MIDTERM

Planning

Planning determines the steps to be taken for the foreseeable future. It precedes all other processes of management. This was defined by Henry Fayol as first step of management (Planning, Organizing, Staffing, Directing, Controlling). The courses of action to take in order to arrive at a desired result is determined.

Planning is based on past and future activities, and leads to the realization for the need for change. It provides basis and is necessary for effective control of the organization. In planning, the following principles are followed:

1. Planning is always based on vision, mission, philosophy, and objectives of the organization.
2. Planning is a continuous, cyclical process.
3. Planning should be pervasive. Every level of the organization should be involved.
4. Planning utilizes all available resources effectively and efficiently. Planning remains within the boundaries of what resources area available or attainable.
5. Planning must be precise. While flexible and contingent, plans should be precise in their scope and goals and the steps to take to reach its objectives.
6. Planning must be time bound.
7. Planning must be documented

Scope of Planning

1. Top Management: the administrative level. This level sets the overall goals, policies, vision, mission, and general guidelines for the whole institution.
2. Middle Management: the coordinators between the top and low managers. They link each end, relaying the guidelines and policies.
3. Lower/First-Level Management: the ones to create daily or weekly plans in their respective units that follow the guidelines formulated by top management.

A good plan...

…is precise, guided by policies, sets priorities, flexible and realistic, logical in sequencing, practical and efficient, and pervasive.

Bases for Planning

1. Forecasting: ultimate conditions or projections that provide the incentive or direction to planning. It anticipates what the future of the organization is desired, which guides planning. This can include the:
   • Hospital: What kind of hospital is desired? What staff will be required? What services are being offered and what facilities are required?
   • Community: What kind of people are going to be served? What are their needs and statistics?
   • Goals of Care: What are the current highest standards of care? Technology in health?
2. Setting the Vision, Mission, Philosophy, and Objectives:
   • The vision refers to what the future role and function of the agency. This commonly sets a year by which the agency achieves its vision.
   • The mission refers to the reason for existence of the agency, outlining what services will be provided.
   • The philosophy states the beliefs and values of an organization that direct its practice.
   • The goals of an agency are broad statements to be achieved, while objectives are specific statements that will be used to achieve the agency’s goals.
3. Developing and Scheduling Programs
4. Establishing Nursing Standards, Policies, and Procedures: the desirable norms by which the department’s performance may be measured against. Each unit should aim to act in conformity or even exceed the acceptable standards of care.
   • Policies are plans reduced to statements that direct organizations in decision-making. This is often consolidated into a policy handbook. These may also be implied, without the necessity to be written.
   • Procedures are plans that establish acceptable ways of accomplishing a specific task and delineate a sequence of steps that require action. An example of this are care bundles and clinical decision flowcharts.

Types of Planning

1. Operational/Short Range: plans that are stable and used for daily, standard, or routine activities, such as in restocking that is done when the available stock reaches a certain threshold. This is often formulated by middle or line managers.
2. Strategic: plans that are future-oriented, intended for the life of the entire organization. An example of this is expansion of the institution, or the creation of a new branch. This spans a longer time span and is broader than an operational plan. This is often formulated by top-level managers.

SWOT Analysis

A method for self-assessment:

1. Strengths: internal attributes that improve an organization’s ability to achieve its objectives.
2. Weaknesses: internal attributes that challenge an organization in achieving its objectives.
3. Opportunities: potential conditions that promote the achievement of the organizational objectives.
4. Threats: potential obstacles to the organizational objectives.

Modes of Planning

1. Reactive Planning: past-oriented; planning is only done when a problem is found.
2. Inactivism: present-oriented; maintaining conformity and the status quo to prevent change.
3. Preactivism: future-oriented; utilizing energy to accelerate change.
4. Interactive/Proactive: consider the past, present, and future to plan for the future of the organization.

Organizational Change

Change occurs in an organization in three phases according to Kurt Lewin (1951):

1. Unfreezing: recognition of established conditions, actions, or activities as needing change.
2. Movement: supplantation of unfrozen elements by new, desired elements with the implementation of appropriate strategies. Driving forces must exceed restraining forces.
3. Refreezing: establishment of the new changes as the status quo.

