What is Controlling ?

- Controlling is one of the basic functions of managers.

It is the measurement and correction of performance.
Its purpose is to make sure that plans succeed.
Who Controls?
- Control activities are essential parts of the responsibilities of managers at all levels in the
organization (first-line managers, department heads, and top management).
Basic Steps of the Control Process
- The basic control process, wherever it is found, and whatever it controls, consist of three
steps as follows:

setting control standards.

measuring performance against these standards (monitoring).
correcting deviations from standards

Example 1: controlling blood pressure

Control standard: systolic blood pressure not more than 140 mmHg.

Measurement: measurement of BP every month.

Corrective action: medication administration

Relationship between controlling and planning:

They are know as the Siamese twins of management.
SETTING CONTROL STANDARDS
- Standards can be quantitative or qualitative
Quantitative: Physical units: thermometers in each examination room in health centre
Qualitative: clean sheets of examination beds.
CONTROL STANDARDS
- It is important to differentiate between practice standards and control standards
Practice standards
Are the organizations detailed definition of the desired level for resources, the delivery
processes and procedures, and the desired outcome of these processes.

- Control standards:
Are indicators selected to monitor compliance with practice standards.
Are measurable variables (characteristics).
Are less detailed than practice standards.
Sources of Standards
1) Official documents.
2) Historical analysis of institutions own data.
3) Comparative standards (benchmarking)
4) Scientific.
5) Expert opinion:
Levels of Standards
Minimum standards:
- Represent the lowest level of acceptable performance.
Appropriate only in health systems and facilities where the general level of care is average so
that those below minimum standards are suspected to constitute a significant problem.
Minimum standards dont.:
- Under such situations, the presence of minimum standards is expected to encourage health
care institutions to reach and even exceed them with the ultimate result of improving the quality
of health services the patients receive.
- Optimum Standards
The best level of performance under the best possible circumstances.
They represent the ultimate goals toward which a health service program would direct its
efforts and continuity try to achieve.
- Optimum Standards dont.:
They are suitable mainly for health facilities which have achieved a reasonable high level of
development concerning their resources, organization and operational systems and processes,
and which have well established successful control programs.
Empirical / average standards:
- Empirical standards are usually averages that are based on actual practice.
They may be based on institutional, regional or national averages within a certain time frame.

 Examples of these standards may include:

The average number of investigations by diagnosis.
The average hospital stay by diagnosis.
The caesarean section rate.
Empirical / average standards dont.:
- Empirical standards are preferred by many people because they represent actual performance
and therefore, provide a realistic target, which has been achieved by some institutions and
exceeded by others.
Empirical standards also have some limitations. The most important limitation is that they
may conceal actual poor performance even though the standards have been achieved.
- Criteria for Setting Good Standards:
- 1)Good standards should focus on critical elements, i.e., elements known by their
demonstrated relationship to the outcome of service (validity).
High volume: affecting large number, e.g., diabetes mellitus.
High risk: serious consequences, e.g., pneumonia.
High cost: e.g., MRI examination.
Problem-Prone: problem specific to the facility or department.
2)Current: standards should be reviewed and revised or changed as necessary so that they reflect
the changes in medical sciences and technology, as well as changes in the socio-economic
condition of the community and in the values and expectations of the people.
3)Good standards should be specific, objective, and preferably expressed in quantitative terms,
thus to leading to reliability of measurement.
4)Standards should be reasonably attainable (realistic) considering resources and environment:
Too high either cause anxiety or tend to be treated with contempt.
Too low tend to breed premature satisfaction and complacency.
Participation of all levels involved in the process in setting standards:
Ensures that they are realistic.
Promotes compliance with standards.
Promotes self-control.
Examples of Hospital Control Standards
Input standards:
- Hospital care should be provided at a level of 4 hospital beds per 1000 population
Activity / process standards :
Except in extreme emergency, all patients undergoing surgery shall have a signed consent.

Examples of Hospital Control Standards

Input standards:
- Hospital care should be provided at a level of 4 hospital beds per 1000 population
Activity / process standards :
Except in extreme emergency, all patients undergoing surgery shall have a signed consent.
Output Standards:
The postoperative wound infection rate should not exceed 2% of clean surgical cases.
MEASURING PERFORMANCE (MONITORING)
What is Measurement ?
Measuring is the process of assigning a value to some objects, events, or phenomena,
according to predetermined rules.
The assigned value is usually numerical (quantitative), but sometimes it is nominal
(qualitative).
The use of the word rules is very critical. It means that the method of assigning value must
explicitly (spelled out) and clearly state what is exactly to be measured, when, and where. This is
important for standardization, which means that similar results should be obtained when the
same measuring instrument is used by the same person or by different persons.
- Importance of measuring performance:
- Provides measures of achievement, so that each member of the organization knows not only
his/her performance, but also that of relevant other members.
To provide an objective basis for rewarding members of the organization.
To provide data useful in setting new expectations (objectives).
For controlling (to identify correctable deviations from the plan).
Characteristics of Good Measures

