Mr. Channabasappa. K.

UNIT –VIII
CONTROLLING

1. QUALITY ASSURANCE- CONTINUOUS QUALITY IMPROVEMENT

Introduction
In the changing health care environment, concerns over quality of care are receiving
greater attention than ever before. As consumer become more knowledgeable as a result of
increased information available to them, much of the mystique surrounding health care is
being dissipated.
Quality management (QM) and quality improvement (QI) are the basic concepts
derived from the philosophy of total quality management (TQM). Now it is preferred to
use the term Continuous Quality Improvement (CQI) since TQM can never be achieved.
And the method of monitoring of healthcare for CQI is done with Quality Assurance (QA).
Definition
 ―Quality assurance is a judgment concerning the process of care based on the extent
to which that care contributes to valued outcomes.‖ -
Donabedian 1982

 ―Quality assurance is the measurement of provision against expectations

with declared intention and ability to correct any demonstrated weakness.‖
-Shaw

 ―Quality assurance is a management system designed to give maximum guarantee

and ensure confidence that the service provided is up to the given accepted level of
quality, the standards prescribed for that service which is being achieved with a
minimum of total expenditure.‖
-British Standards Institute

Quality assurance vs. Continuous quality improvement (Koch, 1993)

Quality improvement is not necessarily a replacement for existing quality assurance
activities, but rather an approach that broadens the perspectives on quality.

Quality assurance (QA) Quality Improvement (QI)

 Planning oriented (prevention)
 Inspection oriented (detection)
 Reaction  Proactive
 Correction of common causes
 Correction of special causes
 Responsibility of all people involved
 Responsibility of few people
with the work
 Cross- functional
 Narrow focus
 Leadership actively leading
 Leadership may not be vested
 Problem solving by employees at all
 Problem solving by authority
levels

1
Objectives
 To successfully achieve sustained improvement in health care, clinics need to design
processes to meet the needs of patients.
 To design processes well and systematically monitor, analyze, and improve their
performance to improve patient outcomes.
 A designed system should include standardized, predictable processes based on best
practices.
 Set Incremental goals as needed.
NASA Ames Research Center Health Unit

 Public accountability- It provides evidence that the funds are being spend both
effectively resulting in optimum utilization of the resource resulting in operational
efficiency and efficiency of services provided.

 Management improvement- This is to provide quality assurance programme as a tool

for managerial problem solving. It includes identification of the problem in areas of
technical quality, efficiency, risk and patient satisfaction to assess its nature, causes
and taking effective actions to reduce or eliminate the identified problems.

 Facilitation of adoption of innovations- It includes evaluation of performance of

individuals professionals, preparation of appropriate criteria for assessment of
processes and outcome, exchange of information within and outside the organization,
and introduction of innovations with assessment of their impact on patient care
outcome, risk and satisfaction by using the patient as a unit for analysis.

Quality assurance whether in health or education had two main objectives:

 To provide technical assistance in designing and implementing effective strategies for

monitoring quality and correcting systemic deficiencies and

 To refine existing methods for ensuring optimal quality health care through an applied
research programme
(Decker, 1985 and Schroeder, 1984).
Purposes/ Need
 Rising expectations of consumer of services.
 Increasing pressure from national, international, government and other professional
bodies to demonstrate that the allocation of funds produces satisfactory results in
terms of patient care.
 The increasing complexity of health care organizations.
 Improvement of job satisfaction.
 Mr. Channabasappa. K.M

 Highly informed consumer

 To prevent rising medical errors
 Rise in health insurance industry
 Accreditation bodies
 Reducing global boundaries.
Principles
 QM operates most effectively within a flat, democratic and organizational structure.
 Managers and workers must be committed to quality improvement.
 The goal of QM is to improve systems and processes and not to assign blame.
 Customers define quality.
 Quality improvement focuses on outcome.
 Decisions must be based on data.
According to W Edward Deming; (Deming’s 14 points)
 Crete consistency of purpose for improvement of product and service.
 Adopt the new philosophy
 Cease dependence on inspection to achieve quality.
 End the practice of awarding business on the basis of price tag.
 Improve constantly and forever the systems of production and service.
 Institute training on the job.
 Institute leadership.
 Drive out fear.
 Break down barriers between departments.
 Eliminate slogans, exhortations, and target for the workforce.
 Eliminate numerous quotas for the workforce and numerical goals of management.
 Remove barriers that rob people of pride and workmanship.
 Institute a vigorous programme of education and self-improvement for everyone.
 Put everyone in the company to work to accomplish the transformation.
Approaches
 General approach
 Specific approach
General approach: - It involves large governing or official bodies evaluating a person or
agencies‘ ability to meet established criteria or standard during a given time.
a) Credentialing- It is the formal recognition of professional or technical
competence and attainment of minimum standards by a person and agency.
Credentialing process has 4 functional components
 To produce a quality product
 To confirm a unique identity
 To protect the provider and public
 To control the profession
 b) Licensure- It is a contract between the profession and the state in which the
profession is granted control over entry into an exit from the profession and over
quality of professional practice.
c) Accreditation- It is a process in which certification of competency, authority, or
credibility is presented to an organization with necessary standards.
d) Certification
e) Charter- It is a mechanism by which a state government agency under state law
grants corporate state to institutions with or without right to award degrees.
f) Recognition- It is defined as a process whereby one agency accepts the
credentialing states of and the credential confined by another.
g) Academic degree

Specific approach: - These are methods used to evaluate identified instances of provider and
client interactions.
a) Audit- It is an independent review conducted to compare some aspect of quality
performance, with a standard for that performance.
b) Direct observation- Structured or unstructured based on presence of set criteria.
c) Appropriateness evaluation- The extent to which the managed care organization
provides timely, necessary care at right levels of service.
d) Peer review- Comparison of individual provider‘s practice either with practice by the
provider‘s peer or with an acceptable standard of care.
e) Bench marking- A process used in performance improvement to compare oneself
with best practice.
f) Supervisory evaluation
g) Self-evaluation
h) Client satisfaction
i) Control committees
j) Services- Evaluates care delivered by an institution rather than by an individual
provider.
k) Trajectory- It begins with the cohort of a person who shares distinguishing
characteristics and then follows the group going through the healthcare system noting
what outcomes are achieved by the end of a particular period
l) Staging- It is the measurement of adverse outcomes and the investigation of its
antecedence.
m) Sentinel- It involves maintaining of factors that may result in disease, disability or
complications such as;
 Review of accident reports
 Risk management
 Utilization review
Elements/ components
 According to Donabedian;
 Structure Element- The physical, financial and organizational resources
provided for health care.
 Mr. Channabasappa. K.M

 Process Element- The activities of a health system or healthcare personnel in

the provision of care.
 Outcome Element- A change in the patient‘s current or future health that
results from nursing interventions.
According to Manwell, Shaw, and Beurri, there are 3A’s and 3E’s;
 Access to healthcare
 Acceptability
 Appropriateness and relevance to need

 Effectiveness
 Efficiency
 Equity

Standards
Standards are written formal statements to describe how an organization or
professional should deliver health service and are guidelines against which services can be
assessed. Kirk and Hoesing (1991) stated that standards are needed to;
 Provide direction
 Reach agreement on expectations
 Monitor and evaluate results
 Guide organizations, people and patients to obtain optimal results.
Standards are directed at structure, process, and outcome issues and guide the review of
systems function, staff performance, and client care. The organizations providing quality
indexes are;
•AHRQ –Agency for Healthcare Research and Quality
•IHI –Institute for Healthcare Improvement
•JCAHO –Joint Commission on Accreditation of Healthcare Organizations
•NAHQ –National Association for Healthcare Quality
•IOM –Institute of Medicine
•NCQA –National Committee for Quality Assurance
Areas of QA
The assurance in various key areas are
 Outpatient department- The points to be remembered are;
 Courteous behavior must be extended by all, trained or untrained personnel.
 Reduction of waiting time in the OPD and for lab investigations by creating
more service outlets.
 Provide basic amenities like toilets, telephone, and drinking water etc.
 Provision of polyclinic concept to give all specialty services under one roof.
 Providing ambulatory services or running day care centers.
  Emergency medical services
Services must be provided by well trained and dedicated staff, and they should
have access to the most sophisticated life- saving equipment and materials,
and also have the facility of rendering pre- hospital emergency medical aid
through a quick reaction trauma care team provided with a trauma care
emergency van.
 In- patient services
Provide a pleasant hospital stay to the patient through provision of a safe,
homely atmosphere, a listening ear, humane approach and well behaved,
courteous staff.
 Specialty services
A high tech hospital with all types of specialty and super- specialty services
will increase the image of the hospital.
 Training
A continuous training programme should be present consisting of ‗on the job
training‘, skill training workshops, seminars, conferences, and case presentations.

Models of quality assurance

1. Donabedian Model (1985): It is a model proposed for the structure, process and outcome
of quality. This linear model has been widely accepted as the fundamental structure to
develop many other models in QA.
 Mr. Channabasappa. K.M

2. ANA Model: This first proposed and accepted model of quality assurance was given by
Long & Black in 1975. This helps in the self- determination of patient and family, nursing
health orientation, patient‘s right to quality care and nursing contributions.

Evaluate Identify
outcome of standards
structure
and criteria
, standard and criteria

Apply the process,

standards and criteria

3. Quality Health Outcome Model:

The uniqueness of this model proposed by Mitchell & Co is the point that there are
dynamic relationships with indicators that not only act upon, but also reciprocally affect the
various components.
System
(Individual,
Group/ organization)

Intervention Outcome

Client
(Individual, Family & Community)

4. Plan, Do, and Study, Act cycle:

It is an improvement model advocated by Dr. Deming which is still practiced widely
that contains a distinct improvement phase.
Use of PDSA model assumes that a problem has been identified and analyzed for its
most likely causes and that changes have been recommended for eliminating the likely
causes. Once the initial problem analysis is completed, a Plan is developed to test one of the
improvement changes. During the Do phase, the change is made, and data are collected to
evaluate the results. Study involves analysis of the data collected in the previous step. Data
are evaluated for evidence that an improvement has been made. The Act step involves taking
actions that will ‗hardwire‘ the change so that the gains made by the improvement are
sustained over time.

5. Six Sigma:
It refers to six standard deviations from the mean and is generally used in quality
improvement to define the number of acceptable defects or errors produced by a process.
It consists of 5 steps: define, measure, analyze, improve and control (DMAIC).
 Define: Questions are asked about key customer requirements and key processes to
support those requirements.
 Measure: Key processes are identified and data are collected.
 Analyze: Data are converted to information; Causes of process variation are
identified.
 Improve: This stage generates solutions and make and measures process changes.
 Control: Processes that are performing in a predictable way at a desirable level are in
control.
6. Achieving Quality Care:

This shows a complex and interactive framework. It illustrates the idea of that
quality of care that is important to clients, practitioners, management and health
organizations, and to society as a whole. These groups may be interested in quality for
different reasons, will have different perspectives on quality and consequently have
different priorities. Their interests may be purely client-centered or influenced by
external pressures such as government policy, scarcity of resources or changing
technology.

 At an individual level, everyone affects quality of care-receptionists, telephones,

building maintenance staff, managers, clerical staff, caterers, and professional staff.
Quality is everyone‘s business. There is a potential problem here- since quality is
everyone‘s business it can become no one‘s business. In any organization someone
needs to take the responsibility for quality.
 Mr. Channabasappa. K.M

Client Professional

Quality care

Management Other

Quality tools
 Chart audits
It is the most common method of collecting quality data using charts as quality
assessment tool.
 Failure mode and effect analysis: prospective view
It is a tool that takes leaders through evaluation of design weaknesses within
their process, enable them to prioritize weaknesses that might be more likely
to result in failure (errors) and, based on priorities decide where to focus on
process redesign aimed at improving patient safety.
 Root- cause analysis: retrospective view
It is sometimes called a fishbone diagram, used to retrospectively analyze
potential causes of a problem or sources of variation of a process. Possible
causes are generally grouped under 4 categories: people, materials, policies
and procedures, and equipment.
 Flow charts
These are diagrams that represent the steps in a process.
 Pareto diagrams
It is used to illustrate 80/ 20 rule, which states that 80% of all process variation
is produced by 20% of items.
 Histograms
It uses a graph rather than a table of numbers to illustrate the frequency of
different categories of errors.

 Run charts
These are graphical displays of data over time. The vertical axis depicts the
key quality characteristic, or process variable. The horizontal axis represents
time. Run charts should also contain a center line called median.
 Control charts
 These are graphical representations of all work as processes, knowing that all
work exhibit variation; and recognizing, appropriately responding to, and
taking steps to reduce unnecessary variation.

Indicators of quality assurance

 Waiting time for different services in the hospital
 Medical errors in judgment, diagnosis, laboratory reporting, medical treatment or
surgical procedures, etc.
 Hospital infections including hospital- acquired infections, cross infections.
 Quality of services in key areas like blood bank, laboratories, X- ray department,
central sterilization services, pharmacy and nursing.

Quality improvement process- Steps

QI process steps include;
 Identify needs most important to the consumer of health care services.
 Assemble a multidisciplinary team to review the identified consumer needs and
services.
 Collect data to measure the current status of these services.
 Establish measurable outcomes and quality indicators.
 Select and implement a plan to meet the outcomes.
 Collect data to evaluate the implementation of the plan and achievement of outcomes.

Quality assurance cycle:

In practice, QA is a cyclical, iterative process that must be applied flexibly to meet the
needs of a specific program. The process may begin with a comprehensive effort to define
standards and norms as described in Steps 1-3, or it may start with small-scale quality
improvement activities (Steps 5-10). Alternatively, the process may begin with monitoring
(Step 4). The ten steps in the QA process are discussed.
 Mr. Channabasappa. K.M

1. Planning for Quality Assurance

This first step prepares an organization to carry out QA activities. Planning begins
with a review of the organizations scope of care to determine which services should be
addressed.

2. Setting Standards and Specifications

To provide consistently high-quality services, an organization must translate its
programmatic goals and objectives into operational procedures. In its widest sense, a standard
is a statement of the quality that is expected. Under the broad rubric of standards there are
practice guidelines or clinical protocols, administrative procedures or standard operating
procedures, product specifications, and performance standards.
3. Communicating Guidelines and Standards
Once practice guidelines, standard operating procedures, and performance standards
have been defined, it is essential that staff members communicate and promote their use. This
will ensure that each health worker, supervisor, manager, and support person understands
what is expected of him or her. This is particularly important if ongoing training and
supervision have been weak or if guidelines and procedures have recently changed. Assessing
quality before communicating expectations can lead to erroneously blaming individuals for
poor performance when fault actually lies with systemic deficiencies.
4. Monitoring Quality
Monitoring is the routine collection and review of data that helps to assess whether
program norms are being followed or whether outcomes are improved. By monitoring key
indicators, managers and supervisors can determine whether the services delivered follow the
prescribed practices and achieve the desired results.
5. Identifying Problems and Selecting Opportunities for Improvement
Program managers can identify quality improvement opportunities by monitoring and
evaluating activities. Other means include soliciting suggestions from health workers,
performing system process analyses, reviewing patient feedback or complaints, and
generating ideas through brainstorming or other group techniques. Once a health facility team
has identified several problems, it should set quality improvement priorities by choosing one
or two problem areas on which to focus. Selection criteria will vary from program to
program.
6. Defining the Problem
Having selected a problem, the team must define it operationally-as a gap between
actual performance and performance as prescribed by guidelines and standards. The problem
statement should identify the problem and how it manifests itself. It should clearly state
where the problem begins and ends, and how to recognize when the problem is solved.
7. Choosing a Team
Once a health facility staff has employed a participatory approach to selecting and
defining a problem, it should assign a small team to address the specific problem. The team
will analyze the problem, develop a quality improvement plan, and implement and evaluate
the quality improvement effort. The team should comprise those who are involved with,
contribute inputs or resources to, and/or benefit from the activity or activities in which the
problem occurs.
8. Analyzing and Studying the Problem to Identify the Root Cause
Achieving a meaningful and sustainable quality improvement effort depends on
understanding the problem and its root causes. Given the complexity of health service
delivery, clearly identifying root causes requires systematic, in-depth analysis. Analytical
tools such as system modeling, flow charting, and cause-and-effect diagrams can be used to
analyze a process or problem. Such studies can be based on clinical record reviews, health
center register data, staff or patient interviews, service delivery observations.
9. Developing Solutions and Actions for Quality Improvement
The problem-solving team should now be ready to develop and evaluate potential
solutions. Unless the procedure in question is the sole responsibility of an individual,
developing solutions should be a team effort. It may be necessary to involve personnel
responsible for processes related to the root cause.
10. Implementing and Evaluating Quality Improvement Efforts
The team must determine the necessary resources and time frame and decide who will
be responsible for implementation. It must also decide whether implementation should begin
with a pilot test in a limited area or should be launched on a larger scale. The team should
select indicators to evaluate whether the solution was implemented correctly and whether it
resolved the problem it was designed to address. In-depth monitoring should begin when the
quality improvement plan is implemented. It should continue until either the solution is
 Mr. Channabasappa. K.M

proven effective and sustainable, or the solution is proven ineffective and is abandoned or
modified. When a solution is effective, the teams should continue limited monitoring.
JCAHO quality assurance guidelines/steps:
1. Assign responsibility:
According to the Joint Commission, ―The nurse administrator is ultimately
responsible for the implementation of a quality assurance program. Completing step one of
the Joint Commission‘s ten step process require writing a statement that described who is
responsible for making certain that QA activities are carried out in the facility. Assigning
responsibility should not be confused with assuming responsibility.
2. Delineate scope of care and services:
Scope of care refers to the range of services provided to patients by a unit or
department. To delineate the scope of care for a given department personnel should ask
themselves,‘ what is done in the department?‘
3. Identify important aspects of care and services:
Important aspects of nursing care can best be described as some of the fundamental
contribution made by nurses while caring for patients. They are the most significant or
essential categories of care practiced in a given setting. There is no prescribed list of
important aspects of care that every organization must monitor.
4. Identify indicators of outcome (no less than two; no more than four):
A clinical indicator is a quantitative measure that can be used as a guide to monitor
and evaluate the quality of important patient care and support service activities. Indicators are
currently considered as being of two general types i.e. sentinel events and rate-based.
Indicators also differ according to the type of event they usually measures (structure, process
or outcome).
5. Establish thresholds for evaluation:
Thresholds are accepted levels of compliance with any indicators being measured.
Thresholds for evaluation are the level of or point at which intensive evaluation is triggered.
A threshold can be viewed as a stimulus for action.
6. Collect data:
Once indicators have been identified, a method of collecting data about the indicators
must be selected. Among the many methods of data collection is interviewing patient/family,
distributing questionnaires, reviewing charts, making direct observation etc.
7. Evaluate data:
When data gathering is completed in the process of planning patients care, nurses
make assessments based on the findings. In the QA process as a whole, when data collection
has been completed and summarized, a group of nurses makes an assessment of the quality of
care.
8. Take action:
Nurses are action-oriented professionals. For many nurses, the greater portion of
every day is spent on patient‘s intervention. These actions and interventions conducted by
nurses promote health and wellness for patients. Converting nursing energy into the QA
process requires formulating an action plan to address identified problems.
9. Assess action taken:
Continuous and sustained improvement in care requires constant surveillance by
nurses of the intervention initiated to improve care.
10. Communicate:
Written and verbal messages about the results of QA activities must be shared with
other disciplines throughout the facility.
APPROACHES FOR MEASURING THE QUALITY OF NURSING PRACTICE:

The VNA [visiting nurse association] measurement approaches are identified:

Practice documentatio n and data management orientation

Client
Case conferences
tisfacti
saon
services

Approaches foe measuring the quality of nursing practice

Accreditation and external audit Shared evaluation visits and observations

Record ,audit
Practice based in-service education
,peer review
and utilization
review

THE ESSENCE OF HEALTH CARE QUALITY ASSURANCE: -

The essential parameters of health care quality assurances are -

1) Concern for Excellence and Standards:-

All quality assurance initiatives whether implicit or explicit, focusing on individual
care or population services, undertaken by professionals, managers or consumers, must
 Mr. Channabasappa. K.M

reflect an abiding interest in the provision of the highest possible quality care. If such
concern is not given primary quality assurance cannot take place, it should extend to all
aspects of care including the technical, the interpersonal and moral.

2) Specificity and explicitness:-

Despite the many difficulties health care quality assurance is, in aspiration at least, a
rational, explicit and practically based exercise. Standards are specified and
operationalised and measurement tools are developed for their appraisal. Respect for
their professional judgment and careful analysis of social and ethical dilemmas
provide essential context but the operation itself remains an attempt at developing
empirically rigorous procedures for the observation, analysis and review of care and
indeed , reflexively, for the observation, analysis and review of techniques for
appraising and improving quality.
3) Adaptation of a cyclical model:
All quality assurance systems involve appraisal of quality standards followed by
action for quality improvement. The American Nurses Association cycle of quality
assurance is an elaboration of the sequence. At each stage in the cycle the
observations and events of the previous stage influence the decisions to be made and
action to be undertaken in the next. If any one stage is missed or inadequately carried
out the others will suffer and the ultimate aim of quality maintenance or improvement
will not be achieved. The cycle is what is known as an ‗open‘ system that is one in
which direction is determined but actual destination may not be. This openness is
necessary to allow for the idea of continual quality improvement. Today‘s highest
possible standards may not satisfy the consumers and professionals of tomorrow.
4) Commitment:
Both individuals and organizations must be positively motivated to implement quality
assurance. Concern for quality and even compliance in the implementation of quality
assurance procedures are necessary but not sufficient. At the individual level time and
energy must be devoted to the exercise and persistence displayed in the face of
opposition. At the organizational level there must be recognition that quality
assurance does not just happen. it must be managed. That implies commitment of
time, energy and resources not just to the quality assurance system itself but to
designing and modifying it to match and complement the organizational climate in
which it operates.

Factors affecting quality assurance in nursing care:-

Quality assurance necessitates that institutions and health professionals render care in
a most efficient, effective and economical manner, there are some factors which are affecting
quality assurance in nursing care. They are as follows.

1. lack of Resources
2. personal problems
3. unreasonable patients and attendants
4. improper maintenance
5. absence of well informed populace
 6. absence of accreditation laws
7. legal redress
8. lack of incident review procedures
9. lack of good hospital information system
10. absence of conducting patient satisfaction surveys
11. lack of nursing care records
12. Miscellaneous factors like lack of good supervision, Absence of knowledge about
philosophy of nursing care, substandard education and training, lack of policy and
administrative manuals.

TOOLS OF THE CQI:

 Pareto Charts
 Fishbone Diagram
 Histograms
 Run Charts
 check sheets
 Flowchart
 Control Charts

Pareto Charts:

Tools define the source of variation in a process, allowing planning to decrease

inappropriate variation and improve quality. In order to validate the problems identified.
Examples of these ‗cause and effect‘ tools are the Pareto chart and analysis and the Fishbone
diagrams. The Pareto chart (see Chart#1) 30 and analysis is used when dealing with chronic
problems and helps one identify which of the many chronic problems to attack first. The
chronic problem with the highest number of events will show up on the Pareto chart with the
tallest bar, which represents the most frequent occurring problem. The idea behind Pareto
analysis is the 20/80 rule in that 20% of your errors / customers / input accounts for 80% of
your complications / income/ output.
 Mr. Channabasappa. K.M

Pareto Chart, Continuous Process Improvement

Fishbone Diagram:

One analysis tool is the Cause-and-Effect or Fishbone diagram. These are also called
Ishikawa diagrams because Kaoru Ishikawa developed them in 1943. They are called
fishbone diagrams since they resemble one with the long spine and various connecting
branches.

Cause and effect chart:

People Equipment

_ _

_ _

_ _
Goal problem

_ _

_ _

_ _

Procedures Materials

The fishbone diagram organizes and displays the relationships between different causes for
the effect that is being examined. This chart helps organize the brainstorming process. The
major categories of causes are put on major branches connecting to the backbone, and various
sub-causes are attached to the branches.

Histogram:

This is a vertical bar chart which depicts the distribution of a data set at a single point in
time. A histogram facilitates the display of a large set of measurements presented in a table,
showing where the majority of values fall in a measurement scale and the amount of
variation. The histogram is used in the following situations:

1. To graphically represent a large data set by adding specification limits one can
compare;
2. To process results and readily determine if a current process was able to
produce positive results assist with decision-making
Run chart:

Most basic tool to show how a process performs over time. Data points are plotted in
temporal order on a line graph. Run charts are most effectively used to assess and achieve
process stability by graphically depicting signals of variation. A run chart can help to
determine whether or not a process is stable, consistent and predictable. Simple statistics
such as median and range may also be displayed.The run chart is most helpful in:

1. Understanding variation in process performance

2. Monitoring process performance over time to detect signals of change
3. Depicting how a process performed over time, including variation.

Allow the team to see changes in performance over time. The diagram can include a trend
line to identify possible changes in performance.

DATA COLLECTION:

Check sheets:

Check sheets are simply charts for gathering data. When check sheets are designed
clearly and cleanly, they assist in gathering accurate and pertinent data, and allow the data to
be easily read and used. The design should make use of input from those who will actually
be using the check sheets. This input can help make sure accurate data is collected and
invites positive involvement from those who will be recording the data.

Flowcharts :

A flow chart of the process is particularly helpful in obtaining an understanding of how the
process works. It provides a visual picture.

There are two types of flow charts that are particularly useful.

• Top Down Flow Chart and

• Deployment Matrix Flow Chart.

