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STANDARDS OF NURSING SERVICES
standards, criteria and measurable elements necessary to help organizations educate the staff. This edition is also a cross-reference to corresponding requirements set forth in the Philippines by ANSAP and the international accrediting body like Joint Commission International (JCI). We view that standards are continuously a work in progress. Hence, we welcome any comments and suggestions for improvement.
This publication is designed to provide nursing administration a guide reference in managing nursing services. It also reflects the ANSAP’s deep commitment in improving the quality of patient care and management of nursing services in the Philippines. The development was actively participated by the Board of Nursing (PRC-BON) and the ANSAP’s Board of Directors and validated by the Chief Nurses/Nursing Directors who are also members of ANSAP. The initial draft was eventually reviewed and discussed by opinion leaders in focus group of experts. The final blueprint was presented to public hearing attended by key stakeholders around the country. This edition contains a complete set of standards presented in two major components namely; the Clinical and Administration management. Each component has five
TABLE OF CONTENTS
• Introduction • Clinical Services
I. Standards on Assessment of Care Standard I. Assessment Process Standard II. Assessment Scope and Content
0. Standar ds o n Ca re of Pa tie nt Standard I. Care Process Standard II. Care Plan Standard III. Implementation of Care Standard IV. Evaluation of Care Standard V. Pain Management StandardVI. Medication Management Standard VII. End-of-Life Care StandardVIII. Patient and Family Rights I.Standards on Patient and Family Education Standard I. Education Assessment Standard II. Education Plan and Programs II. Standards on Access and Continuity of Care Standard I. Access to Care Standard II. Emergency Patients StandardIII. Admitted Patients or In-Patients Standard IV. Intensive and Specialized Services Standard V. Standard VI. Standard VII. Continuity of Care
Discharge, Out on Pass, Referral and Follow-up
Transfer of Patient
III. Standards on Nursing Documentation Standard I. Structural Data Standard II. Clinical Data
on Governance and Direction
Standard I. Governance Structure Standard II. Governance Responsibility and Accountability Standard III. • Direction-Setting Management Administration and Standard IV. Strategic INTRODUCTION and Operational Plans Standard V. Financial Plan and Resource Allocation This manual is designed to Standard VI. Policies and Procedures Development assist health Accountabilities organizations or Standard VII. Ethico – Moral and Legal hospitals with the significant Standard VIII. Professional and Organizational Involvement
standards necessary to deliver quality nursing service to our .Standards on To achieve this, this Human Resource Management clients. designed manual has two Standard I. Administrator of Nursing Services components; Clinical and Administration and Management.
Standard II. Staffing Plan
Standard III. Standard IV. Standard V. Standard VI. Standard V.
Services. This component focuses Recruitments, Selection, Hiring and Appointment on defining what the standards are in the clinical setting. Credentialing Utilizing nursing process – there are Staff Placement five identified standards to wit: Staff Job Description Standards on Assessment of Care . and Environment .Standards on Facility Management Classified under are two which Facility Planning criteria include the process and Environmental Safety scope and content of Staff Education assessment. Standards on Care of Patient . There are seven Communication of Information (7) identified criteria Patient Clinical Record care that identify Administrative Record plan, process, care implementation of care .Standards and evaluation of Improvement on Quality care rendered. Included Leadership and Staff Education
Quality Monitoring, Analysis and Implementation
. Standard I. Standard II. Standard III.
. Standard I. Standard II. Standard III.
.Standards on Communication Management
Standard I. Standard II. Standard III.
also is the medication management and the family rights. Standards on Access and Continuity of Care. IV. There are seven (7) criteria that guide the nurses regarding the importance of access to care. III. . These standards identify the need to establish policies and procedures from admission to discharge and referral follow up. Standards on Patient and Family Education has two criteria in which the nurse’s independent role in providing health education is hereby identified.
This concerns managing the nursing services in the hospital. direction. There are two identified criteria under this component. organization and controlling functions of the nursing service administration and their relationship with other services. It The second part is the Administration and Management. II. V.needed in the delivery of nursing services and training of personnel to effectively carry out their respective roles. These focus also on planning. Standards on Nursing Documentation . Standards on Governance and Direction . which include documentation of significant data both structure. Standards on Human Resource Management . and clinical based on applicable laws and regulations. professional standards and institutional requirements. This part contains five (5) criteria which help the nursing administrators in placing the right person to do the right job through identification of the job requirements and qualifications. There are seven (7) criteria included. accountability and authority of nursing administration. There are five (5) standards identified: I. need for organizational structure which will delineate responsibility. This chapter recommends the .
Standards on Quality Improvement . This standard contains three (3) criteria and covers environmental safety IV. It also enables the chief nurses/adminis trator to develop a specific hospital system which is efficient and effective. III.also includes staffing modalities depending on the type of services. Standards on Facility Management and Environmental Safety . This standard has three (3) criteria which address the need to institutionalize V. . administration record and communication of information. Three (3) criteria are identified focusing on the patient’s record. Standards on Communicati on Management .
Each standard and criteria has identified measurable elements intended to provide clarity to the standards and to help organizations develop their own policies and procedures according to the standards.continuous quality and performance improvement. .
2.0. Those responsible for direct nursing care collaborate with medical and allied staff to analyze and integrate the patient’s assessment data and information. 2.1. There is a well defined policy on nursing assessment in terms of scope and content which include but are not limited on the following: 1. 1. Those responsible for direct patient care inform the patient and family of the assessment outcome and the planned care and treatment regimen and encourage participation of the latter in the decisionmaking about the priority needs to be met. Psychological •Knowledge level •Language spoken •Barriers to learning 1. Standard II: Assessment Scope & Content The scope and content of nursing assessment are well defined in an institutional policy wherein those elements common to all assessments and any differences with other health disciplines are identified.g. plan of care. Physical •Neurological assessment according to institutional policies and procedures •Cardiovascular assessment •Respiratory assessment •Gastrointestinal assessment •Genitourinary assessment •Musculoskeletal assessment •Intergumentary assessment CLINICAL SERVICES me. Pain is . individual needs or (e. Those responsible for direct nursing care prioritize patients’ needs based on assessment results. erval appropriate to patient’s condition. Measurable Elements 1.