- 1. Accuracy of collected data

2. Reliability of measurement
CORRECTIVE ACTION

1- Performance meets standards (In-control loop):

No change is required.
Continue monitoring.
2- Performance below standards:
Determine the cause of the deviation.
a. If the deviation is acceptable, or its cause is uncontrollable, activities continue with no
intervention (Acceptance control loop).
Examples of acceptance deviation:
The size of the waiting list increases because one of the theatres is being renewed.
B- If deviation is unacceptable and the cause is controllable, intervention should occur
(Required change control loop):
- Examples:
- Average stay higher than standard due to unacceptable reasons:
Physicians do not discharge patients in time.
3. Actual performance exceeds standard (positive control loop):
a. If desirable (e.g., % of pregnant women attending antenatal care clinic exceeding standard
in one rural health unit of the district):
Reinforce.
Freeze in place.
Replicate elsewhere (change standard in other units of the district).
If undesirable, the cause should be determined and either acceptance or required change
control loops should be used.
For example, physical plant maintenance expenditures may be below budget, yet this may be
undesirable if preventive maintenance is postponed.
- Steps of Corrective Action:
- Identify the root cause of the problem.
Develop a plan for corrective action that includes:
The changes required.
The appropriate actions needed to overcome the problem.
The person or group responsible for implementing and overseeing the actions (adequate
authority).
The time frame within which the actions should occur.
Implement corrective action.
Monitor and evaluate performance.
- Most Common Causes of Problems Are:

 Insufficient knowledge.
Behavioral problems.
Defects in systems (usually responsible for around 70% of problems).
- Appropriate corrective action:
Insufficient knowledge may be corrected by:
Training and continuing education.
Providing reference source, e.g., books, periodicals, internet
Behavior or performance deficiencies may be corrected by:
Counseling.
Emphasizing supervision and motivation.
Changing duties.
Transferring.
Withdrawing certain privileges.
Discipline.
Defects in systems may be corrected by:
Changing policies and procedures.
Changing lines of authority.
Changing span of control.
Redistribution of staff.
Characteristics of Effective Control Systems
Control systems should be extensions of the planning process.
Actual performance should be compared to planned performance.
Feedback from controlling to planning, which may lead to changing of strategies or
objectives.
Effective control systems should coordinate standards of different units with one another and
with objectives of the organization: Sometimes standards are not coordinate Effective control
systems should be based on good control standards (critical elements, current, objective, realistic,
participation). These standards should be explicit (predetermined, written and formalized.
Effective control systems should be based on appropriate information. If information is not
appropriate, the whole control process will fail.
Either too little or too much information is undesirable. Too much information may cause
important indicators to be lost. Too little information may be missing critical elements.
Effective control systems should be designed to give the manager sufficient valid (measures

what it is supposed to measure), reliable, accurate and sensitive detects changes) information at
the right time in a usable format.
- Participation of all levels involved in a process should be involved in all steps of the control
process:
Ensures that standards are realistic.
Improves compliance with standards.
Promotes self-control.
Improves problem solving and corrective action.
When possible control should be forward looking (input and process control) as well as feed
backward (output control). Neither of three approaches to control is a substitute for the two
others.
- Leads to corrective action:
- An effective control system must lead to corrective action; merely uncovering deviations is
not enough. Therefore, the system should be able to disclose:
Where the problem areas are.
The magnitude of the problems.
Who is responsible for them.
What should be done about them.
- Timeliness:
Control should detect, report and correct deviations quickly. Late feedback may result in a
problem being attacked after it has already cured itself, or worse, it may allow a problem to get
so out of control that more drastic means of intervention must be employed. The consideration of
when feedback is late depends on the process being controlled and the speed with which
intervention can be successfully employed. The control system that is not timely is not only
useless, but also costly.
- Flexibility:
Blind and inflexible use of numerical measures causes distortions. Changes and unforeseen
circumstances require that judgment, common sense, and flexibility be used in control systems.
To help managers concentrate on significant deviations, control standards (UCL & LCL)
should be defined in terms of upper and lower acceptable limits. These are termed (tolerance
limits). This is particularly important in the field of hospital care because most of the work in
hospitals is stochastic (subject to random variation)>
- Economical:
The cost of implementation of the control system (mainly cost of data collection and

analysis) should not exceed its benefits.