A Top Down Flow Chart shows only the essential steps in a process without detail. It focuses
on the steps that provide real value. It is particularly useful in helping the team to focus their
minds on those steps that must be performed in the final ‗improved‘ process.
 Mr. Channabasappa. K.M

A Top Down Flow Chart is constructed as follows: -

 by first listing the main steps across the top of the page and then listing the subsidiary steps
from the top down, below the main steps. The details are not recorded. For example, rework,
inspection, and typing are omitted.

 The flow chart provides a picture of the process that the team can work on and simplify. It
allows people to focus on what should happen instead of what does happen.

 Usually, most processes have evolved in an ad hoc manner. When problems occur, the
process is fixed. The end result is that a simple process has evolved into something complex.
A flow chart is a first step to simplification.

A Deployment Matrix Chart is another type of flow chart. This is useful because it shows
who is responsible for each activity, how they fit into the flow of work and how they relate to
others in accomplishing the overall job.

To construct a Deployment Matrix Flow Chart, the major steps in the process are:

• listed vertically down the left hand side of the page and the people or work groups are listed
across the top.

• The process is then charted to show who does what

CONTROL CHART:

A control chart is a statistical tool used to distinguish between variation in a process

resulting from common causes and variation resulting from special causes. It is noted that
there is variation in every process, some the result of causes not normally present in the
process (special cause variation). Common cause variation is variation that results simply
from the numerous, ever-present differences in the process. Control charts can help to
maintain stability in a process by depicting when a process may be affected by special
causes. The consistency of a process is usually characterized by showing if data fall within
control limits based on plus or minus specific standard deviations from the center line.
Control charts are used to:

1. Monitor process variation over time

2. Help to differentiate between special and common cause variation
3. Assess the effectiveness of change on a process
4. Illustrate how a process performed during a specific period.

Using upper control limits (UCLs) and lower control limits (LCLs) that are statistically
computed, the team can identify statistically significant changes in performance. This
information can be used to identify opportunities to improve performance or measure the
effectiveness of a change in a process, procedure, or system.

CONTINUOUS QUALITY IMPROVEMENT TECHNIQUES:

Some of the continuous quality improvement techniques:

Improving quality by removing the causes of problems in the system inevitably leads
to improved productivity.
The person doing the job is most knowledgeable about that job.
This people want to be involved and do their jobs well.
Every person wants to feel like a valued contributor.
More can be accomplished working together to improve the system than having
individual contributors working around the system.
A structured problem solving process using graphical techniques produces better
solutions than in ',an unstructured process.
Graphical problem solving techniques will let you know where you are, where the
variations lie, the relative importance of problems to be solved .
 Mr. Channabasappa. K.M

BARRIERS OF CONTINUOUS QUALITY IMPROVEMENT:

Responsibility Barriers

Company‘s Directing Board  Because it‘s a general trend;

 Immediate results;
 Lack of a clear definition of the
organizational and the quality goals.

Operation Strategy  Lack of conformity between the

quality goals and the operation‘s
specificities
 Great amount of exceptions in order
to serve a determined number of
client
 Lack of actions that contribute to the
continuous improvement

Indicators  Lack of financial indicators;

 Don‘t represent the reality of the
operations.

Cost strategy  Lack of true analyzes concerning the

 cost of bad
 quality;
 Lack of analyzes of the financial gains
obtain with quality management
 Lack of a parameter for the
investment feedback.

Table 3 - Barriers to the continuous improvement of quality in service operations

SOLUTIONS OF THE QUALITY IMPROVEMENT:

Some of the solutions of quality improvement are:

 Individual problem solving

 Rapid team problem solving
 Systematic team problem solving
 Process improvement solving

Individual Problem Solving

The simplest solution for quality improvement is the traditional focus on an individual
problem. If based on the discussions of your initial quality audit review you decide that you
have only one problem area to address, you can develop an individual problem solution. For
example, if your quality audit shows that you should concentrate on improving the safety
ranking of your line staff on one production line, you can work with those staff members to
develop improved safety protocols and implement a tracking system to document your
progress.
Rapid Team Problem Solving

If you have a more complex system to improve, you may want to try a rapid team
solution. In this model, you will implement small step-by-step changes and test those changes
as they are implemented. If the first step of your changes shows improvement in the quality
measures you are tracking, you will move on to the next step. Rapid team problem solving is
a less rigorous, more spontaneous approach to quality improvement and can be a good choice
for faster paced businesses.
Systematic Team Problem Solving

If your business needs indicate that you should undertake a more extensive quality
improvement goal, you may want to implement systemic team problem solutions. These
solutions require a more detailed analysis of the problem using sophisticated data collection
and evaluation. For example, if you want to concentrate on improving the level of customer
satisfaction with your product, you will want to do extensive surveys or focus groups of
current and potential customers. Based on this data, you can design solutions that address the
public perception of your entire business and improve your brand. But you will need to
 Mr. Channabasappa. K.M

constantly research and reassess your data to ensure that your systematic team solution is
effective.

Process Improvement Solving

Process improvement is the most complex of the quality improvement solutions. If

your business wants to make a full-time commitment to continuous quality improvement,
then process improvement is the solution for you. This solution involves setting up a
permanent quality improvement team to continually assess and amend your quality
interventions to ensure that improvement standards are met. Process monitoring solutions are
often used in health care or other settings where accreditation standards must be maintained.

CONCULSION:-

Quality assurance is the responsibility of the hospital management and (workers)

health personnel to assure a higher quality of care. The administrators generally have to face
the consequences in terms of poor reputation of the hospital, legal expenses and higher
hospital cost.

BIBLIOGRAPHY:

1. eHow.com http://www.ehow.com/about_5110198_basics-continuous-quality-
improvement.
2. BT Basavnthappa ―Nursing Administration‖ second edition Jaypee
brothers medical publishers 515-537
3. http://jama.ama-assn.org/content/266/13/1817.abstract
4. http://www.unboundmedicine.com/medline/
2. EVALUATION OF NURSING SERVICES

INTRODUCTION:

Evaluation is a judgemental process and as such, it reflects the beliefs, values and
attitudes of the participants of the programme. Evaluation is a decision making process that
leads to suggestions for actions to improve participant‘s effectiveness and programme
efficiency. Performance appraisal is a periodic formal evaluation of how the nurse has
performed her duties during a specific period.

DEFINITIONS:

1. Evaluation: Evaluation is an ongoing activity that begins at the first identification of

the need for an (educational) programme process throughout the planning and
implementing phases and extends well beyond the length of the programme itself.
2. Programme evaluation: Programme evaluation is a process of making informed
judgement about the character and the quality of a programme or parts thereof.

PURPOSES OF EVALUATION:

1. Clarify and define education/programme objectives.

2. Facilitate the improvement of curriculum and instruction of the programme.
3. Determine participant progress towards the achievement of the goals of the
programme.
4. Facilitate the maintenance of strength and elimination of weakness on the part of
participants.
5. Motivate the participants.
6. Provide sense of accomplishments (Psychological security) for the participants and
consumer.
7. Develop more reliable and valid instruments for measurement.
8. Determine the overall value (eg: cost efficiency) of undertakings for both participants
and consumer immediately over long period.
9. Establish and maintain standards to meet legal, profession and academic credentials.

TYPES OF EVALUATION:

1. Summative evaluation: Serves traditionally for rank ordering students and justifying
decisions regarding their passage to the following year or the obtaining degree.
Usually it occurs at the end of the programme, course or unit and is concerned with
whether the learner has mastered all designated behavioural objectives.

2. Formative evaluation: Occurs throughout the programme, course or unit, and

through feedback enables teacher and students or authority and worker to diagnose
learning needs or any specific needs to provide appropriate remedial strategies and
pace the student or worker learning or equip according to needs and abilities.
 Mr. Channabasappa. K.M

MODEL OF THE EVALUATION PROCESS

Programme Observing Information

actions Measuring
Relevance
Describing Relatedness
Analysing Accountability

Monitoring Development Validity of goods

worth of actions
Synthesizing support & constraints

Recommending

Evaluation

Explanation of the model:

There are many ways to consider nursing programme. Nursing programme consists
number of related parts, i.e. curriculum, teaching of nursing, practice of nursing and research
and administration, functioning together to achieve common goals or purposes. The values
that reflect the development of a programme are throughout to be:

i) The relevance of the goals, activities, and outcomes of the programme to the particular
client or community.

ii) The relatedness of the different parts of the programmes in seeking common goals and in
discovering means to achieve them; and

iii) The accountability of the programme in assuming responsibility for its goals, methods
and outcomes.

Thus, relevance, relatedness and accountability are viewed as the critical attributes or
criteria of programme development. When these criteria applied in the nursing practice, assist
in describing the development of that programme or performance of the nursing procedures
or carrying out nursing measures for client and form the basis of the evaluations process. The
model outlines the process of evaluation.
 First the evaluator observes measures and describes the programme goals and actions
and in general collects information to provide a database for analysis. The criteria provide the
structure for the analysis and the results, conclusions or inference indicate the development of
the programme.

The state development provides the information base for monitoring the programme so
that the direction of goals and activities may be changed, and the accumulated information
provides a jeed forward into the programme plans or nursing care plans. This process
describes the everyday monitoring and shaping of the nursing programme by the person
involved. Next the information of developments is scrutinized and synthesized in relation to
the questions that the evaluation seeks to answer. This phase usually leads to a series of
recommendations for the purpose of directing the future development of the nursing care
programme.

PROCESS OF EVALUATION:

SET GOALS

EVALUATE PROGRAMME DETERMINE

GOALS GOAL MEASUREMENT
 The first step in the evaluation process is goal setting. The values and beliefs of the
agency, the providers and the clients provide the basis for goal setting and should be
MEASURE GOAL EFFECT IDENTIFY GOAL ATTAINING ACTIVITIES

MAKE ACTIVITIES
OPERATIONAL

considered at every step of the evaluation process. Childhood diseases would lead to a
programme goal to decrease the incidence of early childhood diseases in the place
where the programme is planned.
 The second step is determining goal measurement. In the case of the previous goal,
disease incidence would be an appropriate goal measurement.
 The third step is identifying goal-attaining activities. This would include such
activities as media presentations urging parents to have their children immunized.
 The fourth step is making the activities operational, i.e. actually administering the
immunizations.
 Mr. Channabasappa. K.M

 The fifth step is measuring the goal effect, which consists of reviewing the records
and summarizing the incidence of early childhood disease before and after the
programme.
 The final step is evaluation of the programme, determining whether the programme
goal was achieved.

PRINCIPLES OF PERFORMANCE EVALUATION

1. Assess performance in relation to behaviourally stated work goals:

Evaluation of the employee should be based on behaviourally stated performance standards

for the position occupies, e.g. a nurse‘s job performance should be evaluated with reference
to progress towards those goals.

2. Observe a representative sample of employees total work activities.

An adequate, representative sample of the nurse‘s job behaviour should be observed to

provide a basis for evaluation. Care should be taken to be evaluated nurse‘s usual or
consistent job behaviour and to avoid undue attention to a single, typical instance of superior
or incept behaviour.

3. Compare supervisors evaluation with employees self evaluation:

The nurse should be given a copy of her or his job description, performance standards,
and performance evaluation form to review before the evaluation conference, so that the
nurse and supervisor can approach their discussion from the same frame of reference.

4. Cite specific examples of satisfier and unsatisfactory performance:

While documenting nurse‘s performance, the supervisor should indicate areas of

performance that are satisfactory and the areas that need improvement or that are
unsatisfactory with evidence.

5. Indicate which job areas have highest priority for improvement:

When served areas of performance need improvement, the supervisor should specify
which areas are to be given highest priority.

6. Evaluation conference should be held in good atmosphere:

For which the evaluation conference should be scheduled at a time convenient for nurse
and supervisor, and should be held in pleasant surroundings, and should allow adequate
time for discussion.

7. The purpose of evaluation is to improve work performance and job satisfaction:

The goal of evaluation process should be improve employee performance and

satisfaction, rather than to threaten or punish the employee for performance inadequacy.
An employee can withstand strong criticism from supervisor who is considerate of the
employee‘s feelings and offers to coach her/him towards improved performance.
EVALUATING A GROUP:

Group evaluation includes two important areas, process measurement and outcomes
measurement. The first examines ongoing group interaction, and the second looks at the
group‘s final product.

1. Process evaluation:

Process evaluation is an assessment of how well a group or project is functioning.

Process evaluation can be done in several ways. One useful method is to have an outside
observer sit in on the group, watch for specific behaviours, and then give reactions to the
group. The observer can use one of several guides available for this purpose. Another method
is to have a group member act as an impartial observer during a session in which the member
only observes and retrains from participating. The group itself may diagnose its health by
periodically or even regularly using some form of checklist or questionnaire, followed by
discussion. In general, a group needs to examine all of the roles listed earlier and ask
questions pertaining to areas such as communication skills and patterns, responses to
leadership style, group climate, stage of group development, and progress on group
objectives.

2. Outcome evaluation:

Outcome evaluation is a measurement of the end results or consequences of a programme

or intervention. Clear goals and specific objectives should be stated. Goals are broad
statements of the overall purpose of the group. Objectives are statements measurable
behaviours that describe specific steps toward accomplishment of goals. For example, the
group‘s goal may be to learn the techniques of natural childbirth. Objectives should describe
separate behaviours, such as demonstrating specific breathing techniques or exercises. Thus
objectives that describe outcome behaviours become criteria for measuring the group‘s
performance.

PROGRAMME EVALUATION:

Evaluation is the process of collecting data, presenting them in a convenient form and
using them to form judgements to reach a decision about an activity on other type of process.
A community health service is a process, which starts with planning and ends with evaluation
of that programme.

Purpose of evaluation of community health programme:

1. The modification of the programme to be at par with the problem arising in the
community or with the felt need of the community.
2. Ensuring objectives for the continuing education of the staff members for their
development.
3. Serving as a basis for diagnosis of professional problems and potentialities.
4. Forming a basis for future plan of the programme.
5. Helping in research studies for innovation in community health nursing service.
6. Providing a review of the standards of work for both the supervisor and staff.
 Mr. Channabasappa. K.M

4. DEVELOPMENT OF STANDARDS

INTRODUCTION

Standard is an acknowledged measure of comparison for quantitative or qualitative

value, criterion, or norm. A standard is a practice that enjoys general recognition and
conformity among professionals or an authoritative statement by which the quality of
practice, service or education can be judged. It is also defined as a performance model that
results from integrating criteria with norms and is used to judge quality of nursing objectives,
orders and methods

A standard is a means of determining what something should be. In the case of

nursing practice standards are the established criteria for the practice of nursing. Standards
are statements that are widely recognised as describing nursing practice and are seem as
having permanent value.

NURSING STANDARDS

A nursing care standard is a descriptive statement of desired quality against

which to evaluate nursing care. It is guideline. A guideline is a recommended path to safe
conduct, an aid to professional performance.A nursing standard can be a target or a gauge.
When used as a target, a standard is a planning tool. When used as a gauge against which to
evaluate performance a standard is a control device.

A standard is a statement of quality. It is definite level of excellence or adequately

required, aimed at or possible. Standard is an acknowledged measure of comparison for
qualitative, or qualitative, or qualitative value, criterion, and norm.

DEFINITION

A nursing care standard is a descriptive statement of desired quality against which to evaluate
nursing care. Characteristics of Standard

Characteristics of Standard

 Standards statement must be broad enough to apply to a wide variety of settings.

 Standards must be realistic, acceptable, attainable.
 Standards of nursing care must be developed by members of the nursing profession;
preferable
 nurses practising at the direct care level with consultation of experts in the domain.
 Standards should be phrased in positive terms and indicate acceptable performance
good, excellence etc.
 Standardsof nursing care must express what is desirable optional level.
 Standards must be understandable and stated in unambiguous terms.
 Standards must be based on current knowledge and scientific practice.
 Standards must be reviewed and revised periodically.
 Standards may be directed towards an ideal ,ie,optional standards or may only specify
the minimal care that must be attained,ie, minimum standard.
  And one must remember that standards that work are objective, acceptable,
achievable and flexible.

Purposes of Standards

 Setting standard is the first step in structuring evaluation system. The following are
some of the purposes of standards.
 Standards give direction and provide guidelines for performance of nursing staff.
 Standards provide a baseline for evaluating quality of nursing care
 Standards help improve quality of nursing care, increase effectiveness of care and
improve efficiency.
 Standards may help to improve documentation of nursing care provided.
 Standards may help to determine the degree to which standards of nursing care
maintained and take necessary corrective action in time.
 Standards help supervisors to guide nursing staff to improve performance.
 Standards may help to improve basis for decision-making and devise alternative
system for delivering nursing care.
 Standards may help justify demands for resources association.
 Standards my help clarify nurses area of accountability.
 Standards may help nursing to define clearly different levels of care.

Major objectives of publishing, circulating and enforcing nursing care standards are to:

1. improve the quality of nursing care,

2. decrease the cost of nursing, and

3. determine the nursing negligence.

Sources of Nursing Care Standards

It is generally accepted that standards should be based on agreed up achievable level of

performance considered proper and adequate for specific purposes. The standards can be
established, developed, reviewed or enforced by variety of sources as follows:

 Professional organisation, e.g. Associations, TNAI,

 Licensing bodies, e.g. Statutory bodies, INC,
 Institutions/health care agencies, e.g. University Hospitals, Health Centres.
 Department of institutions, e.g. Department of Nursing.
 Patient care units, e.g. specific patients' unit.
 Government units at National, State and Local Government units.
 Individual e.g. personal standards
 Mr. Channabasappa. K.M

Classification of Standards

There are different types of standards used to direct and control nursing actions.

1. Normative and Empirical Standards

Standards can be normative or empirical. Normative standards describe practices

considered 'good' or 'ideal' by some authoritative group. Empirical standards describe
practices actually observed in a large number of patient care settings. Here the normative
standards describe a higher quality of performance than empirical standards. Generally
professional organisations (ANA/TNAI) promulgate normative standards where as low
enforcement and regulatory bodies (INC/MCI) promulgate empirical standards.

2. Ends and Means Standards

Nursing care standards can be divided into ends and means standards. The ends
standards are patient-oriented; they describe the change as desired in a patient's physical
status or behaviour. The means standards are nursing oriented, they describe the activities and
behaviour designed to achieve the ends standards. Ends (or patient outcome) standards
require information about the patients. A means standard calls for information about the
nurses performance.

3. Structure,Process and Outcome Standards

Standards can be classified and formulated according to frames of references (used for
setting and evaluating nursing care services) relating to nursing structure, process and
outcome, because standard is a descriptive statement of desired level of performance against
which to evaluate the quality of service structure, process or outcomes.

a. Structure Standard

A structural standard involves the 'set-up' of the institution. The philosophy, goals and
objectives, structure of the organisation, facilities and equipment, and qualifications of
employees are some of the components of the structure of the organisation, e.g.
recommended relationship between the nursing department and other departments in a health
agency are structural standards, because they refer to the organisational structure in which
nursing is implemented. It includes people money, equipment, staff and the evaluation of
structure is designed to find out the effectiveness ,degree to which goals are achieved and
efficiency in terms of the amount of effort needed to achieve the goal.

The structure is related to the framework, that is care providing system and resources
that support for actual provision of care. Evaluation of care concerns nursing staff, setting
and the care environment. The use of standards based on structure implies that if the structure
is adequate, reliable and desirable, standard will be met or quality care will be given.
b. Process Standard

Process standards describe the behaviors of the nurse at the desired level of
performance The criteria that specify desired method for specific nursing intervention are
process standards. A process standard involves the activities concerned with delivering
patient care.These standards measure nursing actions or lack of actions involving patient
care.The standards are stated in action-verbs, that is in observable and measurable terms.eg
:the nurse assesses", "the patient demonstrates". The focus is on what was planned, what was
done and what was communicated or recorded. Therefore, the process standards assist in
measuring the degree of skill, with which technique or procedure was carried out, the degree
of client participation or the nature of interaction between nurse and client.In process
standard there is an element of professional judgement determining the quality or the degree
of skill. It includes nursing care techniques, procedures, regimens and processes.

c. Outcome Standards

Descriptive statements of desired patient care results are outcome standards because
patient's results are outcomes of nursing interventions. Here outcome as a frame of reference
for setting of standards refers to description of the results of nursing activity in terms of the
change that occurs in the patient. An outcome standard measures change in the patient health
status. This change may be due to nursing care, medical care or as a result of variety of
services offered to the patient. Outcome standards reflect the effectiveness and results rather
than the process of giving care.

LEGAL SIGNIFICANCE OF STANDARDS

Standards of care are guidelines by which nurses should practice.If nurses do not
perform duties within accepted standards of care,they may place themselves in jeopardy of
legal action.Malpractice suit against nurses are based on the charge that the patient was
injured as a consequence of the nurses failure to meet the appropriate standards of care.

To recover losses from a charge of malpractice, a patient must prove that:

1. A patient-nurse relationship existed such that the nurse owed to the patient a duty of
due care,
2. The nurse deviated from the appropriate standard of care,
3. The patient suffered damages,
4. The patient's damages resulted from the nurses deviations from the standard of care.

CONCLUSION

Quality assurance is to provide a higher quality of care. It is necessary that nurses

develop standards of patient care and appropriate evaluation tools, so that professional
aspects of nursing involving intellectual and interpersonal activities. Quality will be ensured
and attention will be given to the individual needs and responses to patients.The formulation
of standards is the first step towards evaluating the nursing care delivery. The. standards
 Mr. Channabasappa. K.M

serve as a base by which the quality of care can be judged. This judgement may be according
to a rating or other data that reflect the conformity of existing practice with the established
standards. The standards must be written, regularly reviewed and well-known by the nursing
staff.

REFERENCES

1. Basavanthappa BT. Nursing Administration. 1st edn. New Delhi: Jaypee Brothers;
2000
2. Johnson M and Closkey J.C. The Delivery Of Quality Health Care Series On Nursing
Administration. London: Mosby 1992
3. Koch M.W And Fairly T.M. Integrated Quality Management: The Key To Improving
Nursing Care Quality. st Edition.St.Louis,Missouri:MosbyPublications;1993.
4. Ward MJ, Price SA .Issues in nursing administration. St.Louis: Mosby;1991.
5. Marquis B.L. ,Hutson C.J . Leadership roles and management functions in nursing–
Theory and application. 5th ed. Philadelphia: Lippincott Williams and Wilkins; 2006.
6. Douglass L M. The effective nurse- leader and manager. 5th ed. Mosby: St. Louis;
1996.
7. Morrison M. Professional skills for leadership. Mosby: US; 1993.
8. Ellis J R, Hartley C L. Managing and Co-ordinating nursing care. 3rd ed. Lippincott:
Philadelphia;1995.
9. Anthony, Mary K., Theresa; Hertz, Judith .Factors Influencing Outcomes After
Delegation to Unlicensed Assistive Personnel. JONA. 30(10):474-481, October
2000.
10. Cheryl L. Plasters, Seagull F J, Xiao Y. Coordination challenges in operating-room
management: an in-depth field study. Amia annu symp proc; 2003.
 5. STRUCTURE STANDARD

INTRODUCTION

Hospitals are the most complex of building types. Each hospital is comprised of a
wide range of services and functional units. These include diagnostic and treatment functions,
such as clinical laboratories, imaging, emergency rooms, and surgery; hospitality functions,
such as food service and housekeeping; and the fundamental inpatient care or bed-related
function. This diversity is reflected in the breadth and specificity of regulations, codes, and
oversight that govern hospital construction and operations. Each of the wide-ranging and
constantly evolving functions of a hospital, including highly complicated mechanical,
electrical, and telecommunications systems, requires specialized knowledge and expertise.

DEFINITION OF STRUCTURE

According to Van Maanen (1984: 18),‖ structure is the evaluation of the organization
of the institution delivering care; the conditions under which care is provided and its impact
on quality‖, i.e. buildings, budget and equipment.

CONCEPT OF STRUCTURE STANDARD IN QA

 It involves the setup of the institution.
 The philosophy, goals and objectives, structure of the organization, facilities and
equipment and qualifications of the employees.
 It is recommended relationships between the nursing department and other department
in a health agency are structural standards because they refer to the organizational
structure in which nursing implemented.
 It includes people money, equipment, staffing policies etc.
 The structure is related to the framework, that is care providing system and resources
that support for actual provisions of care.
 The use of standards based on structure is adequate, reliable and desirable, standard
will be met or quality care will be given

NURSING ORGANISATIONAL STRUCTURE

 The primary purpose of establishing nursing service is to provide efficient and

effective nursing care services as an integral hospital resource for the achievement of
total delivery of comprehensive health programs offered by the hospital.

 For which the departments and units of the nursing units are organized as a sub
system of patient care system in such a manner that nursing personnel can collectively
work to achieve excellence in nursing care services and assist in meeting the
objectives of the entire hospital system.

 Nursing is a vital aspect of health care and needs to be properly organized. A nurse is
in frequent contact with the patients and hence her or his role in restoring, health and
confidence of the patients is almost importance of the quality of nursing care and the
management of nursing staff, which will reflect the image of the hospital.
 Mr. Channabasappa. K.M

Nursing organizational structure should meet

 Permit the nursing staff of meet physical, socioeconomical, and spiritual needs of the
client.

 Permit adaptiveness to a given situation at a given point of time.

 permit decision making at the level the action takes place

 Permit And Develop Proper Communication System.

 Exact accountability for the job at each level of the organization.

 Allow to develop nursing service policies in the context of general policies of the
hospital.