There is an established screening criteria according to patients’ functional capacity and needs like: 2. Nutritional status. Spiritual •Religion 1.• Sensory assessment 1.4. needs and risks 1.6.Coping – Stress Tolerance Pattern 1.2. Pain assessment 1.Preference and idiosyncrasies 1. skilled care facility •Individual who will accompany the patient home (name.5.5. Activity – Exercise Pattern 2.8.10. Role – Relationship Pattern 2.7. Sleep – Rest Pattern 18.104.22.168.3.3.8. Sensory – Perceptual Pattern 2.Discharge plan •Place: home.7. telephone number. Health history •Developmental history (for pediatrics) •Family history •Medications taken •Allergies 2. address. Nutritional – Metabolic Pattern 2.9. Elimination Pattern 2. relationship) 2. Sexuality – Reproductive Pattern 2. Cognitive Pattern . extended.1. Economic factor •Financial barrier 1. Self – Concept Pattern 2.4. Vital signs 1. Social •Cultura l concerns 1.10.
2.1. technique and instruments.3. Discharge plan is evident in the initial assessment of the nurse particularly to those patients when discharge planning is critical as evidenced by the following: 5.11. 5. Measurable Elements 1.5.Referral for continuity of care as necessary II. but are not limited on the following: 4. Standards on Care of Patient Standard I: Care Process The Nursing Services Department has an established uniform care process across the clinical setting that reflects integration and coordination of care of other health team members particularly to those patients with similar condition. Assistance with activities of daily living 5.4.Value – Belief Pattern 3. The nursing assessment findings are documented in the individual patient’s record and readily available to those responsible for his/her care. Lack of mobility 5. Other pertinent data are collected using the appropriate assessment.2. Age 5. Continuing medical and nursing needs 5. There are existing policies and procedures on care process developed by those responsible for governance which include .
g. religious and other beliefs of patients. Care of patient in pain 1. 1.4. 1.1. Patient participate in planning of care taking into consideration the cultural.12.10. 1. prevention of illness. There is an evidence that nurse caring for patients implements nursing intervention and carries out medical orders utilizing critical thinking and sound clinical judgment based on but are not limited on the following: . Example: Selection of food The care plan reflects the related and relevant identified needs and problems of each patient cared for. The care plan ensures that priorities of care are established. Care of patient receiving medications with narrow margin of safety 22.214.171.124. Care of patient with intravenous therapy Standard II: Care Plan The nurse caring for patients develops and updates an individualized written care plan in the patient’s record within the prescribed time frame. alleviation of suffering and restoration of health. Care of patient with communicable diseases 1.15. Care of emergency patients (including use of resuscitation equipment) Care of patient on life support (e. 4.suppressed patients 1. •Disabled 1. The care plan is documented in the individual patient’s record to promote continuity of care. Care of patient in restraint 1.9. ventilatory equipment) Care of patient on dialysis (hemodialysis.7. Care of patient on nutritional therapy 1. There is a written care plan on every patient cared of by the nurse based on patient’s initial assessment data within the 1 st 24 hours of assessment or earlier. There is an evidence that family and significant others are involved in the planning process. The care plan is updated as appropriate based on the reassessment made. Standard III: Implementation of Care The nurse caring for patients implements nursing intervention and carries out medical orders utilizing critical thinking and sound clinical judgment for the promotion of health.13. Care of perioperative patient 1. Measurable Elements 1. 5. Care of comatose patient 1.5.3. 6.1. Care of immune . Care of patient receiving blood and blood components 1. peritoneal dialysis) Care of patients at risk: •Neonates • Critically-ill •Children • Mentally disadvantaged •Elderly • Under anesthesia 2. 126.96.36.199. Measurable Elements 1. Care of patient on chemotherapy 1. 2.
1.4. Scope of Nursing Practice as provided by law and all relevant legislations (e. Ten (10) Golden Rules in Drug Administration 1. Standard of Care: •Acute and Critical Care Nursing Practice •Chronic Care Nursing Practice •Cardiovascular Nursing Practice •Perioperative Nursing Practice •Maternal and Child Nursing Practice •Psychiatric Nursing Practice •Emergency Nursing Practice •Renal Nursing Practice •Pediatric Nursing Practice •Oncology Nursing Practice •Geriatric Nursing Practice •Ethical and Legal Nursing Practice •Nursing Standard on Intravenous Therapy •Infection Control Nursing Practice 1. 4. Systematic and continuous evaluation of patient’s progress and effectiveness of care is reflected in the individualized patient record. 2. Standard IV: Evaluation of Care Measurable Elements 1. 3. There is evidence that patients receive care according to pain management guidelines. The Philippine Nursing Act of 2002 or Republic Act 9173) The nurse caring for patients systematically and continuously evaluates the patient’s progress based on the effectiveness of nursing intervention rendered and medical management provided.6.2.5. There is an evidence that evaluation of care and patient outcome occurs within an appropriate time frame after the intervention (nursing or medical) is initiated. The revision in care plan if any is reflected in the patient record.based practice 1. Standard V: Pain Management The Nursing Services Department has established pain management guidelines for nurses to appropriately assess. It is evident that implementation of interventions/care is delivered in a safely manner that minimizes complications and life-threatening situations.g. monitor. Measurable Elements 1.3. monitor. 2.Code of Ethics for Nurses 1. Evidence .1. evaluate and manage patients in pain.1. Patient Bill of Rights 2. evaluate and manage patients in pain. There is an evidence that patient’s responses to interventions are documented. . There is an existing pain management guideline for nurses to appropriately assess.