Planned Change as it’s called, may utilized various strategies to be put into place:

1. Rational-empirical Strategy: use evidence (research) to support change, assuming that the individuals are rational beings who will recognize that factual information as proof for the need for change.
2. Normative-Reeducative Strategy: use group norms to influence people to change, assuming that the individuals are social animals that will conform to what they perceive as the social standard.
3. Power-Coercive Strategies: the use of reward or punishment or some other method to enforce change.

Budgeting

A budget is a plan for allocating resources and controlling to ensure that the results comply with the plans. This balances income and resources and expenses and stock. This covers manpower, equipment, and supplies to attempt to minimize costs for the highest quality of care.

• The nursing budget is a plan for allocation of resources based on preconceived needs for a proposed series of programs to deliver patient care during one fiscal year prepared by the chief nurse in collaboration with other heads to submit to the board of directors.

Time Management

The allocation of time through the setting of objectives, priorities, and using managerial techniques for efficiency. Henry Ford emphasizes that complex tasks will become easy when divided into small jobs. Johann Wolfgang Von Geothe emphasizes the importance of prioritization, saying that major tasks must not be held back by minor tasks. It takes form in three steps:

1. Allow time to plan and establish priorities.
2. Complete the most important task when possible and finish one task before beginning another.
3. Reprioritize remaining tasks based on potential new information, opportunities, or constraints.

// I skipped the rest of this lol

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Organizing

Organizing refers to the the establishment of formal authority and organizational structure through identification of groupings, roles and relationships. These are the elements of organizing:

1. Setting up the organizational structure: either pyramidal or plot centralized type
   • An organizational structure specifies responsibilities and roles of every member within the organization, and their superiors or subordinates.. This reduces doubt and confusion and coordinates all organizational activities, minimizing duplication of effort and avoiding conflict.
2. Staffing and Scheduling
3. Developing job descriptions presented in the contract is used to delimit the roles and responsibilities of an employee within the organization, which can be used as a tool for evaluation.

Types of Organization

1. Line Organization: simplest; most direct. A direct “line of authority” flows from top to bottom in a hierarchy.
2. Informal Organization (Flat/Horizontal): small groups with similar interest work together.
3. Staff Organization: purely advisory to the structure; no strict authority exists to convert recommendations into action.
4. Functional Organization: organizations split into units responsible for a specific workload. An example is an ad hoc committee, a temporary subgroup of the organization for a certain purpose, e.g., revising the vision, mission, and philosophy of the organization.

Lines in the Organizational Chart

1. Unbroken, Solid Lines represent direct relationships. Horizontally, this represents similar responsibility and power between two different units. Vertically, this represents official chain of command; attaches a position as a subordinate or as a superior to another position.
2. Dotted, Broken Lines represent advisory positions, who are able to recommend actions to other units, but are not enforcers of said action. These are often experts who act as advisors or consultants for a specific position or unit.

Principles of Organizing

1. Unity of Command: one person will have one superior. An employee should not answer to multiple persons.
2. Scala Principle, Hierarchy, Chain of Command: authority and responsibility flows in a clear, unbroken line from the highest executive to the lowest.
3. Homogenous Assignment/Departmentalization: employees with similar tasks or functions are grouped together.
4. Span of Control: a manager’s subordinates should be limited to their capacity based on the pace and pattern of the working area.
5. Exception Principle: recurring decisions should be handled in a routine manner by lower level managers while unusual matters are referred to higher levels.
6. Decentralization/Proper Delegation of Authority: decision-making is pushed to lower levels of the organization when appropriate.
7. Principle of Requisite Authority: when a task is delegated to a subordinate, the authority for resources needed for that task is also given.
8. Principle of Organizational Centrality: being central (connected) to the most units in the organization will also elevate one’s power in the organization, i.e., the nursing unit is the bridge to many healthcare units in the hospital, giving the nursing unit more power than other units.
9. Principle of Esprit d’ Corps: team spirit and unity form strength.