 Foster the team approach to client care.

 Allow for grouping of patients by level of care and or specialty service.

 Allow highest possible quality of nursing care.

 Develop programs of nursing education.

 Promote nursing research studies.

 Promote participation in the allied health organizations and supportive health

activities.

 Participate the nurse in budget preparation of hospital service.

STAGES OF THE DEVELOPMENT OF INTERNATIONAL STANDARDS

ACCORDING TO NATIONAL INSTITUTE OF BUILDING SCIENCES,-(Hospital)

DEFINITION

"A functional design can promote skill, economy, conveniences, and comforts; a non-
functional design can impede activities of all types, detract from quality of care, and raise
costs to intolerable levels."

Hardy and Lammers

THE BASIC FORM OF A HOSPITAL IS, IDEALLY, BASED ON ITS FUNCTIONS

 Bed-related inpatient functions

 Outpatient-related functions

 Diagnostic and treatment functions

 Administrative functions
  Service functions (food, supply)

 Research and teaching functions

CODES AND STANDARDS

 FGI Guidelines for Design and Construction of Hospitals and Health Care
Facilities,

 State and local building codes are based on the model International Building Code
(IBC).

 NFPA 101 (Life Safety Code), NFPA 70 (National Electric Code), and Architectural
Barriers Act Accessibility Guidelines (ABAAG) or Uniform Federal Accessibility
Standards (UFAS).

 The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO).

 The American with Disabilities Act (ADA) applies to all public facilities and greatly
the building design with its general and specific accessibility requirements.

 The Architectural Barriers Act Accessibility Guidelines (ABAAG) or the Uniform

Federal Accessibility Standards (UFAS) apply to federal and federally funded
facilities. The technical requirements do not differ greatly from the ADA
requirements.

 Regulations of the Occupational Safety and Health Administration (OSHA) the

design of hospitals, particularly in laboratory areas.

GENERAL STANDARDS OF CONSTRUCTION AND EQUIPMENT FOR

HOSPITALS:

The site of the hospital must be away from nuisances that may be detrimental to the
proposed services, such as commercial or industrial. Developments or other types of facilities
that produce noise or air pollution. A site plan must be submitted to the department.

Physical relationships between these functions determine the configuration of the

hospital. Certain relationships between the various functions are required—as in the
following flow diagrams.
 Mr. Channabasappa. K.M

These flow diagrams show the movement and communication of people, materials,
and waste. Thus the physical configuration of a hospital and its transportation and logistics
systems are inextricably intertwined in a large hospital, the form of the typical nursing unit,
since it may be repeated many times, is a principal element of the overall configuration.
Nursing units today tend to be more compact shapes than the elongated rectangles of the past.
Compact rectangles, modified triangles, or even circles have been used in an attempt to
shorten the distance between the nurse station and the patient's bed.

JACHO STRUCTURE STANDARD

JOINT COMMISSION INTERNATIONAL

The Joint Commission International (JCI) was established in 1997 by JCAHO with the
objective of ―helping to improve the quality of patient care by assisting international
healthcare organisations, public health agencies, health ministries, and others evaluate,
improve, and demonstrate the quality of patient care and enhance patient safety.

AN EFFICIENT HOSPITAL LAYOUT SHOULD

 Promote staff efficiency by minimizing distance of necessary travel between

frequently used spaces.
  Allow easy visual supervision of patients by limited staff.

 Include all needed spaces, but no redundant ones. This requires careful pre-design
programming.

 Provide an efficient logistics system, which might include elevators, pneumatic tubes,
box conveyors, manual or automated carts, and gravity or pneumatic chutes, for the
efficient handling of food and clean supplies and the removal of waste, recyclables,
and soiled material

 Make efficient use of space by locating support spaces so that they may be shared by
adjacent functional areas, and by making prudent use of multi-purpose spaces

 Consolidate outpatient functions for more efficient operation—on first floor, if

possible—for direct access by outpatients

 Group or combine functional areas with similar system requirements

 Provide optimal functional adjacencies, such as locating the surgical intensive care
unit adjacent to the operating suite.

FLEXIBILITY AND EXPANDABILITY

Since medical needs and modes of treatment will continue to change, hospitals
should:

 Follow modular concepts of space planning and layout.

 Use generic room sizes and plans as much as possible, rather than highly specific ones

 Be served by modular, easily accessed, and easily modified mechanical and electrical
systems

THERAPEUTIC ENVIRONMENT

 Hospital patients are often fearful and confused and these feelings may impede
recovery.

 Every effort should be made to make the hospital stay as unthreatening, comfortable,
and stress-free as possible.

 A hospital's interior design should be based on a comprehensive understanding of the

facility's mission and its patient profile.

 The characteristics of the patient profile will determine the degree to which the
interior design should address aging, loss of visual acuity, other physical and mental
disabilities, and abusiveness
 Mr. Channabasappa. K.M

PROTRUDING OBJECTS

GENERAL

Objects projecting from walls (for example, telephones) with their leading edges
between 27 in and 80 in (685 mm and 2030 mm) above the finished floor shall protrude no
more than 4 in (100 mm) into walks, halls, corridors, passageways, or aisles Objects mounted
with their leading edges at or below 27 in (685 mm) above the finished floor may protrude
any amount Free-standing objects mounted on posts or pylons may overhang 12 in (305 mm)
maximum from 27 in to 80 in (685 mm to 2030 mm) above the ground or finished floor
Protruding objects shall not reduce the clear width of an accessible route or maneuvering
space .

EACH FLOOR,

Parking and visitor Loading Zone, Drinking Fountains and Water Coolers Storage
,Alarms,Telephones, Seating, Tables, and Work Surfaces,, Assembly Areas.

OTHERS:

Stairs,Elevators, Doors.

HANDRAILS HAVE THE FOLLOWING FEATURES:

 Handrails shall be provided along both sides of ramp segments.

 The inside handrail on switchback or dogleg ramps shall always be continuous.

 If handrails are not continuous, they shall extend at least 12 in (305 mm) beyond the
top and bottom of the ramp segment and shall be parallel with the floor or ground
surface.

 The clear space between the handrail and the wall shall be 1-1/2 in (38 mm).

 Gripping surfaces shall be continuous.

 Top of handrail gripping surfaces shall be mounted between 30 in and 34 in (760 mm

and 865 mm) above ramp surfaces.

 Ends of handrails shall be either rounded or returned smoothly to floor, wall or post.

 Handrails shall not rotate within their fittings.

CLEANLINESS AND SANITATION:

 Hospitals must be easy to clean and maintain. This is facilitated by:

 Appropriate, durable finishes for each functional space

 Careful detailing of such features as doorframes, casework, and finish transitions to

avoid dirt-catching and hard-to-clean crevices and joints
  Adequate and appropriately located housekeeping spaces.

 Special materials, finishes, and details for spaces which are to be kept sterile, such as
integral cove base. The new antimicrobial surfaces might be considered for
appropriate locations.

ALL AREAS, BOTH INSIDE AND OUT, SHOULD:

 Comply with the minimum requirements of the Americans with Disability Act (ADA)
and, if federally funded or owned, the Uniform Federal Accessibility Standards
(UFAS)

 In addition to meeting minimum requirements of ADA and/or UFAS, be designed so

as to be easy to use by the many patients with temporary or permanent handicaps

 Ensuring grades are flat enough to allow easy movement and sidewalks and corridors
are wide enough for two wheelchairs to pass easily

 Ensuring entrance areas are designed to accommodate patients with slower adaptation
rates to dark and light; marking glass walls and doors to make their presence obvious

CONTROLLED CIRCULATION:

 A hospital is a complex system of interrelated functions requiring constant movement

of people and goods. Much of this circulation should be controlled.

 Outpatients visiting diagnostic and treatment areas should not travel through inpatient
functional areas nor encounter severely ill inpatients

 Typical outpatient routes should be simple and clearly defined

 Visitors should have a simple and direct route to each patient nursing unit without
penetrating other functional areas

 Separate patients and visitors from industrial/logistical areas or floors

 Outflow of trash, recyclables, and soiled materials should be separated from

movement of food and clean supplies, and both should be separated from routes of
patients and visitors

 Transfer of cadavers to and from the morgue should be out of the sight of patients and
visitors

AESTHETICS:

 Aesthetics is closely related to creating a therapeutic environment (homelike,

attractive.) It is important in enhancing the hospital's public image and is thus an
important marketing tool. A better environment also contributes to better staff morale
and patient care. Aesthetic considerations include:

 Increased use of natural light, natural materials, and textures

 Mr. Channabasappa. K.M

 Use of artwork

 Attention to proportions, color, scale, and detail

 Bright, open, generously-scaled public spaces

THE OUT PATIENT DEPARTMENT:

 The outpatient department should function along with other departments in all
consideration of the hospital organization –policy, facilities, financing, patient care,
teaching and research.

 The function of the OPD should reflect the other activities of all other departments.

 The OPD should be located close to main entrance particularly where the public
transportation is provided.

 The department should be adjacent to the casualty, emergency and admitting unit.

 The OPD there should be a reception and enquiry both should be connected with
effective communication.

 Depends the type of hospital the OPD should have eye,ear,nose ,throat, dental
,medical .surgical ,obstetric and gynae,paediatric and mental health clinics etc.

 In OPD should have a laboratory and other diagnostic facilities and also there should
be a pharmacy for distribution of drugs to the outpatients.

 The outpatient department should provide an environment which will acquaint the
patient with matter of health and hygienic practices for that the suitable posters should
be displayed on the respective units of the departments.

 The provision has to be made for dealing properly and efficiently with medical and
surgical emergencies from whatever case.

 Every hospital the causuality should provide the provision for single fractures, cuts
needing suturing, abscess conditions, poisoning,tetanus and other conditions.

 The casuality department should provide round the clock services.

 A hospital expecting 500 outpatient perday over 300 normal working days in a year
require 7500 square feer of space.

 8 square feet feet per patient is required in waiting area.reception and enquiry area
should face the patient.

 To avoid noise level in the reception area(150 db) an acoustic ceiling is desirable.

 The OPD should be easy to clean and well ventilated.

 The waiting and enquiry lobby should have display boards.

  Wheel chair and stretcher trolley parking area should be provided very close to the
entrance.

 Each clinic should be equipped and artificial lighting should be provided.

 The outpatient record room should be located at the end of the main waiting hall.

 The dispensary area required is minimum 250 square feet. There should be facilities
for storage ,getting raw materials, preparation and dispensing.

 Adequate waiting space adjoining to the dispensing counters should be given.

 A minor operating theatre should be provided with the facilities of 20 m2.

NURSING UNIT FACILITIES SPACE REQUIREMENTS

 Nursing director‘s office.

 Asst directors and supervisor office

 Reception control area

 Secretarial and clerical area

 Conference room

 Storage –personnel files, administrative files, and office supplies.

 The nurses‘ room can be divided as intensive care, intermediate care, self care and
long term care.

 The ward accommodation should be classified as four groups as primary, auxillary,

sanitary and ancillary.

 The size of the nursing unit depends upon the number of patients admitted.

 The bed room should be 5 m wide and 6 m long. central corridors have to be
minimum of 2.5 0 m wide and ancillary area should have the floor area of 15 m 2per
bed as 25 bedded ward.

 25 bedded as 15 m2 per bed is require 384 m2.

 The shape of the nursing unit can be as t shaped or E, H, box plan or cross plan.

 The minimum floor space for a multiple bed room 4 bedded is 7.0 m2 and single bed
room is 14.00m2 and 2 bed room is 21.oom2.

 Ceiling height of the ward unit should be in-between 3 and 3.60 m.and the width of
the corridors should be 2.40 m to facilitate the movement of the trolley .the windows
openings for admitting light is as 20 percent of floor area.
 Mr. Channabasappa. K.M

 The doors of all patients should be at 2.0 m .a standard hospital bed should be as 1.0
m in breath and 2.15m in length .the doors must not open towards the corridor.
Ventilation grill on the top of the door shutters should be provided.

 Bed side lockers and built in cupboard should be provided.

 The nurses‘ station should be open to the corridor but it should be separated. The
room should be built in cupboards for storage of drugs ,dressings and instruments
.closet for narcotics and dangerous drugs and refrigerator for for storage of antibiotics
and sensitive inject able should be provided.

 Sanitary facilities such as bathrooms, wash basins, dirty utility room should be
provided. The wash basin should have the 91.5 cm at the basin rim.and wheel chair
patients at the height of 70 cm deep with a narrow apron.

 The nurses unit also has treatment and dressing rooms, isolation room, ward pantry,
clean utility room and day room.

INTENSIVE CARE UNIT

 The ICU bed or cubicle require space to accommodate ventilator,cardiac

monitors,pulse oximeter,suction machine ,oxygen machine ,procedure trolley and
mobile x ray machine.each patient bed area should have a minimum floor area of 150-
200 square feet and each bed is separated by adjacent bed by a closed bay design.

 The work zone on both side of the bed requires a width of 19 feet .there should be a
minimum distance of 8 feet between each beds.

 Each bed should have a oxygen outlet and central suction outlet and a number of
power outlets.

 The circulation area should not be less than 20 percent of floor area.

 The central nursing station should be located to view all the patients at a time.

 Bed should be located such a way that the patient can see the nurse directly than other
patient.

 Portable x ray,us,equipment for respiratory theraphy should not be clutter in patient

area but should be located nearby equipment room.

 A storage room for equipment ,ECG machine,and numerous other items.

 The ICU should be centrally air conditioned.7-8 air changes per hr and a positive
pressure to prevent re entry of outside contaminated air.

 Each patient bed should have multible electrical gadgets and 4-5 power sockets can
be provided.

 The main light at the bed head should be fitted with a dimmer light.and the spot
focusing light can be used.
  A reliable alternate source of power is must in ICU.the entire ICU can be connected
by a stabdby generator.

 For relative and friends a visitors lounge with barriers should be provider

. Policies-type of pts admitted,refusal of admission,admission procedure,

THE OPERATION THEATRE SHOULD HAVE THE FOLLOWING FACILITIES

 The operating room should consist of OT tables.

 A lay- up room which connects directly with operating room is used to prepare trolly
with all the equipment needful for an operation.

 Wash-up room opening immediately off the operating room contains the sinks and the
disposal lifts. All used dirty material goes in this room.

 Anesthesia room:which is also open directly into the operating room is equipped
permanently for the use of anesthetist.

 scrubbing up room: in which the surgeons and nurses scrub up and put on sterilized
gloves ,mask and gown

 In addition OT should be equipped with necessary supplies and equipments which

include linen, surgical instruments, OT tables, Boyer apparatus, O2, N2 and other
gases.

 Recovery room should be attached to operation theatre for the reception of the patient
after the surgery.

 Operation room should have the square feet for major 360 square feet and minor 324
s.feet.scrub room and sterllisation 80 s. feet.orthropedic theatre 240 s.feet.and
reception and preparation room 160 s.feet.sterile storage 160 s.feet.equipment storage
160 s.feet.anesthetist room 160 s.feet.anesthetist store 80 s.feet .doctors locker,change
room rest room and toilet 120 s.feet.nurses 120 s.feet.

 General linen storage 120 s.f.recovery room 480 s.feeet.mobile x ray and dark room
120 s,f,trolley bay 80 s,f.safaimans alcove 80 s f. waiting room toilet 160 s
feet.reception 100 s f.gowned waiting booth 80 s f.mens change locker 120 s feet and
female change locker 120 s feet.

MATERNITY AND OBG UNIT

 The maternity ward should be attractive, comfortable and restful.

 The antenatal clinic should be situated where practicable on part of the ground floor
off or adjoining the maternity wing.

 The size of the clinic will be governed to some extent by the number of times the
obstetrician will see the an expectant mother before delivery.
 Mr. Channabasappa. K.M

 in patient facility of maternity department should include admitting room, labor and
delivery room ,equipment for anesthesia, recovery room ,postpartum wards etc.

PAEDIATRIC UNIT:

 The outpatient services for children are important part of the pediatric services.

 In pediatric clinics, more space, have to be kept open to enable the clinic to accept a
patient without appointment who present themselves with urgent conditions.

 Children‘s are should be grouped by age than diagnosis.

 In designing the pediatric unit a large proportion of isolation room and facilities for
mothers to come in to the hospital with their children.

 There is also a large play room and a school room should be provided.

 And also there should be a unit for premature infant.

 Here a separate glass walled cubicle is desirable for each infant.

 Each cubicle should be equipped with devices for controlling temperature and
humidity and each should be connected to a oxygen supply.

 Premature infants are always prone to get infection, so that the it should be facilitated
with readily available to enable the staff entering the cubicle to put on sterile gowns
and masks separate gown for each cubicle.

 Cubicle partitions are used they should be made of shatter proof glass 7 feet high and
extends 7 feet from the wall.

 They should also be constructed to allow visibility by nurses and patients in the same
room.

 It is good to view all the patients from the same nurse‘s station.

INFECTION CONTROL IN A HOSPITAL

 Over the course of the past several years, the AIA (American Institute of Architects),
CDC (Centers for Disease Control), and JCAHO (Joint Commission for Accreditation
of Health Care Organizations ,As it turns out, the two best weapons for controlling
hospital is to manage air delivery systems and contaminant control responsibly and
In preventing the spread of contaminants during construction-related activities.

 The emphasis in managing a safe air quality environment during a construction in a

hospital or other health care facility.

 Design and construction of hospitals present many unique challenges, and the
complexity of maintaining a safe environment is certainly one of the most difficult.
SECURITY AND SAFETY:

In addition to the general safety concerns of all buildings, hospitals have several
particular security concerns:

 Protection of hospital property and assets, including drugs

 Protection of patients, including incapacitated patients, and staff

 Safe control of violent or unstable patients

 Vulnerability to damage from terrorism because of proximity to high-vulnerability

targets, or because they may be highly visible public buildings with an important role
in the public health system.

PUPLIC HEALTH EQUIPMENT

To estimate chorine demand of drinking water so that proper amount of bleaching

power may be added in drinking water storage tank of the hospital.

CHLOROSCOPE

To estimate residual chlorine in the matter treated by chlorine so that quality of

chlorination is assured.

FIRE PROTECTION:

Fire extinguishers 240 kg carbon dioxide type tested for each 1976 square space, with
central alarming indicator or centralized bell should be fitted in the whole hospital.

COMMUNICATION

Paging system, model spirit MK –II, beep and speech wireless selective paging
system.

GENERATOR

Capacity of 75 KVA 110 KV 2 grid system of 500 -700 beded hospital.

SANITATION AND DRAINAGE

Drainage system should directly be fitted with municipal pipe hospital, drainage pipe
should be around 12 inch and municipal pipe should be around 36 inch.

WATER TREATMENT AND SUPPLY:

There should be three stainless steel high level tanks for storing water (capacity: 3
core gallons) stored water should pass through filtration tank. Then it should get stored in
clear water well.chorination of water should be done. Then it should go to overhead tank.

BIOMEDICAL WASTE MANAGEMENT:

Followed as the rules given by the govt.

 Mr. Channabasappa. K.M

TIOLET ROOMS

LONG TERM CARE FACILITIES:

 At least 50 percent of patient toilets and bedrooms; all public use, common use or
areas which may result in employment of handicapped persons.

 Outpatient Facilities: All patient toilets and bedrooms, all public use, common use, or
areas which may result in employment of physically handicapped persons.

HOSPITAL:

 General Purpose Hospital:

 At least 10 percent of toilets and bedrooms, all public use, common use, or areas
which may result in employment of physically handicapped persons.

 Special Purpose Hospital:

 (Hospitals that treat conditions that affect mobility). All patient toilets bedrooms, all
public use, common use, or areas which may result in employment of physically
handicapped persons.

Toilet rooms.

Where alterations to existing facilities make strict compliance with 4.22 and 4.23
structurally impracticable, the addition of one "unisex" toilet per floor containing one water
closet complying with 4.16 and one lavatory complying with 4.19, located adjacent to
existing toilet facilities, will be acceptable in lieu of making existing toilet facilities for each
sex accessible.

TOILET STALLS

LOCATION. Accessible toilet stalls shall be on an accessible route and shall meet the
requirements of WATER CLOSETS: Water closets in accessible stalls .

SIZE AND ARRANGEMENT.

Toilet stalls with a minimum depth of 56 in (1420 mm) (see Fig. 30(a)) shall have
wall-mounted water closets. If the depth of toilet stalls is increased at least 3 in (75 mm), then
a floor-mounted water closet may be used. Arrangements shown for stalls may be reversed to
allow either a left- or right-hand approach

URINALS

HEIGHT.

Urinals shall be stall-type or wall-hung with an elongated rim at a maximum of 17 in

(430 mm) above the floor.
CLEAR FLOOR SPACE.

A clear floor space 30 in by 48 in (760 mm by 1220 mm) shall be provided in front of

urinals to allow forward approach. This clear space shall adjoin or overlap an accessible route
and shall comply with 4.2.4. Urinal shields that do not extend beyond the front edge of the
urinal rim may be provided with 29 in (735 mm) clearance between them.

FLUSH CONTROLS.

Flush controls shall be hand operated or automatic, and shall comply with 4.27.4, and shall be
mounted no more than 44 in (1120 mm) above the floor.

The ADA act

The Americans with Disabilities Act (ADA) is a law that prohibits discrimination against
people with disabilities, including deaf and hearing impaired people.

In general, the ADA expects hospitals and medical service providers to eliminate
anything that discriminates against a deaf person. Naturally, the foremost source of
discrimination against deaf people occurs as some form of communication. The ADA
requires communication that is effective and provides aids that are appropriate in
communicating with a deaf patient. Deaf patients must be able to communicate with doctors,
nurses, admission staff, and other hospital workers.

 The medical facility must be prepared to honor the deaf patient's request. Further, the
deaf patient may NOT be charged for expenses incurred in complying with ADA
requirements.

Standards:

The NFPA publishes the Codes and Standards CMS uses in determining compliance with
the fire safety requirements of our regulations. NFPA 80 5.2.4.requires the following items
shall be verified, at minimum:

 No Open Holes or breaks exist in surfaces of either the door or frame.

 Glazing, vision light frames & glazing beads are intact and securely fastened in place,
if so equipped.

 The door, frame, hinges, hardware, and noncombustible threshold are secured,
aligned, and in working order with no visible signes of damage.

 No parts are missing or broken.

 Door clearances at the door edge of the door frame, on the pull side of the door, do
not exceed clearances listed in 4.8.4 (the clearance under the bottom of the door shall
be a maximum of 3/4") and 6.3.1 (top & edges 1/8")
 Mr. Channabasappa. K.M

 The self-closing device is operational; that is, the active door completely closes when
operated from the full open position.

 If a coordinator is installed, the inactive leaf closes before the active leaf.

 Latching hardware operates and secure the door when it is in the closed position.

 Auxiliary hardware items that interfere or prohibit operation are not installed on the
door or frame.

 No field modifications to the door assembly have been performed that void the label.

 Gasketing and edge seals, where required, are inspected to verify their presence and
integrity.

 According to building and fire codes, annual fire door inspections is the responsibility
of the building owner. However, as with other mandatory fire inspections, such as the
inspection of fire dampers, the fire door inspections are often omitted and many
facilities are out of complianceThe final say on the acceptance of any inspection
requires the approval of the AHJ (Authority Having Jurisdiction).

SUPPLIES AND EQUIPMENT

INTRODUCTION

Supplies are those items that are used up or consumed; hence the term consumable is
used for supplies. The supplies in hospital include drugs, surgical goods (disposables, glass
wares), chemicals, antiseptics, food materials, stationeries, the linen supply etc. The term
equipment is used for more permanent type of article and may be classified as fixed and
movables. Fixed equipment is not a structure of the building, but it is attached to the walls or
floors (egg; steriliser,) Movable equipment includes furniture, instruments etc.

IMPROPER SUPPLIES:

In the most of the hospital and other health institutions no standard has been followed
in the supply of drugs are causing reactions and sometimes causing death for which no
reasons nurses made victims on so many occasions.so it is always better to supply standard
drugs.

For the comfort and the other aspects of patients there is need to change to change
linen everyday.in the real sense sometime it is not practicable due to dhobi system. The nurse
must incharge of maintenance of linen ,and equipments.toreplace or repair or make
condemnation of unserviceable line and other equipment ,the present procedure very very
strict.

And other way that the missing of instrument also nurses become a victim and
reducing amount from their monthly salary.
Medical Equipment that Every Healthcare Facility Must Have

Healthcare facilities include, but aren‘t limited to, nursing homes, hospitals, and out-
patient surgery centers. There are many health and safety hazards associated with these
places. The potential hazards include exposure to dangerous airborne germs and viruses,
exposure to bodily wastes and fluids, among others. This is why there is certain medical
equipment that every healthcare facility should have on hand. Important Medical
Equipment for Healthcare

Facilities:

Every Health Care Facility Should Have The Minimum And The Basic Requirements
And The medical equipment that‘s good to have at healthcare facilities such as nursing
homes and hospitals.

Wheelchair.

The wheelchair is a very popular piece of medical equipment. Wheelchairs are used
quite often in the daily operations of many healthcare facilities. They‘re not only used for
people who can‘t walk, but they‘re also used to transport patients from one place to the next.
Although automatic wheelchairs are available, healthcare facilities always use manual
wheelchairs.

Blood pressure monitor

This is necessary to check a person‘s blood pressure. It‘s also used quite often in
healthcare facilities. Depending on the size of the facility, more than one blood pressure
monitor will be needed. If you‘re using it for home care, you may only need one. There are
two types of blood pressure monitors: manual and automatic.