1. End-of-Life Care The nurse provides an end-of-life care to facilitate a dignified and peaceful closure of life for patients through physiological. Measurable Elements 1. Advance directives Do Not Resuscitate. Monitoring and Storage 1.4. procedures and guidelines on medication management which include but are not limited on the following: 1. 1. In accordance to statutory laws.11. Living will if any.2. are respected. Transcribing and ordering 1. are monitored and recorded. 2.1. Respect for patient’s values. 4.1.Medication Recall System (Expired or Outdated Drugs) 1. Processes to communicate with and evaluate patients and families about pain are evident. Endorsing (especially high valuable drugs) 1. Administering (10 Golden Rules in Drug Administration) 1.Reporting on •Medication effects and adverse effects •Medication error and near-miss Standard VII: Measurable Elements 188.8.131.52. Pastoral services are provided based on the spiritual beliefs of the patient and family. The patient’s right of self-determination and choices are respected and accommodated.12. 2. Patient and family choices to donate organs and other tissue are supported through provision of relevant information. Documenting 1. 1. 1.6. Pain assessment.9. appropriate intervention to alleviate the patient’s pain and discomfort according to wishes of patient and family and re-assessment are evident.Regulated Drugs 1. Labeling 184.108.40.206. Waiver. rules and regulations. Assessment.3. Carrying out physician’s medication order 1. procedures and guidelines on medication management for symptomatic. There are existing education and training programs for nurses on pain management. religion and cultural preferences and practices is evident. There are written policies. intervention and evaluation. Standard VI: Medication Management The Nursing Services Department has established policies. .3. Personal hygiene is rendered based on patient’s need. social and spiritual care taking into consideration the cultural diversities in beliefs and customs and optimize caring environment.1. and palliative treatment of patients’ diseases and for safe nursing practice. psychological. preventive. curative. Emergency Drugs 1. 2. Preparing 1.7.5.
Protection of patient’s possessions from theft or loss 1.5.g. Respect the confidentiality of patient health information 1. Measurable Elements 1. vulnerable patients are infants. Prerogative to determine what information regarding health condition and care is provided to family and under what circumstances. Support patient and family rights by participating in the care decision and care process through information of the following: •Medical condition and confirmed diagnosis and the informant •Planned care.1.7. spiritual and cultural concerns. There are written policies. treatment. Patient’s and family’s beliefs and values 1.Nutritional assessment and risks are identified and nutritional needs are provided such as feeding and hydration.g. There is evidence that nurses are knowledgeable and supportive of patient and family rights. clinical interview. 3. Patient’s and family’s educational level . Respect for patient’s personal values and beliefs 1. 2.4. 1.3.6. Standards on Patient and Family Education Standard I: Education Assessment The nurse assesses the educational needs of each patient and family and documents these in his/her patient record. unanticipated outcome and participation in care decision according to wishes •Informed consent •Refusal or discontinuance of treatment •Withholding life-sustaining treatments •Assessment and management of pain •Compassionate care at the end-of-life •Process on complaints and differences of opinion about patient care •Participation in clinical research •Organ donation and other tissues •Disclosure of information 2. during treatment. processes and guidelines that respect and support patient and family rights which include but are not limited on the following: 1. The patient and family are involved in care management and decision.1. Standard VIII: Patient and Family Rights The Nursing Services Department has established policies.3. Protection of patient from physical assault (e. There is a written evidence that the nurse assesses the educational needs of each patient and family which include but are not limited on the following: 1.2.4. Measurable Elements 1. Patient’s and family’s literacy 1. A place is designated for the patient’s family to stay. outcome of care. transport) 1. Interventions address patient and family’s psychosocial.Respect for patient’s need for privacy (e.2. processes and guidelines that respect and support patient and family rights.2.3. emotional. children and elderly) 1. III. procedure. physical examination. 4.
The written policies and processes on patient access to care are evident which include but are not limited on the following: 1.4. Patient’s and family’s language 1. 3.6. Patient’s willingness to receive information Standard II: Education Plan and Programs The Nursing Services Department has established educational plans and programs that support patient and family participation in care decisions and care processes with the primary objective of rehabilitating the patient back to his/her functional level and optimal health. There is an evidence that nurses who provide education have the subject knowledge. Managing patient when bed or space or facilities is not available st Standard II: Emergency Patients .2. Clinical services available 1.1.3. the Nursing Services Department has established policies and processes on patient access to care aligned with the organization.1 to 4. Measurable Elements 1. Triage or screening • There is evidence that tr iaging or screening is initiated at the point of 1 contact with the patient 1. Safe and effective use of medications and their side effects 4. Education resources are available and organized in an efficient and effective manner. Rehabilitation techniques 4. Process for admitting patient or registering out patient 1. Patient’s and family’s motivations and emotional barriers 220.127.116.11.1. 4. It is evident that standardized materials and processes in educating patient and family on the aforementioned topics (4. Standards on Access and Continuity of Care Standard I: Access to Care In diverse health care setting. Measurable Elements 1. methods and mechanism for education is afforded.3. Criteria for admitting patient or registering out patient 1.4. Holding area for patient on observation 1. 2.4. Preventing interactions between prescribed medications and other medications (over the counter) and food 4. adequate time and communication skills to do so. The educational plan and programs for patient and family are evident according to the type of patient served and his/her learning needs. 6. Patient’s physical and cognitive limitation 1. Safe and effective use of medical equipment 4.6.6. 5. Pain management 4. it is evident that the patient and family are educated on topics considered high risk to patients: 4. The appropriate structure. Treatment and diagnostic procedures IV.1.2.5) are available. When appropriate.5.