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Staffing

Staffing is the process of determining and providing the acceptable number and mix of nursing personnel to produce a desired level of care to meet patient demand. Place emphasis on number, the totality of personnel, and mix, the specific composition (ratio) of the different personnel will be used (registered nurse to nursing aide ratio, and other assistive personnel).

Factors Affecting Staffing

1. Patient Factors:

• Census fluctuations (number of beds occupied)
• Patient acuity: level or complexity of care required by patients, patient age groups (increases with extremes of age), and requisites for special treatment and procedure. This is related to the patient care classification system previously discussed.
• Communicability, which can impact staffing if personnel become infected

2. Staff Factors:

• Number of available staff, including the amount of leave days they schedule or utilize.
• Composition of available staff: professional-to-non-professional ratio of the staff.
• Turn-over rate— the attrition rate or how long nurses remain employed in the institution. Quality care increases with increased seniority or tenure in staff especially with relation to training. Staff leave when they experience poor job satisfaction, negative experiences with other staff, or seek better positions.

3. Nursing Service Factors:

• Nursing Care Modality being used. Some modalities will require adequate staff to provide care, such as in total patient care, while some may be flexible in times when staff is limited and demand is high, such as in functional nursing.

4. Organizational Factors:

• Type of hospital: specially in the case of private vs. public hospitals, care demanded by clients is much higher in a private paid hospital, while government hospitals may stretch resources thin in terms of staffing.

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Staffing Guidelines

The following cases can dictate the necessary hours of staffing required per patient per day, and the composition required for each area.

Cases/Patients	Hours/Pt./Day	RN-to-UAP Ratio
General Medicine	3.5	60:40
Medical	3.4	60:40
Surgical	3.4	60:40
Obstetrics	3.0	60:40
Pediatrics	4.6	70:30
Pathologic Nursery	2.8	55:45
ER/ICU/RR	6.0	70:30

Patient Care Classification System

	Description	NCH	P:NP
Level 1	Minimal care/assistance	1.5	55:45
Level 2	Moderate care/assistance requiring periodic assessment	3	60:40
Level 3	Intensive care; completely dependent	6	65:35
Level 4	Highly specialized care; maximum nursing care	6–9	70:30 – 80:20
The classifications of patients presented in the table above will be distributed differently based on the level of the institution being considered— a tertiary healthcare organization will contain more intensive care patients than a primary healthcare organization. Specifically, the following ratios are expected:

Hospital Level	Level 1	Level 2	Level 3	Level 4
Primary	70%	25%	5%	0%
Secondary	65%	30%	5%	0%
Tertiary	30%	45%	15%	10%
Special Tertiary	10%	25%	45%	20%
These ratios will be necessary to remember for calculating the expected nursing care hours required!

Related Laws

R.A. 5901, the Forty Hour Week Law: hospital employees working in an institution with ≥100 bed capacity is required to work 40 hours per week, and 48 hours if <100. According to this law, the following rights and privileges are given to each personnel per year (with pay): (important numbers are bold)

Annual Rights/Privileges	40-hour worker	48-hour worker
Vacation Leave	15 days	15 days
Sick Leave	15 days	15 days
Legal Holidays	10 days	10 days
Special Holidays	2 days	2 days
Special Privileges	3 days	3 days
Off-duty	104 days	52 days
Continuing Education Program	3 days	3 days
Total Non-working Days	152	100
Total Working Days	213 (1,704 hours)	265 (2,120 hours)

Calculating Staffing Requirements

1. Consider the number of staff available
2. Calculate Relievers: staff who substitute for personnel who schedule leave days. In total, an employee will take 33 leaves in a year. To determine the necessary relievers, divide 33 by the number of days an employee will be working, as these are the days the leaves will affect. This results in a percentage of the working days that the worker will be absent.
3. Shifting: the required number of staff on duty per shift is biased towards the morning, where the most workload is done.
   • The morning shift makes up 45–51% of the nursing personnel.
   • The afternoon shift makes up 34–37% of the nursing personnel.
   • The night shift makes up 15–18% of the nursing personnel.