The practical difficulty is that most managers, particularly in the field of hospital care, find
difficulties in estimating the cost of control and the expected value or benefits to be achieved out
of it.
- Understandability:
- Reports should be simple; those that are too complicated will not be used.
Problem-Solving Capacity:
The manager should have the knowledge, skill, resources, and authority to intervene.
Therefore, effective control systems should consider training managers who are going to
implement and use them.
- Responsibility:
Control systems should reflect the authority-responsibly relationship. As far as possible, the
worker and the immediate supervisor should be involved in the monitoring and correction
processes.
- Backup Support:
There should be an organizational structure behind the manager, which reinforces the
managers authority both to control the process and to step in when circumstances beyond the
managers control cause the process to step to get out of control.
This support structure can be regarded as a super control system over the control system
itself. The super control system is asked to intervene only when the manager calls for help, or
when the whole process (including the manager and the control system) appears not to be
functioning properly.
- Respect for the control system:
All people involved from those in the process to the manager should regard the control
system as a serious and essential part of the organization. This includes respect for the need to
have control, belief in the standards of the performance, a feeling of responsibility for
maintaining control, and a feeling that they do have the ability to intervene when necessary.
Effective control system should emphasize rewards as well as sanctions.
Concentration on sanctions and negative corrective actions will eventually lead to
dissatisfaction, frustration and failure.
Sanctions and negative corrective action when needed must be used promptly, fairly, and
equitable.

Performance appraisal

Definition:
It is a periodic formal evaluation of how well personnel have performed their duties during a
specific period.
- Purposes of performance appraisal:
Improve performance (main purpose).
To determine job competence.
To enhance staff development and motivate personnel toward higher achievement.
To discover the employees aspirations and to recognize accomplishment
To improve communications between managers and staff associates and to reach an
understanding about the objectives of the job and agency.
To determine training and development needs.
To select qualified nurses for advancement and salary increases.
Identify unsatisfactory employees for demotion or termination.
Reinforce standards of job performance.
Select quality individuals for promotion
Discover aspirations of employees and reconcile them with goals of heir organization.
Determine salary standards.
Controlling
Performance appraisal (evaluation):
Performance appraisal is an integral part of management control function.
It requires as a first step, careful gathering information on how employees at all levels in the
organization are carrying out their duties.
The criteria and standards under which performance appraisal is carried out are of great
importance and should be included in the employees job description.
- The basic contents of job appraisal should include examination of:
- The quality and quantity of work accomplished.
The employees attitude toward the organization and its goals.
The employees attitude toward other workers in the organization.
- Interests in performance appraisal:
- Administrative function:

 It provides a method by which most likely fair decisions can be made with regard to
promotion, demotion, and transfer of an employee or termination of employment.
- Informational function:
- It informs an employee as to how his supervisor judges their performance.
It indicates which area needs improvement.
It assesses the organization audit its human resources and specific skills.
Performance appraisal should also alerts the employer to strength and weakness in its
recruitment and selection processes.
- Motivational function:
- Properly conducted performance appraisal should motivate employees to improve heir own
performance, both in their behalf and with assistance of their employers.
- Influence of hallo effect:
Hallo an effect obscures the true nature of the performance being apprised.
Performance appraisal process is described as having both evaluative and developmental
components:
- Evaluative components:
- Focus on past performance and can be accomplished by using behavioral rating scales with
narrative documents summarizing behavior in each category.
- Developmental components:
- Focus on future behavior and includes mutual goal projection by employee and supervisor.
Performance appraisal process includes:
1- Day-by-day supervisor-subordinate interaction.
(Coaching-counseling-discipline).
2- Written documentation: (recording critical incidences completing performance review
form).
3- Formal performance interview.
4- Follow up with coaching and or discipline as indicated.
It is essential to consider the concept that appraisal is an emotionally charged area, and that it
is interpretation by the nurses being evaluated can have a strong impact on their self-esteem and
subsequent performance.
- The process of appraisal for employees should consider three behaviors demonstrated by
the nurse:
- Display of awareness of the rational for actions and self-confidence in performance.
Display of ability to communicate effectively.
Display of autonomy and responsibility for actions.
- Guidelines to decrease the likelihood of discrimination when doing the performance

appraisal:
The appraisal should be in writing and carried out at least once a year.
The performance appraisal information should be shared with the employee, and the
employee should have the opportunity to respond in writing.
There should be a mechanism by which an employee can appeal the results of his
performance appraisal.
The supervisor should have adequate opportunity to observe the employees job performance.
Notes (critical incidences) on the employees performance should be kept during the entire
evaluation period.
The evaluators should be trained how to carry out the appraisal process.
The performance appraisal is preferred to be behaviorally based.
- The nurse manager should rate on several different dimensions such as:
Initiative; including attitudes in dealing with patients and others.
Internal motivation.
Knowledge includes level of knowledge and skills in performing different nursing
procedures/activities.
Ability to work with others.
- Potential problems and Common errors in performance appraisal:
- Leniency error: A = 90 100, B = 80 89, C = 70 79.
Recency error. The appraiser affected by recent events or incidences
Ambiguous evaluation standards.
Written comments.
Appraiser ability.
Appraiser motivation.
- Criteria involving judgments are used for performance evaluation.
Hallo error:
Is result of allowing one trait to influence the evaluation of other traits or of rating all traits on
than basis of a general impression.
A logical error:
Is a rating a nurse possesses another chch or behaviors that is logically related.
-