There is an evidence that nurse actively participated in providing relevant information to patient and family during the admission process which includes but are not limited on the following: 2. Measurable Elements 1. Measurable Elements 1.5. 2. prioritized and received the necessary care as quickly as possible according to established physiologically based criteria. Standard V: Continuity of Care In diverse health care setting.1.2. physical. cultural. There is an evidence that nurse screening assessment focuses on preventive. 3.Proposed plan of care 2. It is evident that criteria is physiologic-based and developed by appropriate individuals. There is an evidence that nurses caring for patients needing intensive and specialized services underwent the related and necessary training. Expected outcome of care 2. Sufficient information to make knowledgeable decision and 2.Expected cost of care 2. 4. There is an evidence that staff who responded to emergency patients underwent the necessary training.3. Standard III: Admitted Patients or In-Patients The needs of in-patients for preventive. . There is an evidence of entry/or transfer criteria for patients that need intensive and specialized services to meet special patient needs. rehabilitative and palliative services and prioritizes these according to the patient’s health condition. rehabilitative and palliative services as well as other relevant information are assessed and prioritized based on his/her health condition at the time of admission in the health care facility. curative.4. It is evident that patients admitted and or transferred to intensive and specialized areas/units meet the established criteria and are documented in the patient record. to access and in the delivery of care Standard IV: Intensive and Specialized Services The Nursing Services Department has established entry/ or transfer criteria for patients that need intensive and specialized services to meet special patient needs congruent with those of the organization. curative. the Nursing Services Department has established policies and processes on patient continuity of care aligned with those of the organization and coordinated among other health professionals. Measurable Elements 1. Limit or overcome barriers such as language.The patients with emergency or immediate needs/care are given priority for assessment and treatment by the nurse. 2. There is an evidence that patients with immediate needs/care are assessed. 2.
Nursing ward services to intensive or special services 1.Nursing ward services to surgical and non surgical services 1. out on pass. and health professionals in the community. identified as responsible for patient care and documented in the patient record.3.6. During all phases of care. Out on Pass.Follow-up instruction in an understandable form and manner •Activity •Diet •Next medical consultation •Urgent care indicators 6.Measurable Elements 1. Medications to be taken at home 6.2. Continuity of care and coordination of services are evident throughout all phases of care.1. Referral for support services to either health care providers.9. Standard VI: Discharge.8. The patient’s discharge summary is prepared by qualified individuals recognized by the organization. Nursing ward services to diagnostic services 1. procedures and guidelines regarding the transfer of patient within and outside of the organization. Other health care settings 2. Significant physical and other findings 6. procedures and guidelines on patient’s discharge.4. referral and follow-up congruent with those of the organization. There are written policies.6. Emergency services to nursing ward admission 1.1. 6. there is a qualified individual. The written policies and processes on patient continuity of care are evident and implemented throughout all phases of patient care particularly but are not limited in the following services: 1. Standard VII: Transfer of Patient The Nursing Services Department has established policies. Significant diagnosis and co-morbidities 6. There is a referral system of patients for transfer to other organization.5. Condition of patient at the time of discharge 6. 5. Reason for admission 6.2.5. referral and follow-up congruent with those of the organization. Between nursing units or clinical departments 1. There is a process on out on pass patients for a defined period of time. Diagnostic and therapeutic procedures performed 6. Medications and treatments 6.4.3. There are criteria that determine patients readiness to be discharged. 3. .7. health organizations or agency. 3.7. 2. Measurable Elements 1. Out patient care programs 1. A copy of patient’s discharge summary is placed in the patient record and another copy is given to the patient which include but are not limited on the following: 6. out on pass. 4. Referral and Follow-up The Nursing Services Department has established policies and processes and guidelines on patient’s discharge.
2. Registration number and or Admission number 1. interventions (medical and nursing) and continuous care rendered are written.4.The guidelines and procedures include but are not limited on the following: 2. Religion 1. Health Care Insurance Standard II: Clinical Data The nurse documents essential clinical data of each patient accurately and completely based on individualized nursing care plan from admission to discharge in health care facility. Situation when transfer is not possible is stated.3. 2. 2. Advance directive 1. procedure and guidelines on transfer of patient within and outside of the organization.9. Transfer is based on the patient’s needs for continuity of care. transferring hospital.1.There is a written policy.3. Language spoken 1. Admitted via: ambulatory. care facility 1. Measurable Elements . Admitted from: home. 2. 2. V.7. age. Attending physician and referring physician.1. Safe and quality medical transport services within and outside of the organization are provided. Summary of patient’s clinical condition. Patient’s transfer is documented. Responsible health care provider during the patient’s transfer is identified. 2. stretcher 18.104.22.168.8.4. Transfer of responsibility to another health provider or health care setting is evident.Measurable Elements 1.6. wheelchair.2.4. Date and time of admission and discharge 1. 2. Standards on Nursing Documentation Standard I: Structural Data applicable forms which include but are not limited on the following: 1. 2.4. Formal and informal arrangements are apparent.2. if any 1. gender. Patient’s addressograph – name.2.5.7. Mode of admission/transport/discharge 1.8. civil status 1.
2.The nurse documents structural data of each patient accurately and completely based on applicable laws and regulations. Measurable Elements 1. There is an accurate and complete documentation of patients’ structural data in all nursing and 1. Physical examination (head-to-toe) 1.1. There is relevant/essential. accurate and complete nursing documentation of patients’ clinical data in all appropriate forms from admission to discharge in health care facility which include but are not limited on the following: 1. professional standards and institutional requirements. Health history Standard II: Governance Responsibility and Accountability .