Sample Calculation

In a tertiary hospital with 250 patients, calculate how many patients is expected to be in each level of care.

Level	Calculation	Answer
Level 1	$250\times 30\%$	75 patients need minimal care
Level 2	$250\times 45\%$	112.5 patients need moderate care
Level 3	$250\times 15\%$	37.5 patients need intensive care
Level 4	$250\times 10\%$	25 patients need specialized care

In each patient class, how many hours of nursing care, in total, will be necessary?

Level	Calculation	Answer
Level 1	$75\times 1.5\text{ hours}$	112.5 hours
Level 2	$112.5\times 3.0\text{ hours}$	337.5 hours
Level 3	$37.5\times 4.5\text{ hours}$	168.75 hours
Level 4	$25\times 6.0\text{ hours}$	150 hours
In total, 250 patients in a tertiary level hospital combined will require 768.75 nursing care hours per day. In a year, this would amount to 280,593.75 nursing care hours per year (365 days).

How many nursing personnel will be required to fill this requirement?

1. Consider the number of hours of service a nurse renders in a year. In this institution (≥100 bed cap.), a nurse will work 8 hours a day for 213 days in a year, giving a total of 1,704 annual hours.
2. Divide the total required number of hours required in a year by the number of hours one nurse can provide, and the total number of staff required to fill the required numbers will be found: $280,593.75\text{ hrs/yr}÷1,704\text{ hrs/yr/nurse}\approx 165\text{ nurses}$
3. Next, take into consideration the required relief personnel to account for nurses who will take absences/leaves (33 days in a year). Remember that this is found by dividing 33 days (constant) with the number of days the nurse will report for duty (213 for ≥100, 265 for <100). This rounds off to 0.15 for ≥100 and 0.12 for <100. You can treat these as constants for calculating relief personnel. Simply multiply these with the number of personnel being given relief ($165\times 0.15=25$) and add the result to the original number of staff ($165+25=190$) for the final answer.
4. Next, find the composition required in relation to the institutional level. In this question, the hospital is a tertiary hospital which requires 65% of its personnel to be registered nurses, an the remaining 35% to be unlicensed assistive personnel. Calculating it is just a straightforward percentage calculation: $190\times 65\%\approx 124\text{ RNs}$, $190\times 35\%\approx 66\text{ NAs}$
5. Finally, determine the shifting to be used according to the distribution discussed earlier, as the morning shift will require more personnel than the noon shift, then the night shift. Disregarding the ranges earlier, the values to be used will be 45%, 37%, and 18% respectively for the AM, PM, and Night shifts.

Personnel and Shift	Calculation and Answer
RNs on AM Shift	$124\times 45\%\approx 56\text{ RNs}$
RNs on PM Shift	$124\times 37\%\approx 46\text{ RNs}$
RNs on Night Shift	$124\times 18\%\approx 22\text{ RNs}$
NAs on AM Shift	$66\times 45\%\approx 30\text{ NAs}$
NAs on PM Shift	$66\times 37\%\approx 24\text{ NAs}$
NAs on Night Shift	$66\times 18\%\approx 12\text{ NAs}$

Scheduling

The actual plotting of duties across areas and shifts. This was commonly done by chief nurses, but is recently becoming decentralized to supervisors. A schedule is a timetable showing planned work days and shifts for nursing personnel. This assigns working days and day offs to ensure that adequate staff is present at any given time. The factors to be considered include:

1. Adequate Coverage and Competence: the set of staff present at any given time should be able to care for the number of patients present, and the competency of the staff should be evenly distributed as well; no single set of staff should be composed only of junior nurses; fully competent nurses should always be present in each rotation.
2. Rotation in shifting and areas is performed (as appropriate) to allow nursing personnel to get a “fair share” of weekends, holidays, and exposure to difficult, light, or undesirable units or shifts.
3. Consider staffing patterns to maintain staff job satisfaction and to prevent burn-out. These patterns include long periods of consecutive working days, vacations, etc. This also includes stability, where the schedule is consistent to allow the staff to plan around their schedules freely.
4. Flexibility is necessary for a schedule. A schedule should be able to handle emergency leaves and unscheduled absences. Additionally, nurses from some areas may be “pulled” when other areas will require more personnel.