Gauze, tape, and bandages.

These are used to care for burns, cuts, bruises, sprains, and breaks. No healthcare
facility should be without a large supply.

Bedpans and urinals.

These allow bedridden patients to use the bathroom without needing to be moved.

Latex and vinyl gloves

(sterile and non-sterile). These help protect hands from being exposed to dangerous germs
and bodily fluids. They also help reduce the chances of cross-infecting patients. These gloves
aren‘t reusable, and should be disposed of following use.

Thermometers.

The thermometer is also an important piece of medical equipment. It‘s often necessary to get
a temperature reading, and you can‘t do it without a reliable thermometer.

Disinfectants.
 Mr. Channabasappa. K.M

It‘s important to keep the facility and yourself as clean as possible. Disinfectants to have are
hand sanitizer, antibacterial soap, antibacterial wipes, sprays, and cleaning and sterilizing
solutions.

Braces, crutches, medical collars, and splints.

These items have different purposes, and are a must have for all healthcare facilities.

CPR equipment and heart monitors.

These are vital pieces of equipment. Healthcare facilities should have enough
equipment for more than one patient at a time.

This list isn‘t all inclusive. There are many more pieces of medical equipment that
healthcare facilities should have. The purpose of this article is to provide a basic overview of
the type of medical equipment any well-equipped healthcare facility should have. Of course,
the type of equipment you need may depend on the type of care you provide. However, there
are some pieces of equipment that are generally needed for most healthcare facilities.

ISO Standards for Hospitals

Hospitals worldwide adhere to ISO-established safety parameters:

Non-surgical gloves must meet ISO standards as well.

ISO 11193: 2008 pertains to hospital gloves that a health care professional would use
in handling contaminated medical materials. ISO 11193:2008 has two sections and concerns
the bulk storage and packaging requirements for non-surgical gloves; it does not cover the
safe and proper usage of examination gloves. Part one concerns packaging and bulk storage
while part two concerns gloves intended for use in diagnostic or therapeutic procedures with
the goal of protecting patients from cross-contamination

Powdered Rubber Medical Gloves:

Some hospital gloves use skin powder to reduce hand irritation.ISO 21171:2006
describes standards for the presence of removable powder on the surface of medical gloves.
There are three methods: Method A pertains to powdered gloves and Methods B and C for
powder-free gloves. The standard does not address safety issues that may be associated with
powdered gloves, nor does it prescribe limits on the amounts that may be present

Medical Face-Mask Quality:

ISO 22609:2004 addresses a laboratory testing method which measures how

effectively medical face masks resist penetration by a splash of synthetic blood. The standard
primarily concerns the performance of materials from which the masks are manufactured and
does not address the mask's design, construction, interfaces or other factors which may affect
the overall protection. Hospitals worldwide adhere to ISO-established safety parameters.:

The International Organization for Standardization (ISO) has several schedules that
hospitals follow in order to maintain their ISO certification. The standards cover surgical
gloves, medical gloves and even the wheels used on hospital beds. All ISO standards for
hospitals are updated regularly and outline the pinnacle of hospital performance and safety
standards for the benefit of patients, families and health care professionals alike.

CASTORS AND WHEELS ON HOSPITAL BEDS:

ISO 22882: 2004 specifies technical requirements and dimensions for wheels and
locking mechanisms on hospital beds. The standard addresses swivel-type castors and wheels
that have a dimension of 100 mm or more. Nine countries adhere to this standard, most of
them in Europe; an additional 12 countries acknowledge the standard's validity.

HOSPITAL BED PERFORMANCE:

ISO 60601:2009 addresses the basic function, performance and safety features of
many hospital beds. The standard comes in two sections, the first of which replaced an earlier
standard. ISO 60601 applies only to beds that are intended for adults and focuses on
modernizing existing safety benchmarks. The first section of ISO 60601 was updated in 2010
and covers electrical equipment associated with hospital beds; the second section was
updated in 2009 and covers the safety of the bed apparatus itself

HEATING PADS AND BLANKETS:

ISO 80601: 2009 covers safety concerns related to heating pads, blankets and other
electrical bedding used on pediatric patients. The standard establishes safety parameters
which minimize health risks to patients and health care professionals, as well as specific tests
for the devices. ISO 80601: 2009 updates the 1996 version of the same standard.

Maintenance standards:

 Biomedical Benchmark- Benchmark, manage and improve your medical equipment

service activities.

 Legal Nurse Consultant Services- up-to-date standards of care and clinical guidelines.

 Universal Medical Technology Service Nomenclature™ (UMTSN™)

 A universal medical technology service nomenclature for the servicing of medical

equipment

 Patient Safety Organization–ECRI Institute PSO-(Share learn and protect)

POLICY

MEANING:

A policy is a statement or general understanding which provides guidelines in

decision making to members of an organization in respect of any course of action.
 Mr. Channabasappa. K.M

Definition:

―Is a mam made rule of predetermined course of action that is accomplished to the
performance of work toward the organization objective. it is a type of standing plan that
serves to guide subordinates in the execution of their task. ‖

ACCORDING TO JOINT COMMISSION, THE HOSPITAL POLICY SHOULD

CONTAIN THE KEY ELEMENTS:

 Hospital Philosophy

The policy should have a brief statement that discusses the Hospital‘s

 Policy Statement

Written and Describe what the policy is, when it applies and what it is intended to
accomplish.

 Definitions of Terms

Define key terms used within the hospital‘s policy and procedure.

 Criteria for Disclosure

 Defining Personnel Roles

 Disclosure Response Team

Pharmacists, Direct Care Givers Staff members, regardless of their job responsibilities, may
find themselves participants in a patient disclosure concerning unanticipated outcomes. Staff

 Patient Contact Algorithm

Set forth guidelines for patient contacts:

 Initial Patient Contact

The staff member who encounters the initial patient contact needs to

Be prepared for this encounter whether it is expected or unexpected

And whether it is by telephone, in person or through a representative.

Dealing with difficult conversations and emotions is a communication

Skill for which all staff members should receive education.

 Directing the Patient to the Appropriate Individual(s)

Depending on the tone and urgency of the initial patient contact, the staff member must
also make the decision of whom to direct the Patient or patient‘s representative. Typically the
patient will be directed to the Hospital‘s Risk Manager or Senior Member of Administration
responsible for the risk management function. A well thought out decision tree that is part of
a policy guideline will be beneficial to reduce staff hesitation and confusion during this
critical patient encounter.

 Investigate Unanticipated Outcome

o Complete root cause analysis if needed

o Review and communicate details of

Investigation with appropriate staff members

 Planning the Disclosure Discussion

 Disclosure Communication Content

 Documentation

 Follow Up

Specific:

OPDorganisations,functions,staffing,equipments,techniques,referals,consultations,interrelatio
nships,supervision,records,timings,drugs,supplies,type of patient
general,paying,referred,eligibility,medicolegal

examination and tx: general,lab investigations,consultations,extent of tx,accidents and

injuries,fractures and injections,dispensing ,records,follow up

staff: organization,duties,responsibilities,shifts,interrelationships.

Equipment and
supplies:inventory,requisition,perchasing,indenting,accounting.storage,maintenance,standard
s,safety,sterilisation.

Records: identification, illing, retention.

Bibliography

1. WWW.JACHO.COM

2. WWW.LIFE SAFETY CODE.COM

3. BM.SAKHAR PRINCIPLES OF HOSPITAL ADMINISTRATION AND

PLANNING,SECOND EDITION,JAYPEE PUBLICATION,NEW DELHI.

4. BASAVANTHAPPA B.T.NURSING ADMINISTRATION,DECOND

EITION,JAYPEE PUBLICATION,NEWDELHI.
 Mr. Channabasappa. K.M

6. PROCESS STANDARDS IN QUALITY

ASSURANCE Introduction

Standard is a predetermined baseline condition or level of excellence that

compromises a model to be followed and practiced. The standards also using as measurement
tools and they should be measurable and achievable.

A nursing care standard is the desired quality against which to evaluate the nursing
care. In order to develop and provide high quality of care it is necessary to develop
appropriate standards of care and appropriate evaluation tools. Setting up of standards is the
first step in the evaluation process. The criteria that specify desired methods for specific
nursing intervention are called as process standards.

Sources of Nursing Care Standards

It is generally accepted that standards should be based on agreed up achievable level

of performance considered proper and adequate for specific purposes. The standards can be
established, developed, reviewed or enforced by variety of sources as follows:

 •Professional organisation, e.g. Associations, TNAI,

 •Licensing bodies, e.g. statutory bodies, INC,
 •Institutions/health care agencies, e.g. University Hospitals, Health Centres.
 •Department of institutions, e.g. Department of Nursing.
 •Patient care units, e.g. specific patients' unit.
 •Government units at National, State and Local Government units.
 •Individual e.g. personal standards

a. Structure Standard

A structural standard involves the 'set-up' of the institution. The philosophy, goals and
objectives, structure of the organisation, facilities and equipment, and qualifications of
employees are some of the components of the structure of the organisation.

b. Process Standard

Process standards describe the behaviours of the nurse at the desired level of
performance. The criteria that specify desired method for specific nursing intervention
are process standards.
The Process Standards define the "action and behaviours of nurses giving care and
what constitutes that care" (Marker, 1988b, p. 5).
The Process Standards include job descriptions, the job performance evaluation tool,
procedures, and protocols. Central to the standards program are the protocols, which
guide the majority of nursing actions and are a key component of the patients' plan of
care. The protocols truly provide what the staff nurse needs. The protocols set the
standard for care, provide a wonderful reference and teaching tool for the nurse, and
serve as the nursing orders to define the plan of care for the patient.
A process standard involves the activities concerned with delivering patient care.
These standards measure nursing actions or lack of actions involving patient care. The
 standards are stated in action-verbs that are in observable and measurable terms.eg:
the nurse assesses , the patient demonstrates.
The focus is on what was planned, what was done and what was communicated or
recorded. Therefore, the process standards assist in measuring the degree of skill, with
which technique or procedure was carried out, the degree of client participation or the
nature of interaction between nurse and client.
In process standard there is an element of professional judgement determining the
quality or the degree of skill. It includes nursing care techniques, procedures,
regimens and processes.

c. Outcome Standards

- Descriptive statements of desired patient care results are outcome standards because
patient‘s results are outcomes of nursing interventions.

STRUCTURE STANDARDS

Philosophy Resources procedures and policies

Equipments

Objectives Facilities personnel job descriptions

PROCESS STANDARDSOUTCOME STANDARDS

Agency procedures Client health status

changes

Practice guidelines Client satisfaction

Practice standards 3 E’s= Efficiency

Legal significance of standards

Standards of care are guidelines by which nurses should practice. If nurses do not
perform duties within accepted standards of care, they may place themselves in jeopardy of
legal action. Malpractice suit against nurses are based on the charge that the patient was
injured as a consequence of the nurse‘s failure to meet the appropriate standards of care.

To recover losses from a charge of malpractice, a patient must prove that:

 Mr. Channabasappa. K.M

1. A patient-nurse relationship existed such that the nurse owed to the patient a duty
of due care.

2. The nurse deviated from the appropriate standard of care,

3. The patient suffered damages,

4. The patient's damages resulted from the nurses deviations from the standard of
care.

DEFINITION

1) The standards which describes the behaviour of a profession and specifies the
desired methods of specific interventions.
2) Process Standards is a guide which presents an outline or framework of
processes that are typically found to be involved in performing supply
chainrelated activities, and a set of standardized activities described in 2 levels of
maturity - "Suggested Minimum" and "Best Practice" for each process.

CATEGORIES

 The second edition of the Standards utilizes the American Productivity &
Quality Centre (APQC) Process Classification Framework (PCF) to present
the minimum and best practice attributes.
 The Standards uses a numbering scheme where each process element is
referred to by categories.
 Those categories includes: Process groups, Processes, and Activities.

 Category: The highest level within the Standards is indicated by whole numbers (e.g.,
1.0)
 Process Group: Items with one decimal number (e.g., 1.1) are considered a process
group.
 Process: Items with two decimal numbers (e.g., 1.1.1) are considered processes.
 Activities: Items with three decimal numbers (e.g., 1.1.1.1) are considered activities
within a process.

 For each activity there is a description of an associated practice in two levels of

maturity.

1. Suggested Minimum
2. Typical Best Practice

BENEFITS OF PROCESS STANDARDS

♥ In measuring nursing actions or lack of actions involving patient care.

♥ In measuring the degree of skill in nursing interventions.
♥ In assessing the level of nurse- client relationship.
♥ In providing high quality of care.
♥ In controlling nursing actions.
 ♥ In providing yardstick towards care.
♥ To provide practitioners, educators and consultants with a reference tool to help
companies identify potential gaps across a broad spectrum of their supply chain
processes.
♥ Practitioners can use this tool to identify process strengths and weaknesses, and then
focus their attention on those areas where improvement efforts will drive the most
benefit.
♥ Results can be shared and compared with other organizations in your supply chain to
improve overall effectiveness.

CHARACTERISTICS:

 •Standards statement must be broad enough to apply to a wide variety of settings.

 •Standards must be realistic, acceptable, and attainable.
 •Standards of nursing care must be developed by members of the nursing profession;
preferable
 •Nurses practising at the direct care level with consultation of experts in the domain.
 •Standards should be phrased in positive terms and indicate acceptable performance
good, excellence etc.
 •Standards of nursing care must express what desirable optional level is.
 •Standards must be understandable and stated in unambiguous terms.
 •Standards must be based on current knowledge and scientific practice.
 •Standards must be reviewed and revised periodically.
 •Standards may be directed towards an ideal, ie, optional standards or may only
specify the minimal care that must be attained, i.e., minimum standard.
 •And one must remember that standards that work are objective, acceptable,
achievable and flexible.

SCOPE OF PROCESS STANDARDS:

A number of key concepts serve as the basis for the scope. These include
responsibilities, core values, technology and innovations, globalization, competency,
model & standards committee.

Responsibilities: NPD responsibilities have expanded and will vary based on the position
and practice environment requirements. The key responsibilities include, but are not limited
to, career development guidance, education, leadership, program management, and assurance
of compliance to a variety of regulating entities.

Core Values: NPD core values in the new document are the same or closely reflect those of
the ANCC CNE Accreditation Program. Of importance are the values that emphasize
knowledge management, innovation and competence, mentoring/peer review, inter-
professional networking and the inclusion of relevant stakeholders, and inclusiveness so that
each program emphasizes integrity, accountability, responsiveness, and diversity.

Technology and Innovation: Advances in technology are driving the NDP Specialist to
become innovative. Innovations in approaches to presenting information make CE learning
easier and more interesting. Examples include the use of color, illustrations, and graphics in
 Mr. Channabasappa. K.M

electronic media. Technology is also advancing how the NPD Specialist can manage one's
practice, including program administration and financial management.

Globalization: Our educational programs may now be available across nations for different
cultures and even different languages. Relevance now means adapting educational
opportunities to meet a target audience's professional learning needs, abilities, and skills.
Globalization challenges the need to assure quality in the development, implementation, and
evaluation of CE learning. Advances in technology are a major driver by increasing
electronic and internet access to information.

Competence: The theme that practice must reflect competence serves as a basic principle for
NPDs whether in CE or other roles. Competence applies to any role and any responsibility. It
sets the expectation for the public that our practice's ultimate goal is to assure safe, high
quality health services for all. Competence is expected from the basic nursing degree through
to advanced practice or certification.

Model: A new framework was created that attempted to operationalize the former domain
model as a professional development system with inputs, throughputs, outputs, and influential
aspects that would be inclusive of all domains. The model accommodates all practice and
learning environments, and all settings and modes of learning.

Standards Committee:

With representation from every nursing unit, the standards committee has a major role
in making sure all the pieces fit the whole. Without this committed group and strong support
from nursing leadership. The clinical nurse specialists played a key role in protocol
development as the content experts. The Standards Committee remains responsible for
overseeing the continued evolution of the standards model and implementation across units.
Nursing leadership commits resources and sets the expectation for department-wide
involvement in the standards program. In support of the on-going work by the standards
committee, a standards consultant facilitates the development and continued maintenance of
the system.

ELEMENTS OF PROCESS STANDARDS

1. Performance
2. Technique
3. Skill
EVAUATION OF PROCESS STANDARDS

A) Performance and process standards

Evaluation is an essential and never ending process, which includes setting up of

goals, measuring progress towards them and determining new goals during this process. By
assessing the elements of process standards we can conclude how well the process standards
are implemented.

Objectives of performance evaluation:

 Provides a reflection and feedback on the work performance for a given period of
time.
 To acknowledge and encourage appropriate and above standards performance.
 To identify and areas of growth for the staff as well as the organisation.
 To ensure quality care and to maintain high standards of care.

Principles of performance evaluation

 Performance of staff is assessed in relation to the behaviourally stated work goals.

 Observation of a representative sample of the staff‘s total work activities should
be taken into consideration.
 Comparison of the supervisors evaluation should be done with the staffs self
evaluation.
 While documenting the staff‘s performance suitable examples of satisfactory and
unsatisfactory performance.
 Mr. Channabasappa. K.M

 When several areas of performance requires improvement indicates which area

has the highest priority for improvement.
 Purpose of the evaluation is to improve the work performance and job satisfaction.

Components to be evaluated:

1. Traits an personal characteristics

This includes assessing the stability and ability of the staff to handle a stressful
situation.
Trait oriented tools are inexpensive to use and can be used for a variety of positions.
But now a days there has been a shift from trait oriented systems of evaluation due to
the reason that they discriminate against some groups. Another reason is that they are
not useful in helping to develop the professional growth of the staff.
2. Results
This includes all the result oriented evaluation systems. In this staff knows in advance
what is expected of her performance wise.
Evaluation of this component gives the staff information whether she has achieved her
goals or not but does not tell how to accomplish it in the future.
3. Behavioural criteria
Here the evaluation focuses on what actually the staff does.
This facilitates staff development.
This is the time consuming and can be useful only for a specific job or a narrow range
of jobs.
4. Combination of various criteria‘s
Each staff has a few major objectives which he is expected to accomplish.
They are evaluated in terms of general personal characteristics and behaviourally
specific criteria.

TYPES OF EVALUATION

a) Absolute judgement method.

This is an evaluation method based on reasonable and acceptable standards set by the
organisation.

Format for absolute judgement method

Desired Fails to meet Does Meets Exceeds Far

characteristic performance performanc performan
not exceeds
s standards e standards ce
quite performance
standards
standards
meet
(1) (3)
performance
(4)
standards (4)

(2)
61
 Initiative
dependabilit
y

Job
knowledge
adherence

to hospital
policies.

b) Comparative judgement method.

An evaluation method in which employees are compared with each other.
ii) Techniques and process standards

In order to conduct evaluation, an evaluation tool should be developed initially. An

effective evaluation tool is one that minimizes bias, encourages objectively and
maximizes reliability and validity.

There are two main methods of evaluation.

1. Structured or traditional methods

2. Flexible of collaborative methods.

1. Structured methods

a) Forced distribution scale

 This is a form of comparative judgement method.
 Here, the evaluator assigns each employee to one of the five groups in a manner as to
force a somewhat normal distribution.
 The evaluator allocates approximately 10% of each staff in the best end of the scale ,
20% in next, 40% in the middle and 20% in the region next to low and 10% in the
lowest level.

Draw backs:

- Problems arise with border line cases.

- The staffs do not know in which area he has to improve.

62
 Mr. Channabasappa. K.M

Format of forced distribution scale or comparative judgement scale:

Performance Bottom 10% Next 20% Middle 40% Next 20% of Top 10% of
criteria of all staffs. of all staffs all staffs. all staffs.
Performance

Depenciability

Appearance

Proper
Utilization of
time

b) Graphic rating scales or merit rating scales:

 This comprises of a numbering system that indicates high and low values for each
evaluating various characteristics like personality traits, knowledge, abilities, skills,
quantity and quality of work.
 The responses are enumerated horizontally as a numerical scale or by indicating
degree of applicability criterion such as excellent, good, average, poor or always,
sometimes, seldom, never.

 Advantages :
- Easy to develop and inexpensive.
- Provides information on a number of characteristics and degree of their applicability.
- Enables evaluation of performance over time.
 Disadvantages :
- Lacks specificity.
- Promotes halo or Recency effect. (Halo effect- evaluation based on isolated positive
events, Recency effect- performance closer to the rating session is better remembered
than that of previous months.

2. Flexible methods:

a) Behaviourally Anchored Rating Scales (BARS)

- This method focuses on the behaviour on job than the personality traits.

- It is more objective than personality traits judgement.

- There is no chance of halo effect.

63
- This method combines rating with critical incidents( examples of whatever incidents that
has occurred) or criterion references ( examples based on standards of practice).

- This descriptive qualitative as well as quantitative performance.

- Steps of development:

o Group of workers who are very familiar with the target job, provides critical incidents
examples of superior and inferior job behaviours.
o These are stated in qualifiable, measurable behaviours.

-Disadvantages:

o Expensive to develop and time consuming to implement.

o Must be prepared specifically for each job category.

b) Evaluation of management by objectives:

o This involves establishment of learning goals between the employee and the
employer.
o Progress is documented throughout the rating period regarding the accomplishment of
these goals.
o It also involves establishment of clear and measurable objectives at the beginning of
each rating period.
o Steps involved:
- The top management formulates goals for a definite period.
- Departmental heads translate these organisational goals into specific departmental
objectives and lays down priorities in terms of key result areas.
- Each individual develops a specific time bound action plan to achieve the key task.
The supervisor coordinates this process.
- At the end of specified period (6months to 1 year) the individual and his superior
meets to evaluate the performance.
c) Peer review :
- Staffs are involved in developing and implementing the evaluation process.
- The advantage is that, staffs tend to function in their normal patterns in the presence
of peers.
- It is important to get objective ratings based in performance and not subjective ratings
based on personal friendships.
- The employees must trust and respect each other to willingly participate in this
process.

Other methods:

1. Free written scales or essay evaluation:

 The superior write short essays on each staff‘s performance detailing her strength,
weakness, potentials etc.
 The format can be a structured one or an unstructured one.
 In a structured format, the supervisor is asked to write short notes on each of the
specified criteria.
 Mr. Channabasappa. K.M

 In unstructured format, the evaluation can determine which aspects of the staff she
will elaborate on.
 Limitations :
- Writing skill of the evaluator can mask the staff‘s true performance.
- It is time consuming.
- Comparisons are not easy since evaluations are in a descriptive form and lacks
uniformity.

2. Ranking methods:

 This involves establishing a rank order of employees based on their relative merit.
 Alternation ranking:
Here, the supervisor lists the staffs in a random order. Then she chooses the most
valuable staff, crosses her name off the list and notes it on the top of the list. Next, she
selects the least valuable staff and notes the name on the bottom of the list. This
continues till all the staffs have been ranked.
 Paired comparison ranking :
Here, each employee is compared with another. The evaluator judges which of the
two staffs being compared is superior and puts a tick mark against the name on each
slip. Final ranking is based on the number of totally marks against each name.
 Disadvantages: It is very difficult when the number of staffs to be evaluated is 20 or
more.

3. Critical incident method :

- The evaluator records the factual incidents involving the staffs which have been
critical to the staff‘s effective or ineffective performances (anecdotal records).
- Disadvantages :
o The idea of an evaluator hovering at the background taking notes on the
conduct is not a mature attitude.
o Critical incidents can be rare.
o The evaluator should jot down incidents occurred on daily or weekly basis and
this is difficult.

4. Forced rating method :

This consists of a number of statements, the evaluator should indicate those
statements which best fit the staff and those which least describes the individual. Such
a method can be used in self evaluation.
Disadvantages: Scale construction is time consuming and requires lot of effort.

Problems with staff performance evaluation:

Leniency error :
Here, the performance of the staff is overrated. Rating all staffs above average. This
method is liked by the poor performances and disliked by the superior ones.
 Recency error:
When the evaluation period extends over a long time and when the superior is
evaluating 2-3 staffs this occurs. The evaluator may recall only the recent
performance of the staff and tends to forget the previous ones. So, the performance
ratings are based on what the staff contributed lately rather than over the entire period
of evaluation.

Halo error :
There is no differentiation among various dimensions like implementing nursing
process, communication etc. the ratings are assigned on the basis of overall positive or
negative impression.

Ambiguous evaluation standards :

Wordings such as ―outstanding‖, ―above average‖ etc does not give a specific picture.

Written comments problem :

The evaluator should utilize the specific given space in the evaluation tool to justify
the basis of ratings and should also suggest improvement measures. But it often
happens that this space is left back.

iii) Skills and process standards

Nurses should have skills in:

1) Control or alleviate symptoms of disease,

2) Maintain or improve ability to function as independently as possible,
3) Cope with progressive impairment, and
4) Minimize or prevent development of complications.

It is important that the skills and competencies included here be available to each
individual and family or caretaker, and that the care provided be coordinated by one
professional health practitioner. The decision as to which health professional will provide and
coordinate the services should be made on the basis of who on the health team possesses the
greatest number of the skills required to provide the care.
 Mr. Channabasappa. K.M

Why we need skills?

FINANCIAL STRATEGY FOR PROCESS STANDARDS:

CONCLUSION:

Quality assurance is to provide a higher quality of care. It is necessary that nurses

develop standards of patient care and appropriate evaluation tools, so that professional
aspects of nursing involving intellectual and interpersonal activities. Quality will be ensured
and attention will be given to the individual needs and responses to patients.The formulation
of standards are the first step towards evaluating the nursing care delivery. The standards
serve as a base by which the quality of care can be judged. This judgement may be according
to a rating or other data that reflect the conformity of existing practice with the established
standards. The standards must be written, regularly reviewed and well-known by the nursing
staff.