Psychological. authority.Patients’ response and outcome 1. Standards on Governance and Direction Standard I: Governance Structure The Nursing Services Department has governance structure designed to delineate lines of relationship.8. The Nursing Services governance structure is represented or displayed in an organizational chart that shows functional and positional relationships and span of control. The Nursing Services governance structure depicts decentralization or unit-based wherein decisionmaking prevails to support and promote patient safety and quality improvement. The Nursing Services governance structure and processes support professional communication. clinical planning and services and policy development.Health teachings – patient and family 1.4.6.Diagnostic and therapeutic interventions 1. 2. 4. responsibility and accountability and the mechanisms for communication and coordination within the Nursing Services and other services/departments of the health care facility.3.10. The Nursing Services governance structure is described in written documents with the approval of proper authority.Actual and potential health problems and needs 1.9.7.Pharmacological management 1. spiritual and economic evaluation 1.5. . Measurable Elements 1. 3.1. social.Nursing interventions 1. Preferences and idiosyncrasies ADMINISTRATION & MANAGEMENT I.
managers. primarily sets its direction by formulating its vision. Measurable Elements 1. attainable. Those responsible for the Nursing Services Department governance. Those responsible and accountable for governing and managing the Nursing Services Department are identified by position title and name. philosophy. Standard III: Direction-Setting The Nursing Services Department has an established vision. core values and quality objectives congruent with that of the institution and the Nursing profession. The governance responsibility and accountability are described in organization’s by-laws. mission. 2. philosophy. 4. professional technical staff and assistive nursing personnel to carry out the functions of the Nursing Services Department. philosophy and core values are written ( specific. The vision. mission. 3. mission. Those responsible for governance appoint the Nursing Services Administrator. measurable. job description and other similar documents. Measurable Elements 1.The governance responsibility and accountability are described in a written document to guide how they are to be carried out. core values and quality objectives congruent with that of the institution and the Nursing profession. 2. Standard II: Governance Responsibility and Accountability . reliable. There is a written document that describes how the performances of the governing entity are appraised by specific criteria.
Measurable Elements 1. Those in the managerial and clinical levels translate the overall Nursing Services Department’ strategic and management plans into action which include: the management of patient care. Those responsible for governance have established current financial plans and allocation of resources . resources required and contingencies. 3. timeframe. updated.time bound. The Nursing Services Department has documented strategic and operational plans consistent with the hospital wide quality plan. ethical and recorded ). 2. Standard IV: Strategic & Operational Plans based on the needs of the Nursing Services Department. nursing manpower and unit operation of responsibility areas. There is an existence of strategic and operational plans periodically set and reviewed which contains goals and objectives. Those responsible for governance forecast and direct the future and operation of the Nursing Services Department in order to achieve its overall goals. Measurable Elements 1. action plan/activities. widely disseminated. Standard V: Financial Plan & Resource Allocation The Nursing Services Department has financial plan and allocation of resources required to meet its goals and sustain its operation. interpreted and operationalized. reviewed.
The medical supplies. Measurable Elements 1. 3. The Nursing Services Department has a written Code of Ethical Behavior which observes the rights and safety of patients and health care providers. Each Nursing Unit has an individual budget plan periodically monitored for variances. 2. An updated manual of Nursing Services policies and procedures exists and provides clear directive for nursing personnel at different levels on the scope and limitations of their functions and responsibilities to patient care. 3.2. Measurable Elements 1. Standard VII: Ethico – Moral & Legal Accountabilities The Nursing Services Department has an established framework for ethico-moral and legal management to support the ethical decision-making in the clinical areas. materials and equipment recommended by professional organizations and authoritative sources are obtained and appropriately used. professional and interprofessional relationships and other related endeavors. Those responsible for governance formulate policies and procedures to serve as guidelines for those confronted by ethico-moral dilemmas in patient care. rules and regulations. Nursing Practice on Patient Care are developed and communicated to serve as operational guidelines. 4. . Standard VIII: Professional & Organizational Involvement The administrator of the Nursing Services Department actively participates and collaborates with leaders within the organization and professional associations for continuous quality improvement of nursing services. Those responsible for governance ensure compliance with the applicable statutory laws. Those responsible for governance develop and implement policies and procedures based on established Standards of Nursing Administration and Nursing Service on Patient Care. The capital and operating budgets are implemented as approved by the authorized person/office and monitored based on responsibility accounting. Measurable Elements 1. Those responsible for Nursing Services Department governance initiate and maintain formal liaison/linkage with other departments/sections of the institution and professional associations and agencies pertinent to nursing standards and practices. and conforms with the applicable statutory laws. 2. Standard VI: Policies & Procedures Development The policies and procedures of the Nursing Services Department that reflect Standards of Nursing Administration. regulations and standards.
4. RA 9173 appropriate education.administration courses at the graduate level. and other experience and criteria set demonstrable proven by the ability in nursing organizatio practice and n/institutio administration. Standards on Human 1. Be a member of good standing of the accredited professional organization of nurses.1 accountable for the Qualificatio operation of the entire ns Nursing Services of the of organization/instituti on. and 1. There are Resource Management presence of Standard I: evidences Administrator of that the Nursing Services Nursing Service The Nursing Administra Services Department tor is is administered by a qualified qualified nursing to the administrator position pertinent to based on licensure. Nursing Measurable Elements Service Admini strators : . n such as: fully responsible and 1.1. II.
Poss ess a degr ee of bach elor of Scien ce in Nursi ng. 1. with a least nine ( 9) unit s in man age ment and .2.1.A person occupy ing supervi sory or manage rial positio ns requirin g knowle dge of nursing must: 1. 1. Be a regist ered nur se in the Philippi nes. 22.214.171.124. Have at least two (2) years experie nce i n gener al nursi ng servi ce adminis tratio n.
1. A master’s degree major in nursing. possess: 1. At least five (5) years of experience in a supervisory or management p o s it i o n i n n u r s i n g 1.2.4. . and (1.1).1.A person occupying the position of chief nurse of director of nursing service shall. the maximu m academic qualificati ons and experienc es for a chief nurse shall be as specified in subsectio ns (1. 1.1. That for chief nurses in .1.2. That for primary hospitals . in addition to the foregoing qualificatio ns.). 1.2.3) of the above.3.1.1. (1. a n d 1.
