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Leadership Approaches and Control Mechanisms
Healthcare Organization and Management · Chapter 5: Core Management Functions in Healthcare OrganizationsSection 5.2 · lesson 26 of 1059 min · free with a free account
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In this lesson
Design management controls that catch failures while they can be fixed.
- Explain the four-step control cycle and why the action step is often skipped
- Distinguish feedforward, concurrent, and feedback control and weight them by how reversible the harm is
- Evaluate a control against five traits and its risk of distorting behavior
- Choose a directive or participative approach and assign a named owner to each control
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Transcript
Everything said in the video, section by section (1,177 words). Read along, or search it.
Opening Case
Waiting on CT Results
Saturday night in Larkfield's emergency department. Jamal Carter, the nurse manager, watches patients wait hours for their CT results. It's the third time this month he has flagged the delay to imaging.
The Problem
A Report Seven Weeks Late
In imaging, manager Nora Lindqvist gets a monthly report on CT turnaround. It lands around the twentieth of the following month. By then, the delays it describes are up to seven weeks old, and nothing in it can still be acted on. Her instinct is to ask for a second, faster report. Is a second report the fix?
Purpose of Control
Finding Failure in Time
Nora takes it to Farah Siddiqui, Larkfield's director of quality and patient safety. Farah starts with what control is for. Staff hear the word and think of restriction. Managers think of reports. Neither is the point. Control checks whether performance matches the plan, and acts on the difference, so a failure shows up while there's still time to fix it. A unit without working controls doesn't have more freedom. It has the same failures, found later, by someone else.
Control Cycle
Standard, Measure, Compare, Act
Control is a four-step cycle. First, set the standard, in advance and in measurable terms. A standard written after the fact is a rationalization. Second, measure the result, with a defined method, interval, and source. Third, compare. How big is the gap, which way does it run, and is it bigger than ordinary variation would produce? Fourth, act. Fix the process, fix the standard, or decide the gap is acceptable, and record that decision. Step four is where most cycles break. A report that's filed and never acted on costs as much as a control, and delivers none of the benefit.
Timing of Control
Feedforward, Concurrent and Feedback
Control can also act at three points in time. Feedforward control acts before the work begins, to prevent a problem. Verifying a surgeon's credentials before granting privileges is feedforward. Its successes are invisible: nothing happens, which is exactly what it was for. So it's often underfunded. Concurrent control acts during the work. A second nurse verifying a high-alert drug at the bedside is concurrent. It catches problems in time, but it costs constant attention. Feedback control acts afterward: monthly variance reports, audits, incident reviews. It's the cheapest, and the only one that spots patterns. But the harm has already happened. So weight them by consequence. Where an error can't be undone, feedforward and concurrent controls carry the load, and feedback watches for drift.
Quick Check
The Evening Crash Cart Check
Quick check. At seven each evening, the emergency department's charge nurse checks every crash cart: sealed, fully stocked, and its defibrillator tested. Which kind of control is that? Pause, and decide. Feedforward. The check comes before any resuscitation starts, so a missing drug or a dead battery is found before a patient needs it. Concurrent is tempting, because the check happens during the shift. But the process being controlled is the code itself, and it hasn't begun.
Control Systems
Financial, Operational, Quality and Compliance
Larkfield also runs four control systems side by side. Financial control compares spending and revenue with the budget. Operational control tracks throughput, capacity, and turnaround. Quality control compares clinical and service results with standards, often after risk adjustment. Compliance control checks required practice against external rules, where the acceptable gap is often zero. The four interact. Tom Brennan, the chief financial officer, tightens approval for agency nurses. Months later, the quality numbers can feel it. A manager who reads only one system sees a quarter of the picture.
Effective Controls
Five Traits Worth the Cost
Back in Farah's office: what makes a control worth its cost? She lists five traits. Timely: the information arrives while the decision is still open. Accurate: a control that's believed and wrong is worse than none. Economical: it costs less than the loss it prevents. Understandable: the person who must act on it can explain it. And focused on the exception: it flags what's outside tolerance, instead of giving forty indicators equal weight. Nora's report has a standard, a measure, a comparison, and an intended action. What fails is timeliness alone.
Unintended Effects
How Bad Controls Distort Behavior
Badly built controls don't just fail to help. They distort behavior, in ways you can predict. Measure fixation: effort goes to the indicator instead of the result. Gaming: moving the number without changing performance. That's a design failure, not a character flaw. Tunnel vision: neglecting whatever isn't measured, which is often where harm builds. And unexplained controls on professional work erode the motivation to do it well. The common root is disproportion. A serious failure that can't be reversed deserves a hard stop. A cheap, recoverable one deserves a light touch, or none. In clinical work, standardize what shouldn't vary, like how equipment is disinfected. Protect what should vary: a clinician's judgment about a particular patient.
Introducing Controls
Directive or Participative Approach
How a control is introduced matters as much as its design. That's where a manager's leadership approach comes in. A directive approach, where the manager sets the method and checks compliance, fits work where the right method is known and variation is pure risk, like the steps of a central-line dressing change. A participative approach, where staff help design the standard and the measure, fits judgment work, where staff know things the manager doesn't. People who help build a control know where it can be gamed, where its definition breaks, and which exceptions it misses. A memo written in an office meets those problems later.
Quick Check
Prioritizing Call Lights
Quick check. 4 North wants a standard for how nurses prioritize call lights during a busy evening. Which approach should the manager use to introduce it? Pause, and decide. Participative. Prioritizing call lights is judgment work, and the nurses hold the information about their patients that the manager doesn't. Directive is tempting, because a standard sounds like a fixed method. But no single correct order exists to impose, and compliance has to hold when the manager isn't there.
Control Ownership
Every Control Needs a Named Owner
Farah adds one more design rule. Every control needs a named owner, who keeps the standard, the measure, the comparison, and the action alive. Without an owner, controls decay silently. The data source changes, the definition drifts, and the report keeps arriving, so everyone believes the process is watched. So review the control set itself. Which controls produce no decisions, and should retire? And which risks have no control at all?
Case Resolution
A Weekly Report Built for Exceptions
Back to Nora's late report. She doesn't add a second one. She moves the interval from monthly to weekly, with the same definition, so the history still compares. She cuts the report to the order types outside tolerance, and sets that tolerance with Jamal and the CT lead technologist, not for them. And she names herself the owner, with a review in six months and one question: how many decisions has this report produced? If none, retire it.
Key Takeaways
Design, Timing and Ownership of Controls
To recap. Control exists to find failure while it can still be fixed. The cycle is standard, measure, compare, and act, and acting is the step most often skipped. Control can act before, during, or after the work. Weight the three by how reversible the harm is. Timely, accurate, economical, understandable, and focused on the exception: that's what earns a control its cost. And match the approach to the work, directive or participative, then give every control a named owner.
About Healthcare Organization and Management at UPI Study
Healthcare Organization and Management (Health 302) is a self-paced online course of 105 video lessons in 18 chapters, from health systems and the law to ethics, leadership, teams, strategy, informatics, finance, quality, human resources, marketing and evidence-based practice. It carries a NCCRS credit recommendation for 3 semester credits.
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