REFERENCES

1. Basavanthappa B.T. ―Nursing Administration.‖ 2nd edition. New Delhi:

Jaypee Brothers; 2000.
2. Johnson M and Closkey J.C. The Delivery of Quality Health Care Series on Nursing
Administration. London: Mosby 1992, pp; 365-398.
3. Anthony, Mary K., Theresa; Hertz, Judith .Factors Influencing Outcomes after
Delegation to Unlicensed Assistive Personnel. JONA. 30(10):474-481, October 2000.
4. S.Sridhar. Quality assurance in nursing Indian Journal of Nursing and Midwifery Vol.
2 Sept 1988.
5. ALA Report on Comprehensive Care for Patients with Chronic Disease, 1975.
6. Google.Com
7. Wikipedia.Com
8. Pubmed.Com
9. Quality assurance.Com

7. OUTCOMES-STANDARDS

INTRODUCTION:-

A nursing standard can be a target or a gauge. When used as a target, a standard is a

planning tool. When used as a gauge against which to evaluate performance, a standard is a
control device. The standard of nursing care for a particular health agency is the level of
care that nursing staff believe necessary to achieve care or treatment goals for a specific
type of patient. The standard of care in a heavily endowed private hospital may be higher
than that in an inadequately funded municipal hospital. The standard of care in a research
unit with all professional nurse staffs may be higher than that in a general medical- surgical
unit with mixed professional – nonprofessional staffs.

DEFINITION:-

1) Standard: - A standard is a practice that enjoys general recognition and conformity

among professionals or it is an authoritative statement by which quality of practice,
service or education can be judged.
 Mr. Channabasappa. K.M

2) A nursing care standard:- is a descriptive statement of desired quality against which

to evaluate nursing care.
Lang and Marek (1990) identified 12 categories of patient outcomes for which care
standards could be developed. They are-

1. physiological outcomes
2. psychosocial outcomes
3. functional status
4. behavior outcomes
5. knowledge
6. symptom control
7. home maintenance
8. well being
9. goal attainment
10. patient satisfaction
11. safety
12. resolution of nursing diagnosis

Publications of these patient outcome categories may stimulate nurse specialists to

construct standards in each category for patients with common nursing diagnoses.

Which each frame work (i.e. normative, empirical standards, structure, process or outcome
standard) nursing personnel should specify the proactive areas needing control through
standards implementation. The purpose of standards is to improve care quality while
containing cost. Therefore standards are frequently focused on eliminating symptoms,
eliminating hazards, facilitating treatment, preventing complications and hastening
rehabilitation. The following are examples of standards from the American Nurses
Association standards of child and adolescent psychiatric and mental health nursing practice.

1) Eliminate symptoms: The nurse sets limits in a humane manner with the least
restrictions necessary for assuring the safety of client and others.
2) Eliminate causes of injury: The nurse uses crisis intervention to promote growth and
aid the personal and societal integration of the child or adolescent and family in
developmental crises, situational crises.
3) Eliminate treatment: The nurse uses daily situations as a means for therapeutic
intervention.
4) Prevent complications: The nurse provides for continuity of care for the child or
adolescent and family in the therapists absence.
5) Foster rehabilitation: The nurse provides anticipatory guidance to the child or
adolescent and family regarding situational and developmental needs.

Sample of care outcome standards:

(Spinal cord – injury patients)

A. Physical welfare:-
 1. Body temperature range between 97.6 and 99.60 F
2. Skin is clean and free of discoloration, irritation, abrasion, infection and ulceration
3. lungs are clear at auscultation
4. Urine culture shows less than 10 5 bacteria/mm3
5. Urine elimination is managed without spillage through evening fluid restriction and
condom catheter or self cauterization.

B. Emotional welfare:

1. Participates actively in physiotherapy, occupational therapy and recreational therapy

sessions.

2. Performs self – care measurements as instructed: evening fluid restriction, self

catherization, position change, cough and deep breath etc.

3. Verbalize plans to modify premorbid life style to accommodate changed abilities.

4. Demonstrates and accepts affection to and from significant

others. C. Social welfare:

1. Initiates friendly overtures towards other patients, professional caregivers, visitors.

2. Voluntary joins formal and informal groups and participants in group activities.

3. Asks for information about vocational opportunities for persons with quadriplegia and
paraplegia.

COST AND BENEFITS

COSTS

INTRODUCTION:

The expense budget consists of salary and non salary items. Expenses should reflect
patient care objectives and activity parameters established for the nursing unit. The expenses
budget should be comprehensive and thorough; it should also take into consideration all
available information regarding the next year‘s expectations.

CLASSIFICATION OF COSTS: Costs are commonly classified as-

1) Fixed cost: - Fixed costs are costs that will remain the same for the budget period
regardless of the activity level of the organization. Such as rental payments and
insurance premiums.
2) Variable cost: - It depends on and changes in direct proportion to patient volume and
patient acuity, such as patient care supply expenses. If more patients are admitted to a
nursing unit, more supplies are used causing higher supply expenses.
 Mr. Channabasappa. K.M

3) Semi-variables:- some costs contain both fixed and variables elements. These costs,
called mixed or semi variable costs, may vary with volume, but not directly. An
example of this type of costs is utility bills. They are regular costs that vary with
increases and decrease in census.
4) Direct costs: - direct costs are those expenses that directly affect patient care. For
example salaries for nursing personnel who provide hands –on patient care are
considered direct costs.
5) Indirect costs: - Indirect costs are expenditures that are necessary but don‘t affect
patient care directly. Salaries for dietary or housekeeping personnel for example are
classified as indirect costs.

COST CONTAINMENT:-

The goal of cost containment is to keep costs within acceptable limits for volume,
inflation, and other acceptable parameters. It involves cost awareness, monitoring,
management, and incentives to prevent, reduce and control costs.

a) Cost awareness: - it focuses the employee‘s attention on costs. It increases

organizational awareness of what costs are, the process available for containing them,
how they can be managed, and by whom.
b) Cost monitoring: - Cost monitoring focuses on how much will be spent, where, when
and why. It identifies, reports and monitor costs. Staffing costs should be identified.
Recruitment, turnover, absenteeism, and sick time are analyzed and inventories are
controlled.
c) Cost management: - It focuses on what can be done by whom to contain costs.
Programmes, plans, objectives and strategies are important. Responsibility and
accountability for the control should be established. A committee can identify long
and short range plans and strategies.
d) Cost avoidance: - it means not buying supplies, technology or services. Supply and
equipment costs should be carefully analyzed. Costs and disposable versus reusable
items are compared. The receipt, storage and delivery of disposables and labor and
processing costs of reusable items are part of the analysis. The least expensive and
most effective supplies, equipment, and services should be identified and expensive
and less effective items avoided.
e) Cost reduction: Cost reduction means spending less for goods and services. The
amount of reduction depends on the size of the agency, previous efficiency, and skills
of managers and cooperation of employees.
f) Cost control: - Cost control is effective use of available resource through careful
forecasting, planning, budgeting preparation, reporting and monitoring.

COMPENSATION AND BENEFITS

All institution has the means to provide compensation and benefits to their
employees. Not all institutions, however, have stated objectives and planned programmes to
achieve the objectives. Instead, salaries and benefits have often evolved haphazardly and
disjointedly in reaction to internal and external pressures. Although the responsibility for the
development of the compensation process and benefits programs is usually that of the human
resource department, the nurse administrator and nurse manager have to be very familiar with
them. There should be five goals for compensation and benefits programs that are developed
by institutions. These goals address the objectives of the retirement program, life and health
insurance benefits, disability benefits, medical care reimbursement, and compensation. In
each of these major areas, it is necessary to identify the needs of the employees, the extent to
which these needs are being met through other programs such as social security or
Workmen‘s Compensation and finally, the amount or level of benefit the institution will
provide.( Rawland and Rawland , 1984) .

BENEFITS:-

This factor can be calculated by determining the average number of vacation days, paid,
holidays, personal days, bereavement days or other days off with pay that the organization
provides and the average number of sick days per employees as experienced by the cost
centre. By definition replacement time is not calculated for indirect staff.

To determine FTEs required for replacement.

Determine hours of replacement time per individual.

Benefit time hours/shift replacement hours

15 vacation days 8hours 120

8 holidays 8 hours 64

4 personal days 8 hours 32

5 sick days 8 hours 40

Total 256

CONSUMER EXPECTATIONS

In the relationship between health professional and client, trust is still a very
important ingredient but today‘s patient is viewed as an active member of the health team
rather than a passive recipient of care. No longer its felt that the doctor or nurse or any other
health professional has a ‗Devine right‘ to knowledge that is too far above their heads to be
understood by average citizens. The average citizen of today is much more knowledgeable
about the complicated mechanism of the human body and things that can go wrong with it,
than his parents or grandparents were. He learns from the popular media about the latest
advances in medical treatment and surgical procedures. He also feels that he has a right to
question the treatment he is being given, to have a say in this treatment and to be informed of
his progress.
 Mr. Channabasappa. K.M

THE SERVICE QUALITY MODEL:

Consumers from service expectations from many sources, such as past experiences,
word of the mouth, advertising. In general consumers compare the perceived service with the
expected service. If the perceived service falls below the expected service, customers are
disappointed. If the perceived service meets or exceeds their expectations, they are apt to use
the provider again. Successful companies add benefits to their offering that not only satisfy
customers but surprise and delight them. Delighting consumers is a matter of exceeding
expectations.

Parasuraman, Zeithaml and Berry formulated a service quality model that highlights
the main requirements for delivering high service quality. They identified five gaps which
leads to unsuccessful service delivery. So, it is also known as service quality model.

1. Gap between the consumer expectation and management perceptions.

Management does not always correctly perceives what consumers want. Hospital
administrators may think that patient may want better food but patient may be more
concerned with nurse responsiveness.

2. Gap between management perception and service- quality specification.

Management might correctly perceive consumers‘ want but not set a performance
standard. Hospital administrators may tell the nurses to give ‗fast‘ service without
specifying it in minutes.

3. Gap between service quality specifications and service delivery.

Personnel might be poorly trained, or incapable of or unwilling to meet the standard; or

they may be held to conflicting standard, such as taking time to listen to consumers and
serving them fast.

4. Gap between service delivery and external communications.

Consumers expectations are affected by statements made by company representatives and

ads. If the hospital brochure shows a beautiful room, but the patient arrive and finds the
room to be cheap and tacky looking, external communications have distorted the
consumer‘s expectations.

5. Gap between perceived service and expected service.

The gap occurs when the consumers misperceives the service quality. The physician may
keep visiting the patient to show care, but the patient may interpret this is an indication
that something really is wrong.
Fig: the service quality model.

Based on the service quality model, the following determinants of service quality
according to the importance are:

 Reliability: The ability to perform the promised service dependably and

accurately. Eg: providing services as promised, performing service right at time,
maintaining error free records.
 Responsiveness: the willingness to help consumers and to provide prompt
service. Eg: keeping consumers informed as to when the services will be
performed, prompt service to consumers, willingmess to help the consumers,
readiness to respond to consumers request.
 Assurance: The knowledge and the courtesy of employees and their ability to
convey trust and confidence. Eg: employee will instill confidence in consumers,
making consumers feel safe in their transactions, employees who have knowledge
to answer to the consumers questions.
 Empathy: The provision of caring, individualized attention to consumers. Eg:
giving consumers individual attention, employee who treat consumers in a caring
fashion, having consumers best interest at heart, employees who understand the
needs of the consumers.
 Tangibles: The appearance of physical facilities, equipment, personnel and
communication materials. Eg: modern equipments, visually appealing facilities,
employees who have a neat, professional appearance, visually appealing materials
associated with the service.
 Mr. Channabasappa. K.M

THE CONSUMER FOCUS:

Consumer‘s relationships are constantly changing and thus affect the providers of
health services, hospitals, home health agencies, nursing homes, physicians and nurses. As in
patient services stabilize and outpatient‘s services grow, competition for patients become
fierce. The focus has moved from the healthcare providers to health care consumers. There
are three distinct relationships that consumers enter into in meeting their healthcare needs.
These are with the physician, the health facility and the nurse.

PHYSICIAN/ CONSUMER RELATIONSHIP:

Physician/ consumer relationships changed as the physician‘s mode of practice moved

from a single, private enterprise to the multigroup practice. When consumers visit a group
practice they may be unable to select a specific physician. Patients no longer know, trust, and
respect their physicians as they did in the past and physicians may be unfamiliar with their
patients. This has resulted in insecurity and lack of trust on the part of the physician. Rural
consumers of health care have been seen their local hospitals close and have had to seek care
in regional health centers. They do not know the physicians from whom they are forced to
seek care. This leads the consumers to be more critical and less accepting of the care
delivered. They feel insecure in the unfamiliar circumstances even though they may be
receiving the best medical attention.

AGENCY/ CONSUMER RELATIONSHIPS:

Consumers of health services are accustomed to receiving treatment and care in an

inpatient setting. In many situations, this option is no longer available. Patient may be angry
and frightened at the thought of being on their own or with service provided only periodically
from home health agencies. When impatient services are deemed appropriate, the specific
hospital or health agency that the client must patronize most likely will be dictated by the
type of insurance coverage.

NURSE/ CONSUMER RELATIONSHIPS:

Nurses are the healthcare providers who spend the most time with the consumer. This
encounter is generally personal and intensely meaningful. Therefore, the nurse is in a unique
position to influence and promote positive consumer relationships. The nurse manager sets
the tone for effective staff/ patient interactions. Four major responsibility of nurse in
promoting successful consumer relationships are developed in this chapter.

1) Service
2) Advocacy
3) Teaching
4) Leadership.

SERVICE:

A service orientation responds to the needs of the customer or all activities are
centered around the patient. The seven dimensions of patient- centered care are as follows.
 Respect for patient values, preferences and expressed needs, which includes attention to
quality of life, involvement in decisions making, preserving a patient‘s dignity, and
recognizing patients needs and autonomy.
 Coordination and integration of care, i.e. clinical care, ancillary and support services.
 Information, communication and education, Which includes information on clinical status,
progress and prognosis, information on processes of care and information and education to
facilitate autonomy, self care and health promotion.
 Physical comfort, Which considers pain management; help with activities of daily living,
and hospital enviourmrnt.
 Emotional support and alleviation of fear and anxiety, This demands attention to anxiety
over clinical status, treatment and prognosis, anxiety over the impact of the illness on self
and family, and anxiety over the financial impact of the illness.
 Involvement of family and friends, Which recognizes the need to accommodate family and
friends in decisions making, to support the family as caregiver and recognizes family needs.
 Transition and continuity, Which addresses patient anxieties and concern about information
on medication, treatment regimens, and follow up, danger signals after leaving the hospital,
recovery, health promotion and prevention of recurrence; coordination and planning for
continuity care and treatment and access to continuity of care and assistance.

ADVOCACY:-

Nurses today practice in a healthcare enviourment dominated by unrest and insecurity.

Consumers have some basic rights that need to be protected. – Those are the right to
individualized care, the right to their own values, beliefs and cultural ways and the right to
know and participate in care decisions. Advocacy is a multidimensional concept and has many
different meanings and applications. An advocate is one who-------

(a)Defends or promotes the rights of others

(b) Changes systems to meet the needs of others

(c) Empowers and promotes self- determination in others
(d) Promotes autonomy of diverse cultures and social groups
(e) Assures respect, equality and dignity for others and
(f) Cares for humaneness of all
Nurses need to recognize the culture of their work setting and realize it differs from
the culture of the consumer and the system. The nurse can advocate by being a liaison
between the consumer and system. To provide culturally appropriate care, the nurse must
possess knowledge about various culturally diverse groups. It takes time to develop cultural
sensitivity and awareness. Some guidelines that are useful in learning to appreciate and value
diversity are.

1. avoid stereotyping
2. avoid making assumption
3. learn by observing ethnic groups in interaction
4. Create a more level playing field – modifying your behaviors to accommodate
diversity.
 Mr. Channabasappa. K.M

TEACHING:

Consumers of healthcare have a right to know and a need to know how to care for
their own health needs. Nurses have an obligation to reach the consumer. Teaching is
wonderful, fun rewarding and hard work. It is one of the most positive experience nurses can
have. Consumer must knowledgeable about their health concerns, participate in caring for
their health needs and contribute to finding solutions to their health problems. Education
empowers consumers to excise self- determination. It allows having control over what
happens, to make informed decisions, and to choice wisely from options. Knowledge is
power and sharing knowledge is sharing power.

LEADERSHIP:

Nurse Manager is in a pivotal position to influence the cost and quality of care
delivered by the staff. The role of nurse managers in this are as follows.

1) Keep the consumer as the center of focus

2) Recognize that each staff member has a unique contribution to make to the success of
the unit. Accomplish this is by allowing the staff to be creative and flexible in their
work, asking for suggestions and new approaches to old problems and seeking
participation in decisions making.
3) Promote dignity, worth, caring, individual contribution and cultural diversity in the
staff.
4) Understand the economic value of service
5) Evaluate patient outcome and perception of care.

CONCLUSION:-

Time has changed and the role of nurse manager has changed. The move in to the
community, home, clinic and outpatient setting has placed a whole new perceptive on how to
provide quality and cost effective nursing care. Patients must participate in their care and
need service oriented nurses to be teachers, advocates, leaders in their behalf. Managing care
delivery in these diverse settings requires the use of flexible and creative skills.

BIBLIOGRAPHY:

 BT Basavanthappa‘s ‗Nursing Administration‖ 2nd Edition. Published by Japee

brother‘s medical publishers (P) ltd. Pg: 718-721.
 Philip Kotler & Roberta N Clarke‘s ―Marketing for Health Care Organizations‖
Published by Prentice Mall, New Jersey. Pg:75, 289-298.
 Philip Kotler & Kelvin Lane Kella‘s ‗Marketing Management‖ 12th Edition.
Published by Pg: 412-415.
 8. NURSING AUDIT

Introduction

The world trend of professional accountability to an enlightened public can no longer

be ignored by nursing. We nurses easily use the words ―quality nursing‖ but have we defined
what we mean by quality? Do you know our deficiencies? Are we ready to admit our
deficiency to our peers? Are we taking steps to remedy them? Only by such self regulation
we can relate our identity with the health professional as nature partners‘ .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
programmes.

Brief history of nursing audit

Nursing is an evaluation of nursing service. Before 1955 very little was known about
the concept. It was introduced by the industrial concern and the year 1918 was the being of
medical audit. George Groword pronounced the term physician for the first time medical
audit ten years later Thomus R Pandon MD established a method of medical audit based on
procedures used by financial account. He evaluated the medical care by reviewed the medical
records
First report of nursing audit of the hospital published in 1955. For the next 25 years nursing
audit is reported from study or records on the last decade. The programmer is reviewed from
record nursing plan, nursing care.

Definition

1) According to elision -

‗Nursing audit refers to assessment of the quality of clinical nursing‘

2) According to Goster welfare

a) Nursing audit is an exercise to find out whether good nursing practices are followed
b) The audit is a means by which nurses themselves can define standards from their
point of view and describe the actual practice of nursing
c) A nursing audit is a method of evaluating care that evolve reviewing patient records
to assess the outcomes were achieved

3) Nursing audit is defined as:

Nursing audit is the part of the cycle of quality assurance. It incorporates the systematic
and critical analysis by nurses, midwives and health visitors, in conjunction with other staff,
of the planning, delivery and evaluation of nursing and midwifery care, in terms of their use
of resources and the outcomes for patients/clients, and introduces appropriate change in
response to that analysis (NHS ME, 1991 Framework for Audit for Nursing Services).
 Mr. Channabasappa. K.M

4) Clinical Audit: “is a quality improvement process that seeks to improve care and
outcomes through systematic review of care against criteria and the implementation of
change‖

Purposes of Nursing Audit

1. Evaluating Nursing care given,

2. Achieves deserved and feasible quality of nursing care,

3. Stimulant to better records,

4. Focuses on care provided and not on care provider,

5. Contributes to research.

6. To orient nurse with the quality control programme for nursing.

7. To justify the proposal for additional staffing or resources to the

management.

Types of audit

1) Internal auditing

Internal auditing is a control technique performed by an external auditor who is an

employee of the organization. He makes an independent appraisal the policies, plans and
points the deficits in the policies or plans and give suggestion for eliminating deficits

2) External auditing

It is an independent appraisal of the organizations financial account and statements. The

external auditor is a qualifed person who has to certify the annual pprofit and loss account
and prepare a balance street after carefull examination of the relevant books of accounts and
documents

Methods of Nursing Audit

There are two methods:

a. Retrospective view -

This refers to an in-depth assessment of the quality after the patient has been
discharged, have the patients chart to the source of data.

Retrospective audit is a method for evaluating the quality of nursing care by examining
the nursing care as it is reflected in the patient care records for discharged patients. In this
type of audit specific behaviors are described then they are converted into questions and the
examiner looks for answers in the record. For example the examiner looks through the
patient's records and asks:

a. Was the problem solving process used in planning nursing care?

b. Whether patient data collected in a systematic manner?

c. Was a description of patient's pre-hospital routines included?

d. Laboratory test results used in planning care?

e. Did the nurse perform physical assessment? How was information used?

f. Were nursing diagnosis stated?

g. Did nurse write nursing orders? And so on.

b. The concurrent review –

This refers to the evaluations conducted on behalf of patients who are still undergoing
care. It includes assessing the patient at the bedside in relation to pre-determined criteria;
interviewing the staff responsible for this care and reviewing the patient‘s record and care
plan.

Method to Develop Criteria :

1. Define patient population.

2. Identify a time framework for measuring outcomes of care,

3. Identify commonly recurring nursing problems presented by the defined patient

population,

4. State patient outcome criteria,

5. State acceptable degree of goal achievement,

6. Specify the source of information.

7. Design and type of tool

Points to be remembered:

a. Quality assurance must be a priority,

b. Those responsible must implement a programme not only a tool,

c. A co-ordinator should develop and evaluate quality assurance activities,

 Mr. Channabasappa. K.M

d. Roles and responsibilities must be delivered,

e. Nurses must be informed about the process and the results of the programme,

f. Data must be reliable,

g. Adequate orientation of data collection is essential,

h. Quality data should be annualized and used by nursing personnel at all levels.

Audit Committee:

Before carrying out an audit, an audit committee should be formed, comprising of a

minimum of five members who are interested in quality assurance, are clinically competent
and able to work together in a group. It is recommended that each member should review not
more than 10 patients each month and that the auditor should have the ability to carry out an
audit in about 15 minutes. If there are less than 50 discharges per month, then all the records
may be audited, if there are large number of records to be audited, then an auditor may select
10 per cent of discharges.

Training for auditors should include the following:

a. A detailed discussion of the seven components.

b. A group discussion to see how the group rates t he care received using the notes
of a patient who has been discharged, these should be anonymous and should
reflect a total period of care not exceeding two weeks in length.

c. Each individual auditor should then undertake the same exercise as above. This
is followed by a meeting of the whole committee who compares and discusses its
findings, and finally reach a consensus of opinion on each of the components.

Steps to problem Solving Process in Planning Care:

a. Collects patient data in a systematic manner,

1. includes description of patient‘s pre-hospital routines,

2. has information about the severity of illness,

3. has information regarding lab tests,

4. has information regarding vital signs,

5. Has information from physical assessment etc.

b. States nurses diagnosis,

c. Writes nursing orders,

d. Suggests immediate and long term goals,

e. Implements the nursing care plan,

f. Plans health teaching for patients,

g. Evaluates the plan of care,

Procedure for nursing audit

I. Formulation of nursing audit committee consisting of chairman (e.g. senior nurse )

and 3-4 members (supervisors /head nurse )
II. Committee should meet once a month to audit records of patients discharge during
that time.
III. Chairman should assign the number of charts each members will audit. Steps out lined
for evaluation /auditing care
 Visit the unit to complete the evaluation form
 Compile the score for each patients
 Meet the committee to discuss the findings.
IV. Members should be very honest and impartial in their judgment. A confidential note
should be sent to the individual if something very outstanding has been recorded.
V. Review of audit is done by the members of the committee, compiled and submitted to
the authorities with recommendations for future action.

Steps of development of nursing audit tool

Nursing audit tool as an instrumental is designed to measure the quality of care

received by a patient during a particular cycle of care. The audit is useful in evaluating the
quality of the care provided in any programme and setting in which a record is an integral
part of providing comprehensive and continuing nursing care .

The steps given below may be followed in the development of nursing audit tool.

i. Review with the nursing staff the steps in evolution to provide some common base for
understanding.
ii. Develop a list of criteria statements for high quality care and ensure concerns on the
final criteria used for evolution.
iii. The criteria finally derived are grouped in broad area and stated as questions which
could be answered ―Yes‖ or ―No‖ (a criteria either met or not met)
Example for broad group may include:
a) Standard physical needs
b) Safety
c) Medication and treatment
d) Emotional needs
e) Spiritual needs
 Mr. Channabasappa. K.M

f) Teaching
g) Post hospital care
h) Environmental
i) Recording

1. Identify problem or issue

 Select a topic that is important or significant

 This may come from personal experience.
 A problem may be identified from every day practice or a feeling that something
could or should have been done better.

Problems can be identified in 3 basic areas of Practice work:

 Structure - what you need.