That for chief nurses in military hospitals. Standard II Staffing Plan : .5. priority shall be given to those who have finished a master’s degree in nursing and the completio n of the General Staff Course (GSC).the public health agencies. Those responsible for the overall administration and management of Nursing Services is a member of the top Executive/Ma nagement Committee who participates in their regular meetings and provides advice and recommendati ons in relation to nursing practice. 1. 2. those who have a master’s degree in public health/com munity health nursing shall be given priority.
staff and skills mix and other factors affecting the projection of staffing needs. hiring. work experience) and other pertinent requirements. appointment and promotion of nursing service personnel in accordance with the statutory laws and regulations and the institutional policies and procedures. 2. level and modality of care. 3. Selection. education. select. Those responsible for Nursing Services governance develop a staffing plan that identify the number. reviewed and updated on an ongoing basis. patients’ needs and applicant qualification. Standard V: Staff Placement The Nursing Services Department has defined criteria and processes to ensure the clinical staff knowledge and skills are consistent with the patients’ needs. Standard III: Recruitment. 2. hire and appoint nursing services personnel and are uniformly implemented. verifying and evaluating the nursing staff credentials (licensure. training and work experiences of nursing personnel are documented and updated. type and desired qualification of nursing services staff which is written. verifying and evaluating the nursing staff credentials. hiring and appointment are based on institutional. Measurable Elements 1. Measurable Elements 1. 2. selection. selection. . type of services. reviewed and updated on an ongoing basis. skills and experience) of Nursing Services staff. Hiring and Appointment The Nursing Services Department has an established system and processes for recruitment. Measurable Elements 1. 3. There are legitimate and legitimized processes to recruit. Standard IV: Credentialing The Nursing Services Department has an effective process for gathering. There is evidence of standardized procedure to gather the credentials of all nursing staff. Staff recruitment.The Nursing Services Department has a staffing plan that identify the number. selection. appointment and promotion of human resources in accordance with the statutory laws and regulations and the institutional policies and procedures. Those responsible for Nursing Services governance consider the organization’s mission. hiring. Those responsible for the Nursing Services governance actively participate/collaborate in the development of system and processes for recruitment. The licensure. patients’ mix. type and desired qualification (education. The staffing plan is defined in writing and meets the needs of the patients/population served and scope of services. 3. training. education. Those responsible for Nursing Services governance develop an effective process for gathering.
3. Measurable Elements 1. Staff placement/assi gnment is based on patient needs. Measurable Elements 1.2. which specifies duties and responsibilities based on established standards of performance. available resources and staff competencies. 2. There is evidence that the Job Description of Nursing Services personnel is reviewed at least once every 3 years and revised when necessary. There is a written Job Description for each position classification of Nursing Services personnel which . Standard VI: Staff Job Description The Nursing Services Department has job description for each position classification of Nursing personnel. There are written core competencies required for every job position in the Nursing Services organization to ensure that the staff skills are consistent with the patients’ needs. Those responsible for Nursing Services governance develop and define the criteria (core competencies) and processes to match the clinical staff knowledge and skills with the patients’ needs.
Functional relationship 1. Duties and responsibilities 1. Accountability 1.1. There is evidence of staff development programs for all nursing personnel .4. 2. Measurable Elements 1. Those responsible for Nursing Services governance design and implement staff development programs for nursing personnel at all levels based on training needs analyses.specifies: 1.2.3. Qualification and experience required Standard VII: Staff Development The Nursing Services Department has an established staff development program for all nursing personnel to encourage and promote continuing personal and professional growth and development.
Resources are available to implement the staff development program such as: . Safety program to protect the patient. Career counseling and career advanceme nt/ladder. b. Continuing education. training and opportunitie s for professional advanceme nt of staff member to enhance their knowledge and skills. c. Orientatio n program for newly hired and promoted staff.throughout the year which include: a. 3. d. staff and property. to the organizatio n department /unit to which they are assigned as well as their specific job responsibili ties.
Measurable Elements 1. implementation and evaluation of hospital – wide programs to provide a safe and secure physical environment. Title of the program 5. regulations and other requirements that are applicable. Evaluation of the attendees 5. Standards on Facility Management & Environment Safety Standard I Facility Planning : 2. Effectiveness of the program 5. Audiovisual equipment 3. Program design and content 126.96.36.199. staff and visitors aligned with that of the organization’s master plan. staff and others.5. plan and budget for upgrading or replacing key components based on facility inspection findings. destruction or loss. 5.2.3. chemicals. Hazardous Materials and Waste •There is a current list of hazardous materials and waste to safely control them (e. the Nursing Services Department provides a safe. implementation and evaluation of programs/activities to manage the risks within the environment which includes but is not limited on the following: 1.1. tampering. visitors. Educational resources 3. chemotherapeutic agents.5. Those responsible for governance. Space and facilities 3. List of attendees/participants III. Medication Room) 1. Objectives of the program 5. Those responsible for governance comply with relevant laws.g. •Monitoring mechanism of all risk areas is in place and kept secure to patient from unauthorized access or use.3.1. Clinical and clerical staff 3. Standard II Environmental Safety : The Nursing Services Department actively participates in the planning. . functional and supportive facility to patients and their families.6. Safety and Security •There is an existing provision for the identification of patient and their families. For efficient and effective delivery of nursing care and services. Ther e is a wr itten and up-to-date plan.4.4. (e. Records of staff development program are maintained which include: 5. Those responsible for governance actively participate in space planning as well as medical equipment and supplies procurement.g. Policies and procedures on continuing education staff attendance to staff development programs are evident. Resource speakers 4.2. Measurable Elements 1. radio-active materials and waste. 3.