As mentioned, plotting schedules has varying methods based on the institution:

Type of Scheduling	Description
Centralized Schedule	One person, often the chief nurse or her designate, assigns the personnel to the various units of the hospital.
Decentralized Schedule	Supervising nurses or head/senior nurses of the unit being scheduled will submit their own schedules for approval by the chief nurse.
Cyclical Schedule	A designated schedule cycles every few weeks. For example, Staff A will be on the morning shift for two weeks, then the evening shift for two weeks, then the night shift for two weeks. In such a case, there will be a six-week cycle. After the graveyard shift, Staff A will be back on the morning shift.

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Directing

The “doing phase” of management where managers work to bring objectives into reality. These is the issuance of orders, assignments, and instructions, and supervision and guidance. It follows the principles of:

1. Harmony of Objectives: aligned individual goals and company goals\
2. Unity of Command: each individual will only have one superior to follow. One person, one boss
3. Appropriate Direction Techniques: the use of motivation techniques (incentives, awards, sanctions)
4. Use of Informal Organization: informal organization can act as a strong backbone of the formal organization.
5. Managerial Communication: direct and personal contact or feedback with managers should be allowed and encouraged for quality improvement.
6. Appropriate Leadership Style: the use of leadership style in accordance to what will be effective in the situation or subordinates.
7. Follow through Follow-up: enforce policies; follow through the directions given and policies put in place.

Elements of Directing

1. Delegation: provision of tasks to the right person in the right circumstance with appropriate direction, communication, supervision, feedback, and evaluation.
2. Supervision: providing guidelines for the accomplishment of a task. This includes initial direction and periodic inspection.
3. Coordination: synchronization of activities for external, internal, horizontal, and vertical coordination.
4. Communication: transmission of information opinions and intentions between individuals. These may be verbal, written, or non-verbal. In an organization, this may be downward, upward, horizontal, outward, or grapevine.
5. Problem-Solving and Decision-Making
6. Motivation: a complex set of social, professional and economic factor. These may be internal (ambition, aspiration) and external (verbal reward, promotion, salary) and put human resources into action. This is a large determinant of efficiency and stability.

Controlling

Assessing and regulating performance. This makes sure that plans are adopted, instructions are issues, and principles are established. Performance is measured against standards to ensure that they are met, or even exceeded.

Evaluation Principles

An evaluation tool should be objective, reliable, valid, and sensitive.

1. Based on behavioral standards of performance which the position requires.
2. Enough time should be allotted to observe an employee’s behavior. A single period of error or success should not be used to evaluate an employee. A scheduled evaluation in a convenient time and place should be decided by the rater and employee.
3. Employees should be clearly given their job description, performance standards, and evaluation forms.
4. The evaluation report and conference should be used, perceived, and accepted as a means of improving job performance, and not as a method for sanctioning employees.

The process for evaluation is divided into five basic components: standards/objectives/methods for measurement, actual measurement, comparison/analysis of results, action for reinforcing success, and corrective action for weaknesses.

1. Comparison of results may be outcome-based: were the results appropriate?, process-based: were the steps taken appropriate?, or structure-based: was the environment appropriate when health care was delivered?

Discipline

Discipline is training or moulding the mind or character to bring about desired behaviors. In an organization, this is a constructive tool for improving performance. In a good workplace environment, self-discipline may be a driving force in quality improvement. Discipline should be:

1. Prompt and fair
2. Forewarning
3. Immediate consequence
4. Consistent
5. Impartial
6. Followed Through

Discipline may take the form of punishment, constructive discipline, or progressive discipline (repeating offenders will have incrementing punishments)