This refers to the resources required, for example, the number of staff and the skills they
require, space and equipment.

 Process - what you do.

This refers to actions and decisions taken by practitioners, such as communication,

assessment, education, investigations, prescribing, interventions, evaluation and
documentation.

 Outcome - what you expect.

 This refers to the outcome of interventions such as health levels, patient knowledge or
satisfaction

Problem Priorities

 Is the topic concerned of high cost, volume or risk to staff or users

 Is there evidence of a serious quality problem e.g. patient complaint or high
complication risk
 Is good evidence available to inform standards e.g. Systematic review or national
clinical guidance.

2. Set criteria and standards

This is where you can say what should be happening.

 A criterion is an item of care or an aspect of practice that can be used to assess

quality.
 This is where you can say what should be happening.
 The criterion is written as a statement defining what you want to measure.
 Criteria are the way you should be doing things in an ideal world
 To make the criteria (statement) useful the Standard needs to be defined.

Standards – Setting Targets

For each criterion you will need to set targets for something you should always do (100%)
and / or something that should never happen (0%).
 Mr. Channabasappa. K.M

Remember to be valid follow

• S
• Specific ,Standards should relate to a specific area of care and should give
specific boundaries. They should be unambiguous.
• M
• Measurable, If standards are vague and woolly how can you compare your
practice against them. You need to be able to physically measure aspects of
the standard to allow comparison.
• A
• Achievable, There is no point writing standards that are not achievable either
due to resource or clinical limitations.
• R
• Research Based, Peer reviewed research evidence will have shown the best
available treatment / method for your topic area.
• T
• Timely, Standards should reflect current practice not what you thought you
did two years ago.

 Who should write Criteria and Standards?

Recent government publications state that health professionals will be expected
to develop standards that measure a wide range of features of quality in healthcare
 What if no standards are available?

You will need to develop and write your own in conjuction with the
clinical team.

 Who needs to be involved?

You can write standards alone, but if you are going to use them to
measure practice other than your own, you must involve the relevant people

3. Collecting data on performance

Identify what data needs to be collected, how and in what form it needs to be collected,
and who is going to collect it. Remember only collect information that is absolutely essential.

4. Assess performance against criteria and standards

With the information collected analysis is possible, and identification of any area of
care below the predetermined standard of the criteria can be made. The results can then be
used to develop an action plan ie what needs to be done, how it needs to be done, who is
going to do it and when is it going to be done.
5. Identify need for change/Implementing change

The audit cycle is now almost complete, but without re-evaluating the care the
practice is giving it is impossible to see if recommendations have been implemented and the
level of care improved.

Nursing Audit Model:

Nursing audit model consists of three aspects.

Outcome/effectiveness refers to an end result, effect or benefits for population achieved in

relation to the stated objectives.

Activities are the goal directed transaction between provider and recipient. The activities may
pertain to diagnostic nursing, medical, rehabilitation, promotive and preventive purposes.

Resources are the human and material that are needed to carry out desired health care.

Cost refers to the expenditure occurred in the resources available. Relationship between
outcome, activities and resources may be clarified from the diagram given below:

Relationship between Objectives & outcomes

Outcome Alteration in the health status of consumer

Activities
Diagnostic nursing
Medical
Rehabilitative
Promotive
preventive

Doctors
Technician
Nurses and auxiliaries

Human and material resources

 Mr. Channabasappa. K.M

Conducting an audit:

The process of implementing an audit has both developmental and organizational

implications. It is development in that the people who conduct an audit and those whose
actions are being audited can learn from the feedback derived from the audit.

It has organizational implications since the audit may reveal differences in policies,
procedures, rules or methods of operations used to support patients care.

It is important that everyone participating in the audit process be informed about the
procedure being used. So that input and learning can be part of process.

Audit is a procedure that is conducted by specified people. But it measures the effects
of nursing actions in general and every attempt should be made to ensure that the feed back
from auditing with relevant.

APPROACHES TO NURSING AUDIT:

1. The Phaneuf nursing audit:

This was developed by Maria Phaneuf in the mid 1970s.it is an audit of nursing care
taken from the patient‘s notes.

The first part of the audit consists of patients detail and the second part is the
evaluation of patient care. The criteria‘s are evaluated using yes/no certain categories and
scores accordingly. To arrive at the final score the total of the individual component scores is
multiplied by the value of the does not apply scores

Score Quality of care

0-40 Unsafe

41-80 Poor

81-120 Incomplete

121-160 Good

161-200 Excellent

Scoring method:

This tool is often criticized as that is conversely documents are that is never given to
the patients and frequently given care have documented. It has the advantage that it is quick
in evaluating quality, simple and comprehensive familiarization and training for assessors.
2. Audit tool by Joint Commission for Accreditation of Hospitals (JCAH)

This tool utilizes criteria for outcome 24hrs prior. to discharge. Patient charts are
reviewed according to the outcome criteria after the patients are discharged. The review
criteria are stated in terms of expected outcome that should have occurred 24 hours prior to
discharge. Complications are indications that these expected outcomes were not met. If
complications occur, then the committee tries to find out why they have occurred.
Assessment, therapy and other procedures are evaluated to see if they were done as per the
standards for prevention of complications. This evaluation indicates weather the complication
would have been prevented and whether they were detected and managed appropriately

3. Blue cross nursing audit method:

This nursing audit method was designed by the associated hospital service of New
York called as blue cross. A list of 7 functions with this components and descriptive
statements was developed and this could be used by any hospital to evaluate the nursing care.

I – Application and execution of physician legal order

1. Medical diagnosis is complete.

2. orders complete
3. orders current
4. orders promptly executed
5. evidence that nurses understand cause and effects
6. evidence that nurses look medical history into account

II- Observation of symptoms and reactions related to cause of design in general

1. R/T the course of disease in the patients

2. Related complications due to therapy
3. vital signs
4. Patients to his conditions
5. Patients to his course of disease

III- Supervision of the patients

1. Evidence that initial nursing diagnosis was made

2. Safety of patients
3. Security of patient
4. Adaptation
5. Continuing assessment of patients condition and capacity
6. Nursing plans changed in accordance with assessment
7. Interaction with family and others.

IV- Supervision of those participating in care

1. Care taught to patients, family or other nursing personnel

 Mr. Channabasappa. K.M

2. Physical, emotional, mental capacity to learn considered

3. Continuity of supervision to those taught support of those guiding care

V- Recording and reporting

1. Facts on which further care depended were recorded

2. Essential facts reported to physicians
3. Reporting of facts
4. Patient or family alerted to report to physicians
5. Record permitted continuity of intramural and extramural care

VI- Application and execution of nursing procedure and techniques

1. Administration and supervision of medication

2. Personal care
3. Nutrition
4. Fluid balance
5. Rest or sleep
6. Physical activity
7. Rehabilitation
8. Prevention of complication and infections

VII- Promotion of physical and emotional health by direction and teaching:

1. Plans for medical emergency evident

2. Emotional support to patients and family
3. Teaching preventive health care
4. Analysis of an audit result
The process of evaluation begins with analyzing the audit findings. For example, if
non compliance in a given area is demonstrated, the resources for it should be
investigated. The reason may be multiple like 1) charting was inadequate 2) staff turn
over temporarily influenced quality of care.

The analysis of audit result is usually conducted by a committee. The purpose of an

audit committee is to review the data in terms of changes in current practice that could be
made to improve care.

4. Goldstone Ball and Collier’s Monitor (1989): process monitoring

It is developed by Goldstone Ball and Collier (1989). It is centrally organized

method of quality assurance which looks at the process of nursing care along with
management of ward and environment. It is an indication of nursing quality based on
information gathered periodically at ward level. It is based on nursing process and can be
applied concurrently.

Monitor assesses quality of nursing in relation to the following areas of

care. Planning and assessment

 Physical care – non physical care

Evaluation of care

The patients in ward are classified according to categories of dependency ranging

from category 1- requiring minimum nursing care to category 4 – requiring intensive nursing
care.

3 patients are then randomly selected from each category and their care is scored either from
observations checking the nursing records or talking with patients or nurses. Following data
collection the assessors scores the results on a percentage basis, write a report, feed back
results to staff at ward level and agree action plans.

Limitation: Does not include all aspect of quality in nursing care and focuses on process
rather than structure or outcome.

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 patients 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. Examples 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 focuses 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.
 Mr. Channabasappa. K.M

Difference between Audit and research

Audit Research
Is not randomized May be randomized
Compares actual performance against Identifies the best approach, and thus the
standards sets the standards
Conducted by those providing the service Not necessarily provided by those providing
the service
Usually led by service providers Usually initiated by researchers
Does not involve investigation of new Involves comparators between new
treatments, but evaluates the use of current treatments and placebos
treatments
Involves review of records by those Requires access by those not normally
entitled to access them entitled to access them
Ethical consent not normally required Must have ethical consent
Results usually not transferable Results may be generalisable
Hypothesis used to generate the standard Testable hypothesis generated

Compares performance against the Presents clear conclusions

standard

Advantages of Nursing Audit:

1. Can be used as a method of measurement in all areas of nursing.

2. Seven functions are easily understood,
3. Scoring system is fairly simple,
4. Results easily understood,
5. Assesses the work of all those involved in recording care,
6. May be a useful tool as part of a quality assurance programme in areas where accurate
records of care are kept.

Disadvantages of the Nursing Audit:

1. Appraises the outcomes of the nursing process, so it is not so useful in areas where the
nursing process has not been implemented,
2. Many of the components overlap making analysis difficult,
3. Is time consuming,
4. requires a team of trained auditors,
5. Deals with a large amount of information,
6. Only evaluates record keeping. It only serves to improve documentation, not nursing
care
Summary

Nursing audit is an evaluation of nursing service. Purpose of nursing audit is evaluating

nursing care plan methods of nursing audit are retrospective, concurrent and peer review
methods of nursing audit methods to develop criteria, audit cycle nursing standards
advantages of nursing audit. Disadvantage of nursing audit is audit committee steps to
problem solving process in planning care are collects a patient data in a systematic manner
states nursing diagnosis plans health teaching for patients evaluates the plan of care

Conclusion
A professional concerns for the quality of its service constitute the heart of its
responsibity to the public. An audit helps to ensure that quality of nursing care desired and
feasible is achieved. This concept is often referred to as quality assurance

Bibliography

1) B.T.Basavantappa. ―NURSING ADMINISTRATION‖ 1st edition, Jaypee

brothers publication, 2003. page. no 161-164, 435-438
2) Carol Taylor ―FUNDAMENTAL OF NURSING THE ART AND SCIENCE OF
NURSING CARE‖ 5th edition Lippincott Williams, Wilkms publication 2005,
page no 331
3) Kozier Barbar. ―FUNDAMENTAL OF NURSING CONCEPTS, PROCESS
AND PRACTISE‖ 7th edition Darling Kindersley publication 2006. Page no
361
4) Potter and Perry ―FUNDAMENTAL OF NURSING‖ 6th edition, Mosby
publication, 2005, page no. 481
5) Sr Nancy ―PRINCIPLES AND PRACTICE OF NURSING‖ 2nd volume, 4th
edition, N.R.Brother‘s publication, 2005, page no 570

6) Kamal S Jogelkar. Hospital word management; professional adjustments and

trends in nursing. Mumbai; Vora medical- publications : 1990.
7) Web site http://www.atcpr.gov/audit
 Mr. Channabasappa. K.M

9. PERFORMANCE APPRAISAL

INTRODUCTION

A continual and troublesome question facing nurse managers today is why some
employees perform better than others. Making decisions about who performs what tasks in a
particular manner without first considering individual behaviour can lead to irreversible long
term problems. Each employee is different in many respects. A manager needs to ask how
such differences influence the behaviour and performance of the job requirements. Ideally,
the manager performs this assessment when the new employee is hired. In reality, however,
many employees are placed in positions without the managers having adequate knowledge of
their abilities and / or interests. This often results in problems with employee performance, as
well as conflict between employees and managers.

MEANING

Performance appraisal means the systematic evaluation of the performance of an

expert or his immediate superior.

Performance appraisal is a method of evaluating the behavior of employees in the

work spot, normally including both the quantitative and qualitative aspects of job
performance. Performance here refers to the degree of accomplishment of the tasks that make
up an individual's job. It indicates how well an individual is fulfilling the job demands. Often
the term is confused with effort, but performance is always measured in terms of results and
not efforts.

The performance appraisal process includes day-to-day manager-employee

interactions (coaching, counseling, dealing with policy/procedure violations, and
disciplining); written documentation (making notes about an employee's behavior,
completing the performance appraisal form); the formal appraisal interview; and follow-up
sessions that may involve coaching and/or discipline when needed.

DEFINITION

Edwin b flippo, ―performance appraisal is a systematic, periodic and so far as

humanly possible, an impartial rating of an employee‘s excellence in matters excellence in
matters pertaining to his present job and to his potentialities for a better job‖

The performance of an employee is compared with the job standards. The job
standards are already fixed by the management for an effective appraisal.

According to scott, clothier and spriegal, ―performance appraisal is a record of

progress for apprentices and regular employees, as a guide in making promotions, transfer or
demotions, as a guide in making lists for bonus distribution, for seniority consideration and
for rates of pay, as an instrument for discovering hidden genius, and as a source of
information that makes conferences with employees helpful‖.
OBJECTIVES OF APPRAISAL.

1. To determine the effectiveness of employees on their present jobs so as to decide their

benefits.
2. To identify the shortcomings of employees so as to overcome them through systematic
guidance and training.
3. To find out their potential for promotion and advancement.

PURPOSES AND BENIFITS

Performance appraisal can serve many purposes and has several benefits. Among them are:

1. To provide backup data for management decisions concerning salary standards, merit
increases, selection of qualified individuals for hiring, promotion or transfer, and
demotion or termination of unsatisfactory employees.

2. To serve as a check on hiring and recruiting practices and as validation of

employment tests.

3. To motivate employees by providing feedback about their work.

4. To discover the aspirations of employees and to reconcile them with the goals of the
organization,

5. To provide employees with recognition for accomplishments,

6. To improve communication between supervisor and employee, and to reach an

understanding on the objectives of the job,

7. To help supervisors observe their subordinates more closely, to so a better coaching

job, and to give supervisors a stronger part to play in personnel management and
employee development,

8. To establish standards of job performance.

9. To improve organizational development by identifying training and development

needs to employees and designing objectives for training programmers based on those
needs,

10. To earmark candidates for supervisory and management developments and

11. To help the organization determine if it is meeting its goals.

IMPORTANCE

Now a day, the management uses performance appraisal as a tool. The scope of
performance appraisal is not limited to pay fixation and is enlarged to include many
decisions.

1. Performance appraisal helps the management to take decision about the salary
increase of an employee.
 Mr. Channabasappa. K.M

2. The continuous evaluation of an employee helps in improving the quality of an

employee in job performance.
3. The Performance appraisal brings out the facilities available to an employee, when the
management is prepared to provide adequate facilities for effective performance.
4. It minimizes the communication gap between the employer and employee.
5. Promotion is given to an employee on the basis of performance appraisal.
6. The training needs of an employee can be identified through performance appraisal.
7. The decision for discharging an employee from the job is also taken on the basis of
performance appraisal.
8. Performance appraisal is used to transfer a person who is misfit for a job to the right
placement.
9. The grievances of an employee are eliminated through performance appraisal.
10. The job satisfaction of an employee increases morale. This job satisfaction is achieved
through performance appraisal.
11. It helps to improve the employer and employee relationship.

CONCEPT OF PERFORMANCE APPRAISAL

1. The appraisal should be in writing and carried at least once a year.

2. The performance appraisal information should be shared with the employee.
3. The employee should have the opportunity to respond in writing to the appraisal.
4. Employees should have a mechanism to appeal the results of the performance
appraisal.
5. The manager should have adequate opportunity to observe the employees job
performance during the course of the evaluation period.
6. Anecdotal notes on the employee‘s performance should be kept during the entire
evaluation period.
7. Evaluator should be trained to carry out the performance appraisal process.
8. As for as possible, the performance appraisal should focus on employee behavior and
results rather than on personal traits or characteristics.

CHARECTERISTICS AND OBSTACLES

The following characteristics are essential elements of effective performance appraisal:

1. The philosophy, purpose, and objectives of the organization are clearly stated so that
performance appraisal tools can be designed to reflect these.

2. The purposes of performance appraisal are identified, communicated, and understood.

3. Job descriptions are written in such a manner that standards of job performance can be
identified for each job.

4. The appraisal tool used is suited to the purposes for which it will be utilized and is
accompanied by clear instructions for its use.

5. Evaluators are trained in the use of the tool.

6. The performance appraisal procedure is delineated, communicated, and understood.

 7. Plans for policing the appraisal procedure and evaluation appraisal tools are
developed and implemented.

8. Performance appraisal has the full support of top management.

9. Performance appraisal is considered to be fair and productive by all who participate in

it.

The principal obstacles to effective performance appraisal are:

1. Lack of support from top management.

2. Resistance on the part of evaluators because:

a. Performance appraisal demands too much of supervisors efforts in terms of time,

paperwork, and periodic observation of subordinates performance.

b. Supervisors are reluctant to play god by judging others.

c. Supervisors do not fully understood the purpose and procedures of performance

appraisal.

d. Supervisors lack skills in appraisal techniques.

e. Performance appraisal is not perceived as being productive.

3. Evaluation biases and rating errors, which result in unreliable and invalid ratings.

4. Lack of clear, objective standards of performance.

5. Failure to communicate purposes and results of performance appraisal to employees.

6. Lack of a suitable appraisal tool.

7. Failure to police the appraisal procedure effectively.

PRINCIPLES OF PERFORMANCE APPRAISAL

1. Single employee is rated by two ratters. Then, the comparison is made to get accurate
rating.
2. Continuous and personal observation of an employee is essential to make effective
performance appraisal.
3. The rating should be done by an immediate superior of any subordinate in an
organization.
4. A separate department may be created for effective performance appraisal.
5. The rating is conveyed to the concerned employee. It helps in several ways. The
employee can understand the position where he stands and where he should go.
6. The plus points of an employee should be recognized. At the same time, the minus
points should not be highlighted too much, but they may be hinted to him.
7. The management should create confidence in the minds of employees.
8. The standard for each job should be determined by the management.
 Mr. Channabasappa. K.M

9. Separate printed forms should be used for performance appraisal to each job
according to the nature of the job.

KINDS OF PERFORMANCE APPRAISAL

There are many kinds of performance appraisal available. But the management wants
to adopt only one of the types of performance appraisal. The appraisal is done adopting any
one of the two approaches. These two approaches are traits and results. The traits approach
refers to appraising the employee on the basis of his attitudes. The result approach refers to
appraising the employee on the basis of results of his accomplishments of a job.

1. Ranking method

This method is very old and simple form of performance appraisal. An employee is
ranked one against the other in the working group under this method.

Example: if there are ten workers in the working group, the most efficient worker is
ranked as number one and the least efficient worker is ranked as number ten.

Advantages

a. Each employee or worker can be compared with the other person.

b. A small organization can get maximum benefits through the ranking method.

Disadvantages

a. A big organization is not able to get sizable benefits from the ranking method.
b. Ranking method does not evaluate the individuality of an employee.
c. It lags objectivity in the assessment of employees.

2. Paired Comparison Method

This method is a part of ranking method. Paired comparison method has been developed
to be used in a big organization. Each employee is compared with other employees taking
only one at a time. The evaluator compares two employees and puts a tick mark against
an employee whom he considers a better employee. In the same way, an individual is
compared with all other existing employees. Finally an employee who gets maximum
ticks for being a better employee is considering the best employee.

Advantages
a. This method is suitable for big organizations.
b. Individual traits are evaluated under this method.

Disadvantages

a. The understanding of this method is difficult one.

b. It involves considerable time.

3. Forced distribution method

 A method which forces the rater to distribute the ratings of the overall performance of an
employee is known as forced distribution method. Group wise rating is done under this
method. This method is suitable to large organizations, but the individual traits could not
be appraised under this method.
Example: a group of workers doing the same job would fall into the same group as
superior, at and above average, below average and poor. The rator rates 15% of the
workers as superior, 35% of the workers as at and above average, 35% of workers as
below average and 15% of workers as poor.

4. Grading
Certain categories of abilities or performance of employees are defined well in advance to
fall in certain grades under this method. Such grades are very good, good, average, poor
and very poor. Here the individual traits and characteristics are identified.
5. Checklist
The appraisal of the ability of an employee through getting answers for a number of
questions is called the method of check list. These questions are related to the behaviour
of an employee. The evaluation is done by a separate department, but the duty of
collection of checklist answers is given to a person who is designated as a rator. The rator
indicates the answers of an employee against each question by putting a tick mark. There
are two columns provided to each question as yes or no.
A model check list is given below.
A. Is the employee satisfied with the job? Yes No
B. Does he finish the job accurately? Yes No
C. Does he respect the superiors? Yes No
D. Is he ready to accept responsibilities? Yes No
E. Does he obey the orders? Yes No

6. Forced choice method

A series of groups of statements are prepared positively or negatively under this method,
both these statements describe the characteristics of an employee, but the rator is forced
to tick any one of the statements either out of positive statements or out of negative
statements. The degree of description of the characteristics of an employee varies from
one statement to another.
The following are the positive statements;
a. The employee completes the job in time usually.
b. The employee has the ability to complete the job and complete the job as and when
there is a need.

The negative statements are also prepared. The final rating is done on the basis of all such
statements. But the ratter does not know the statements which are for final rating.

7. Critical Incident method

The performance appraisal of an employee is done on the basis of the incidents occurred
really to the concerned employee. Some incidents occurred due to the inability of the
employee, but the rating is done on all the events occurred in a particular period.
 Mr. Channabasappa. K.M

Some of the events or incidents are given below.

a. Refused to co-operate with other employees
b. Unwilling to attend further training
c. Got angry over work or with subordinates
d. Suggested a change in the method of production
e. Suggested a procedure to improve the quality of goods
f. Suggestion of a method to avoid or minimize wastage, spoilage and scrap.
g. Refused to obey orders
h. Refused to follow clear cut instructions
8. Field review method
An employee‘s performance is appraised through an interview between the rator and the
immediate superior or superior of a concerned employee. The rator asks the superiors
questions about the performance of an employee, the personnel department prepares a
detail report on the basis of this collected information. A copy of this report is placed in
the personnel file of the concerned employee after getting approval from the superior.
The success of this type of appraisal method is based on the competence of the
interviewer.
9. Essay evaluation
With easy evaluation technique the nurse manager is required to describe the employee‘s
performance over the entire evaluation period by writing a narrative detailing the strength
and weaknesses of the appraise. If done correctly this approach can provide a good deal
of valuable data for discussion in the appraisal interview.

COMPONENTS TO BE EVALUATED

Nurse engages in a variety of job related activities to reflect the multi dimensional
nature of the job. The performance appraisal form usually acquires a nurse manager to rate
several different performance dimension.

The components are

a. Use of nursing process

b. Professionalism
c. Maintaining safety
d. Continuing education
e. Initiative character.

STEPS FOR PEER REVIEW

1. The employee selects peers to conduct the evaluation. Usually two to four peers are
identified through a pre determined process.
2. The employee submits self evaluation port folio. The port folio might describe how he
or she met objectives and/or pre determined standards during the past evaluation
cycle. Supporting materials are included.
3. The peer evaluates the employee. This may be done individually or in a group. The
individuals are group then submit a written evaluation to the manager.
4. Manager and employee meet to discuss the evaluation. The manager‘s evaluation is
included and objectives for the coming evaluation cycle are finalized.
APPRAISAL INTERVIEW

Once the manager completes an accurate evaluation of performance, he/she should

arrange an appraisal interview. The appraisal interview is the first step in employee
development.

1. They provide feedback to an employee which enables him to improve his

performance in future.
2. They help management to ascertain and assess the training needs of individual
employees.
3. They enable management to know the problems and difficulties experienced by
subordinates in discharging their responsibilities and also their suggestions for
removing these difficulties.

Types of appraisal interview

1. Tell and sell interview

It is based on the assumption that employees have some deficiencies but they need to
be convinced about these deficiencies. The purpose of this interview is
a. To let the employee to know how well he is doing.
b. To draw up a plan of improvement for him.
c. To gain the employees acceptance of the evaluation.
2. Tell and listen interview.
The objective of this interview is to communicate the evaluation to the employee and
then listen sympathetically to his reactions. It consists of two parts
The first part covers the strong and week points of the employee‘s performance.
The second part is used to explore thoroughly the employee‘s feelings about the
evaluation.
3. Problem solving interview.
In this interview the aim is not appraisal but development of an employee. Therefore,
the interviewer takes himself out of his usual role as a judge and puts himself in the
role of a helper. He does not communicate the evaluation to the employee. He does not
communicate the evaluation to the employee. He does not point out the areas of
improvement; rather he stimulates the employee into thinking about improving his own
performance. He does not supply remedies or solutions but considers all ideas on job
improvement suggested by the employee. This he does by skilful questions
Example. Can you plan to deal with emergencies?

Key behaviours for an appraisal interview

1. Put the employee at ease

2. Clearly state the purpose of the appraisal interview
3. Go through the ratings one by one with the employee.
4. Draw out the employee reactions to the ratings.
5. Decide on specific ways in which performance areas can be strengthened.
6. Set a follow up date.
7. Express confidence in the employee.
 Mr. Channabasappa. K.M

METHODS OF APPRAISIGN PERFORMANCE

There is no one performance appraisal system, which will work equally well in all
work patterns, a number of techniques are available to managers and occasionally more than
one method is used. An organisation must decide whether it wants to measure in terms of
performance and what method of measurement works best. It can then experiment with that
method.