procedures and guidelines on infection control are implemented. inventory. E EThere is an evidenceis an fire safety plan and program of the •There that existing written organization/institution is implemented on handing.policies. : 1.and comprehensive manner to all patient care and staff work areas. •A written emergency processes is in place in the event of water interruption or contamination. inventory and 1. Standard III Staff Education 1. electrical power. labeling. use. • prevention and control programsinvestigation of spills. Infection Control disposal of hazardous materials E EThere is evidencewaste.4. epidemics.hazardous gases and vapors. and disasters. electrical failure or interruption and medical gases unavailability. processes in a continuous storage. hazardous materials and wastes. Medical Equipment •There is and Nursing Services Department ensures educationan updated policy andstaff to effectively carry out their roles in creating training of a safe and sound patient and processes on medical equipment asurable Elements procurement. 1. regular inspection. seven (7) days a week.7. Fire Safety waste). and medical gases are available 24 hours a day.3. Utilities •Potable water. •Monitoring of equipment functionality and utilization is in place for purposes of planning and improvement.6. and that E EThere Documentation and reporting system are are infection surveillance. and recall system. preventive maintenance. •Monitoring of utilities is evident for . infectious institutional emergencies. to identify and reduce the risks of acquiring and transmitting infections among patients and nursing in place for E EThere exposures and that the nursing staffto is evidence other accidents related is provided with education on infection control practices.
1.purposes of planning and improvement. Emergencies •An emergency management plan and processes are evident to likely community/ .5.
Clinical record for every patient assessed or •Patient/nursing care services treated. Standards on Communication Management E EPatient care and response to care (referral) E E clinical data (diagnostic Standard I Communication of InformationPatient examinations and therapeutic procedures) E ECircular The Nursing Services Department has efficient and Standard II Patient Clinical Record effective system of communication with the community. Directives. to patients and their families. Other Health Professionals (clinical and non.4.1. nursing personnel and other health professionals throughout the organization. programs. There is efficient and effective system of communication that exist which include but are not limited on the following: 1. E EPolicies. : : Measurable Elements 1.2.2. There is an evidence that the staff can describe andService Philosophy. There is an evidence of staff training EMemorandum.E EEducational materials and methods in an understandable format and language 1.Community The Nursing Services Department has established •Patient/nursing care services policies.clinical staff) VI. and •Patient health condition guidelines on patient clinical record which include •Care provided to patient but are not limited on the following: •Patient’s response to care 1. 1. Confidentiality of record 1.3. Circular. E ENursing 2. Core Values demonstrate their role in the aforementioned safety Procedures. Security of record •Alternative sources of care and services . Vision. •Health programs •Process to access care Measurable Elements 1.1. Guidelines. to operate E medical equipment appropriate to their job Activities description. Patients and Families 1. in-patient or out-patient available 1. There are written policies.3. procedures. Mission. Nursing Personnel E ENursing endorsement in between work shifts 1. Standards 3. There is an evidence of staff education and training E ENursing on facility management and environmental safetydocumentation E EReferral programs. procedures and guidelines on patient clinical record.
Manuals of the Organization •Quality System •Infection Control •Emergency Preparedness •Employees’ Manual •Others 2. Guidelines 1.Master Staffing Plan 1. Data Integrity •Protection from tampering 1. Control that only current policy and procedures are implemented 2. Organization and Nursing Services Department Policies. There is a written policy or protocol in keeping and maintaining Nursing Services Department administrative records which include but are not limited on the following: 1. Census of Patients and Diseases 1.9. authorized person) V.5. References originating outside the organization 2. There is written policy or protocol in developing and maintaining policies and procedure which include but are not limited on the following: 2. Nursing and the Organization 1.10.5. Committees. symbols. Standards 1. procedure codes and definitions 188.8.131.52.184.108.40.206. Retention period of records (as prescribed by law and institutional policy) Standard III Administrative Record : The Nursing Services Department has established policies or protocol in keeping and maintaining its administrative record and defining the requirements for developing and maintaining policies and procedures. Process and frequency of review and continued approval of policies and procedures 2.g.4.6.Review and approval of all policies and procedures before implementation 2. Bed Capacity and Occupancy Rate 1. Staffing Pattern 1. date of issue.• Protection from loss and destruction and unauthorized access and use 1. Procedures. Staff Development Programs 1.1. Retention of obsolete policies and procedures 2.Minutes of Meeting.1. Use and monitoring of standardized abbreviations.5. Measurable Elements . Nursing Services Department 1. Standards on Quality Improvement Standard I Leadership and Staff Education : The Nursing Services Department has continuous quality improvement on patient and staff safety programs through monitoring and analyzing variation of data and undesirable trends of events.Quality Improvement Program and other Projects 1. Identification of charges in policy and procedures 2.6. Measurable Elements 1.2. Tracking of policy and procedures in circulation (e.3.Budget Plan 220.127.116.11. title.
18.104.22.168.6. 5. Measurable Elements 1. Prevention and control measures aligned with International Patient Safety Goals. Those responsible for governing and managing the Nursing Service Department lead or actively participate in planning. .4.3. 3 . clinical pathway) 2. Standard II Quality Programs : and other relevant evidence – based information. reporting (needle stick injury.5. There is a clinical monitoring that exists but is not limited on the following: 1. clinical standards. Th er e i s an e v i de n c e t h at t h e qu a li t y improvement/processes and safety programs are approved by governance. high risk and problemprone processes. guidelines. Total parenteral nutrition 1. (Isolation Procedure) The Nursing Services Department has priority quality programs to reduce high volume. 4.8. monitoring. Measurable Elements 1. surveillance.2. Clinical research 1. analyzing and implementing quality improvement and patient and staff safety programs congruent with the organizational needs. Infection control. Surgical safety (sterilization/disinfection) 1. scientific literature. 3. hand hygiene and barrier technique. Nursing documentation 1. There is an established reporting system on the quality and safety programs to governance. Standard III Quality Monitoring. There is an existing plan and program to reduce the risk of community/hospital acquired infectious for patients and health care associated infections for staff. (e. processes and results and data are aggregated. implemented and monitored for consistent use and effectiveness. Blood and blood products 1. There is a training program for staff consistent with their role in quality improvement and patient safety program. Medication error 1. Analysis & Implementation : The Nursing Services Department has established key indicators to monitor the clinical and managerial structure. analyzed and transformed to useful information.g.1. 2. Those in governance support and take action on recommendation for quality improvement and patient and staff safety programs based on the result of root cause analysis. There is an evidence that information on quality improvement and patient and staff safety programs are communicated to staff on a regular basis through effective channels inclusive of progress on compliance. Intravenous fluids 1. body fluids and waste segregation/disposal) 1. Medication safety. There is a qualified trainer who provides the training and staff participation as part of their regular work assignment. There is written plan or policy or document of a well designed new processes or modified existing processes consistent with current practice.
