to be reasonable or perhaps to represent a desirable target. Benchmarking frequently involves targeting the various organization s best practices and comparing with their results in an effort to improve results in the benchmarking organization. with organizations having characteristics similar to our own. Dr. ibtihal Almakhzoomy 30 15
Quality Control Tools Checksheet The function of a checksheet is to present information in an efficient, graphical format. This may be accomplished with a simple listing of items. Flowchart Flowcharts are pictorial representations of a process. breaking the process down into its constituent steps, useful in identifying where errors are likely to be found in the system. Histogram Histograms provide a simple, graphical view of accumulated data, including its dispersion and central tendancy. In addition to the ease with which they can be constructed, histograms provide the easiest way to evaluate the distribution of data. Dr. ibtihal Almakhzoomy 31 Flowcharts Process Manual operation Decision Terminator Document Data used specifically for a process. a pictorial representation describing a process being studied or even used to plan stages of a project. Four particular types of flow charts have proven useful when dealing with a process analysis: top-down flow chart, detailed flow chart, work flow diagrams, and a deployment chart. basic flow chart symbols are used when analyzing how to operate a process Dr. ibtihal Almakhzoomy 32 16
Fishbone Diagram: Cause and Effect Dr. ibtihal Almakhzoomy 33 Fishbone Diagram: Cause and Effect Dr. ibtihal Almakhzoomy 34 17
Control Chart Dr. ibtihal Almakhzoomy 35 Quality Control Tools Control Chart The control chart is the fundamental tool of statistical process control, indicates the range of variability that is built into a system (known as common cause variation). helps determine whether or not a process is operating consistently or if a special cause has occurred to change the process mean or variance. bounds of the control chart are marked by upper and lower control limits Data points that fall outside these bounds represent variations due to special causes, which can typically be found and eliminated. Pareto Chart useful in identifying those factors that have the greatest cumulative effect on the system, and thus screen out the less significant factors in an analysis. created by plotting the cumulative frequencies of the relative frequency data (event count data), in decending order. When this is done, the most essential factors for the analysis are graphically apparent, and in an orderly format. Dr. ibtihal Almakhzoomy 36 18
Quality Control Tools Cause and effect diagram fish bone diagram, is used to associate multiple possible causes with a single effect. Thus, given a particular effect, the diagram is constructed to identify and organize possible causes for it. The primary branch represents the effect (the quality characteristic that is intended to be improved and controlled) and is typically labelled on the right side of the diagram. Each major branch of the diagram corresponds to a major cause (or class of causes) that directly relates to the effect. Minor branches correspond to more detailed causal factors. This type of diagram is useful in any analysis, as it illustrates the relationship between cause and effect in a rational manner. Scatter diagram Scatter diagrams are graphical tools that attempt to depict the influence that one variable has on another. A common diagram of this type usually displays points representing the observed value of one variable corresponding to the value of another variable. Dr. ibtihal Almakhzoomy 37 Gantt Chart Dr. ibtihal Almakhzoomy 38 19