Several common methods of performance appraisal including their advantages and

disadvantages are described next.

When using the easy technique the evaluator writes a paragraph or more regarding a
particular employee‘s strengths and potential. Essay content should reflect the employee‘s
performance in relation to his job description. It may also include information about personal
characteristics which are pertinent to the employees job, such as the ability to work well with
others or motivation for professional growth. Well done essays have the advantage of
providing an in-depth analysis of performance. Essays are also especially suitable for
identifying training and development needs and problem areas.

1. The disadvantages of essays are

2. They are time consuming

3. They tend to vary greatly in length and content

4. They are difficult to combine or compare since different essays cover different
aspects of performance.

The graphic rating scale requires the rater to assign a numerical value or letter grade to
each dimensions of performance to indicate judgements ranging from superior to
unsatisfactory. The advantages of the graphic rating scale are that it is generally more
consistence and reliable than the essay, it is usually acceptable to raters, and it is easy to
construct. The graphic rating scales primary disadvantages are that it does not yield the depth
of information attained in the essay approach, and its validity can be challenged unless the
factors to be rayed are chosen carefully and comprehensively.

The critical incidence technique operated by supervisors collecting and recording

instances of their subordinates are performing in ways that are of critical importance to the
success or failure of the job. These critical incidents are reviewed with the employees during
a scheduled feedback interview. The advantage of the critical incident technique is that the
evaluator rates performance rather than personality traits. In addition, this method is useful in
helping supervisors do a better coaching job and communicate performance appraisal
information to subordinates. The disadvantage of the critical incident technique is that if
requires the supervisors to write down incidents daily, or at least weekly which can be very
time consuming and sometimes difficult to accomplish.
LIMITATIONS OF PERFORMANCE APPRAISAL

The following are the limitations of performance appraisal:

1. The performance appraisal methods are unreliable.

2. If an employee is well known to an employer, the performance appraisal may not be
correct.
3. The inability of supervision to appraise an employee does not bring out the accurate
performance appraisal.
4. Some qualities of an employee cannot be easily appraised through any performance
appraisal method.
5. A supervisor may appraise an employee to be good to avoid incurring his displeasure.
6. Uniform standards are not followed by the supervisors in the performance appraisal.

POTENTIAL APPRAISAL PROBLEMS.

1. Leniency error: the tendency of a manager to over rate staff performance.

2. Recency error: the tendency of a manager to rate an employee based on recent events
rather than over the entire evaluation period.
3. Halo error: the failure to differentiate among various performance dimensions when
evaluating.
4. Ambiguous evaluation standards problem: the tendency of evaluators to place
differing connotations on rating scale words
5. Written comments problem: the tendency of evaluators does not include written
comments on appraisal forms.

CONCLUSION

A member in an organization expresses an opinion or views about others. The opinion

may be about the way of mixing with others, way of working, character, etc. These opinions
become a basis for the appraisal of an employee. A superior has some opinion about his sub-
ordinates for determining many things like promotions, transfer, pay fixation, etc.

BIBLIOGRAPHY
1. Ruth M Tappen. Nursing leadership and management. 3rd ed. Philadelphia: FA Davis
Company; 1989.
2. BT Basavantappa. Nursing administration. 2nd edition. New Delhi: jaypee publication;
2008.
3. Ann Marriner Tomey. Guide to nursing management. 4th ed. St Luis: Mosby year
book; 1992.
4. Mamoria CB, Gankar SV. Personnel management. 25th ed. Mumbai: Himalaya
Publishing House; 1994.
Janice RE, Celia LH. Managing and co-ordinating nursing care. 4th ed. Philadelphia:
Lippincott Williams and Wilkins; 2005.
 Mr. Channabasappa. K.M

10. SUPERVISION AND MANAGEMENT

Introduction

Supervision is one of the important functions in an organization. In every organization

there is a provision for supervision. Supervision means overseeing the employees at work. So
in this session we will see in detail regarding supervision and supervisor roles in managing
people.

Terminologies:

What is "Management"?

Traditional Interpretation
There are a variety of views about this term. Traditionally, the term "management"
refers to the set of activities, and often the group of people, involved in four general
functions, including planning, organizing, leading and coordinating activities. (Note that the
four functions recur throughout the organization and are highly integrated.)

Another Interpretation
Some writers, teachers and practitioners assert that the above view is rather outmoded
and that management needs to focus more on leadership skills, e.g., establishing vision and
goals, communicating the vision and goals, and guiding others to accomplish them. They also
assert that leadership must be more facilitative, participative and empowering in how visions
and goals are established and carried out. Some people assert that this really isn't a change in
the management functions, rather it's re-emphasizing certain aspects of management.

What Do Managers Do?

Both of the above interpretations acknowledge the major functions of planning,

organizing, leading and coordinating activities -- they put different emphasis and suggest
different natures of activities in the following four major functions.

What is "Supervision"?

There are several interpretations of the term "supervision", but typically supervision is
the activity carried out by supervisors to oversee the productivity and progress of employees
who report directly to the supervisors. For example, first-level supervisors supervise entry-
level employees. Depending on the size of the organization, middle-managers supervise first-
level supervisors, chief executives supervise middle-managers, etc. Supervision is a
management activity and supervisors have a management role in the organization.
Definition

1. It is been defined as the authoritative direction of the work of one‘s subordinates.

2. Supervision is defined as ― guiding and directing efforts of the employees and other
resourses to accomplish stated work outputs‖
----- Terry and Franklin.
 3. Supervision is defined as a process by which workers are helped by a designated staff
member to learn according to their needs, to make the best use of their knowledge and
skills and to improve their abilities so that they do their jobs more effectively and with
increasing satisfaction to themselves and the agency.
----- Williamson

Objectives of supervision

1. Help the staff to do their job skillfully and effectively to give maximum output with
minimum resources- cost effectiveness.
2. Help the staff develop the individual capacity to the fullest extent with a view to
channelize the same in favor of work.
3. Guide and /or assist in meeting predetermined work objectives or targets. Ex in
nursing preventive, promotive, curative and rehabilitative care of the people.
4. Help to promote effectiveness of the subordinates/ staffs. Ensuring that the
subordinate staff or supervise does what he/she supposed to do.
5. Help to motivate subordinates to maintain high morale, i.e. promotion of motivation
and morale among all the nursing staff.
6. Help the members of the team to recognize problems, identify solution and to take
action.
7. Help to develop team spirit and promote team work for effective functioning.
8. Help to improve the attitudes of the members towards the work or program i.e.
bridging the gap between the worker‘s personal goal and the organizational goal by
providing guidance in the right direction.

Factors of effective Supervision

Following factors are responsible for effective supervision

 Human relations skills

 Technical and managerial knowledge
 Leadership position
 Improved upward relation
 Relief from non supervisory duties
 General and loose supervision

Human relations skills

Supervision is mainly concerned with instructing, guiding and inspiring human beings
towards greater performance. For purpose of direction, the supervisor has to rely on
leadership, counseling, communication and other determinants of human relation.

Technical and managerial knowledge

Guidance implies a complete understanding of all work problems, for which the supervisor
should have good knowledge about technical aspect of job and also the managerial aspects.
 Mr. Channabasappa. K.M

Leadership position

The authority of supervisors must be made commensurate with their duty so as to

make the job of supervision a satisfying, rewarding and challenging one. So, the supervisors
are to be vested with necessary authority for enabling them to exercise leadership over the
group and influence the employees.

Improved upward relation

To ensure good quality of supervision, the supervisor‘s upward relations must be well
established, which means to say that supervisors should be regularly allowed to present their
views and suggestions to top executives in regard to the personnel and their work
performance, for which, the top management must pay adequate attention and thought on
supervisory jobs to ensure good quality supervisions.

Relief from non supervisory duties

To make the supervisory duties purposeful, the supervisors are to be relieved of many
routine activities that divert their attention from the real job.

General and loose supervision

According to some experience, the general and loose supervision is more productive
than close supervision. Here the leader must allow freedom and initiatives to his followers for
pursuing a common course of action.

Functions of Supervision

 Orientation of newly posted staff

Transfers and postings, or new postings of personnel are common in all organization.
All new comers should be informed about their functions, the method that they should
use, the personnel with whom they will work and the community wherein they will
work, that needs an orientation.

 Assessment of the workload of individuals and groups

It must be ensured that the workload is within the physical and mental competence of
a worker. Otherwise job should not be assigned to them. A supervisor should not
expect from workers a level of effort that is beyond them.

 Arranging for the flow of materials

A supervisor must find out the needs for supplies and equipment and arrange for their
supply in good time.

 Coordination of the efforts

A supervisor coordinates the work of his/her workers and agencies and promotes team
work.
  Promotion of effectiveness of workers
This may be done through performance evaluation and introducing concepts of the
staff development.

 Promotion of social contact within the work team.

Social contacts help to bring the staff together and increase group cohesiveness. A
good supervisor should provide opportunity.

 Helping individuals to cope with their personal problems

Personal problems are likely to come up while dealing with workers. Those may be
the supervisors‘ duties but a sympathetic understanding on his part improves the
individual morale.

 Facilitating the flow of communication

A free flow of communication among members is necessary for team work.
Supervisor should encourage free communication among peer, team members.

 Raising the level of motivation

All good work should be given due credit through recognition. Supervisor must
provide opportunities for growth and achievements.

 Establishment of control
Supervision is a control measure as well as leadership technique. The supervisor must
know is being done and with what effectiveness. A number of techniques such as
observation and record review can be used for this purpose.

 Development of confidence
Supervisors must know the background of workers and try to develop mutual
confidence. There is a need to combine understanding with firmness and to take a
personal interest without sacrificing impartiality or discipline.

 Emphasis on achievement
It has been proved that the development of a smooth work routine and the
improvement of human relations without corresponding emphasis on goal
achievement are not likely to increase productivity.

 Record keeping
The supervisor should maintain good record system.

Principles of Supervision

 Supervision should not be overburned to any individual or group.

 Supervision causing unreasonable pressure for achievement results in low
performance and low confidence in the supervisor.
 Supervise diagnosis, do not overestimate his understanding and memory.
 Mr. Channabasappa. K.M

 Human behavior with due consideration to human weakness. This should be kept in
minds of supervisors.
 Supervisors should create atmosphere of cordiality and mutual trust.
 Supervision should be planned and adopted to the changing conditions. It calls for
good planning and organization.
 Supervisors must possess sound professional knowledge.
 Supervision must be exercised without giving the subordinate a sense that they are
being supervised.
 Supervision strives to make the unit a good learning situation. It should be a teaching-
learning process.
 Supervision should foster the ability of each staff member to think and act for
himself/herself.
 Supervision should encourage workers‘ participation in decision making.
 Supervision needs good communication
 Supervision should have strength to influence downwards depends on capacity to
influence upwards.
 Supervision is a process of cooperation and coordination.
 Supervision should create suitable climate for productive work.
 Supervision should give autonomy to workers depending from personality,
competence and characteristics.
 Supervision should respect the personality of the staff.
 Supervision should stimulate the workers/ staff ambitions to grow in effectiveness.
 Supervision should focus on continued staff growth and development.
 Supervision is responsible for checking and guidance.
 Good leadership is part of good supervision.

Purpose of supervision:
Changing concepts of supervision

Today, there is more democracy in supervision. Educators think of supervision either

as guidance or a working together for common goals. The nature and scope of supervision
varies with the kind of the work to be supervised, the type of the people to be supervised, the
extent of the supervisor‘s responsibility and the level of supervision.

Conceptual model of supervision:

Need for supervision

 The effectiveness of the workers depends on the supervision they reserve.
 Quality of work is directly related to the degree of supervision. High degree
supervision improves work, poor supervision leads to poor work.

Stages and activities of supervisory technique

There are 3 stages

 Stage one: Preparation for supervision

 Stage two: Supervision
 Stage three: Follow up of supervision

Stage one: preparation for supervision

For successful supervision preparation is one of important stage. While getting prepared to
supervise the supervisor should focus on specific issues like efficacy of the services provided
to the patient.

- Relevant problems which may arise.

- The performance of individual members of staff.
- The effective utilization and management of limited resources covering 3 M‘s
--Manpower
 Mr. Channabasappa. K.M

--Money
--Material
- Study of documents such as hospital policy, routines, rules guidelines job
description etc in detail.
- Identification of the priorities for supervision such as priorities areas, activities
and tasks related to nursing care services in a hospital or in a community which
should be supervised. This will make supervision most effective.
- Preparation of a supervision schedule- it is essential that you prepare checklist for
observation in the wards in the institutional settings and for field visit in the
community settings. Prepare a planned schedule of visits on the basis of the
priority needs and content supervision as set out in the checklist.

Stage two: Supervision

After preparation is over the supervisor can begin his supervision work. In this stage the tools
which are to use may include

- Job description
- Task description
- Weekly time table
- Checklist and or rating scale for each task

As a supervisor the following activities are expected to perform in this stage

 Establish contracts
 To know about other members of the team providing comprehensive care to the
patient.
 Review the objectives, targets and norms
 Review the job description
 Observe the nursing staff‘s motivation
 Observe individual nursing staff carry out his/her tasks- her skills, attitude, utilization
of resources.
 Identify the gaps and needs for follow up action based on feedback.

Stage three: follow up of supervision

In this stage the supervisor should make a report on the observation made during supervision
which includes

o Organizing in-service training programme / CNE programme for the nursing

personnel
o Reorganization of time table / duty roster
o Initiating changes in logistic support or supply system.
o Initiating actions for organizing staff welfare activities
o Counseling and guidance regarding career development and professional growth.
Qualities of a good supervisor

According to Halsey a good supervisor must possess the following qualities

 Thoroughness
 Fairness
 Initiative
 Tact
 Enthusiasm
 Emotional control

Others

 Personal qualification
 Teaching ability
 General look
 Interpersonal and professional skills
 Professional and technical knowledge
 Attitude

Styles of supervision

There are two main styles

 Task centered: when the supervisor emphasizes the task more than the performer
whom she / he supervises. This type of supervisor probably believe that ends are more
important than the means
 Employee centered supervisor: such supervisor are people oriented. They believe that
a concern for workers/ staff, their need and welfare is very important. Therefore if the
employees are well taken acre they will be able to work well and be capable of taking
on responsibilities. However such a supervisory style at an extreme can also lead to
inefficiency if the subordinates take them as lenient persons.

Other styles of the supervisor

 An autocratic or critical supervisor who cannot tolerate any deviation from norms,
lack of quality in work, lack of discipline etc. the decisions are made by themselves.
 A benevolent supervisor who is very protective of his/ her subordinates, keep telling
them what they should do and what they should not, thus providing constant direction,
such supervisor are usually liked by the workers but are effective as long as they are
physically present as they tend to develop the subordinates as dependent followers.
 Democratic supervisor who believes in a style of ― let us agree on what we are to do‖
in dealing with the subordinates. Such supervisor provides guidance only when
requested by the subordinates. The subordinates with this type of supervisor tend to
develop confidence in their work. They are quite independent and cooperate with one
another and work together. The effectiveness of the style of supervisor depends on job
factors and personal factors.
The job factors include
- The complexity of the job
 Mr. Channabasappa. K.M

- The difficulty of the job

- The nature of the job
- The urgency of the task
- Consistency of the task
- Need for creativity or new idea.

The personal factors include

- Skills
- Knowledge
- Expertise and experience
- Attitude
- Independent decision making.

Types of Supervision

Generally there are two types of supervision

 Direct supervision
 Indirect supervision

 Direct supervision

This is done through face to face talk with the workers. This can be exercised at the
ward/ unit level in the hospital or PHC or subcenter of the community setting. The
following are the considerations which are essential for this type of supervision

o Do not loose temper or abuse

o Use democratic approach and avoid autocratic methods.
o Reprimand if necessary in private and do it promptly.
o Give workers a chance to reply.
o Do not talk too much and too fast.
o Be human in behavior
o Do not take it granted that the worker has understood everything told to him
o Do not give instructions in haphazard way.

 Indirect Supervision
It is done with the help of record and reports of the workers and through written
instructions or through some agency between the supervisor and supervisee. This
includes
o Ensuring that every worker is carrying out allotted work in accordance with the plan
of operation and with the prescribed methodology and in keeping pace with the time
as far as possible.
o Analyzing the monthly progress reports to know the inputs of efforts and the
achievements of the workers and their relations with each other.
o Analyzing what amount of work allotted for the month has been done with reasons
for non performance and providing suitable guidance for the same.
 o Providing support and guidance to all workers in implementation of various
activities.
o Analyzing the stage of program or job in each sector/ unit and village and to
suggest plan for future months on the above basis.
o Ensuring that the worker is utilizing his/her full capacity in the program. Ex how
many hours per day have been spent in the field or unit/ ward, and what efforts
have been done by him/ her during this time.

Types of supervision
i) Direct supervision and
ii) Indirect supervision.

Direct supervision Indirect supervision

It is done through face-to-face It is done with the help of record and reports of the
talk with the workers. This can be workers and through written instruction or through some
exercise in the ward or unit level agency between the supervisor and supervisee. This
in the hospital or PHC or includes:
subcentre of the community  Ensuring that every worker is carrying out
setting. The following are allotted work in accordance with the plan of
essential in direct supervision: operation and with the prescribed methodology
 Do not loose temper or and in keeping pace with the time as far as
abuse. possible.
 Use democratic approach  Analyzing the monthly progress reports to know
and avoid autocratic the input of efforts and achievement of the
methods. workers and their relations with each other.
 Reprimand if necessary in  Analyzing what amount of work allotted for the
private and do it properly. month has been done with reasons for non-
 Give workers a chance to performance and providing suitable guidance for
reply. the same.
 Do not talk too much and  Providing support and guidance to all the
too fast. workers in the implementation of various
 Be human in behaviour. activities.
 Do not take it granted that  Analyzing the stage of programme or job in each
the worker has understood sector or unit and village and to suggest plan for
everything told to him. future months on the above basis.
 Do not give instruction in  Ensuring the worker is utilizing his/her full
a haphazard way. capacity in the programme. How many hrs per
day have been spent in the field or unit/ward, and
what efforts have been done by him/her during
this time.
 Mr. Channabasappa. K.M

Method of supervision

Supervision is a cooperative process that has for its objective the improvement of nursing
service. To achieve these objectives, there are different methods of supervision which
include:

1. Technical vs creative supervision

2. Cooperative vs authoritarian supervision
3. Scientific vs intuitive supervision.

Technical vs creative supervision

Technical methods are some of the basic supervisory skills which need to be
trained. Group conferences, group discussions. Creative supervision provides
maximum adaptation to the situation. Ex instead of an orientation period of two weeks
for each new staff member, a variable plan in both contents and time according to the
needs of each individual should be formulated.

Cooperative vs Authoritarian supervision

In cooperative supervision there is a full participation of each member of the
group in planning, action and decision whereas in authoritarian supervision
responsibility centers entirely on the supervisor, with the staff following his/her
orders. Both are needed according to situation and circumstances.

Scientific vs Intuitive supervision

Scientific supervision relies on objective study and measurement than personal
judgment or opinion. Whereas intuitive supervision needs to maintain the
interpersonal relationship. The supervision needs a sensitive and intuitive reaction to
the emotional needs of another person.

Techniques of supervision

 Group conferences
 Individual conference
 Anecdotal records
 Initial conference
 Control of early experience
 Assistance with bed side care
 Reassurance
 Supervision of nursing procedures
 Incidental teaching

Tools for supervision

Checklist
Rating scale
Nursing rounds
Nurse‘s reports
Core skills in management & supervision

1. Problem Solving and Decision Making

2. Planning
3. Effective Delegation
4. Basics of Internal Communications
5. Meeting Management & Managing Yourself

1. Problem Solving and Decision Making

A. Define the problem

Defining complex problems:

Prioritize the problems:
Understand your role in the problem:

B. Look at potential causes for the problem

C. Identify alternatives for approaches to resolve the problem

D. Select an approach to resolve the problem

E. Plan the implementation of the best alternative (this is your action plan)

F. Monitor implementation of the plan

G. Verify if the problem has been resolved or not

2. Planning

a. Goals
Goals are specific accomplishments that must be accomplished in total, or in some
combination, in order to achieve some larger, overall result preferred from the system, for
example, the mission of an organization. (Going back to our reference to systems, goals are
outputs from the system.)

b. Strategies or Activities
These are the methods or processes required in total, or in some combination, to
achieve the goals. (Going back to our reference to systems, strategies are processes in the
system.)

c. Objectives
Objectives are specific accomplishments that must be accomplished in total, or in
some combination, to achieve the goals in the plan. Objectives are usually "milestones" along
the way when implementing the strategies.
 Mr. Channabasappa. K.M

d. Tasks
Particularly in small organizations, people are assigned various tasks required to
implement the plan. If the scope of the plan is very small, tasks and activities are often
essentially the same.

e. Resources (and Budgets)

Resources include the people, materials, technologies, money, etc., required to
implement the strategies or processes. The costs of these resources are often depicted in the
form of a budget. (Going back to our reference to systems, resources are input to the system.)

f. Phases in planning

- Reference Overall Singular Purpose ("Mission")

- Take Stock Outside and Inside the System
- Analyze the Situation
- Establish Goals
- Establish Strategies to Reach Goals
- Establish Objectives Along the Way to Achieving Goals
- Associate Responsibilities and Time Lines With Each Objective
- Write and Communicate a Plan Document
- Acknowledge and Celebrate Accomplishment of the Plan

g. Guidelines to Ensure Successful Planning and Implementation

A common failure in many kinds of planning is that the plan is never really implemented.
Instead, all focus is on writing a plan document. Too often, the plan sits collecting dust on a
shelf. Therefore, most of the following guidelines help to ensure that the planning process is
carried out completely and is implemented completely -- or, deviations from the intended
plan are recognized and managed accordingly.

 Involve the Right People in the Planning Process

 Write Down the Planning Information and Communicate it Widely
 Goals and Objectives Should Be SMARTER
 Build in Accountability (Regularly Review Who's Doing What and By When?)
 Note Deviations from the Plan and Replan Accordingly
 Evaluate Planning Process and the Plan
 Recurring Planning Process is at Least as Important as Plan Document
 Nature of the Process Should Be Compatible to Nature of Planners
 Critical -- But Frequently Missing Step -- Acknowledgement and Celebration of
Results

3. Effective Delegation

The hallmark of good supervision is effective delegation. Delegation is when

supervisors give responsibility and authority to subordinates to complete a task, and let the
subordinates figure out how the task can be accomplished. Effective delegation develops
people who are ultimately more fulfilled and productive. Managers become more fulfilled
and productive themselves as they learn to count on their staffs and are freed up to attend to
more strategic issues.

Delegation is often very difficult for new supervisors, particularly if they have had to
scramble to start the organization or start a major new product or service themselves. Many
managers want to remain comfortable, making the same decisions they have always made.
They believe they can do a better job themselves. They don't want to risk losing any of their
power and stature (ironically, they do lose these if they don't learn to delegate effectively).
Often, they don't want to risk giving authority to subordinates in case they fail and impair the
organization.

The following general steps to accomplish delegation:

-Delegate the whole task to one person

-Select the right person
- Clearly specify your preferred results
-Delegate responsibility and authority -- assign the task, not the method to
accomplish it
-Ask the employee to summarize back to you, their impressions of the project and the
results you prefer

-Get ongoing non-intrusive feedback about progress on the project

-Maintain open lines of communication

-If you're not satisfied with the progress, don't take the project back.

-Evaluate and reward performance

4. Basics of Internal Communications

Effective communications is the "life's blood" of an organization. Organizations that are

highly successful have strong communications. One of the first signs that an organization is
struggling is that communications have broken down. The following guidelines are very basic
in nature, but comprise the basics for ensuring strong ongoing, internal communications.

o Have all employees provide weekly written status reports to their supervisors
o Hold monthly meetings with all employees together
o Hold weekly or biweekly meetings with all employees together if the organization is
small (e.g., under 10 people); otherwise, with all managers together
Have supervisors meet with their direct reports in one-on-one meetings every month

5. Meeting Management & Managing yourself

 Opening Meetings
 Establishing Ground Rules for Meetings
 Mr. Channabasappa. K.M

 Time Management
 Evaluations of Meeting Process
 Evaluating the Overall Meeting
 Closing Meetings

Managing Yourself

 There are many sources of additional information and advice referenced at the end of
this section.

Role of New Manager or Supervisor of Often Very Stressful

The experience of a first-time supervisor or manager is often one of the most trying in
their career. They rarely have adequate training for the new management role -- they were
promoted because of their technical expertise, not because of their managerial expertise. They
suddenly have a wide range of policies and other regulations to apply to their subordinates.
Work is never "done". They must represent upper management to their subordinates, and
their subordinates to upper management. They're stuck in the middle. They can feel very
alone.

Guidelines to Manage Yourself

Everyone in management has gone through the transition from individual contributor
to manager. Each person finds their own way to "survive". The following guidelines will help
you keep your perspective and your health.

-Monitor your work hours

-Recognize your own signs of stress
-Get a mentor or a coach
-Learn to delegate
-Communicateas much as you can
-Recognize what's important from what's urgent -- fix the system, not the problem
-Recognize accomplishments

A narrative-based approach to supervision: the seven Cs:

One aim of supervision is to help people to find new versions of a situation which has
become stuck by asking questions which invite change. Palazzoli Selvini et al (1980)
suggest that supervisors should not give advice, offer solutions or make interpretations.
Educational supervision may, however, require a more directive approach such as asking
questions which help people think from new angles (Tomm, 1988). These techniques, and
ways of asking questions, have been formulated into core concepts (the ‗seven Cs‘,
adapted from Launer, 2006b), which illustrate how to put supervision into practice.