and other specific . This applies within an organization or across multiple organizations. Credentialing – is the process of obtaining. information technology. Clinical Pathways – is an agreed-upon treatment regime or improvement are appropriate to the care. elements of care.g. sharing and disposal of data or information for effective and efficient operation of organization activities. use. or spiritual and social care or service. the procedures performed. ulation and those in governance and actions taken. the significant findings.hat exists but is not limited on the following: iagnoses d complaints. the treatment rendered. Discharge Summary – is a section of patient record that summarizes the reasons for admittance. the patient’s condition on discharge. and information services. or nursing care. level of medical. Continuity of Care – is the matching of an individual’s ongoing needs with the appropriate care setting. Emergency Kart contents) GLOSSARY Adverse Event – is an unanticipated or potentially dangerous occurrence in health care organization. It includes the role of management to produce and control the use of data and information in work activities. and assessing the qualifications of a health care practitioner like the nursing personnel. information resources management. Communication Management – is the creation. tested and implemented. scope and severity of the problems. demonstrate that the improvements are effective and sustained. if any supplies essential to most patient needs (e. that includes actions for improvement or changes are planned. verifying. The process determines if an individual can provide patient care services in or for a health care organization. psychological.
nurse.” and “governing body. over time.” Health Care Organization – is a generic term used to describe many types of organizations that provide health care services. maintaining quality of care. laboratories and long term organizations. End-of-Life Care – is the provision of care to the patient whose disease condition is not responsive to curative treatment. systems. follow –up.” “board of commissioners. or process. hospitals. This includes ambulatory care centers. and his/her life expectancy is estimated to be within days or months. Indicator – is a measure of the performance of functions. risks.” board of governors. Health care professionals are often licensed by a government agency or certified by a professional organization. and alternatives of a medical procedure or treatment before the . or allied health professionals. This includes a physician. Informed Consent – is an agreement or permission accompanied by full information on the nature.” Health Care Professional – is any person who has completed a course of study and is skilled in a field of health.instructions given to the patient or family (for example. home care organizations. behavioral/mental health institutions. group or agency that have ultimate authority and responsibility for establishing policy.” “board of trustees. medications). and providing for organization management and planning. dentist. Governance – refers to the individual(s). Other names for this group include “board. It is also known as a “health care institution.
or certification. progress notes and discharge summary. Qualification is determined by the following: education. and documents the individual’s progress in meeting specified goals and objectives. Management. outlines the criteria for ending intervention. treatment details. This record is created by nurses. Coulter M (2004). clinical paths or a combination of these. .Robbins. Plan of Care – is a plan that identifies the patient’s care needs. competence. In-Service Education – is an organized education. law or regulation. practice guidelines. designed to enhance the skills of staff members or teach them new skills relevant to their jobs and disciplines. The plan of care may include prevention. Patient Record/Clinical Record – is a written account of a variety of patient health information. protocols. Qualified Individual – is an individual or staff member who can participate in one or all of the organization’s care activities or services. 7 Pearson Education South Asia PTE LTD. Palliative Services – are treatments and support services intended to alleviate pain and suffering rather than to cure illness. S. The format of the plan in some organizations may be guided by specific policies and procedures. registration. such as assessment findings. th Edition. documents treatment goals and objectives. It is based on data gathered during patient assessment. lists the strategy to meet those needs. usually provided in the workplace. care. training. and rehabilitation. experience. applicable licensure. habilitation. physicians and other health care professionals involved in the care of patients. treatment. physician or other health care professional begins the procedure or treatment.
3 rd Edition Printed in USA 54321 Joint Commission International (2004). treatment. Gerhart. REFERENCES an organization to provide safe and high-quality care. and other persons. Inc. Hollenback. Fundamental of Human Resource Management. Wright (2004). 1 st Edition Joint Commission International (2008). Association of Nursing Service Administrators of the nursing practitioners are accountable. including health care providers. Inc. Philippines. Accreditation Standards for Hospitals.opulations increase the likelihood of environment are reduced for a patient desired health outcomes and are consistent with current professional knowledge. . The Administration of Hospital Nursing Services in Philippine Department of Health. and Philippine Nurses Association. New York Republic Act 9173 or The Philippine Nursing Act of 1991. Credentialing. (1999). Inc. and service. Metro Manila ctures. Edition Printed in USA 54321 Noe. (2001) Standards of Nursing Services Association of Nursing Service Administrators of the Philippines. Human Resources for Hospitals. McGraw-Hill Co. Inc. Edition Printed in USA 54321 Joint Commission International (2004). Republic of the Philippines. or process that must be in place for escribe the responsibilities for which t to receive. Standards of Safe Nursing Practice Committee on the Revision of the Hospital Nursing Service Administrative Manual (1990).
Aspen Publication Tomey A.M (2004). Lippincott Williams & Wilkins th . th Editi Rowland H & Rowland B (1980). 7 Pearson Education South Asia PTE LTD. Nurse’s Handbook of Health Assessment. Management. S. Coulter M (2004). Guide to Nursing Management and Leadership. Nursing Administration Handbook.Robbins. 5 Edition. J (2006). 7 th Edition Weber.
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