Horns error:
the evaluator is hyper perfectionist may rate personnel lower than they should.
- Contrast error:
Tendency of managers to rate the nurse opposite from the way they receive themselves.

Central tendency error:

A small range of scores was applied in evaluation.
Methods of Performance Management

- Anecdotal notes:
Are objective description of behavior recorded on plain paper or a form. The notation include
who was observed, by whom, When, and where.
It comprises a description setting or background and the incident, and interpretation and
recommendations may be included.
Value laden words such as good and bad should be avoided. It is advisable to make several brief
observations over a time span to allow for temporary Variables and to identify patterns of
behaviors.
An advantage of anecdotal note readings is that not coerced into a rigid structure.
Check list:
`The manager categorically assess the presence or absence of desired chch or behaviors.
Checklists are mostly for tangible variables, Such as inventory of supplies, and may be used to
evaluate nursing skills also.
-

Rating scale:
It does more than just note the presence or absence of desirable behavior. It locates the
behavior at a point on a continuum and notes quantities and qualitative abilities. The numerical
rating scale usually includes numbers against which a list which a list of Behaviors are evaluated.
- Ranking:
It forces managers to rank the staff in descending order from highest to lowest even if they do
not think there is deference.
- Key behaviors in performance review:
- Put the person at ease.
Make it clear that the purpose of the performance review is to help the employee to do the
best possible job.
Review the ratings with the employee, citing specific examples of behavior that resulted in a

particular rating.
Ask for the employees feelings about the ratings and listen, accept and respond to them.
Together decide on specific ways in which weak areas can be strengthened.
Set a follow up date.
Express your confidence in the employee.
- Remember:
- Evaluation should be done day-by-day.
The nurse must be informed about his strong and weak areas.
The performance appraisal usually done annually and as needed.
The nurse must be informed about the results of appraisal.
According to the results, the employer can determine the staff needs for reward,
development, updating
Coordinating

It is the act of synchronising people and activities so that they function smoothly in the attainment of organization
objectives. Coordination is more important in the health services organization, because functionally they are
departmentalized. Different kinds of organization require different amount of coordination.

Basic approaches to coordination:

Corrective co ordinations are those coordinative activities that rectify the present error or correct a
dysfunction in the organization.

Preventive coordination comprises those coordinative activities that are aimed at preventing the
occurrence of anticipated problems of coordination, or at least minimizing the impact of these problems.

Regulatory coordination comprises those coordinative activities that are aimed at the maintenance of
existing structural and functional arrangements in the organizations.

Promotive coordination has those coordinative activities that are aimed at attempting to improve the
articulation of the parts of the organization, or to improve the existing organizational arrangements
without regard for specific problems.

Controlling

Controlling can be defined as the regulation of activities in accordance with the requirements of plans.

Steps of control:
o

The control function, whether it is applied to cash, medical care, employee morale or anything else,
involves four steps.

1. Establishments of standards.
2. Measuring performance

3. Comparing the actual results with the standards.

4. Correcting deviations from standards.
Reporting and recording
Reports are oral or written exchanges of information shared between caregivers or workers in a number of ways. A report
summarizes the services of the person, personnel and of the agency. Reports are written usually daily, weekly, monthly or
yearly.
Purposes of reporting:

To show the kind and amount of services rendered over a specified period.

To illustrate progress in reaching goals.

As an aid in studying health conditions.

As an aid in planning.

To interpret services to the public and to the other interested agencies.

Records and reports must be functional, accurate, complete, current organized and confidential.
Budgeting

Budgeting, though primarily recognized as a device for controlling, becomes a major part of the planning process
in any organization. It is expressed in financial terms and based on expected income and expenditure. Budget is
the heart of administrative management. It served as a powerful tool of coordination and negatively an effective
device of eliminating duplicating and wastage.

Features of budget:

Should be flexible.

Should be synthesis of past, present and future.

Should be product of joint venture & cooperation of executives/ department heads at different levels of
management.

It should be in the form of statistical standard laid down in specific numerical terms.

It should have support of top management throughout the period of its planning and supplementation