 Conversations
 Here the conversation itself is seen as the working tool. Effective conversations do not
simply describe people‘s view of reality, they create new understanding of it through
the opportunity for people to rethink and reconstruct their stories.
 Curiosity
Curiosity changes chat into a more substantial conversation in which the story about
patients, colleagues and oneself is developed. Supervisors need to pay close attention
to verbal and non-verbal language used, and their own responses and feelings (such as
criticism, boredom or anxiety). It is important to consciously take a neutral and non-
judgmental stance which allows us become curious about different positions others
might take, including the position of no change.
 Contexts
This includes the person‘s networks, his/ her sense of culture, faith, beliefs,
community, values, history and geography and how these may impinge on the
conversation. An important context is that of how power is understood. Who holds
the power and how is this seen by others? Who is asking for supervision and for what
purpose? The context helps the conversation come alive.
 Complexity
This involves thinking about things in a non-linear way, getting away from fixed ideas
of cause and effect, thinking about the interactions between people and the kind of
patterns which develop between people and events over time to produce a richer
description of the story.
 Creativity
Creativity means finding a way to create a story or account of reality which makes
better sense for people than the one they are going through. To do this involves using
oneself, intuition and sensitivity to fine-tune the conversation. It also implies the
creative process of jointly constructing a new version of the story.
 Caution
This consists of looking for cues from the supervisee to monitor his/her responses. It
involves working on the cusp between affirmation and perturbation in order to
challenge appropriately without being confrontational or too bland. Sometimes it is
appropriate to give straightforward advice (although you need to be aware of its
limitations).
 Care
Being respectful, considerate and attentive to patients, your supervisee and yourself
is important, as is ensuring that supervision and clinical activities are carried out
ethically.

The supervision process

The process of supervision gives an opportunity for supervisees to reconstruct their

view of a particular situation or issue through the supervisor asking questions to try to help
them see things from different perspectives. This is part of an iterative process which might
take place within one session or over a period of time. In order to help people come to their
own conclusions and solutions it is often better to withhold advice until towards the end of
 Mr. Channabasappa. K.M

the conversation. This does not mean that you should not tell a supervisee what to do,
especially within an urgent clinical setting.

Ten tips for managing people well

1. Acknowledge that managing people is different from your core technical skills, and
recognize that people management is essential to your own career growth. If he/she is not
good at it, work at getting better. Not only will he/she will be a better executive, but also a
better person.

2. Realize that the role of the manager is just that: a role. It sets you apart and requires to
make decisions and take responsibility. Being a great boss doesn't mean being your
subordinates' friend. It means providing direction and then doing everything that can make
sure tjat the subordinates are allowed to do their jobs.

3. Find the right distance to manage from. Micromanagers are too close; this lowers trust,
disempowers subordinates and destroys their motivation. Absentee managers are too far
away; they provide insufficient guidance, don't keep track of work being done, and aren't
there to listen and provide answers to questions that come up. The optimal distance is in
between. Provide direction and guidance, let your subordinates know you're keeping track
from your own vantage point, and check in with them periodically.

4. Make your subordinates' careers a priority. The better they do, the better you look;
becoming known as an incubator of talent makes you more valuable to your company. Ask
your subordinates what their career goals are, and tell them you'll do everything you can to
promote them, whether in your department or elsewhere. Then take action to make good on
that promise, like putting individuals on projects that will help them grow

5. Acknowledge, acknowledge, acknowledge. At a psychological level, people value

acknowledgement of their good work more than they value money (though it should never be
a substitute). Make acknowledgement a routine part of your communication with
subordinates; without acknowledgement, they have no way of knowing what they've done
right, which means your feedback is incomplete and misleadingly negative. Be accurate in
your acknowledgement; this gives weight to your praise. Frequent acknowledgement also
makes discussions easier when problems occur.

6. First coach, then counsel, finally discipline. Coaching is the proactive encouragement of
mutually agreed-upon, positive outcomes (see How to coach someone you manage). Do that
first. Counseling is close attention to a problem identified by you, with specific requests for
change. Do that if it becomes necessary. Discipline is punishment as an incentive for change
you've previously requested and not gotten, or as preparation for firing someone. Do that only
when you've done the other two first.

7. Document your work. Managers are accountable for their actions with respect to their
subordinates, and this is as it should be. It's important that you be able to show what you did
and when you did it. In good times, this will help demonstrate how well you did your job. In
bad times, it will protect you and/or your company.

8. Work by agreement. managers can't expect the subordinates to be on board with every
goal, but can and should expect them to abide by company decisions. Make agreements with
those who work for you. You can refer to those agreements if subordinates don't come
through. But that's actually less likely to happen if they've made explicit agreements with
you; when people have said out loud what they will do, the chances are higher that they will
carry out those actions.

9. Translate, don't channel. Passing on everything you get from above, without alteration,
isn't helpful. Recast and reframe direction from above so that subordinates are well-informed
yet remain optimistic, and can see what downward-flowing decisions will mean to their own
work situations.

10. Be objective. This has several aspects. For example, be consistent and constructive in
your communication; the emotional objectivity required will give you a solid foundation and
make you appear reliable to others, a key factor in your work relationships (see What is the
Shadow Job and why is it important?).

Conclusion

Supervision and management is a vital and important role where the supervisor and
the subordinates should have a cordial relation in order to run the organization effectively.
 Mr. Channabasappa. K.M

11. DISCIPLINE

INTRODUCTION
One method by which a nurse manger can control subordinates behavior is to invoke
official disciplinary procedure. Discipline can be self-control by which an employee brings
his or her behavior into agreement with the agency‘s official behavior code, or it can be a
managerial action to enforce employee compliance with agency rules and regulations.
Discipline in the board sense means orderliness-the opposite of confusion. Unless there is
discipline, the organization cannot be carried on efficiently. Discipline does not mean strict
observance or rigid rules and regulations. It simply means working, cooperating and behaving
in a normal and orderly way, as any reasonable person would expect an employee to do.

DEFINITION
 Discipline is defined as a training or moulding of the mind and character to bring
about desired behaviours.
 Discipline refers to working in accordance with certain recognized rules, regulations
and customs, whether they are written or implicit in character.

AIMS AND OBJECTIVES OF DISCIPLINE

The aims and objectives of discipline are:
1. To obtain a willing acceptance of the rules, regulations and procedures of an
organization so that organizational goals can be achieved.
2. To impart an element of certainty despite several differences in informal behavior
patterns and other related changes in an organization
3. To develop among the employees a spirit of tolerance and a desire to make
adjustments
4. To give and seek direction and responsibility
5. To create an atmosphere of respect for the human personality and human relations
6. To increase the working efficiency and morale of the employees so that their
productivity is stepped up, the cost of production brought down and the quality of
production improved.

TYPES OF DISCIPLINE:
Two types of discipline are there, they are
1. Self-controlled discipline
In the case of self-controlled discipline, the employee brings her or his
behaviour into agreement with the organizations‘ official behaviour code i.e. the
employee regulates their own activities for the common good of the organization. As
a result, human beings are introduce to work for a peak performance under self
controlled discipline.
2. Enforced discipline
In the case of enforced discipline a managerial action enforces employee
compliance with organization‗s rules and regulations, i.e. it is a common discipline
imposed from the top. Here, the manager exercises his authority to compel the
employees to behave in a particular way.
 PRINCIPLES OF DISCIPLINARY ACTION

1. Have a positive attitude:

The manager‘s attitude is very important in preventing or correcting undesirable
behavior. People tend to do what is expected of them. Therefore the manager must
maintain a positive attitude by expecting the best from the staff.
2. Investigate carefully:
The ramifications of a disciplinary action are serious. If a staff nurse is disciplined
unfairly or unnecessarily, the effects on the entire staff nurse may be severe. Therefore
managers must proceed with caution. They should collect facts, check allegations, and
even ask the accused employees for their side of the story.
3. Be prompt:
If the disciplinary action is delayed, the relationship between the punishment and the
offense becomes less clear.

4. Protect privacy:
Disciplinary actions affect the ego of the staff nurse. Discussing the situation in
private, causes less resentment and greater chance for future co-operation. However, a
public reprimand may be necessary for the nurse who does not take private criticism
seriously.
5. Focus on the act:
When disciplining a staff nurse, the manager should emphasize that it was the act that
was unacceptable, not the employee.
6. Enforce rules consistently:
Consistency reduces the possibility of favoritism, promotes predictability, and fosters
acceptance of penalties.
7. Be flexible:
Individuals and circumstances are never the same. A penalty should be determined
only after the entire record is reviewed.
8. Advise the employee:
The employees must be informed that their conduct is not acceptable. Anecdotal notes
can be of little value if the staff nurse is not informed of the contents promptly.
9. Take corrective, consistent action:
The manager should be sure that the staff nurse understands that the behavior was
contrary to the organizations requirements.
10. Follow up:
The manager should quietly investigate to determine whether the staff nurse behavior
has changed. If not, the manager should determine the reason for the nurse‘s attitude.

COMPONENTS OF A DISCIPLINARY ACTION PROGRAM

1. Codes of conduct: The employees must be informed of codes of conduct. Agency
handbooks, policy manuals, and orientation programs may be used. Eg. Employee code of
conduct.
 Mr. Channabasappa. K.M

2. Authorized penalties: The agency‘s disciplinary action program should indicate that the
current action is being administered without bias and is directly related to the offense.
3. Records of offences and corrective measures: The personnel record should clearly
indicate the offense, management‘s efforts to correct the problem and the resulting
penalties.
4. Right of appeal: Formal provision for right of employee appeal is a part of each
disciplinary action program.

EMPLOYEE CODE OF CONDUCT

The basic pre-requisite for effective discipline is employee awareness of agency rules
and regulations governing employee behavior. Behavior rules should be written in clear and
concise language, incorporated in a hand-book and given to new employees during induction,
posted in each work unit and discussed with employees by manager of each unit. The
significance of code of conduct is that each employee should behave and perform in a way
that preserves the company values and commitments.

PENALTIES
 Oral reprimands: For minor violations that may have occurred for the first time,
managers may opt give an oral warning in private. When oral warning is given, the nurse
manager is advised to make an anecdotal record of time, place, occasion and gist of the
reprimand.
 Written reprimand: If the offense is more severe or repeated, the reprimand may be
written. The written notice should include the name of the employee, name of manager,
nature of the problem, the plan for correction, and consequences of future repetition. The
employee has to sign it, to indicate that the employee has read it. A copy should be given
to the employee and one retained for the personnel file. If again the terms are not met,
other penalties will probably be necessary.

 Other penalties:
 Fines may be charged for offences such as tardiness.
 Loss of privileges might include transfer to a less desirable shift and loss of
preference for assignments.
 Demotion is a questionable solution. It creates hard feelings which may be contagious
and more likely places offenders in a position for which they are overqualified.
 Suspension: for a period of time
 Withholding increment
 Termination(dismissal): permanent termination of services.

APPROACHES OF DISCIPLINE
1. Traditional approach
It emphasizes punishment for undesirable behavior. The purposes of traditional
discipline are punishment for sin, enforce conformity to custom, and strengthen authority
of the old over the young. Here discipline is always applied by superiors to subordinates,
the severity of punishments is designed to be proportional to the severity of the offense,
 and when no single individual admits to the violation, the whole group is punished to
motivate group members to identify the violator or punish him or her themselves
2. Developmental approach
It emphasizes discipline as a shaper of desirable behavior. The purpose of
developmental discipline is to shape behaviour by providing favourable consequences for
the right behaviour and unfavourable consequences for the wrong behavior; and avoidance
of physical punishment, protection of the rights of the accused and replacement of
arbitrary individual judgements of guilt.
3. Positive discipline approach
 It is based on the assumption that an employee with self-respect, respect for authority, and
interest in the job will adhere to high quality work standards; and when an interested,
respectful and self-respecting worker temporarily strays from his/ her usually highs
standards, a friendly reminder is enough to redirect their efforts in the desired direction
 Organisations that have employed a positive discipline have noted a subsequent decrease
in absences, dissmisals, disciplinary actions, grievances and arbitration, along with
improvement of employee morale.

4. Self controlled discipline approach

The employees bring his or her behaviour into agreement with the organisations
behavioural official code i.e. the employees regulate their own activities for the common
good of the organisation. As a result human beings are reduced to work for a peak
performance under self controlled discipline.
5. Enforced discipline approach
A managerial action enforces compliance with organization‘s rules and regulations ie.
It is a common discipline imposed from the top. Here the manager exercises his authority
to compel the employees to behave in a particular way.
SELF DISCIPLINE
It refers to one‘s effort at self-control for the purpose of adjusting oneself to certain
needs and demands. This form of discipline is based on two psychological principles. First,
punishment seldom produces the desired results. Often, it produces undesirable results.
Second, a self-respecting person tends to be a better worker than one who is not.
The Five Pillars of Self-Discipline
The five pillars of self-discipline are: Acceptance, Willpower, Hard Work, Industry,
and Persistence. If the first letter of each word, is taken we will get the acronym ―A WHIP‖
— a convenient way to remember them, since many people associate self-discipline with
whipping themselves into shape.

CONSTRUCTIVE VS DESTRUCTIVE DISCIPLINE

Constructive discipline (positive discipline) uses discipline as a means of helping the

employees grow, not as a punitive measure. The primary emphasis here is assisting
employees to behave in a manner that allows them to be self-directive in meeting
organizational goals.
 Mr. Channabasappa. K.M

Destructive discipline (also called enforced or negative discipline): If employees are

forced to follow the rules and regulations of the organization by inducing fear in them, then it
is termed as negative discipline
DEALING WITH DISCIPLINARY PROBLEMS
Disciplinary action may be ineffective because of methodological weakness or of procedural
omissions by the manager. Methodological problems result from improper documentation of
disciplinary interview and procedural problems from failure to apply discipline in a timely
fashion and to follow due process.
1. Disciplinary conference
It is a group discussion using both directive and non-directive interview techniques. It is
damaging to employee‘s self-esteem to receive criticism from an authoritative figure. Thus a
disciplinary conference is anxiety provoking situation for both employee and the manager.
2. Disciplinary letter
It is a letter sent to the nurse/employee immediately after the conference, documenting the
interview content from the manager‘s viewpoint. It is needed as sometimes employee‘s
anxiety may block perception of the painful feedback offered by the manager.
3. Model standing orders
It specifies the terms and conditions which govern day to day employer-employee
relationship, infringement of which could result in a charge of misconduct
4. Errors in disciplinig employees
The frequent errors encountered while disciplining the employees are:
 Delay in administering discipline
 Ignoring rule violation in hope that it is an isolated event
 Accumulations of rule violations, causing irritated manager to ―blow up‖
 Administering sweetened discipline
 Failure to administer progressively severe sanctions
 Failure to document disciplinary actions accurately
 Imposing discipline disproportionate to the seriousness of the offense
 Disciplining inconsistently

DISCIPLINARY PROCEEDINGS ENQUIRY IN MANAGEMENT

CCSR (CENTRAL CIVIL SERVICES RULES) AND KCSR (KARNATAKA CIVIL
SERVICES RULES)
General Civil Services Rules
The essence of Government service is the sense of discipline to which all Government
employees are subject and it is related to the employees code of conduct and discipline.
 Article 311 of the constitution enumerates two fundamental principles upon which
the whole procedural law concerning departmental punishments on civil servants
rests.
  The first clause of the article contains the guarantee that no civil servant shall be
dismissed or removed by an authority subordinate to that by which he was
appointed.
 The second clause guarantees to him a reasonable opportunity of defence on the
charges against him, supplemented by a second opportunity of showing cause
why such a punishment should not be imposed on him, if after enquiry it is
proposed to dismiss or to remove or to reduce him in rank.
 Only the appointing authority can impose major punishment (dismissal, removal
or reduction in rank). The power of punishment can never be delegated.
 Enquiry officer is a officer subordinate to the appointing authority; who conducts
formal enquiry about the charges on the charged official. The enquiry report
contains findings of the charges, but there should be no recommendations about
the punishment.

CAUSES OF DISCIPLINARY PROCEEDINGS

A. Acts
1. Acts amounting to crimes
Eg. Bribery, corruption
2. Acts amounting to misdemeanor
Eg. Misbehavior, insurbordination, disobedience

3. Acts amounting to misconduct

Eg. Violation of conduct rules or standing orders
B. Omissions
Eg. Habitual late attendance, irresponsibility, negligence.

STAGES OF DISCIPLINARY PROCEEDING ENQUIRY

1. Preliminary enquiry
2. Decision to start formal departmental enquiry
3. Suspension
4. Charge sheet and its service
5. Appointment of enquiry officer
6. Written statement of defence
7. Recording of evidence by the enquiry officer
8. Personal hearing of charged official
9. Report of enquiry officer
10. Show cause notice by the disciplinary authority
11. Reply to show-cause notice and decision thereon
12. Review of punishment order
13. Appeal or revision
14. Reinstatement and restitution
15. Show-cause notice against withholding of emoluments for suspension period
in the case of a reinstated.
 Mr. Channabasappa. K.M

Summary and conclusion:

Most people prefer an orderly and efficient atmosphere in work. They will readily
conform to rules of conduct and obey reasonable orders as long as they clearly understand
what is expected of them. Discipline is the most intimate term needed by all organisations.
Management should also know the issues and challenges commonly occurring and the ways
to resolve and bring discipline and harmony in the organization.
Bibliography:
1. BT Basavanthappa, Nursing dministration, Jaypee Publication, Delhi, 2nd edition, 2008,
pg no. 590-610.
2. Dee Ann Gillies, Nursing management-A Systems Approach, 3rd edition, W.B.
Saunders Company, pg. 550-558, 528, 84.
3. B. Sankaranarayan, B. Sindhu, Learning and Teaching Nursing, 1st edition, Brainfill
publications, pg no. 203

12. EVALUATION
INTRODUCTION
The realisation of goals and objectives is based on the accuracy of the judgments and
inferences made by decision-makers at every stage. To arrive at a good decision the test,
measurements and evaluation are being used in all situations. Thus evaluation has become a
part and parcel of every system to determine the achievement of goals in a given period.
MEANING AND DEFINITION
The term evaluation is derived from the word ‗valoir‘ which means ‗to be worth‘.
Thus evaluation is the process of judging the value or worth of an individuals achievements
or characteristics.
―It is an act or process that involves the assignment of a numerical index to whatever is being
assessed‖
―Evaluation is an act or process that allows one to make a judgement about the desirability or
value of a measure‖
SELF EVALUATION
DEFINITION
Self evaluation is defined as judging the quality of one‘s work, based on evidence and
explicit criteria, for the purpose of doing better work in the future.
PURPOSES OF SELF EVALUATION
1. To encourage continuing self-evaluation and reflection and to promote an ongoing,
innovative approach.
2. To encourage individual professional growth in areas of interest to the employee
3. To improve morale and motivation by treating the employee as a professional in charge of
his or her own professional growth.
4. To encourage collegiality and discussion about practices among peers in an organisation
5. To support employees as they experiment with approaches that will move them to higher
levels of performance
BENEFITS OF SELF EVALUATION
1. Increased confidence in their own learning, in trying out new ideas, in changing their
practice and in their power to make a difference.
2. Enthusiasm for collaborative working, despite initial anxieties about being observed and
receiving feedback
3. Improved team-work and greater flexibility in their use of their skills
4. Increased awareness of new techniques and greater insight into thinking
5. Enhanced planning skills to ensure more effective task management.
TOOLS FOR SELF EVALUATION
Staff annual professional review procedures
Peer support
o Coaching
o Joint preparation of materials
o Planning
o Team building
Observation can involve experts, can be informal or formal procedures. Feedback from
such observation is very valuable, but must be handled sensitively
Audit checklist

PEER EVALUATION
INTRODUCTION
In response to the public‘s clamor for improved care quality, some nursing
organizations instituted peer review as one method for increasing nurses‘ accountability for
effective decision-making and interventions. It is a mechanism for developing faculty leaders
who can meet the challenges posed by public demands for accountability in healthcare
management.
DEFINITION
Peer review is a process by which employees of the same rank, profession, and setting
evaluate one another‘s job performance against accepted standards.
- O’ Loughlin and Kaulbach
THE SUCCESS OF PEER EVALUATION DEPENDS ON
 Short but objective method
 Trained observers
 Constructive feedback for faulty development
 Open communication and trust
METHODS OF PEER EVALUATION
Direct observation
Videotaping
 Mr. Channabasappa. K.M

Evaluation of course materials

Analysis of portfolios
PROCESS OF PEER REVIEW
I. Establish a policy requiring peer reviews
II. Establish criteria for peer evaluations
III. Procedure for conducting peer evaluations
a. Faculty chosen to conduct peer evaluations shall be tenured and hold on academic
rank higher than that of the faculty member being evaluated
b. A written report, addressing the criteria, shall be prepared and signed by the
evaluator
c. The department shall archive the written evaluations for use in future evaluations
d. One copy of the peer evaluation shall be placed in the permanent personnel file of
the person being evaluated
e. All reports of peer evaluations shall be included in the tenure file, and are to be
carefully reviewed at the department.

PATIENT SATISFACTION
INTRODUCTION
Consumers of health care services demand quality care. Patient satisfaction has been used
as an indicator of quality services provided by health care personnel. The most important
predictor of patients overall satisfaction with hospital care is particularly related to their
satisfaction with nursing care. In recent years, the focus on consumerism in a highly
competitive environment has led to increased interest in measuring patient satisfaction with
health care.
DEFINITION
―Patient satisfaction is defined as a health care recipients reaction to salient aspects of the
context, process, and result of their service experience.‖ -
Pascoe (1983)
―Patient satisfaction is defined as the extent of the resemblance between the expected
quality of care and the actual received care.‖
- Scarding (1994)

NEED FOR EVALUATING PATIENT SATISFACTION

 Data about patient satisfaction equips nurses with useful information about the structure,
process and outcome of nursing care
 It is a requirement for therapeutic treatment and is equivalent to self therapy. Satisfied
patients help themselves get healed faster because they are more willing to comply with
treatment and adhere to instructions of health care providers, and thus have a shorter
recovery time.
METHODS OF MONITORING PATIENT SATISFACTION
Medical audit
Quality assurance committee reviews
Indices of nursing performances
Judgemental method
COMPONENTS OF EVALUATION OF PATIENT SATISFACTION
1. Evaluation of the programs and activities of various departments including outpatient
care, inpatient care, overall health education activities of the hospital
2. Evaluation of the various resources available in the hospital for effective health care
3. Evaluation of effectiveness of hospital personnel including medical, paramedical,
nursing as well as non-medical employees of the hospital.
4. Services are relevant to the needs of the population it serves.
5. Patient satisfaction with nursing care is important for any health care agency because
nurses comprise the majority of health care providers and they provide care for
patients 24 hours a day.

ULITILISATION REVIEW
The utilisation review program includes determining appropriate hospital length of
stay and necessary treatments for various illnesses and conditions and reviewing patient
medical records on admission and at intervals during hospitalisation to ensure that the patient
receives appropriate care.

AIMS AND OBJECTIVES

1. The main aim is to curb the exploding health care costs with conservative use of
hospitalisation and expensive diagnostic and treatment procedures.
2. They work in liason with a business organisation to provide healthcare services to the
organisation‘s employees at discounted rates.
3. Cost containment to limit each patient‘s diagnostic and treatment measures to the
fewest, least expensive procedures that will relieve patient symptoms, avert costly
complications, and return the patient to fullest possible function in the shortest time
possible.
UTILISATION REVIEW NURSE
 A utilization review nurse is a registered nurse who reviews individual medical cases
to confirm that they are getting the most appropriate care.
 They can work for insurance companies, determining whether or not care should be
approved in specific situations, and they can also work in hospitals.
 Members of this profession do need to possess compassion, but they also need to be
able to review situations dispassionately to make decisions which are fair, even if they
may be uncomfortable.
 At a hospital, a utilization review nurse examines patient cases if the hospital feels
that a patient may not be receiving the appropriate treatment.
 Mr. Channabasappa. K.M

 In an insurance company, the utilization review nurse inspects claims to determine

whether or not they should be paid.
 The nurse weighs the patient's situation against the policy held by the patient, the
standards of the insurance company, and the costs which may be involved in
treatment.
 To work in this field, it is usually necessary to hold a current nursing license, and to
have experience in the field.

BIBLIOGRAPHY
4. BT Basavanthappa, Nursing dministration, Jaypee Publication, Delhi, 2nd edition, 2008,
pg no. 590-610.
5. Dee Ann Gillies, Nursing management-A Systems Approach, 3rd edition, W.B.
Saunders Company, pg. 550-558, 528, 84.
6. B. Sankaranarayan, B. Sindhu, Learning and Teaching Nursing, 1st edition, Brainfill
publications, pg no. 203
7. Lynne E Young, Teaching Nursing, 1st edition, Lippincott Publications, pg no. 183,
586
8. K.P. Neeraja, Textbook of Nursing Education, 1st edition, Jaypee Publications, pg
no.404.
9. http://journals.lww.com/naqjournal/Abstract/2009/07000/Implementing_Peer_Review_
_Guidelines_for_Managers.11.aspx (Nursing Administration Quarterly: July/September
2009 - Volume 33 - Issue 3 - p 251-257)